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Postpartum Hemorrhage (PPH)
- From delivery up to 6wks postpartum
- SVD Spontaneous vaginal delivery: greater than 500ml (considered PPH) o Estimated blood loss o Quantitative blood loss (weighing everything)
- CS C-Section: greater than 1000ml
Two main reasons for PPH
- Full bladder
- Retained placenta
What you will assess when you walk into a patient’s room for PPH
- Assess Fundus -should always be right at umbilicus If it feels like your cheek: boggy; (massage it) Don’t stop unless it firms up
- Call for help
- Call Dr.
- Meds
- VS and O2 stat
- Weigh under pads (add this amount of blood loss to what she lost at delivery
- Change under pads
- Empty bladder (foley)
- Start 2nd^ IV; may need to give patient blood
o Once you start to feel the fundus firm up you can stop massaging o Only thing that can misplace the fundus is a full bladder
- The uterus has to contract to stop bleeding
Meds (all usually standing orders)
- Pitocin : usually IV sometimes IM every patient after they deliver will get this drug (immediately) o If there is a fetus in the uterus; has to be on pump and is piggybacked o If not given wide open
- Methergine : given IM; if patient has HTN CANNOT be given this drug
- Hemabate : given IM; CANNOT give if patient has asthma (can cause explosive diarrhea)
- Cytotec : rectally; given 800-1000 mcg
*Methergine and Hemabate: work within 2-3 minutes
If all of this doesn’t work then back to the OR
- Should be dark brown
- Firm w/ Bright red blood- laceration
- After delivery check every 15 minutes x 4
- Every 30 minutes x 4
G- # of pregnancies
T- # of term deliveries
P- # of preterm deliveries (20- 36 6/7 weeks) A- # of abortions (less than 20 weeks)
L- # of living children
Fetus cannot survive before 20 weeks
Antepartum
o fetus in uterus
Prenatal Visit (1st^ things that need to be checked)
- Vital signs
- Estimated Date of Confinement (Estimated Due Date)
- Medical hx
- CBC
- Hep B
- HIV
- VDRL- STI
- Blood type- Rh factor
- Rubella titters; drawn at prenatal visit (if nonimmune she needs Rubella titters w/in 72hrs after delivery)
- TB skin test
- Pap smear
- Weight
- UA- urinalysis
- Fetal heart tones (can be heard at 6 weeks)
If mother is Rh-(negative), she needs Rhogam (26-28wks), she needs that because negative
antigens may try to fight off pregnancy
- If mom is negative and baby blood positive; mom needs Rhogam within 72hrs after delivery to protect next pregnancy
*Only run babies cord blood to find out blood type if moms blood type is negative
Next visits
- VS
- Weight
- UA
- Fetal heart tones
- Measure abdomen
Office Visits- doctor for normal pregnancies
Changes in Body Systems: Reproductive
- Uterus o F
- Cervix o Chadwick signs: bluesish/purplish o Goodell’s sign: cervix softening o Mucus plug: keeps the uterus safe from any germs getting into uterus; can cause some spotting as separating from cervix wall o Hrg’s sign: softening of lower segment of the uterus
- Vagina and vulva o Increased vascularity o Vaginal mucosa thickens o Vaginal rugae becomes prominent o Increased roiduction
- Breast o Grow larger o Areola gets darker o Colostrum- thick yellow discharge; body getting ready for breast home
- Heart
- Blood o Blood volume increase o Plasma volume increases: o Cardiac output increase
- Relaxin: o body releases during pregnancy; smooth muscle relaxer; keeps BP normal - Has clotting factors in it
- Oxygen needs increase o RR will go up about 20%
- Appetite o increase after 1st^ trimester
- Mouth o gums may bleed, can get gingivitis, ptyalism
- Esophagus o acid reflux; heart burn
- Large and small intestines
o Amenorrhea o N/V o Fatigue
o Urinary frequency o Breast changes o Vaginal & cervical color changes
o Quickening (fetal movement)- flutter of gas
- Probable (objective) o Abdominal enlargement o Goodell’s sign softening of the lower part of the cervix-soft like your cheek. o Hagar’s sign (softening of the lower uterine segment) o Ballottement- Dr. does a dig vag exam & can push up on cervix. Fetus will go up & come back down o Braxton Hicks pre-contractions ATI o Palpation of fetal outline- Enlarged abdomen o Positive pregnancy test o Chadwick sign- - bluish purple color of the cervix
- Positive o Fetal heart sounds o Fetal movement detected by provider o Visualization of the embryo or fetus
First Trimester
Second Trimester
- Physical evidence of pregnancy
- Fetus as the primary
- Narcissism and introversion
- Body image
- Changes in sexuality; changes in sex drive
Third Trimester
- Vulnerability
- Increasing dependence
- Preparation for birth o Nesting behavior (happen later on; just before labor)
Maternal Role Transition
- Three stages of attachment
- Things to know: o Mom needs 600mcg/day of folic acid o Mom: needs extra calcium o hCG: levels go up when pregnant o Moms should gain 25-35lbs: normal weight gain o Should drink 6-8liters/day o DO NOT ovulate during pregnancy o Never lie a pregnant women supine/flat on back; always needs to have a pillow wedged behind her back
Week 2 Notes Effects of the birth process: Maternal Response
Variability- (goes up & down) when we look at a fetal monitor strip. We’re always going tolook for variability It’s the babies hear beat from beat to beat
Absent- 0 BPM Minimal 0-5 BPM
Moderate 5-25 BPM—Always wantMarked
25 BPM
Characteristics of contractions:
- Coordinated o Frequency ▪ Beginning of one uterine contraction to the beginning of the next ▪ Range in minutes; how often (ex. 1.5- 2 minutes) ▪ Don’t want a frequeny to be any more than 2 min’s lasting about 60- 90 sec’s o Duration ▪ Beginning of a uterine contraction to the end of the same contraction whenit comes back to baseline ▪ Range in seconds; how long is last (ex. 60-90 sec’s)
- Involuntary
- Intermittent- relaxation of the contraction (we must have this relaxation period, because ifnot. That means the uterus is not contracting & it’s where the fetus is getting most nutrients & oxygen. During that resting tone)
Contraction Cycle
o Increment ▪ Period of increasing strength o Acme ▪ Period during which the contraction is most intense
Early (starts right w/contraction) Head Compression (usually est. 8cm)
-mirrors mom contraction -Sterile vaginal exam (find out dilation)
Acceleration (above baseline)-lack of baseline Oxygenated
-Baby is saying he is ok
Late (declaration and contraction don’t match) Placental insufficiency
-Baby suffering -Not getting enough oxygen & nutrients
Characteristics of late- beginning, middle, & end are off
LATE deceleration (what to do)
- Reposition mom
- Shut off Pitocin (causes contractions)
- Increase IV fluids
- o2 via nonrebreather mask (8-10/L)
- Sterile vaginal exam-
- Call provider
*Anything goes below baseline; deceleration
*Want to see lots & lots of acceleration (when baby moves HR should go up)
*NEVER nasal cannula in L&D
Accelerated
Increase in fetal heart rate
- 15 beats by 15 beats above baseline (32+weeks)
- 10 beats by 10 beats above baseline (under 32 weeks)Fetus well oxygenated
Uterine body
- Upper two thirds of the uterus contracts actively to push fetus down
- Lower one third remains less active
Cervical changes
- Effacement (thinning and shortening: cervix)
- Dilation (opening)
- Effacement and dilation occur concurrently during labor bur at different rates
- Powers o Contractions o Maternal pushing
- Passage o Pelvis
- Passenger o Baby o Placenta o Membranes Baby can’t come out if it’s extended or hyperextended
- Psyche (how mom feels about pushing) o Anxiety o Culture and expectation o Birth as an experience o Support o Impact of technology
- Position o Fetal head position o Want baby to be in an anterior position (occipital) OA o OT- occipital transverse
Presentation
- Fetal part that first enters the pelvis
- Cephalic o Vertex, military, brow, face
- Breech o Frank, full, footling
- Shoulder
- Cephalic Presentation
- The cephalic presentation is more favorable than others for the following reasons:
- • The fetal head is the largest single fetal part, although the breech (buttocks), with the legs and feet flexed on the abdomen, is collectively larger than the head. After the head is born, the smaller parts follow easily as the extremities unfold.
- • During labor, the fetal head can gradually change shape, molding to adapt to the size and shape of the maternalpelvis.
- • The fetal head is smooth, round, and hard, making it a more effective part to dilate the cervix, which is alsoround.
- Cephalic presentation has the following four variations (Fig. 12.8):
- • Vertex—This is the most common type of cephalic presentation, in which the fetal head is fully flexed. It is called a vertex or occiput presentation and is the most favorable for normal progress of labor because the smallest suboccipitobregmatic diameter is presenting.
- • Military—The head is in a neutral position, neither flexed nor extended. The longer occipitofrontal diameter is presenting.
- • Brow—The fetal head is partly extended. The brow presentation is unstable, usually converting to a vertex presentation if the head flexes or to a face presentation if it extends. The longest supraoccipitomental diameter is presenting. C-section
- • Face—The head is extended, and the fetal occiput is near the fetal spine. The submentobregmatic diameter ispresenting. C-section
