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Uterine Atony
A failure of the myometrium to contract and retract to compress torn blood vessels and control blood loss.
Normal postpartum condition with contracted uterus preventing hemorrhage.
Predisposing Factors
1. Previous history of PPH or retained placenta 2. High parity 3. Presence of fibrosis 4. Maternal anemia 5. Ketoacidosis
Prophylaxis
Screening thorough and accurate health history Delivery arrangements must be explained carefully Early detection and treatment of anemia (Hgb > 10 g/dl) Good management during the first and second stage of labor to prevent prolonged labor and ketoacidosis Prophylactic administration of oxytocic agent Prepare 2 units of cross-matched blood for placenta previa
8 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Treatment of PPH
3 Basic Principles (CSR) 1. 2. Call a doctor
F So that help in on the way whatever happens; pts condition can deteriorate very rapidly which urgently requires physicians assistance.
3.
5. 6.
7.
Nursing Diagnoses
Fluid volume deficit r/t decrease in blood volume/loss of ECF. Altered tissue perfusion r/t reduction in tissue oxygenation and rapidity of blood loss. Anxiety r/t feelings of uncertainty and apprehension. Risk for infection r/t retention of placental tissue and excessive blood loss. Knowledge deficit r/t the cause of the excessive bleeding.
11 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Treatment
Bimanual compression of the uterus and D&C to remove clots. Repair of lacerations IV replacement of fluids and blood If bleeding persist, uterine rupture must be suspected Hysterectomy
12 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Nursing Interventions
Monitor v/s to assess for complications. Continue to monitor 24-48hrs. Inspect the placenta and membranes for completeness since retained fragments are often responsible for uterine atony. Massage the fundus, and express clots from the uterus. Perform a pad count to assess the amount of vaginal bleeding. Monitor lochia, including amount, color, and odor to assess for infection. Monitor fundus for location to assess for uterine displacement. Provide emotional support to help alleviate fear and anxiety. Provide quiet period, private room, restricted to visitors to promote recovery. If bleeding at home, lie down flat until help arrives.
13 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Placenta Adherent
A condition where the placenta remains attached to the uterus for an abnormally long time following birth.
2 Types 1. Partially adherent. The uterus is well contracted. Deliver the placenta by applying controlled cord traction or manually if unsuccessful. 2. Complete adherent. Does not usually bleed however, the longer the placenta remains in situ the greater the risk of partial separation, which may cause profuse hemorrhage.
14 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Management
Bimanual compression of the uterus Manual removal of the placenta
Uterine Inversion
A rare complication of vaginal delivery in which the uterus partially or completely turns inside out.
Classifications
According to severity According to timing of the prolapse 1. Acute prolapse occur within 24 hours of delivery. 2. Subacute over 24hrs up to 30th postpartum day.
2. Second degree uterus body is inverted to internal os. 3. Third degree uterus, cervix and vagina are inverted and are visible.
Causes
Associated with uterine atony and cervical dilation: Mismanagement in the 3rd stage of labor Combining fundal pressure and cord traction to deliver the placenta Use of fundal pressure while the uterus is atonic Pathologically adherent placenta Primiparity Fetal macrosomia (abnormally large size of body) Short umbilical cord Sudden emptying or distended uterus
18 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Interventions
1. 2. Call the physician including appropriate medical support. STAT attempt to replace to the uterus by pushing with the palm along the direction of the vagina.
Interventions
3. Initiate IV access and fluid replacement. 4. If placenta is still attached, it SHOULD be left in situ as attempts to remove it at this stage may result in uncontrollable hemorrhage. 5. Once the uterus is repositioned, the nurse/midwife should keep the hand in situ until firm contraction. 6. Administer oxytocic agents.
20 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Medical Management
If manual replacement fails Hydrostatic method of replacement instillation of warm saline infused into the vagina Medications to relax the constriction and facilitate the return. Throughout the events, the mother and partner should be kept informed of what is happening. V/S including LOC is of utmost importance.
Shock
A complex syndrome involving a reduction in blood flow to the tissues with resulting dysfunction of organs and cells.
3 Types 1. Hypovolemic the result of a reduction in intravascular volume 2. Cardiogenic impaired ability of the heart to pump blood 3. Distributive an abnormality in the vascular system that produces a maldistribution of the circulatory system (septic and anaphylactic shock)
22 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Hypovolemic Shock
Loss of circulating fluid volume or blood Decrease venous return to the heart Ventricles of the are inadequately filled Reduction in stroke volume and cardiac output Decrease blood pressure Decrease oxygen supply to the tissues Altered cell function
23 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Hypovolemic Shock
Decrease blood pressure SNS activation (receptors at aorta and carotid arteries) Adrenaline is released from the medulla and aldosterone from the adrenal cortex Vasoconstriction and cardiac output venous return to the heart
Hypovolemic Shock
Compensatory mechanism fails Inadequate perfusion to vital organs Further fall in BP and cardiac output Insufficient supply to coronary arteries Poor peripheral circulation Multisystem failure and irreparable cell damage Death
25 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Management of Shock
1. Maintain the airway. Turned unto side and administer 40% oxygen at 4-6 LPM. 2. Replace fluids. Plasma expander or fresh frozen plasma of pts blood crossmatched. 3. Avoid warmth. Constriction of the peripheral blood supply occurs in response to the shock and keeping the mother warm may interfere with this response, causing further deterioration in condition. 27
Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Clinical Observations
1. 2. 3. 4. 5. 6. 7. Assessment of LOC. Continuous monitoring of blood pressure (q 30mins) note any drop. Cardiac rhythm may be monitored continuously. Measurement of UO hourly, using indwelling catheter. Assessment of skin color, core and peripheral temperature hourly. Hemodynamic measure of pressure in right atrium. Fluid balance is maintained accurately. Observation of the occurrence of further bleeding, including oozing from wound or puncture site.
28 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009
Septic Shock
A form of distributive shock where an overwhelming infection develops commonly from gram negative organisms (E. coli, Proteus, or Pseudomonas pyocyaneus).
Septic Shock
Overwhelming infection Damaged cells release histamine and enzymes Vasodilation and increased permeability of the capillaries Reduced systemic vascular resistance Vasodilation and hypotension continue
34 Prepared by Ariel Jul Delos Reyes Alon, BSN, RN (c) 2009