HCC Postpartum
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| Normal Lochia | Scant to moderate amount, earthy odor, few small clots. Normal progression first 1-3 days is rubra(bright red), serosa(pink) 3-10 days, alba(pale yellow-white) 7-14 days.
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| Large Amount of Lochia | Hemorrhage. Assess for firmness, expel additional clots, begin peripad count.
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| Foul-smelling Lochia | Infection. Assess for other signs of infection, report to physician or certified nurse-midwife.
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| Subinvolution | Failure to progress normally or return to rubra from serosa.
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| Lochia Assessment | Amount of lochia discharge is assessed by weighing the peripad and visual measurement. Fundal height and firmness are assessed as well in relation to lochia discharge. Always have the woman empty her bladder before fundal assessment.
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| Scant Amount of Lochia | Perineal pad has a stain less than 1 inch in length after 1 hour or lochia is only on tissue when the woman wipes.
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| Small (Light) Amount of Lochia | Perineal pad has a stain less than 4 inches in length after 1 hour, 10 to 25 mL of lochia.
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| Moderate Amount of Lochia | Perineal pad has a stain less than 6 inches in length within 1 hour, 25-50 mL of lochia.
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| Heavy Amount of Lochia | Perineal pad has a stain larger than 6 inches in length within 1 hour, 30-80 mL of lochia.
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| Weight of Lochia | 1 g = 1 mL of blood. DONT FORGET TO ACCOUNT FOR THE WEIGHT OF THE PERIPAD.
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| Heavy Bleeding or Clots with Lochia | Ask her to put on a clean peripad and then reassess the pad in 1 hour. Also ask her to call you before flushing any clots she passes into the toilet during voiding.
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| Expelled Clots | While supporting the fundus, press down on the fundus while watching to see if any clots are expelled.
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| Lochia Discharge Teaching | Educating the client on how to assess her own fundus, lochia, and clots is very important to prevent severe complications at home.
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| Standard Vaginal Discharge Blood Loss | SVD. Loss of approximately 500 mL of blood.
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| C-section Blood Loss | Loss of approximately 1000 mL of blood.
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| Hemorrhage | Greater than 1500 mL of blood loss and s/sx of shock may be seen.
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| S/sx of Shock | Tachycardia, diaphoretic, decreased BP, decreased oxygen sats and PaO2, decreased capillary refill, tachypnea, decreased urine output, pallor, cool clammy skin, weak thready pulse, restlessness, anxiety, thirst, lethargy.
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| What is the most common cause of postpartum hemorrhage? | Uterine Atony(lack of tone or muscle contractility).
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| Postpartum Trauma Hemorrhage | Vaginal or cervical lacerations, hematoma, uterine inversion, uterine rupture.
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| Postpartum Tissue Hemorrhage | Retention of placental fragments, abnormal placental implantation.
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| Uterine Atony | When the uterus is not contracting and clamping down blood vessels. Uterine atony is responsible for 70% of hemorrhages. BLOOD MAY POOL IN THE VAGINA AND NOT BE SEEN RIGHT AWAY.
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| Nursing Interventions of Uterine Atony | Support and massage the fundus, promote breast feeding, administer uterotonic medications.
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| Nursing Interventions of Hemorrhage | Massage fundus, monitor VS's skin color temp turgor cap refill SaO2 LOC, Hct, Hbg, ABG's, administer oxytocin, assess perineum, bleeding, I&O, admin oxygen, IV 18 gauge or > for isotonic sol or blood, educate.
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| If Interventions Don't Work? | CALL THE DOCTOR!
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| Bimanual Massage | Locating fundus then placing hand in vagina and push against uterus.
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| Uterotonic Medications | Oxytocin(Pitocin) IV 40 units/Liter at 250 mL/hr. Contraindications: non in postpartum hemorrhage, IV bolus not recommended. Side effects: hyperstimulation, mild transient HTN, cramping.
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| Ergotamine(Methergine) | Helps maintain contractions, DO NOT GIVE IV, assist mom when getting out of bed due to SE's, contraindications: HTN, preg induced HTN, hypersensitivity. Side effects: HTN, dizziness, flushing, cramping. MONITOR BP
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| Prostaglandin(Hemabate) | Should not be given in hx of bronchospasms(can induce asthma sx), cardiovascular, renal, liver disease. SE's: N&V, diarrhea(may need lomotil), wheezing. Monitor breath sounds. MONITOR TEMP FOR HYPOTHERMIA OR HYPERPYREXIA
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| Misoprostol(Cytotec) | Rectal is quickest route of absorption and most common. Does not cause vascular changes hemabate does. Used when failed attempts of oxytocics. No significant effect on the lungs or blood vessels.
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| Nursing Interventions with Oxytocics | Assess fundus Q10-15min post admin, weigh pads for EBL, Monitor BP pulse Q15min x 1hour then 30min, then hourly, analgesics for uterine cramping.
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| Nursing Interventions with Prostaglandins | Same as oxytocics, check temp Q1-2hrs or after chill, administer antipyretic, lung sounds, assess N&V, diarrhea, admin antiemetic antidiarrheal meds, alert client to SE's so they can let the nurse know.
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| Hematoma | Collection of 250-500 mL in soft tissues, increased intense pain = increased risk of hypovolemic shock.
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| Uterine Inversion | Uterus turned inside out.
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| Retention of Placental Fragments | Prevents uterus from fully contracting, placenta Accreta and Percreta. Most common late partum hemorrhage. Uterus will become boggy and bleed.
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| Uterine Rupture | Emergency surgery. S/sx pain, vag bleeding, 0 contractions, late decels for FHR-resuscitation and tx of shock.
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| Disseminated Intravascular Coagulation(DIC) | Causes: preeclampsia, amniotic fluid embolism, sepsis, abruption placentae, prolonged fetal demise. Tissue destruction, reaction by body causees small clots throughout system, then destroys clots using clotting factors causing massive bleeding.
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| DIC Risk | If not corrected death will occur. Tx- vit K, clotting factors & blood given.
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| Subinvolution | Uterus fails the normal pattern of involution. Caused by retained placental fragments, infections. S/sx enlarged, boggy. Normal involution 1 cm/day.
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| Subinvolution Tx | Methergine, antibiotics, D&C
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