Help I'm bleeding out
(postpartum hemorrhage)
(postpartum hemorrhage)
What is the measuring range for blood loss when defining PPH in both vaginal and c-section?
>500ml within 24 hours for vaginal
>1,000ml OR blood loss with s/s of hypovolemia within 24 hours for C/S
List three risk factors for PP hemorrhage that are NOT the four T's
Grand multiparity (≥5 pregnancies → uterine fatigue), Previous PPH (high recurrence risk), Obesity (increased risk of atony, C-section, and infection), Advanced maternal age (>35 years old)
What are the major risks associated with PP psychosis?
Maternal suicide and infanticide
What are three s/s of potential newborn sepsis?
May be hyper OR hypo thermic, lethargy, hypoglycemic, poor feeding
What are the four 'T's for PPH?
BONUS 100
What are each of their primary causes?
Tone (atony, boggy uterus, PRIMARY CAUSE)
Trauma (Lacs, hematomas, uterine inversion, FIRM uterus with bleeding)
Tissue (often discovered later, placental fragments)
Thrombin (HELLP, AFE--->DIC)
What are the immediate nursing actions to manage PP hemorrhage?
Immediate assessment to identify cause, interventions related to cause (Tone- fundal massage), two large bore IVs of 18g or larger and administer fluids, continue to monitor and emotionally support patient and family
List five risk factors for PPD
History of depression/anxiety before preg
Complications of pregnancy/delivery
Dysfunctional relationship w/ partner
Low support from mother/mother figure
Low socioeconomic status*
Chronic stress
Infant with illness or anomalies
Isolation/lack of support
Hx of childhood sexual abuse
IPV
What is the leading cause of neonatal sepsis?
BONUS 200
What is the treatment?
Group B Streptococcus (GBS)
Antibiotic prophylaxis in labor, IV Ampicillin every 4 hours
Only works if given during labor (grows back too quickly), must be given within 4 hours of delivery -treatment starts as soon as admitted
What are the four medications used to help treat PP hemorrhage r/t uterine atony?
BONUS 100
List the contraindications mentioned in class
Pitocin, methylergonovine maleate (Methergine), prostaglandins – Carboprost (Hemabate), misoprostol (Cytotec)
Methergine- HTN, preeclampsia
Hemabate- asthma
What clinical manifestations would you expect to see with a uterine hematoma?
Pelvic or rectal pressure/ pain
Difficulty voiding/ sitting
Both after delivery
What are the key differences between PP depression and psychosis?
PP depression- much more common, often undiagnosed, slower onset (weeks to months), emotional symptoms (persistent sadness, hopelessness, or excessive crying), physical symptoms (fatigue, exhaustion, or difficulty sleeping even when baby is asleep), behavioral symptoms (difficulty bonding with the baby, withdrawal)
PP psychosis- rare and life threatening, fast onset (days to weeks), severe thought/ mood disturbances, suicidal or infanticidal thoughts WITHOUT insight (believes harming the baby is justified)
What is the patho for Rh alloimmunization?
Occurs when an Rh-negative mother is exposed to Rh-positive fetal blood, leading to the production of maternal anti-D antibodies. These antibodies can cross the placenta in future pregnancies and attack Rh-positive fetal red blood cells, causing hemolytic disease of the fetus and newborn (HDFN).
Why is IUFD syndrome a cause for primary postpartum hemorrhage?
Uterine Atony (Most Common Cause); with IUFD, the uterus often becomes overdistended due to prolonged retention of the fetus and amniotic fluid.
DIC; when fetal death occurs, thromboplastin is released from the placenta, activating widespread clotting in the maternal circulation and depletion of said clotting factors.
Retained Placental Fragments---> increased risk with IUFD
A postpartum client at 2 weeks postpartum calls the clinic reporting heavy bleeding with large clots, pelvic pain, and fever. What is the nurse’s priority intervention?
A) Reassure the client that some increased bleeding is normal
B) Administer IM oxytocin and re-evaluate in 24 hours
C) Instruct the client to go to the emergency department
D) Advise the client to increase fluid intake and rest
Answer: C – Instruct the client to go to the emergency department.
Rationale: Late PPH (after 24 hours–6 weeks postpartum) is often caused by retained placental fragments or infection (endometritis). Heavy bleeding, large clots, pain, and fever suggest a serious complication requiring immediate evaluation, ultrasound, and possible D&C.
How is PP depression diagnosed?
Depressed mood or loss of pleasure/ interest in normal activities for two weeks
AND AT LEAST FOUR OF THE FOLLOWING:
5% weight loss or gain
Insomnia/ hypersomnia
Changes in psychomotor activity (agitation)
Decreased energy fatigue
Feelings of worthlessness/ guilt
Decreased ability to concentrate/ make decisions
What is the protein marker looked for to indicate inflammation/ sepsis in babies?
BONUS 300
What is the treatment regimen?
Procalcitonin
Start on broad spectrum abx for 48 hours until cultures return, then more specific abx ordered.
A postpartum client (G4P4) delivered 6 hours ago and appears pale, restless, and weak. Her fundus is firm and midline, with scant lochia. VS: HR 120 bpm, BP 98/50 mmHg, RR 24, SpO₂ 95% on room air. Which assessment is most critical?
A) Hemoglobin and hematocrit levels
B) Measurement of urine output
C) Inspection of perineum and retroperitoneal space
D) Assessment of D-dimer and fibrinogen levels
Answer: C – Inspection of perineum and retroperitoneal space.
Rationale: A firm fundus with shock symptoms suggests a hidden hemorrhage, most likely a retroperitoneal hematoma. A large hematoma can hold 500-1,500 mL of blood without obvious external bleeding. Immediate perineal and abdominal assessment, followed by imaging, is critical.
You are caring for a G5P5 patient with a history of C-sections and placenta previa who is actively hemorrhaging after delivery. Which of the following interventions is most important to anticipate?
A) Administer misoprostol and IV fluids
B) Prepare for Bakri balloon tamponade
C) Call for massive transfusion protocol and OR team
D) Insert a second large-bore IV
Correct Answer: C – Call for massive transfusion protocol and OR team.
Rationale: A patient with placenta previa and multiple C-sections is at high risk for placenta accreta. This often requires emergency hysterectomy to stop life-threatening hemorrhage. While other interventions may be helpful, calling for immediate blood products and surgical intervention is the priority.
List three priority nursing actions for a patient with PP depression or psychosis?
Assess for Suicide Risk & Safety Concerns
Promote Maternal-Infant Bonding
Encourage Prompt and Professional Treatment
Support Psychosocial Needs and Offer Patient Teaching
A nurse is caring for a 2-day-old newborn who has a temperature of 98°F (36.7°C) and is exhibiting lethargy and poor feeding. What is the nurse's priority action?
A) Monitor the newborn's temperature every hour.
B) Obtain a complete blood count (CBC).
C) Administer a bolus of IV fluids.
D) Notify the healthcare provider immediately.
Answer: D) Notify the healthcare provider immediately.
Rationale: Lethargy and poor feeding in a newborn can be early signs of sepsis. Prompt notification of the healthcare provider is crucial for initiating further assessment and potential interventions, as sepsis can rapidly progress.