THE�OB PATIENT AND PACU

Caring for those recovering from or at risk for Postpartum Hemorrhage (PPH)

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JMcGee, BSN, RNC-EFM

December 8, 2016

DESPITE ADVANCEMENTS IN MEDICINE…

• The US remains 47^th in the world for maternal mortality. Here, 2-3 women die daily from birth complications.
• Every 10 minutes, 1 in 10 US women come close to dying from pregnancy complications.
• Maternal deaths in the US have been on the increase in the last 12 years, primarily due to conditions of uterine atony.
• The leading causes of maternal deaths are related to hypertension and hemorrhage.
• About 2.9% of all US births will result in a hemorrhage.

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WHERE WE RANK IN THE WORLD:

• The US is one of the only countries where maternal deaths and injuries have increased
• Comparing 1998-1999 and 2008-2009 (10 year span) there was a 75% increase in serious injuries
• It is estimated that 70-90% of deaths related to PPH in the US could be prevented

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Ranked 47^th in the world

CONTRIBUTING FACTORS THAT INCREASE THE RISK OF A PPH:

• Prior uterine surgery
• Multiple Gestation or conditions that overdistend the uterus (polyhydramnios, LGA)
• Chorioamnionitis (Acute inflammation/infection of the amniotic membranes and/or chorion of the placenta)
• More than 4 previous vaginal births
• History of PPH with a previous pregnancy
• Abnormal placental attachment (placenta accreta, increta or percreta)
• Placenta Previa (partial or complete)
• Coagulopathy or platelets < 100,00
• Prolonged use of oxytocin prior to delivery
• HCT < 30 with any other risk factor

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THE ROLE OF HYPERTENSION AND PPH

• There are 3 types of HTN in pregnancy: (Postpartum HTN also occurs)
• Chronic Occurring/diagnosed prior to 20 weeks gestation
• Gestational Occurring/diagnosed after 20 weeks gestation
• Preeclampsia HTN occurring with or without proteinuria. In the absence of proteinuria, Preeclampsia is diagnosed if multisystem symptoms are present (one or more of the following: thrombocytopena, renal insufficiency, liver impairment, pulmonary edema, or cerebral or visual symptoms)
• Preeclampsia can exist on its own, or be superimposed onto any hypertensive disorder. Preeclampsia occurs in about 5-8% of US pregnancies
• Hypertensive disorders increase risk to the mother and the fetus. HTN contributes to poor placental perfusion, which can lead to intrauterine growth restriction (IUGR) and a decrease ability of the fetus to withstand the stressors of labor (increasing the chance of fetal distress).
• Left untreated, preeclampsia can progress to eclampsia (grand mal seizures). It can also lead to stroke, MI, ARDS, organ damage, and death. It can cause preterm birth or fetal demise.
• Preeclampsia (treated or untreated) will lead to HELLP Syndrome 15% of the time

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PREDICTING IMPENDING ECLAMPSIA

• Observe the patient for persistent occipital or frontal HEADACHE
• Ask about visual disturbances (such as photophobia, blurred vision, scotomata, or seeing “floaters or flashers”)
• Epigastric or RUQ pain (with or without N/V)
• Altered mental status Eclampsia will usually occur 24-48 hours before or after delivery

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HELLP Syndrome – a worsening of preeclampsia

Classified by a cascade of symptoms and lab values:

H Hemolysis

EL Elevated Liver enzymes

LP Low Platelets

Treatment of choice is Magnesium Sulfate

Along with antihypertensives and DELIVERY

These can progress to DIC

COMMON MEDICATIONS USED:

To control BLEEDING:

Oxytocin- if the patient was exposed to oxytocin for prolonged periods during the labor, the uterus may not clamp down effectively after delivery, and other drugs may need to be added.

Cytoec- an E1 synthetic prostaglandin. Generally, the first drug added after oxytocin. Safe for asthmatics.

Methergine- an ergot derivative. Can cause HA & severe HTN. Also increased cholinergic responses (N/V/D).

Hemabate- an E2 partially synthetic prostaglandin. Stimulates smooth muscles. Usually results in excessive diarrhea. Can induce bronchospasm- contraindicated with asthmatics.

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To control BLOOD PRESSURE:

Labetalol- Adrenergic receptor blocker. Contraindicated with asthmatics and with heart block greater than 1^st degree.

Hydralazine- Calcium channel blocker.

Magnesium Sulfate – See next slide

When using magnesium sulfate, be sure calcium gluconate is readily available to treat overdoses.

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MAGNESIUM SULFATE IS A HIGH ALERT DRUG:

• It is an anticonvulsant, acting as a CNS depressant
• It is given in obstetrics to treat preeclampsia (with or without severe features)
• It also can be used as a fetal neuroprotectant for preterm labors (<32 wks GA) and as a strategy to prolong pregnancies (24-34 wks GA) long enough for a course of antenatal corticosteroids to be given
• It has a narrow therapeutic index. Generally, 5-7 mg/dL is considered therapeutic. Loss of reflexes can occur near 8-9 mg/dL with loss of respiratory reflexes around 12 mg/dL. The earliest sign of toxicity is a decrease in breath sounds. Critical Value @ Harrington is 7.5 mg/dL. Stop infusion immediately
• Effects are based on renal function
• Follow established hospital policy {“Magnesium Sulfate”}
• Patient should have 2 IV access points (preferably on opposing sides). Magnesium should always be on a pump, piggybacked to a mainline fluid (which should also be on a pump) at the most proximal port. Lines should be labeled.
• Magnesium administration needs to be co-signed by 2 RNs. The co-signer is responsible for checking medication, pump settings, and line attachments for adherence to policy and compliance to MD orders.

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NURSING ASSESSMENTS WITH ANY OB PATIENT ON MAGNESIUM:

• Educate patient on S/S to expect. Document discussion in EMR
• Baseline Assessment (prior to start of Magnesium):
• VS including T, DTRs, SpO2, clonus, lung sounds and LOC
• RN @ bedside throughout bolus infusion (1:1). Q 15” assessments.
• Initiating maintenance rate: q 15”x4, q 30” x 2, then hourly as below
• Hourly output (measured with FC with urimeter) Alert MD if < 30 mls
• Hourly LS/SpO2
• Q2 hr DTR/LOC assessments Alert MD if absent DTRs, presence of clonus or change in LOC
• Continuous FH monitoring if pregnant, frequent fundal and lochia checks PP (q 15” x4, q 30” x2 during recovery, then Q2 hrs once stable) (Higher risk of PPH)

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EARLY RECOGNITION/MANAGEMENT OF PPH

• Any condition that increases the risk of HTN, will increase the risk of PPH
• PPH is defined as greater than 500 ml blood loss in a vaginal delivery; greater than 1000 ml blood loss in a cesarean delivery. (Massive PPH is > 1500 ml loss)
• Blood loss is cumulative. Patients can silently slip into a MASSIVE hemorrhage.
• Harrington OB uses QBL at all vaginal deliveries and during PP assessments where PPH is at risk or suspected.
• QBL (Quantitative Blood Loss) is measurement of blood-soaked material through the use of gram weights.
• Early recognition of PPH is the best practice for improved maternal outcomes
• MD notification occurs in intervals of roughly 500 ml losses, with cumulative quantities also reported (“The patient had pads changed for 525 mls, and now has a loss of 825 mls since delivery”).

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EARLY RECOGNITION/MANAGEMENT OF PPH (CON’T):

• At the LEAST, this will lead to increased alertness of staff and more frequent assessments
• Initiation of Harrington’s MTP (*66 “Transfusion Team to [location]) will bring added personnel and supplies, as well as initiate emergency release from the blood bank of 2 units PRBCs.
• Consider placing a second IV access if not already done, placement of a FC to decompress the bladder, retrieval of DIC panel tubes from the OB refrigerator, and ensuring the PPH Cart in nearby.
• Use of the Bakri Balloon to provide uterine tamponade is an effective (studies cite 69-100% effectiveness) treatment for PPH. Once placed, the balloon will stay in place for roughly 24 hours.

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NURSING RESPONSIBILITIES

• Monitor for vaginal flow
• Monitor for flow from the Bakri balloon
• Assess fundal tone
• Monitor for changes in patient status, including VS, pallor, urinary output and pain levels.
• Maintain QBL during pad changes

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The patient should have 2 drainage bags: one connected to the foley catheter, and one connected to the Bakri balloon.

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Clot formation in the Bakri tubing may necessitate flushing with isotonic (NS) solution. Check with MD.

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Betadine-soaked vaginal packing will also be in place.

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DRAWER 1: MEDICATION TRAY

DRAWR 2: IV SUPPLIES

DRAWER 3: SUPPLIES (Vaginal� packing, � speculum, towels)

DRAWER 4: IV FLUIDS

DRAWER 5: CATHETER KIT, LAP� SPONGES, RED� BAGS

DRAWER 6: BAKRI BALLOON KIT

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THANK YOU

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