Nazran’s Blog


Post Partal Hemoragic
April 30, 2009, 3:31 am
Filed under: Keperawatan Maternitas | Tags:

POST PARTAL HEMORRHAGE

PURPERAL HEMORRHAGE HAS BEEN DIVIDED INTO EARLY AND LATE POST PARTAL HEMORRHAGE
EARLY POSTPARTAL HEMORRHAGE OCCURS WHEN BLOOD LOSS IS GREATER THAN 500 ML IN THE FIRST 24 HOURS AFTER DELIVERY.
LATE POSTPARTAL HEMORRHAGE OCCURS AFTER THE FIRST 24 HOURS.

EARLY POSTPARTAL HEMORRHAGE
THE MAIN CAUSES OF EARLY POSTPARTAL HEMORRHAGE ARE:
• UTERINE ATONY
• LACERATIONS OF THE GENITAL TRACT
• RETAINED PLACENTA OR PLACENTA FRAGMENTS

FACTORS PREDISPOSE TO HEMORRHAGE

• OVERDISTENTION OF THE UTERUS DUE TO HYDRAMNIOS
• A LARGE INFANT OR MULTIPLE GESTATION
• GRAND MULTIPARITY
• USE OF ANESTHETIC AGENTS TO RELAX THE UTERUS
• TRAUMA DUE TO OBSTETRIC PROCEDURES SUCH AS MIDFORCEPS DELIVERY, INTRAUTERINE MANIPULATIONS OR FORCEPS ROTATION
• PROLONGED LABOR OR VERY RAPID LABOR
• USE OF OXYTOCIN TO INDUCE
• UTERINE INFECTIONS
• MATERNAL MALNUTRITIONS, ANEMIA, PIH, OR HISTORY HEMORRHAGE

UTERINE ATONY

THE RELAXATION OF THE UTERUS FOLLOWING BIRT, CAN FRECUENTLY BE ANTICIPATED IN THE PRESENCE OF:
• OVERDISTENTION OF THE UTERUS THAT OCCURS WITH MULTIPLE FETUSES, MACROSOMIC FETUS OR HYDRAMNIONS
• DYSFUNCTIONAL LABOR THAT HAS ALREADY INDICATED THE UTERUS IS CONTRACTING IN AN ABNORMAL PATTERN
• OXYTOCIN STIMULATION
• THE USE ANESTHESIA THAT PRODUCES UTERINE RELAXATION.

HEMORRHAGE FROM UTERINE ATONY MAY BE SLOW AND STEADY RATHER THAN SUDDEN AND MASSIVE. THE MAY ESCAPE THE VAGINA OR COLLECT IN THE UTERUS.
BECAUSE OF THE INCREASED BLOOD VOLUME, CHANGES IN THE MATERNAL BLOOD PRESSURE AND PULSE MAY NOT OCCUR UNTIL BLOOD LOSS HAS BEEN SIGNIFICANT.

AFTER DELIVERY OF THE PLACENTA, THE FUNDUS SHOULD BE PALPATED TO ASSURE THAT IS FIRM AND WELL CONTRACTED.
IF IT IS NOT FIRM, VIGOROUS MASSAGE SHOULD BE INSTITUTED UNTIL THE UTERUS CONTRACTS. OXYTOCICS MAY BE GIVEN
WITH THIS PROCEDURE THE UTERUS IS COMPRESSED AND MASSAGED AND HEMOEEHAGE CAN USUALLY BE CONTROLLED.
OXYGEN IS ADMINISTERED BY MASK. BLOOD TRANSFUSION MAY BE ORDERED.

THE DOSE MAY BE REPEATED WITHIN 90 MINUTES, AND AGAIN AS NECESSARY. THE SIDE EFFECTS, SUCH AS NAUSEA, VOMITING AND DIARREA. OTHER SIDE EFFECTS INCLUDE FEVER, FLUSING AND ELEVATED DIASTOLIC BLOOD PRESSURE.

LACERATIONS OF THE BIRT CANAL

LACERATIONS OF THE BIRT CANAL ARE THE SECOND MAJOR CAUSE OF POSTPARTUM HEMORRHAGE.
COUNTINUOUS BLEEDING FROM SO CALLED MINOR SOURCES MAY BE JUST AS DANGEROUS AS A SUDDEN LOSS OF LARGE AMOUNT OF BLOOD, ALTHOUGH OFTEN IT IS IGNORED UNTIL SHOCK DEVELOPS.
BIRT CANAL LACERATIONS MAY INCLUDE INJURIES TO THE LABIA, VAGINAL, PERINEUM AND CERVIX

LABIAL LACERATIONS
EXTREME VASCULARITY IN THE LABIA AND PERICLITORAL AREAS OFTEN RESULTS IN PROFUSE BLEEDING IF LACERATION OCCURS.

PERINEAL LACERATIONS
LACERATIONS OF THE PERINEUM ARE THE MOST COMMON OF ALL INJURIES IN THE LOWER PORTION OF THE GENITAL TRACT

VAGINAL LACERATIONS AND HEMATOMAS
PROLONGED PRESSURE OF THE FETAL HEAD ON THE VAGINAL MUCOSA ULTIMATELY INTERFERESWITH THE CIRCULATION AND MAY PRODUCED ISCHEMIC OR PRESURE NECOSIS.

CERVICAL LACERATIONS
CERVICAL LACERATIONS USUALLY OCCUR AT THE LATERAL ANGLES OF THE EXTERNAL OS.

SUB INVOLUTION OF THE UTERUS
LATE POST PARTUM BLEEDING MAY OCCUR AS A RESULT OF SUBINVOLUTION OF THE UTERUS.
SUBINVOLUTION IS DEFINED AS THE DELAYED RETURN OF THE ENLARGE PUERPERAL CORPUS TO NORMAL SIZE AND FUNCTIONS
THE CAUSES OF SUBINVOLUTIONS INCLUDE REDUCED CIRCULATIONS BECAUSE OF MALPOSITION, INFECTIONS.

RETAINED PLACENTA
HEMORRHAGE MAY OCCUR AFTER THJE BIRT OF THE NEWBORN BUT BEFORE DELIVERY OF THE PLACENTA.
WHEN THE PLACENTA IS READY TO SEPARATE DELIVERY OF THE PLACENTA IS ENHANCED BY MASSAGING THE FUNDUS. IF SIGNS OF PLACENTAL SEPARATION HAVE NOT OCCURRED, THE PHYSICIANS MANUALLY REMOVES THE PLACENTA BY INSERTING A GLOVED HAND INTO THE UTERUS AND PLACING THE FINGERS AT THE PLACENTA MARGIN
AFTER DELIVERY OF THE PLACENTA, THE CONSISTENCY OF THE FUNDUS IS ASSESSED.

NURSING CARE PLANS

NURSING ASSESSMENT
• EVALUATIONS OF THE WOMANS PRENATAL HYSTORY AND ONGOING ASSESSMENT DURING LABOR AND BIRT WILL HELP IDENTIFY FACTORS THAT PUT THE WOMAN AT RISK FOR POST PARTAL HEMORRHAGE
• ASSESSMENT VAGINAL BLEEDING
• ASSESSMENT CONTRACTIONS UTERUS
• UTERUS DOES NOT INVOLUTE
• APPROPRIATELY SHOULD BE INVESTIGATED FOR POSIBLE RETAINED PLACENTAL TISSUE AND INFECTION.

ESSENTIAL NURSING DIAGNOSES
• ALTERED TISSUE PERFUTION RELATED TO BLOOD LOSS
• DECREASED CARDIAC OUTPUT AND SHUNTING OF BLOOD TO CENTRAL CIRCULATION
• FEAR /ANXIETY RELATED TO THREAT TO SELF OR KNOWLEDGE DEFICID OF PROSEDURES AND OPERATIVE MANAGEMENT
• FLUID VOLUME DEFICID RELATED TO UTERINE ATONY, LACERATIONS OR UTERINE INVERSION
• INEFFECTIVE BREAST-FEEDING RELATED TO SEPARATION FROM INFANT SECONDARY TO TREATMENT
• POTENTIAL FLUID VOLUME DEFICIT RELATED TO EXCESSIVE BLOOD LOSS SECONDARY TO UTERINE ATONY, LACERATIONS OR UTERINE INVERSION
• POTENTIAL FOR INJURY MATERNAL RELATED TO ATTEMPTED MANUAL REMOVAL OF RETAINED PLACENTA OR OPERATIVE PROSEDUR
• RISK FOR INFECTION RELATED TO EXCESSIVE BLOOD LOSS OR EXPOSED PLACENTAL ATTACHMENT SITE

PLANNING
• REGULAR ASSESSMENT OF FUNDAL HEIGH, CONTRACTIONS AND BLEEDING FOR GENETALIA
• ASSESSMENT VITAL SIGN, ADMINISTRATION OF OXYTOCIN OR OTHER DRUGS TO STIMULATE UTERINE CONTRACTION
• GIVEN INFORMATION FOR WOMAN AND HER FAMILY FOR PROSEDURE
• IF THE WOMAN IS BLEEDING MORE PROFUSELY THE NURSE ADMINISTERS OXYGEN BY FACE MASK
• THE NURSE ALSO ADMINISTERS MEDICATIONS AS ORDERED AND ASSESSES THEIR EFFECTIVENESS.
• INTRAVENOUS OXYTOCIN WILL PROBABLY BE CONTINUED FOR SEVERAL HOURS IF BLEEDING IS SEVERE
• URINARY OUTPUT IS MEASURED TO DETERMINE THE ADEQUACY OF FLUID REPLACEMENT.
• THE NURSE ALSO ENCOURAGES THE WOMAN TO OBTAIN ADEQUATE REST AND HELPS HER PLANS ACTIVITY SO THE REST IS POSSIBLE
• PROMOTE MATERNAL INFANT ATTACHMENT WHILE BEING COGNIZANT OF THE HEALTH NEEDS OF THE MOTHER
• HELPING THE MOTHER AS NEEDED IN CARING FOR THE NEWBORN

EDUCATIONS FOR SELF CARE
• THE MOTHER MAY BE DISCHARGED ANY TIME AFTER FOUR HOURS POSTBIRT
• BECAUSE HEMORRHAGE MAY DEVELOP AFTER DISCHARGE, EXPLANATIONS OF THE NORMAL POST PERTUM AQND SIGN COMPLICATIONS
• INSTRUCTIONS FOR ASSESSING FUNDAL HIGH AND CONSITENCY AND FOR MASSAGING THE FUNDUS SHOULD BE INCLUDED
• THE WOMAN AND HER FAMILY ARE ADVISED TO CONTACT HER CARE GIVER IF ANY OF THE SIGN OF POST PARTAL HEMORRHAGE OCCURE

POSTPARTUM INFECTION (SEPSIS)

POSTPARTUM INFECTION IS ANY CLINICAL INFECTION OF THE GENITAL CANAL THAT OCCURS WITHIN 28 DAYS AFTER ABORTIONS OR CHILDBIRT
INFECDTIONS MAY RESULT FROM BACTERIA COMMONLY FOUND WITHIN THE VAGINA OR FROM OUTSIDE THE VAGINA.

AN EPISIOTOMY OR LACERATIONS OF THE VAGINA OR CERVIX MAY OPEN AVENUES FOR SEPSIS
COMMONLY THE INFECTION IS COMPLICATED BY MEDICAL DISORDER SUCH AS ANEMIA, MALNUTRITION, AND DIABETES MELLITUS.
OBSTETRIC PROBLEMS, INCLUDING PREMATURE RUPTURE MEMBRANE, A LONG AND EXHAUSTING LABOR, OPERATIVE BIRT, HEMORRHAGE.
CHORIOAMNIONITIS MAY BE CAUSE OR RESULT OF PROM
ENDOMETRITIS, USUALLY AT THE PLACENTAL SITE, PERMITS INFECTION TO BEGIN.

LOCALIZED INFECTION MAY BE FOLLOWED BY SALPINGITIS, PERITONITIS, AND PELVIC ABCESS FORMATION
THE SYMTOMS
• A TEMPERATURE OF 38 C OR MORE ON SUCCESSIVE DAYS, NOT COUNTING THE FIRST 24 HOURS AFTER BIRT, MUST BE CONSIDERED TO HAVE BEEN CAUSED BY POST PARTUM INFECTION
• FATIGUE AND LETHARGY
• PERINEAL DISCOMFORD
• ABDOMINAL DISTRESS
• NAUSEA
• VOMITING
• PROFUSE LOCHIA IS USUALLY PRESENT

NURSING CARE MANAGEMENT
ASSESSMENT
٭ HISTORY
• ANTENATAL FACTORS THAT INFLUENCE THE DEVELOPMENT OF VAGINAL INFECTION OR UTIs
• CHRONIC IMMUNOSUPRESSIVE STATE
• POOR FLUID AND NUTRITIONAL STATUS
• POOR GENITAL HYGIENE
• FREQUENT VAGINAL EXAMINATIONS
• PROLONGED SECOND STAGE OF LABOR
• BIRT TRAUMA TO THE VAGINA, CERVIX, BLADDER AND URETRA.

PHYSICAL EXAMINATION
• FINDINGS ON EXAMINATION VARY.
• VAGINAL DISCHARGE MAY OR MAY NOT BE PRESENT. FEVER OR PAIN MAY BE MILD
• ABDOMINAL OR PERINEAL DISCOMFORT
• NAUSEA
• VOMITING
• FOUL – SMILE LOCHIA IS A SIGN OF UTERINE INFECTION
• OTHER POTENTIAL SITES OF INFECTION INCLUDE THE BREASTS
• EPISIOTOMY OR CESAREAN INCISION AND THE BLADDER.

NURSING DIAGNOSIS
• PAIN/IMPAIRED TISSUE INTEGRITY RELATED TO EFFECT OF INFECTION PROCESS OR HYGIENE PRACTICES
• KNOWLEDGE DEFICIT RELATET TO TRANSMISSION OF INFECTION, SAVER SEX BEHAVIORS
• MANAGEMENT AND COURSE OF INFECTION
• ANXIETY/SELF ESTEEM DISTURBANCE/BODY IMAGE DISTURBANCE RELATED TO LONG TERM SEQUELAE TO INFECTION
• RISK FOR ALTERED PARENTING RELATED TO FEAR OF SPREAD OF INFECTION TO NEWBORN
• ALTERED PATTERNS OF URINARY ELIMINATION RELATED TO PRESENCE OF EDEMA AND PAIN
• ALTERED FAMILY PROCESSES RELATED TO UNEXPECTED COMPLICATION

PLAN OF CARE AND IMPLEMENTATION
• ASSESSING FOR SIGN AND SYMTOMS OF INFECTION
• ASSESSING FOR PAIN
• MONITORING LABORATORY RESLUTS
• ADMINISTERING ANTIMICROBIAL AGENT, ANALGESICS
• ADEQUATE HYDRATION
• REST
• GIVE HIGH NUTRITION

EDUCATION FOR PATIENT
• PRACTICE GENITAL HYGIENE


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