WEBVTT 00:00:07.880 --> 00:00:10.759 You're in the bay. Once you get over to the bed, 00:00:10.919 --> 00:00:13.560 we'll give you the story. Everything's going 00:00:13.560 --> 00:00:17.339 to happen super fast. Welcome to the emergency 00:00:17.339 --> 00:00:44.320 room. Usually when we talk about a medical diagnosis, 00:00:44.520 --> 00:00:47.039 there's this expectation of absolute precision, 00:00:47.240 --> 00:00:49.630 right? You know, you break your arm, the x -ray 00:00:49.630 --> 00:00:52.210 shows a jagged white line, and the clinical path 00:00:52.210 --> 00:00:54.109 is just obvious. Oh, exactly. It's black and 00:00:54.109 --> 00:00:56.770 white. Yeah. But step into obstetric nursing, 00:00:57.229 --> 00:01:00.229 specifically the postpartum period, and that 00:01:00.229 --> 00:01:03.570 x -ray machine essentially shatters. You're looking 00:01:03.570 --> 00:01:06.590 at a diagnostic landscape that is entirely murky. 00:01:06.859 --> 00:01:08.939 Welcome to today's deep dive, by the way. Thank 00:01:08.939 --> 00:01:12.180 you. And it's murky because a postpartum client 00:01:12.180 --> 00:01:16.280 is going through such massive, rapid physiological 00:01:16.280 --> 00:01:18.780 shifts. I mean, the line between an expected 00:01:18.780 --> 00:01:21.280 recovery symptom and a life -threatening complication 00:01:21.280 --> 00:01:24.280 is just razor thin. Right. The body is essentially 00:01:24.280 --> 00:01:27.120 rewiring its entire cardiovascular and endocrine 00:01:27.120 --> 00:01:30.239 system in, well, a matter of hours. Which is 00:01:30.239 --> 00:01:32.540 why today we are stepping into the role of your 00:01:32.540 --> 00:01:35.040 clinical mentors. We're looking at a stack of 00:01:35.040 --> 00:01:37.450 sources focused entirely on postpartum obstetric 00:01:37.450 --> 00:01:40.049 care, and our mission is to aggressively apply 00:01:40.049 --> 00:01:42.049 the Pareto principle. Yes, we love the Pareto 00:01:42.049 --> 00:01:44.569 principle. We are bypassing the minor details 00:01:44.569 --> 00:01:47.989 to isolate that 20 % of clinical concepts that 00:01:47.989 --> 00:01:51.769 will yield 80 % of the value on your exams and 00:01:51.769 --> 00:01:54.170 in your actual practice. We are focusing purely 00:01:54.170 --> 00:01:57.709 on high yield safety critical patterns. Things 00:01:57.709 --> 00:02:01.109 like distinguishing normal physiological changes 00:02:01.109 --> 00:02:04.920 from hidden shock. or navigating cognitive traps 00:02:04.920 --> 00:02:06.980 that even veteran clinicians fall into. Because 00:02:06.980 --> 00:02:09.479 it's not just about a grade. No, not at all. 00:02:09.879 --> 00:02:12.620 Recognizing these patterns early is the fundamental 00:02:12.620 --> 00:02:14.840 difference between a patient crashing and a patient 00:02:14.840 --> 00:02:17.620 recovering. And the sources note a really critical 00:02:17.620 --> 00:02:20.699 sobering fact here. Decreased access to care 00:02:20.699 --> 00:02:23.340 increases the risk of maternal morbidity for 00:02:23.340 --> 00:02:26.479 black clients by three times. compared to white 00:02:26.479 --> 00:02:29.379 clients. Wow. Three times. Yeah. So understanding 00:02:29.379 --> 00:02:31.479 these complications isn't just about passing 00:02:31.479 --> 00:02:34.340 the NCLEX. It's about saving lives and being 00:02:34.340 --> 00:02:36.639 a vigilant advocate at the bedside. Absolutely. 00:02:36.780 --> 00:02:38.780 So let's start with the most immediate threat 00:02:38.780 --> 00:02:41.060 in that postpartum window, which is postpartum 00:02:41.060 --> 00:02:43.520 hemorrhage or PPH. This is the fourth leading 00:02:43.520 --> 00:02:45.419 cause of pregnancy related death in the U .S. 00:02:45.460 --> 00:02:47.219 Meaning it is guaranteed to be on your exam. 00:02:47.740 --> 00:02:50.270 Guaranteed. And the sources highlight a major 00:02:50.270 --> 00:02:53.009 clinical update from ACOG, the American College 00:02:53.009 --> 00:02:55.750 of Obstetricians and Gynecologists, regarding 00:02:55.750 --> 00:02:58.150 how we even define a hemorrhage now. Right, because 00:02:58.150 --> 00:03:00.090 the older definitions used to rely on how the 00:03:00.090 --> 00:03:02.270 baby was delivered. You know, setting a threshold 00:03:02.270 --> 00:03:05.189 of 500 milliliters for a vaginal birth and a 00:03:05.189 --> 00:03:07.270 thousand for a cesarean. Which is outdated now. 00:03:07.509 --> 00:03:09.830 Completely outdated. The high -yield core fact 00:03:09.830 --> 00:03:11.990 you need to know is that PPH is defined as a 00:03:11.990 --> 00:03:14.289 cumulative blood loss of a thousand milliliters 00:03:14.289 --> 00:03:17.300 or more. or, frankly, any amount of bleeding 00:03:17.300 --> 00:03:20.159 accompanied by signs of hypovolemia within 24 00:03:20.159 --> 00:03:22.719 hours of birth, regardless of the delivery route. 00:03:23.000 --> 00:03:24.639 I mean, the body really doesn't care what door 00:03:24.639 --> 00:03:27.280 the baby used, right? A liter of blood lost is 00:03:27.280 --> 00:03:29.759 a liter lost. Exactly. So to identify the cause 00:03:29.759 --> 00:03:32.099 of PPH, instructors want you to know the four 00:03:32.099 --> 00:03:36.360 T's. That's tone, trauma, tissue, and thrombin. 00:03:36.439 --> 00:03:39.090 And the most critical of those is tone. Specifically, 00:03:39.349 --> 00:03:41.430 uterine adenine. This is the primary cause of 00:03:41.430 --> 00:03:44.409 PPH. To understand tone, you have to visualize 00:03:44.409 --> 00:03:46.550 what the uterus is actually doing after birth. 00:03:46.569 --> 00:03:49.750 Right, the involution process. Yes. The muscle 00:03:49.750 --> 00:03:52.349 fibers of the myocytrium contract in this unique 00:03:52.349 --> 00:03:54.810 criss -cross pattern around the spiral arteries. 00:03:55.150 --> 00:03:59.120 They act like... physiological tourniquets. If 00:03:59.120 --> 00:04:01.439 that muscle loses its tone, if it becomes boggy 00:04:01.439 --> 00:04:03.620 and relaxed, those arteries are essentially left 00:04:03.620 --> 00:04:06.379 wide open, bleeding directly into the uterine 00:04:06.379 --> 00:04:08.879 cavity. And the other three T's just compound 00:04:08.879 --> 00:04:11.719 that issue. Trauma refers to physical lacerations 00:04:11.719 --> 00:04:14.539 and tissue is an interesting one. I always visualize 00:04:14.539 --> 00:04:17.259 it as an obstruction. Like if even a tiny fragment 00:04:17.259 --> 00:04:20.019 of the placenta is retained, the uterus cannot 00:04:20.019 --> 00:04:22.079 clamp down fully. It's like trying to make a 00:04:22.079 --> 00:04:23.779 tight fist with a marble sitting in your palm. 00:04:23.819 --> 00:04:26.019 You just can't close the gap. That is a perfect 00:04:26.019 --> 00:04:29.240 mental image. And finally, thrombin points to 00:04:29.240 --> 00:04:31.860 underlying coagulopathies. But let's talk about 00:04:31.860 --> 00:04:33.959 the assessment. What are we looking for? So, 00:04:34.199 --> 00:04:37.079 an expected healthy finding is a firm contracted 00:04:37.079 --> 00:04:40.139 fundus located right around the umbilicus. The 00:04:40.139 --> 00:04:43.069 priority concerning finding is that boggy, squishy 00:04:43.069 --> 00:04:45.389 uterus. And there's a huge exam trap here, right? 00:04:45.569 --> 00:04:48.490 Oh, massive. If that boggy uterus is deviated 00:04:48.490 --> 00:04:51.290 to the side, usually the right side, you are 00:04:51.290 --> 00:04:53.750 likely looking at a full bladder physically pushing 00:04:53.750 --> 00:04:56.110 the uterus out of alignment. That prevents the 00:04:56.110 --> 00:04:58.689 muscle fibers from contracting. OK, so if I walk 00:04:58.689 --> 00:05:01.910 into a room and assess a boggy, deviated uterus, 00:05:02.610 --> 00:05:05.149 my absolute first priority action, before I even 00:05:05.149 --> 00:05:08.250 call a provider, is bimanual uterine massage. 00:05:08.680 --> 00:05:12.060 I am physically applying pressure to stimulate 00:05:12.060 --> 00:05:14.779 those muscles. Yep. Massage the fundus first. 00:05:15.180 --> 00:05:17.300 And at the same time, another nurse should be 00:05:17.300 --> 00:05:19.600 placing an indwelling Foley catheter to drain 00:05:19.600 --> 00:05:22.040 that full bladder, giving the uterus the physical 00:05:22.040 --> 00:05:24.120 real estate it needs to clam down. And we also 00:05:24.120 --> 00:05:26.699 need to quantify the blood loss. Don't just eyeball 00:05:26.699 --> 00:05:29.920 it. Human beings are terrible at visually estimating 00:05:29.920 --> 00:05:32.000 fluid on bedsheets. We really are. You have to 00:05:32.000 --> 00:05:34.560 weigh the blood -soaked pads. The standard clinical 00:05:34.560 --> 00:05:36.800 conversion to remember is that one gram of weight 00:05:36.920 --> 00:05:39.620 equals one milliliter of blood volume. Okay, 00:05:39.680 --> 00:05:41.920 wait. Let me push back here, acting as the student. 00:05:42.339 --> 00:05:44.740 If a patient is bleeding heavily and loses a 00:05:44.740 --> 00:05:47.579 full liter of blood, won't their heart rate skyrocket 00:05:47.579 --> 00:05:50.459 and their blood pressure tank immediately? Why 00:05:50.459 --> 00:05:52.959 wouldn't I see alarms going off? I am so glad 00:05:52.959 --> 00:05:54.879 you asked that because this is a top cognitive 00:05:54.879 --> 00:05:58.800 trap. The answer lies in the hypervolemia of 00:05:58.800 --> 00:06:02.180 pregnancy. A pregnant person's blood volume increases 00:06:02.180 --> 00:06:05.079 by almost 50 % over nine months. Right. They 00:06:05.079 --> 00:06:07.600 have a massive fluid reserve. Exactly. They built 00:06:07.600 --> 00:06:10.199 that up to prepare for the blood loss of childbirth. 00:06:10.899 --> 00:06:13.600 Because of that buffer, changes in vital signs 00:06:13.600 --> 00:06:17.199 like tachycardia might not register at all until 00:06:17.199 --> 00:06:20.199 blood loss drastically exceeds 1 ,000 milliliters 00:06:20.199 --> 00:06:22.860 or until shock is already setting in. So their 00:06:22.860 --> 00:06:25.120 body is essentially masking the hemorrhage until 00:06:25.120 --> 00:06:27.259 they just run out of reserves and fall off a 00:06:27.259 --> 00:06:30.360 physiological cliff. Yes. Do not wait for late 00:06:30.360 --> 00:06:33.839 vital sign changes to act. If the uterus is boggy 00:06:33.839 --> 00:06:36.480 and the bleeding is heavy, you intervene immediately. 00:06:37.000 --> 00:06:39.259 Which brings us to the crash cart. If funnel 00:06:39.259 --> 00:06:41.959 massage fails, we move to pharmacological interventions. 00:06:42.519 --> 00:06:44.500 Nursing instructors love testing the specific 00:06:44.500 --> 00:06:46.839 contraindications of uterotonic meds. Oh, they 00:06:46.839 --> 00:06:48.920 do. Because it's not just about knowing what 00:06:48.920 --> 00:06:51.459 drug to give. It's about knowing exactly which 00:06:51.459 --> 00:06:54.040 patient will be harmed by it. Right. So the baseline 00:06:54.040 --> 00:06:57.319 intervention is oxytocin. Right. Yes. Oxytocin 00:06:57.319 --> 00:07:00.639 is your first -line IV or IM drug. It stimulates 00:07:00.639 --> 00:07:03.600 smooth muscle contraction. But if the uterus 00:07:03.600 --> 00:07:06.259 isn't responding, we pivot to secondary uretonics. 00:07:06.620 --> 00:07:08.759 And this is where the look -alike, sound -alike 00:07:08.759 --> 00:07:11.579 danger zones exist. Let's dissect methylurganavine 00:07:11.579 --> 00:07:14.959 first. This causes very intense sustained uterine 00:07:14.959 --> 00:07:17.620 contractions, but the systemic effect is the 00:07:17.620 --> 00:07:20.110 danger. Right, because it causes massive systemic 00:07:20.110 --> 00:07:22.870 vasoconstriction. Giving methylargonamine to 00:07:22.870 --> 00:07:26.069 a patient with a history of hypertension or preeclampsia 00:07:26.069 --> 00:07:29.490 is a catastrophic error. You risk inducing a 00:07:29.490 --> 00:07:32.050 hypertensive crisis or even a stroke. So here 00:07:32.050 --> 00:07:35.410 is your memory anchor. Think M in methylargonamine 00:07:35.410 --> 00:07:38.230 means monitor blood pressure, no hypertension. 00:07:38.509 --> 00:07:41.910 Love that. Next is carboprostermethamine. This 00:07:41.910 --> 00:07:43.949 one is a prostaglandin, but it affects smooth 00:07:43.949 --> 00:07:46.410 muscle beyond just the uterus, specifically the 00:07:46.410 --> 00:07:48.879 airways. So it can trigger severe bronchospasm. 00:07:49.459 --> 00:07:51.639 Exactly. The absolute contraindication here is 00:07:51.639 --> 00:07:53.459 a patient with a history of asthma or active 00:07:53.459 --> 00:07:56.000 cardiovascular disease. Administering this to 00:07:56.000 --> 00:07:57.699 an asthmatic patient could secure the uterus 00:07:57.699 --> 00:08:01.439 but close off their airway. So the C in carboprost 00:08:01.439 --> 00:08:04.899 is a reminder to check for cough or asthma. Then 00:08:04.899 --> 00:08:07.300 we have mesoprostol. Now this is technically 00:08:07.300 --> 00:08:10.040 an off -label anti -ulcer drug, right? Yes. It's 00:08:10.040 --> 00:08:12.740 a synthetic prostaglandin for the stomach. But 00:08:12.740 --> 00:08:16.319 in OB, A potent side effect is severe uterine 00:08:16.319 --> 00:08:19.019 contraction. It's uniquely useful because you 00:08:19.019 --> 00:08:21.800 can give it rectally. allowing for rapid absorption 00:08:21.800 --> 00:08:24.899 if IV axis is compromised during a crisis. Okay, 00:08:24.920 --> 00:08:27.779 let's pivot to a medication that creates a direct 00:08:27.779 --> 00:08:30.800 physiological contradiction, magnesium sulfate. 00:08:31.100 --> 00:08:33.159 We see this used in the antipartum phase for 00:08:33.159 --> 00:08:35.899 preeclampsia or preterm labor. Right, because 00:08:35.899 --> 00:08:38.480 mag sulfate is a potent, smooth muscle relaxant. 00:08:38.779 --> 00:08:40.860 It blocks the calcium channels that muscles need 00:08:40.860 --> 00:08:43.139 to contract, which is great for stopping preterm 00:08:43.139 --> 00:08:45.500 labor. But terrible for postpartum. Exactly. 00:08:45.759 --> 00:08:47.840 Postpartum, our entire goal is to make the uterus 00:08:47.840 --> 00:08:50.379 contract to stop bleeding. If a patient is on 00:08:50.379 --> 00:08:52.620 a MAG drip, their uterus is chemically blocked 00:08:52.620 --> 00:08:54.940 from clamping down. They are at an exceptionally 00:08:54.940 --> 00:08:57.840 high risk for PPH. So your priority nursing action 00:08:57.840 --> 00:09:00.419 is hypervigilance for uterine adenine, while 00:09:00.419 --> 00:09:02.980 monitoring deep tendon reflexes and respirations 00:09:02.980 --> 00:09:05.700 to prevent MAG toxicity. And you must have the 00:09:05.700 --> 00:09:08.820 antidote ready. Calcium gluconate. Since MAG 00:09:08.820 --> 00:09:11.360 blocks calcium channels, flooding the system 00:09:11.360 --> 00:09:14.059 with calcium gluconate reverses that blockade. 00:09:14.330 --> 00:09:17.509 Perfect. Now, sometimes giving a drug to contract 00:09:17.509 --> 00:09:19.850 the uterus is the exact wrong move, especially 00:09:19.850 --> 00:09:22.389 with structural emergencies like uterine inversion. 00:09:22.730 --> 00:09:25.169 Uterine inversion is a catastrophic event where 00:09:25.169 --> 00:09:28.039 the fundus collapses downward, literally turning 00:09:28.039 --> 00:09:30.620 the uterus inside out through the cervix. And 00:09:30.620 --> 00:09:32.840 exams will test this because it's often iatrogenic, 00:09:32.879 --> 00:09:35.340 meaning we accidentally cause it, like a provider 00:09:35.340 --> 00:09:38.159 applying excessive cord traction or a nurse applying 00:09:38.159 --> 00:09:40.480 aggressive fundal pressure on a boggy uterus. 00:09:40.659 --> 00:09:43.059 Right. And if inversion happens, the nursing 00:09:43.059 --> 00:09:45.360 instructor will test the order of operations. 00:09:45.779 --> 00:09:48.409 You absolutely cannot give oxytocin yet. Giving 00:09:48.409 --> 00:09:50.769 oxytocin during an inversion is like locking 00:09:50.769 --> 00:09:52.590 the door while the intruder is still inside the 00:09:52.590 --> 00:09:54.610 house. You have to put the uterus back where 00:09:54.610 --> 00:09:56.870 it belongs before you lock it down. That is the 00:09:56.870 --> 00:09:59.990 perfect analogy. Your priority action is to administer 00:09:59.990 --> 00:10:02.730 a tocolytic like turbutylene first. You have 00:10:02.730 --> 00:10:04.929 to relax the uterus so it can be manually replaced, 00:10:05.250 --> 00:10:07.870 and only then do you give oxytocin to keep it 00:10:07.870 --> 00:10:10.409 clamped in place. Let's touch on another structural 00:10:10.409 --> 00:10:14.879 issue. Placenta accreta spectrum, or PAS. This 00:10:14.879 --> 00:10:17.299 is where the placenta attaches abnormally deep. 00:10:17.480 --> 00:10:20.519 Yes. In placenta accreta, it attaches too deeply. 00:10:21.000 --> 00:10:24.039 In creta, it invades the muscle layer. And in 00:10:24.039 --> 00:10:26.179 procreta, it penetrates right through the uterine 00:10:26.179 --> 00:10:28.620 wall and can attach to surrounding organs like 00:10:28.620 --> 00:10:30.840 the bladder. And the big risk factor to know 00:10:30.840 --> 00:10:33.320 here is a history of prior cesarean sections, 00:10:33.639 --> 00:10:36.259 right? The placenta bypasses the scar tissue, 00:10:36.360 --> 00:10:39.639 looking for a richer blood supply. Exactly. Knowing 00:10:39.639 --> 00:10:42.139 that risk factor prepares the team for a complex 00:10:42.139 --> 00:10:45.500 delivery, often a planned hysterectomy, because 00:10:45.500 --> 00:10:48.419 forcibly detaching it will cause fatal hemorrhage. 00:10:48.759 --> 00:10:51.419 Okay, moving on to section four, hidden dangers. 00:10:52.149 --> 00:10:54.710 Mentors know exams love testing your ability 00:10:54.710 --> 00:10:56.570 to spot problems that don't bleed openly onto 00:10:56.570 --> 00:10:59.169 the bed. How do we detect a hemorrhage we can't 00:10:59.169 --> 00:11:02.210 see? We use the shock index, or SI. You calculate 00:11:02.210 --> 00:11:03.990 it by dividing the patient's heart rate by their 00:11:03.990 --> 00:11:05.730 systolic blood pressure. Because the heart rate 00:11:05.730 --> 00:11:07.750 creeps up early, but blood pressure drops late. 00:11:08.009 --> 00:11:10.549 Exactly. A normal shock index is less than 0 00:11:10.549 --> 00:11:13.590 .6. A score greater than 1 .4 means the patient 00:11:13.590 --> 00:11:16.769 is entering severe hypovolemic shock. One cause 00:11:16.769 --> 00:11:19.330 of that hidden blood loss is a postpartum hematoma. 00:11:19.580 --> 00:11:22.720 A vessel in the genital tract gets nicked, the 00:11:22.720 --> 00:11:25.500 skin stays intact, and it bleeds into the connective 00:11:25.500 --> 00:11:28.600 tissue. The exam trap here is differentiating 00:11:28.600 --> 00:11:32.200 expected trauma from a hematoma. Expected is 00:11:32.200 --> 00:11:35.320 just general perineal soreness. The priority 00:11:35.320 --> 00:11:38.460 concerning finding is intense localized pain. 00:11:38.799 --> 00:11:41.600 They might feel the urge to bear down, have urinary 00:11:41.600 --> 00:11:44.299 retention, and show signs of shock tachycardia 00:11:44.299 --> 00:11:46.480 but with absolutely no visible vaginal bleeding. 00:11:46.759 --> 00:11:48.340 The pain is out of proportion to what you're 00:11:48.340 --> 00:11:51.419 seeing. Another hidden danger is clots, deep 00:11:51.419 --> 00:11:54.759 vein thrombosis. Pregnancy is a hypercoagulable 00:11:54.759 --> 00:11:57.279 state. Right, fibrinogen increases, fibrinolytic 00:11:57.279 --> 00:11:59.840 activity decreases, and c -sections dramatically 00:11:59.840 --> 00:12:02.500 increase this VTE risk due to surgical trauma 00:12:02.500 --> 00:12:05.080 and immobility. So your priority action is to 00:12:05.080 --> 00:12:07.539 assess for unilateral leg edema. Statistically, 00:12:07.860 --> 00:12:10.139 88 % of these occur in the left leg because the 00:12:10.139 --> 00:12:12.399 gravid uterus compresses the left iliac vein. 00:12:12.539 --> 00:12:14.799 Use pneumatic compression devices, administer 00:12:14.799 --> 00:12:17.159 low molecular weight heparin, and get them emulating 00:12:17.159 --> 00:12:19.159 early. Do not let them sit for long periods. 00:12:19.559 --> 00:12:23.019 OK, let's look at the next major hurdle. Postpartum 00:12:23.019 --> 00:12:26.299 infections. Exams love testing your ability to 00:12:26.299 --> 00:12:29.250 spot the lookalikes. Let's compare endometritis 00:12:29.250 --> 00:12:31.789 and mastitis. Endometritis is the most common. 00:12:32.110 --> 00:12:33.970 It's an infection of the inner uterine lining. 00:12:34.429 --> 00:12:36.769 Watch for significant uterine tenderness, foul 00:12:36.769 --> 00:12:39.309 -smelling lochia, and fever. And the risk goes 00:12:39.309 --> 00:12:42.149 up five times with a C -section. Versus mastitis, 00:12:42.350 --> 00:12:44.590 which presents with flu -like symptoms and a 00:12:44.590 --> 00:12:47.570 unilateral red, hot, swollen breast. And here's 00:12:47.570 --> 00:12:50.379 the classic student question. If the mom has 00:12:50.379 --> 00:12:52.779 an active mastitis infection, does she have to 00:12:52.779 --> 00:12:55.279 stop breastfeeding or dump her milk? Absolutely 00:12:55.279 --> 00:12:58.240 not. That is a huge exam trap. The treatment 00:12:58.240 --> 00:13:00.379 is to keep emptying the breast to clear the milk 00:13:00.379 --> 00:13:03.120 stasis, educate the patient to increase feeding 00:13:03.120 --> 00:13:06.320 frequency, ensure proper latch lips flanged like 00:13:06.320 --> 00:13:09.440 a fish, chin in the breast, and use cool compresses. 00:13:09.679 --> 00:13:11.960 Now, if these infections aren't controlled, they 00:13:11.960 --> 00:13:15.120 cascade into maternal sepsis. Yes. We use the 00:13:15.120 --> 00:13:17.700 SOFA score to monitor for organ failure. Your 00:13:17.700 --> 00:13:20.039 priority action for sepsis is to administer broad 00:13:20.039 --> 00:13:22.379 -spectrum antibiotics in crystalloid fluids like 00:13:22.379 --> 00:13:25.179 lactated ringers immediately. And to monitor 00:13:25.179 --> 00:13:28.379 perineal and surgical wounds, use the RIDA mnemonic. 00:13:29.100 --> 00:13:32.139 Redness, edema, ecumosis, drainage, and approximation. 00:13:32.299 --> 00:13:34.779 It gives you an objective framework for a subjective 00:13:34.779 --> 00:13:37.230 visual assessment. Perfect. All right, we've 00:13:37.230 --> 00:13:39.669 covered a ton of ground. Let's wrap up this clinical 00:13:39.669 --> 00:13:41.750 rotation with our top five non -negotiables for 00:13:41.750 --> 00:13:44.350 the exam. If you only remember five things, here 00:13:44.350 --> 00:13:47.710 they are. Number one, PPH is greater than 1 ,000 00:13:47.710 --> 00:13:51.289 milliliters of blood loss. Always massage a boggy 00:13:51.289 --> 00:13:54.250 fundus first. Number two, know your med traps. 00:13:55.360 --> 00:13:57.960 Methylragonavine, no hypertension. Carboprost, 00:13:58.279 --> 00:14:01.220 no asthma. Number three. For uterine inversion, 00:14:01.539 --> 00:14:04.139 relax first with tributyline, replace it, then 00:14:04.139 --> 00:14:07.539 contract it with oxytocin. Number four. Disproportionate 00:14:07.539 --> 00:14:10.080 perineal pain plus shock vitals with no visible 00:14:10.080 --> 00:14:12.909 bleeding equals a hematoma. And number five, 00:14:13.090 --> 00:14:15.210 for mastitis, keep the patient breastfeeding 00:14:15.210 --> 00:14:18.029 to clear the stasis. You've got this. But before 00:14:18.029 --> 00:14:19.730 we go, we want to leave you with a final thought 00:14:19.730 --> 00:14:21.730 to mull over. We discussed at the top of the 00:14:21.730 --> 00:14:24.070 deep dive that black maternal clients have three 00:14:24.070 --> 00:14:26.389 times the risk of morbidity due to decreased 00:14:26.389 --> 00:14:29.190 access to care. Now that you know the clinical 00:14:29.190 --> 00:14:31.929 signs, like the intense out of proportion pain 00:14:31.929 --> 00:14:35.120 of a hidden hematoma. How will you consciously 00:14:35.120 --> 00:14:38.539 fight systemic bias in your future practice to 00:14:38.539 --> 00:14:40.419 ensure your patient's pain isn't just dismissed 00:14:40.419 --> 00:14:43.860 as normal postpartum discomfort? It's an essential 00:14:43.860 --> 00:14:46.279 question because it's not just about passing 00:14:46.279 --> 00:14:48.639 a test. It's about who you will be at the bedside. 00:14:48.840 --> 00:14:51.539 Exactly. Keep that in mind as you study. We'll 00:14:51.539 --> 00:14:52.720 see you on the next Deep Dive.