Postpartum hemorrhage: Nursing

Postpartum hemorrhage or PPH is an obstetrical emergency which occurs when there is any significant loss of blood after delivery of a baby.

Now, some blood loss is expected during childbirth, but PPH is when the blood loss during the first 24 hours exceeds 500 mL after vaginal birth or 1000 mL after cesarean delivery.

Significant bleeding in the first 24 hours after delivery is called early or primary postpartum hemorrhage, while late or secondary postpartum hemorrhage occurs 6 weeks to 12 weeks after birth.

Okay, let’s start with some physiology. So, after delivery, the uterus tends to regress back to its normal size and resume its pre-pregnancy position by the sixth week, a process known as involution.

Immediately after the delivery of placenta, the smooth muscles of the uterus continue to contract and squeeze down on the placental arteries where they are attached to the uterine wall, causing them to clamp them shut and reduce uterine bleeding.

There are also some physiological changes that occur during pregnancy that begin to change back to pre-pregnancy levels in the postpartum period.

For example, during pregnancy there is increased blood plasma volume in relation to red blood cell mass. As a consequence, maternal hemoglobin and hematocrit are usually relatively low during pregnancy, since the same amount of red blood cells are circulating in a higher volume of blood.

After delivery, through increased diuresis or urine production, and increased diaphoresis or sweat production, blood volume returns to normal in about 6 to 12 weeks, and hemoglobin, and hematocrit levels normalize in 4 to 6 weeks.

Likewise, during pregnancy, plasma fibrinogen and other pro-coagulant factors increase, and they stay elevated until 4 to 6 weeks following delivery.

The most common causes of postpartum hemorrhage can be divided into two groups; the early causes and the late causes. The early causes can easily be remembered as the 4 Ts: Tone, Trauma, Tissue, and Thrombin.

Tone refers to a lack of uterine tone, meaning the uterine contraction is weak or absent. This is also known as uterine atony, which is the most common cause of PPH.

Repeated distention of the uterus as a result of multiple previous pregnancies or overstretching from multigestational pregnancy can interfere with effective uterine contractions after birth and lead to uterine atony after birth.

Uterine atony can also occur when uterine muscles become fatigued after prolonged labor, or if urine retention causes a distended bladder that interferes with uterine involution.

The next T is Trauma, and it refers to damage to any of the reproductive structures, like the uterus, cervix, vagina, or perineum during delivery.

Next is Tissue, which refers to when a part of the placenta is retained in the uterus after birth, interfering with the involution process.

Lastly, Thrombin, refers to the mother having some condition that prevents blood clots from forming normally, for example, a coagulation disorder like von Willebrand disease.

These conditions can turn even a tiny bleed into a serious bleed due to the inability to form blood clots. Finally, some risk factors for PPH which include a history of PPH in previous pregnancies; placental disorders like placenta previa, placenta accreta or placental abruption; an overdistended uterus due to polyhydramnios, multiple gestation, or macrosomic infant; infection, prolonged labor, and lastly delivery by cesarean section.Clinically, postpartum hemorrhage can be overt, in which a large amount of blood loss can be assessed; or occult, which is when blood pools up somewhere inside the body or inside a hematoma.

This can be within the uterus or in the pelvic or abdominal cavity. The lochia rubra, which is the vaginal discharge after delivery, can appear abnormal with large amounts of fresh blood and numerous large blood clots.

Severe bleeding can cause signs and symptoms of hypovolemic shock, such as orthostatic hypotension, dizziness, tachycardia, palpitation, shortness of breath, and cold, clammy skin.

Some clients can have a severe backache with a feeling of pelvic heaviness due to hematoma formation. Abdominal inspection may reveal the uterine fundus to be above the expected level, which could indicate internal bleeding and formation of hematoma.

With uterine atony, palpation can reveal a boggy, soft and enlarged uterus instead of a firm, contracted one. Vaginal examination can reveal bright red discharge with numerous blood clots, indicating that the uterus is the source of the bleed, and not a cervical or vaginal laceration.

Finally, close inspection of the placenta after delivery can show some of the placenta has been left behind. The diagnosis of postpartum hemorrhage starts with the client’s history and physical assessment.

A steady or heavy flow of blood is usually noticed first. Additionally, blood tests such as CBC can be done at intervals to assess hemoglobin and platelet count, and specific tests can be done to look for coagulopathies.

An ultrasound can also be done to identify retention of the placenta, which usually looks like a hyperechoic intrauterine mass.

Treatment of postpartum hemorrhage is an obstetric emergency and maintaining adequate circulating volume is the priority.

Regardless of the cause, intravenous fluids and blood products can be used to ensure that the vital organs are well perfused.

Another essential part of treatment includes keeping the uterus firmly contracted. If there is severe bleeding after delivery of the placenta a bimanual uterine massage can promote contractility of the uterus to further reduce bleeding.

This is done by cupping one hand and placing it under the uterus at the level of the symphysis pubis and then cupping the other hand over the top part of the uterus, called the fundus, and gently but firmly massage the fundus in a circular motion.

Frequent massaging of the fundus during the postpartum period also helps keep the uterus contracted and reduces bleeding.

In addition, giving uterotonic medications like oxytocin, misoprostol, methylergonovine, or carboprost will also help the uterine muscles contract firmly.

Other options for severe hemorrhage include intrauterine balloon tamponade, uterine artery embolization or ligation, and hysterectomy as a last resort.Alright, now let’s talk about management of care for a client with postpartum hemorrhage.

Your priority goals are to control the bleeding, maintain normal fluid volume, and provide emotional support. Begin by assessing the height, position,and consistency of your client's fundus and massaging it until it is firm.

Keep a close eye on the amount of bleeding and clots that are produced during massage. Determine how long it takes for one perineal pad to become saturated, and document the amount of blood by weighing the pad.

Then, maintain IV access, continue the administration of fluids and oxytocin, and titrate it per protocol. Also start a second IV, which should be at least 18 gauge.

Next, institute pulse oximetry, provide supplemental oxygen per protocol, and assess their vital signs frequently. Insert indwelling urinary catheter and keep a close eye on their intake and output.

Also, draw labs for hemoglobin, hematocrit, type and cross-match, and coagulation studies, and compare these values with admission labs.

Notify the blood bank that packed RBCs may be needed, and confirm that OR staff including an anesthesia provider are available if surgical intervention is needed.Assess your client for signs of hypovolemic shock.

Check skin and mucous membranes and check their urine output as well as their vital signs. Keep in mind that due to the increased blood volume that occurs during pregnancy, traditional signs of hypovolemia are not always evident until 10 to 30 percent of blood is lost.

Maintain your client on bedrest with their legs elevated 30 degrees to help to increase venous return to the heart and maintain cardiac output.

Immediately report to the health care provider if the uterus remains boggy, if hemorrhage continues in spite of interventions, or if signs of shock are evident.

Increase the IV flow rate, administer blood products, administer additional uterotonics as prescribed; and prepare your client for surgical intervention.During care, provide reassurance and support, and keep them informed about your interventions using clear, brief statements.

Alright, now let’s move on to the teaching you'll provide for a client diagnosed with postpartum hemorrhage. Begin by teaching them that postpartum hemorrhage is when there’s severe bleeding after giving birth.

Explain the plan of care and reassure them that they will be monitored closely and that the team will work together to stop the bleeding.Next, teach your client that after discharge, instruct them to get plenty of rest ,eat a balanced diet and stay well hydrated; and instruct them to take their prescribed iron supplement as directed.

Also monitor the amount and characteristics of their lochia. Instruct them to seek immediate medical care for signs of heavy bleeding, including a pad saturated within one hour, and the presence of numerous blood clots.

Alright, as a quick recap… Postpartum hemorrhage is when there is significant loss of blood after childbirth. It is considered an obstetrical emergency and is the number one cause of maternal morbidity and mortality in the world.

Now, the causes for early postpartum hemorrhage can be remembered as the “4Ts, “which are tone, trauma, tissue, and thrombin.

Risk factors for postpartum hemorrhage include having a prior history of postpartum hemorrhage, having a placental disorder such as placenta previa or placental abruption, having a multiple gestation pregnancy, polyhydramnios, infection, or prolonged labor, as well as cesarean section delivery.

Remember that blood loss may be overt, where you can see large amounts of blood loss, or occult, where blood pools up somewhere inside the body.

Severe blood loss can lead to shock with signs and symptoms such as tachycardia, shortness of breath, cool and clammy skin, and hypotension.Postpartum hemorrhage is diagnosed based on history and physical assessment and a CBC may aid in diagnosis.

Treatment and management focus on increasing uterine contraction through medication and uterine massage to stem the bleeding and maintaining adequate circulating volume.

Goals of nursing care include controlling the bleeding, maintaining normal fluid volume, and providing emotional support.

Client and family teaching is focused