POSTPARTAL HEMORRHAGE

POSTPARTAL COMPLICATIONS

The postpartal period refer to the first six weeks following childbirth, is a time when women are very susceptible to
hemorrhage and thrombophlebitis.

It’s important to be knowledgeable about predisposing factors and clinical manifestations of postpartum complications
to ensure the prompt initiation of corrective measures in order to prevent long-term consequences to a woman and her
family (Guntupalli, Karnad, Bandi, et al., 2015).

Postpartum complications are always potentially serious because they can impact so many people.

A complication may be so serious it could cause a personal injury, leave a woman with her future fertility impaired, or
even result in death.

POSTPARTAL HEMORRHAGE

 PPH is defined as blood loss of more than 500 mL following vaginal delivery or more than 1000 mL following cesarean
delivery.

- If postpartum more than 500 mL

 Early or Primary PPH

Excessive blood loss within 24 hours of delivery

 Late or Secondary PPH

 if bleeding occurs 24 hours after delivery to 6 wks. PP.

 Early or Primary PPH

 Causes:

 Uterine atony (failure of the uterus to contract) due to:

 Retained membranes

 Placenta not delivered within 30 min. after birth of baby

If gi force ug kuha ang placenta – daghan complications; daghan ma bira ug apil – if case: uterus kuhaon

 Late or Secondary PPH

 Retained placental fragments – expect of completeness of its parts; basin nay nabilin sa endometrium sa
uterus

 Subinvolution of the uterus – slow involute sa uterus (cause: overdistention of the uterus, big baby, multiple
gestation)

 Infection

 Etiology

 The causes of PPH have been described as the "four T's":

 Tone: uterine atony, distended bladder (displaced) - not feel the urge to urinate

Bladder – 4-6 hours (maka-urinate); 4 hours filled completely with urine

 Tissue: retained placental fragments or clots.

 Thrombin: pre-existing or acquired coagulopathy (DIC); active bleeding (abrutio placenta)

 The most common cause of PPH is uterine atony, followed by retained placenta.

 ASSESSMENT:

1. During immediate PP period, blood loss should be monitored closely and continuously by assessing:

 Fundus

 V/S (Bp, PR) – tell us if there is internal bleeding; if bleeding – below BP, PR increase

 Vaginal bleeding

 Hgb-Hemoglobin (NORMAL: 12 – 16gms/dl) and, Hct-Hemotocrit (NORMAL: 38% - 46%) 50% of RBC

2. Palpate the fundus

 Consistency – if contracted

 Size – fundal height measurement; landmark is umbilicus going down (postpartum)

 Position – if displaced to the side meaning pushed by the distended bladder

 The following are reported ranges of normal hematocrit levels:

• Newborns: 55%-68%

• One (1) week of age: 47%-65%

• One (1) month of age: 37%-49%

• Three (3) months of age: 30%-36%

• One (1) year of age: 29%-41%

• Ten (10) years of age: 36%-40%

• Adult males: 42%-54%

• Adult women: 38%-46%

• Adult pregnant women: about 30% - 34% lower limits and 46% upper limits

3. Inspect the vagina & perineal area

 Continuous oozing of blood

 Hematoma formation – big baby, big forceps

4. Monitor blood loss per vagina

 Weigh perineal pad before & after use

 weighing of packs and sponges used to absorb blood;

 1 milliliter of blood weighs approximately one gram).

 Check under the hips where blood tends to pool

 Tachycardia (PR >100) and hypotension (systolic < 100 mmHg) are the most significant V/S changes in
hemorrhage.

6. Monitor urine output

 Kidneys very sensitive to circulating blood volume.

 As blood volume decreases, so does the blood supply to the kidney and the amount of urine formation.

Monitor intake and output of patient

7. Monitor tissue perfusion

 Pulse oximetry is useful for assessing O2 saturation.

8. Assess level of consciousness

 Due to decreased blood supply to the brain.

9. Lab. Work

 CBC

 Prothrombin time (PTT)/ activated partial thromboplastin time (aPTT)

 The reference range of the aPTT is 30-40 sec.

 The reference range of the PTT is 60-70 sec.

 Critical values that should prompt a clinical alert are as follows:

 aPTT: More than 70 seconds (signifies spontaneous bleeding)

 PTT: More than 100 seconds (signifies spontaneous bleeding)

 PPH may be due to DIC (disseminated intravascular coagulation) associated with premature separation of the
placenta, missed miscarriage, or fetal death in utero.

 Reflected by falling levels of PTT (Normal: 60-70 sec.) and aPTT (Normal: 30 – 40 sec.)

10.Ultrasound

 To detect causes of hemorrhage.

 NURSING DIAGNOSIS:

 Deficient fluid volume r/t excessive blood loss after birth.

 OUTCOME IDENTIFICATION:

 Client’s Bp remains higher than 100/60 mmHg; PR remains between 70-90 bpm; lochia flow <1 saturated
perineal pad/hr.

 RELATED INTERVENTIONS:

1. Place pt. in Trendelenburg position /

 To improve venous return.

3. Adm. O2 as ordered.

4. Two IV lines are usually ordered:

 For fluids and drugs given thru IVTT (immediate effect)

 For possible BT (blood loss of >2,000 ml)

5. Monitor for DIC due to shock.

 Hypoperfusion of tissues cause tissue damage and stimulates release of thromboplastins, manifested
by:

 Spontaneous bleeding at IV puncture sites.

 Lab. Test results of:

 D-dimer levels (specific for fibrin)

 Very low fibrinogen levels (<200 mg/100 ml plasma)

 Prolonged *thrombin time (NORMAL: <20 sec.)

* an enzyme that converts fibrinogen to fibrin.

* fibrin forms the matrix on which blood clot is formed

UTERINE ATONY

 DESCRIPTION:

 Failure of uterus to contract after delivery.

 Most common cause of PPH.

 RISK FACTORS/CAUSES:

1. Overdistention

 Hydramnios, macrosomia, fibroids, multiple gestation

2. Complication of labor

 Precipitate labor (less than 3 hours nanganak), prolonged labor

3. Uterine relaxing agents

 Anesthesia, analgesia, terbutaline, MgSO4

4. Oxytocin given during labor

5. High parity and advanced maternal age.

6. Infection

 chorioamnionitis

7. Over massage of the uterus.

8. Retained placental fragments

 Anemia

 Coagulopathy (blood normally clots within 5 min.)

10.Prolonged 3rd stage of labor (>30 min.)

11. varied placental site or attachment

 Placenta previa, placenta accreta, abruption placenta, retained placental fragments

 MANAGEMENT:

1. Priorities in managing PPH:

1) Call for help

2) Make rapid assessment of woman’s condition (V/S check)

3) Find the cause of bleeding

4) Stop the bleeding

5) Stabilize or resuscitate the woman

6) Prevent further bleeding.

2. 1st action to take when a relaxed uterus is palpated is to massage the uterine fundus. Support hypogastric area, other
hand support fundus – prevent uterine conversion

3. Keep the bladder empty.

4. Administer uterotonics to stimulate uterine contractions.

1) Oxytocin (1st drug of choice)

 10 unit intramuscularly (IM) after delivery of placenta

 Add 10-40 units; not to exceed 40 units; to 1000 mL of 0.9% saline or Ringer Lactate intravenous (IV) solution
and infuse at necessary rate to control uterine atony

 It acts within 2 ½ minutes when given IM but does not have a sustained action.

 Monitor Bp.

2) Methylergonovine maleate (Methergine)

 Takes 6-7 min. to take effect when given IM (preferred route); 45 sec. when given IV

 Repeated every 2-4 hrs. up to 5 doses

 Monitor Bp

3) Carboprost tromethamine (Hemabate)

o Prostaglandin F2a derivative

 Given if oxytocin is ineffective

 Given I.M.

 Given every 15 – 90 min. up to 8 doses.

 Monitor Bp

4) Misoprostol (Cytotec)

o Administered rectally

o Monitor Bp

5. Adm. O2 by mask @ 10 – 12 L/min.

6. Position patient supine (flat) to allow adequate blood flow to her brain and kidneys.

7. External bimanual compression – massage uterus

8. Internal bimanual compression – IE ang doctor

9. Uterine packing

 Removed after 24-36 hrs.

 Monitor for possible infection

 Fever

 Foul vaginal discharge

8. Blood transfusion

9. Laparotomy

10. Hysterectomy (last resort)

LACERATIONS

 DESCRIPTION:

 Bright red bleeding from vagina inspite of contracted uterus.

 Can occur anywhere in the cervix, vagina and perineum.

 RISK FACTORS/CAUSES:

 Primiparas

 Forceps delivery

 Precipitate delivery

 Large infants (>9 lbs.)

 Multiple pregnancy

 Abnormal fetal presentation and position

CERVICAL LACERATIONS

 Usually found on the sides of the cervix, near the branches of the uterine artery.

the blood loss may be so great that blood gushes from the vaginal opening.

it is a brighter red than the venous blood lost with uterine atony.
 Fortunately, this bleeding ordinarily occurs immediately after detachment of the placenta, when the primary care
provider is still in attendance.

 Therapeutic Management

1. Suturing of cervical laceration usually requires sutures and can be difficult because, if the bleeding is intense,
this obstructs visualization of the area.

2. Vaginal packing.

3. Try to maintain an air of calm and, if possible, stand beside the woman at the head of the table.

4. If the cervical laceration appears to be extensive or difficult to repair, it may be necessary for the woman to
be given a regional anesthetic to relax the uterine muscle and to prevent pain.

5. Explain the need for an anesthetic and the procedures being carried out.

6. Be certain the primary care provider has adequate space to work, adequate sponges and suture supplies, and
a good light source.

VAGINAL LACERATIONS

 Vaginal lacerations are easier to locate and assess than cervical lacerations because they are so much easier to view.

 Therapeutic Management

1. Suturing

2. A balloon tamponade similar to the type used with a uterine hemorrhage may be effective if suturing does not
achieve hemostasis (Atilgan, Ozkan, Orak, et al., 2014).

3. Vaginal pack

 to maintain pressure on the suture line.

4. An indwelling urinary catheter (Foley catheter) may be placed following the repair

 packing causes such pressure on the urethra that it can interfere with voiding.

5. Be certain to document in the woman’s electronic record when and where packing was placed so you can be
certain it is removed after 24 to 48 hours or before hospital discharge to prevent infection.

PERINEAL LACERATIONS

 Lacerations of the perineum are more apt to occur when a woman is placed in a lithotomy position for birth rather
than a supine position because a lithotomy position increases tension on the perineum.

 Perineal lacerations are classified by four categories, depending on the extent and depth of the tissue involved.

 MANAGEMENT:

 Suturing of 3rd and 4th degree laceration, bleeding lesions of >2 cm.

 After suturing, Vaginal packing may be applied to help stop bleeding and maintain placement of the suture.

 Constipation should be avoided.

 Assess for bladder distention.

 Adm. Analgesics as ordered.

 Heat application after 24 hrs.

HEMATOMAS

 DESCRIPTION:

 Collection of blood in the subcutaneous layer of the perineum.

 TYPES:

 Vulvar hematoma

 Vaginal hematoma

 Retroperitoneal hematoma

 MANAGEMENT:

1. Proper suturing of lacerations & episiotomies

2. Apply ice pack 1st 24 hrs. After delivery; warm compress after 24 hrs.

3. Analgesic for pain.

4. Large hematomas (>5 cm)

 Brought back to DR for evacuation of hematoma.

5. Administer broad spectrum antibiotics to prevent or treat infection.

DISSEMINATED INTRAVASCULAR COAGULATION

 DIC is a deficiency in clotting ability caused by vascular injury.

 It may occur in any woman in the postpartal period, but it is usually associated with premature separation of the
placenta, a missed early miscarriage, or fetal death in utero.

SUBINVOLUTION

 Subinvolution is the incomplete return of the uterus to its prepregnant size and shape.

 With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft.

 Lochial discharge usually is still present.

- Rubra, serosa, alba

 Subinvolution may result from a small retained placental fragment, a mild endometritis (infection of the
endometrium), or an accompanying problem such as a uterine myoma that is interfering with complete contraction.

THERAPEUTIC MANAGEMENT

 Oral administration of methylergonovine, 0.2 mg four times daily, is the usual prescription to improve uterine
tone and complete involution.

 If the uterus feels tender to palpation, suggesting endometritis is present, an oral antibiotic also will be
prescribed.

 A chronic loss of blood from subinvolution will result in anemia and a lack of energy, conditions that possibly
could interfere with infant bonding or lead to infection.
RETAINED PLACENTAL FRAGMENTS

 Occasionally, a placenta does not detach in its entirety; fragments of it separate and are left still attached to the
uterus.

 Because the portion retained keeps the uterus from contracting fully, uterine bleeding occurs.

 Although this is most likely to happen with a succenturiate placenta—a placenta with an accessory lobe (see
Chapter 23)—it can happen in any instance.

 Placenta accreta—a placenta that fuses with the myometrium because of an abnormal decidua basalis layer—
may also be retained.

 This is associated with previous cesarean birth and in vitro fertilization and occurs at an incidence of about 1
out of 3,000 births; it can be identified by an ultrasound exam during pregnancy.

 Removing such a deeply embedded placenta can lead to severe postpartal hemorrhage (Silver, 2015).

 To identify the complication of a retained placenta, every placenta should be inspected carefully after birth to be
certain it is complete.

 Retained placental fragments may also be detected by ultrasound.

 A blood serum sample that contains human chorionic gonadotropin (hCG) hormone also reveals that part of a placenta
is still present.

Assessment

 If an undetected retained fragment is large, bleeding will be apparent in the immediate postpartal period
because the uterus cannot contract with the fragment in place.

 If the fragment is small, bleeding may not be detected until postpartum day 6 to 10, when the woman notices
an abrupt discharge and a large amount of vaginal bleeding.

 On examination, usually the uterus is found to not be fully contracted.

Therapeutic Management

 Removal of the retained placental fragment is necessary to stop the bleeding and can usually be accomplished
by a dilatation and curettage (D&C).

 If it cannot be removed, methotrexate may be prescribed to destroy the retained fragment.

 Because the hemorrhage from retained fragments may be delayed until after a woman is at home, be certain
women know to continue to observe the color of lochia and to report any tendency for the discharge to change
from lochia serosa or alba back to rubra.

 In some instances, placenta accreta is so deeply attached that balloon occlusion and embolization of the
internal iliac arteries may be necessary to minimize blood loss.

 In others, a hysterectomy must be performed (Silver, 2015).