Postpartum Hemorrhage Complications

Normal Blood Loss After Delivery

• Vaginal Delivery

  • < 500 mL

• C-Section:

  • < 1000 mL

Postpartum Hemorrhage Blood Loss

• Vaginal birth:

  • > 500 mL

• C-Section:

  • > 1000 mL

Postpartum Hemorrhage TIming

• Early:

  • Within 24 hrs after birth

• Late:

  • 24 hrs to 12 weeks after birth

Hypovolemic Shock (Mild)

• 20% Blood loss

• S/S:

  • Diaphoresis

  • Increase capillary refilling

  • Cool extremities

  • Maternal anxiety

Hypovolemic Shock (Moderate)

• 20-40% blood loss

• S/S:

  • Tachycardia

  • Postural hypotension

  • Oliguria

Hypovolemic Shock (Severe)

• > 40% blood loss

• S/S:

  • Hypotension

  • Agitation/ confusion

  • Hemodynamic instability

Risk for PPH

• Over distention of the uterus

• Multiparity

• Precipitate labor or birth

• Prolonged labor

• Use of forceps or vacuum extractor

• C-Section

• Manual removal of placenta

• Etc.

PPH Related to:

• Tone

• Tissue

• Trauma

• Thrombin

• Traction

Bleeding Related to Tone

• Uterine atony

  • Uterus remains inadequately contracted

• Boggy fundus

• Deviated fundus

• Causes:

  • Overdistention of uterus

  • Multiparity

  • Chorioamnionitis

  • Use of anesthesia/ mag. sulfate

  • Distended bladder

  • Prolonged, rapid, or forceful labor

Bleeding Related to Tissue

• Tissue prevents the uterus from contracting to clamp down on blood vessels

• Boggy uterus (uterine atony)

• Fundal height above expected location

  • Subinvolution

• Profuse hemorrhage

• Abnormal lochia progression

• Causes:

  • Retained placental fragments

  • Clots in the uterus

  • Uterine leiomyomas (fibroids)

Causes of Subinvolution

• Retained placental fragments

  • Often the reason for late hemorrhage

• Distended bladder

• Infection or uterine myoma

Subinvolution Clinical Signs

• “Boggy” uterus

• Abnormal lochia progression

• Postpartum fundal height higher than expected

Bleeding Related to Trauma

• Continuous trickling of bright red blood w/ contracted uterus

  • Laceration

  • Not going to stop

  • Fundal assessment (Usually found WDL)

  • Call the provider (Sutures)

• Causes:

  • Damage to the genital tract (including hematomas)

  • Lacerations (vaginal, perineal, periurethral, cervical, etc.) or hematomas

  • Pushing too soon, precipitous delivery

  • Abnormal fetal presentation (Occiput, vertex, cephalic, Breach)

  • Use of forceps or vacuum extractor

Bleeding Related to Thrombin

• Disorders that interfere w/ clot formation

  • Coagulopathies

• Decreased platelet & fibrinogen levels

• Increased PT, PTT

• Prolonged bleeding time

• Determine risk during pregnancy

• Family & personal history

Bleeding Related to Traction

• Excessive force on umbilical cord during 3rd stage of labor

• Pulling on cord to hasten 3rd stage

  • Results in cord detachment from placenta

• Can result in uterine inversion

  • Pulls hard to the point the uterus comes inside out (prolapse)

  • Risk for infection (outside the body)(Antibiotics)

  • Have to use their fist to put it back in

• Risk for having retained placental fragments

PPH Nursing Mangement

• Think of it as a Code

• Call for help!!!

• Fundal assessment

  • Massage if boggy

  • Empty bladder if deviated

• Hemorrhage cart

• Mon. VS

• Maintain IV access & prepare for second IV

  • Fluids, meds

  • Blood transfusion

• Admin. uterotonic meds

PPH Nursing Management Cont.

• Assess/ quantify blood loss

• Notify provider

  • Fundal assessment

  • Blood loss

  • VS

  • Interventions

• Prepare for possible exploration or surgery

• Assess for S/S of hypovolemic shock

• Pad counts

  • What percentage of the pad is saturated

• Prevent postpartum hemorrhage!

PPH Meds.

• Oxytocin

  • Uterotonic

• Misoprostol (Cytotec)

  • Uterotonic

• Methylergonovine (Methergine)

  • Uterotonic

• Carbopost (Hemabate)

  • Uterotonic

• Tranexamic acid (TXA)

  • Anti-fibrinolytic

• All of these can be stacked w/ each other

  • If one doesn’t work, then they add more

  • They could give all of these

PPH Oxytocin

• IV infusion or IM

• Never give undiluted IV

• NO IV push

PPH Misoprostol (Cytotec)

• Buccally or per rectum

  • NOT giving through the vagina

• Contraindicated w/ active cardiovascular, pulmonary, or hepatic disease

• Use w/ caution in women w/ asthma

• Can cause fever & diarrhea

PPH Methylergonovine (Methergine)

• IM, PO after acute bleeding stops

  • First dose is ALWAYS IM

• Contraindicated w/ HTN

  • Can spike her BP to the point of a stroke

PPH Carboprost (Hemabate)

• IM

• Contraindicated:

  • Asthma

  • Active cardiovascular, pulmonary, renal, or hepatic disease

• Can cause fever & diarrhea

  • Major diarrhea

PPH Tranexamic Acid (TXA)

• IV infusion

• Anti-fibrinolytic

• Inhibits the breakdown of clots

• Use cautiously w/:

  • Renal impairment

  • Active thromboembolic disease

  • Intracranial bleeding

Hemorrhage Control Devices

• Intrauterine balloon tamponade

• Vacuum-induced hemorrhage control device

  • Suctions the walls of the uterus in to stop the bleeding

Quantitative Blood Loss

• Triton machine

• Take everything that has blood on it

• Put in bucket then calculates how much blood on the objects in the bucket

• Estimated:

  • Not accurate

  • More of an estimation

  • From provider

• Possible hysterectomy if nothing works

PPH Prevention

• Recognition

• Readiness

• Response

• Reporting

PPH Prevention (Recognition)

• Risk factor on admission to L&D

• Risk factors during/ after delivery

• If present, second IV, CBC, type, & screen or cross for blood

• Review protocol for hemorrhage

PPH Prevention (Readiness)

• Hemorrhage protocol

• Mass transfusion protocol

• Hemorrhage cart

• Who to call, how to get the blood

PPH Prevention (Response)

• Get help & assign roles

• Second IV

  • 16 to 18 gauge

• Stat labs:

  • CBC, coagulations studies, fibrinogen

• Announce VS & cumulative blood loss

• Transfusion, if necessary

PPH Prevention (Reporting)

• Post-hemorrhage huddle & debrief

• Incident/ event report

• Conduct multidisciplinary review for all events

• Mon. outcomes of all hemorrhages to increase response & positive outcomes

PPH Interventions General

• ALWAYS check the fundus after EVERY intervention

• Can be multiple causes & multiple interventions

  • Mon. blood loss & VS

  • May need blood transfusion, fluids, etc.

• If still hemorrhaging after meds & interventions

  • Hemorrhage control device

• If still hemorrhaging, may need uterine artery embolization or hysterectomy

PPH Tone (Boggy) Interventions

• Massage fundus if MIDLINE

• Have patient void (If NOT hemorrhaging)

• Straight cath if DEVIATED

• May need PPH med

PPH Tissue Interventions

• Massage fundus

• Manual evacuation/ exploration (Provider ONLY)

• Possible D&C

  • Dilation & Curettage

• Antibiotic

• May need PPH med

PPH Trauma (Trickling)

• Provider repair lacerations

PPH Thrombin Interventions

• Dependent upon cause

PPH Traction Interventions

• Uterine inversion

  • Gentle replacement of uterus (provider)

• Possible manual evacuation/ exploration (provider)

• PPH meds.

• Antibiotics

Thromboembolic Conditions Types

• Superficial venous thrombosis

• DVT

• PE

Thromboembolic Causes

• Venous stasis

• Hypercoagulation

• Injury to blood vessel

• Other

  • Inactivity

  • Obesity

  • C-Section

  • Smoking

  • Hx

  • DM

  • Etc.

Thromboembolic Nursing Management

• Focus on PREVENTION

• Promote adequate circulation

  • Active & passive ROM

  • SCDs

  • Early ambulation

  • Incentive spirometer/ deep breathing

  • Increase fluid intake

  • Enoxaparin (Lovenox)

    • If ordered

Thromboembolic Therapeutic Management

• Analgesics

• Rest

• Warm packs

• Elevation of extremity

• Anticoagulant therapy

• Oxygen

Thromboembolic Conditions Education

• S/S of DVT & PE