special populations postpartum hemorrhage and uterine changes

what is postpartum hemorrhage

excessive blood loss in a woman after childbirth

describe primary postpartum hemorrhage

excessive blood loss within first 24 hours after childbirth

describe secondary postpartum hemorrhage

occurs between 24 hours and 6 weeks after childbirth

what is the mean blood loss without hemorrhage associated with vaginal delivery 

500 cc

what is the mean blood loss with hemorrhage associated with vaginal delivery 

1000cc 

what is the mean blood loss without hemorrhage associated with c-sections

1000cc

what is the mean blood loss with hemorrhage associated with c-sections

more than 1500cc

what are prenatal risk factors for postpartum hemorrhage

previous history of postpartum hemorrhage 

preeclampsia

placenta problems 

obesity 

nulliparity and multiparity 

previous c-section 

multiple gestation which can create high amniotic fluid levels 

what are risk factors that can increase postpartum hemorrhage risk

prolonged labor

large fetus

stillbirth

chorioamnionitis

augmented labor, forceps, episiotomy, c-section

what are the 4 T’s

tone (uterine tone)

tissue (retained tissue-placenta)

trauma (lacerations and uterine rupture)

thrombin (bleeding disorders)

what is the most common cause of postpartum hemorrhage

uterine atony 

what does uterine atony

uterus does not respond to oxytocin

lower levels of oxytocin

what happens if there is traction on the umbilical cord

tear and inversion of uterus

retention for 30+ minutes, can be due to abnormal placental implantation

what is placenta accreta

placenta invades myometrium

placenta doesn’t easily separate

what does retained placenta lead to 

prevented contractions causing uterine atony 

what are examples of trauma we need to be worried about in postpartum hemorrhage that dont involve the uterus

episiotomy

hematoma

what traumas do we need to be worried about in the uterus for postpartum hemorrhage

uterine invasion

uterine rupture 

what can damage to genital structures include in postpartum hemorrhage

c-section incision

child going through birth canal

medical instruments (forceps, vacuum, epioistomy)

how will a hematoma present in postpartum hemorrhage

severe pain

persistent bleeding

what processes is thrombin involved in

coagulopathies

work up with platelets

what is needed to diagnose postpartum hemorrhage

physical exam

lab tests

imaging (ultrasound, angiography)

what lab tests can help confirm a diagnosis of postpartum hemorrhage

blood tests

blood clotting test

clot observation test

number of pads/sponges that absorb blood

blood pressure and pulse

how do we treat postpartum hemorrhage 

fluid, oxygen, resuscitation 

bimanual uterine massage 

trauma/surgical repair

medications 

where is the fundus located following placental expulsion

umbilicus

where is the utereus follwoing 1 week of placental expulsion

cavity of the pelvis

where is the location of the uterus within 9 days of placental expulsion 

regains non pregnant size 

descend 1cm/day 

process can speed up if mother is nursing 

what state does the puerperal uterus tend to remain in

tonic contraction w

what is the effect of the infant suckling

oxytocin releases causing uterine contractions

occasionally analgesic

when does lochia occur 

early in pueperium 

describe lochia

early in peurperium

sloughing of decidual tissue

vaginal discharge of variable quantity following childbirth

what is lochia rubia

blood in lochia

when does lochia rubra occur

first few days after delivery

wehn does lochia serosa occur

after 4 days

when does lochia alba occur 

after the 10th day 

describe lochia serosa appearance

progressively more pale in color

describe lochia alba appearance

white or yellowish color

how long does lochia persis for

2-4 weeks after delivery

when does mensturation occur without nursin 

6-8 weeks 

when does mensturation occur with constant nursing

prolactin levels prevent ovulation

mensturation returns after nursing