Four Main Reasons for Postpartum Hemorrhage

Four Main Reasons for Postpartum Hemorrhage

• Uterine Antobt

• Trauma

• Retained placental fragments

• Development of Disseminated Intravascular Coagulationn (DIC)

4 T’s of Postpartum Hemmorage

• Tone

• trauma

• Tissue

• Thrombin

Tone (Uterine Atony)

• Uterine atony, or the uterus relaxing after childbirth, is the most common cause of postpartum bleeding. It’s more likely to happen to Asian, Hispanic, and Black women.

• If the uterus suddenly relaxes, there will be an abrupt gush of blood vaginally from the placental site.

• The best safeguard against uterine atony is to palpate a woman’s fundus at frequent intervals to be assured her uterus is remaining contacted.

• Regular assessments on the lochia (to make sure the flow is under a saturated pad per hour and that any clots are small) and vital signs, like pulse and blood pressure, are equally important.

Therapeutic Management (Tone)

• Fundal massage

• If a woman’s uterus does bot remain contracted, contact her primary care provider so interventions to increase contraction will be given

• Drugs available for postpartum hemmorage

  • Oxytocin (Pitocin)

  • Methylergonovine maleate (Methergine)

  • Carboprost tromethamine (Hematite)

  • Misoprostal (Cytotec)

Additional Measures to Combat Uterine Atony

• Elevate the woman’s lower extremities to improve circulation to essential organs.

• Offer a bedpan at least every four hours to ensure her bladder is emptying, as a full bladder increases the risk of uterine atony. Alternatively, insert a urinary catheter to reduce the likelihood of bladder pressure.

• Administer Oxygen by a face mask at a rate of about 10 to 12 L/min if the woman is experiencing respiratory distress from decreasing blood volume. Position her supine (flat) to allow adequate blood flow to her brain and kidneys.

• Obtain vital signs frequently and assess them for tends such as continually decreasing blood pressure with continuously rising pulse rate

If fundal massage and administration of uterotonics (drugs to contract the uterus) are bot effective at stopping uterine bleeding, ___________

A sonogram may be done to detect possible retained placental fragments

During Uterine Atony, the primary care provider may attempt to do:

1. Bimanual compression

2. Blood replacement to replace blood loss with postpartum hemorrhage

3. Hysterectomy or suturing (last resort, ligation of the uterine arteries or a removal of the uterus

Trauma

• 20% of postpartum hemorrhage cases

• Cause:

  • Lacerations and episiotomy

  • Hematoma

  • Cesarean Section

  • Uterine rupture and uterine inverion

  • UTerine perforation during forceps application or curettage

Lacerations (cervix, vagina, or perineum)

Birth canal lacerations are pretty common, but big ones can be serious and lead to infection or bleeding.

Cervical Lacerations

• Usually found on the sides of the cervix, near the branches of the uterine artery. If the artery is torn, blood loss can be so severe that blood gushes from the vaginal opening and is much brighter red than the blood lost during uterine atony.

• Therapeutic Management

  • The repair of cervical lacerations, it usually needs stitches. But sometimes, if the bleeding is too heavy, it can be hard to see the cut clearly. In those cases, might need to give the person some local anesthesia to relax the muscles around the cut and make it easier to work. Also make sure the primary care provider has enough space to work, plenty of sponges and suture supplies, and a good light source.

Vaginal Lacerations

• Easier to locate and assess than cervical laceration because they are much easier to view

• Therapeutic Management

  • Vaginal tissue is friable making it difficult to suture. Some oozing often occurs after cagina repair, so the vagina maybe packed to maintain pressure on the suture line. An indwelling urinary catheter may be place follow the repair because the packing causes such pressure on the urethra that I can interfere with voiding.

  • Document when and where packing was placed so you can be certain it is removed after 24 to 28 hours or before hospital discharge to prevent infection

Perineal Laceration

• More apt to occur when the woman is paced in lithotomy position for birth rather than supine position because a lithotomy position increases tension on the perineum

• Classification

  • 1st degree

  • 2nd degree

  • 3rd degree

  • 4th degree

Perineal Laceration: 1st degree

Vaginal mucous membrane and the skin of the penne, to the forchette

Perineal Laceration: 2nd degree

Vagina, perineal skin, fascia, levator anti muscle, and perineal body

Perineal Laceration: 3rd degree

entire perineum, extending to reach the anal sphincter

Perineal Laceration: 4th degree

Entire perineum, rectal sphincter, and some of the mucous membrane of the rectum and some of the mucous membrane of rectum

Perineal Hematoma

• Collection of blood in the subcutaneous layer of tissue of the perneum

• As A RULE: Overlying skin is intact with no noticeable trauma

• Hematomas are most likely to occur after rapid, spontaneous births and in women who have perineal varicosities. Injury to the vagina and the perineum during delivery may cause swelling, Bruising or a collection of blood under the skin.

• Small hematomas usually go away without treatment. Painful large hematomas may need drainage of the blood that collects in them.

Therapeutic Management for Perineal Hematomy

• Administer mild analgesic for pain relief

• Apply ice pack (covered with a towel to prevent thermal injury to the skin) may prevent bleeding. Usually, a hematoma is absorbed over the next 3-4 days.

• If hematoma is large or continues to increase in size, the woman may have to be returned to the birthing room ro have the site incised and the bleeding vessel ligated under local anesthesia.

Uterine Inversion

• Prolapse of the fungus of the uterus through the cervix so that the uterus turns inside out. Usually occurs right after birth of the fetus or delivery of the placenta

• Occurs in about 1 in 20,000 births

• Causes:

  • May occur if traction is applied to the umbilical cord to remove the placenta or if pressure his applied to the uterine funds when the uterus is not contracted.

  • May also occur if the placenta is attached at the fungus so that during birth, the passage of the fetus pulls the fundus downward

When inversion occurs:

• A large amount of blood suddenly gushes from the vagina

• The fund is no longer palpable in the abdomen

• The women begins to show sighs of blood loss; hypotension, dizziness, paleness, or diaphoresis

• The uterus is not able to contract in this position, bleeding can’t be halted or will continue to such an extent exsanguination could occur within 10 min.

Uterine Inversion Management

• An IVF line is inserted if one os not already present, open for restoration of fluid

• Use a large gauge needle because blood will need to be replaced

• Administer oxygen by mask

• Assess vital signs especially BP and pulse

• Be prepared to perform cardiopulmonary resuscitation (CPR) if the ear should fail from sudden blood loss

• The women will immediate beg even anesthesia or possibly nitroglycerin or tocolytic drug by IV to relax the uterus

• The primary care provider then replaces the fundus manually

• Administer oxytocin after manual replacement helps the uterus to contact and remain in its natural place.

• The women will need antibiotic therapy to prevent infection because the uterine endometrium was exposed.

• Inform the client that cesarean birth will probably be necessary in any future pregnancy to prevent the possibility of repeat inversion

Tissue

• Presence of retained placental tissues prevents full uterine contractions resulting in failure to seal off bleeding vessels.

• Cause:

  • Presence of succenturiate or accessory lobe

  • Preterm gestation especially in less than 24 weeks gestation

• Identify the complication of a retain placenta ( Severe postpartum hemorrhage), every placenta should be inspected carefully after birth to be certain it is complete.

• How to detect retained placental fragments?

  • Ultrasound

  • Bood serum sample for presence of HCG reveal that part of placenta is present

Therapeutic Management: retained Placental Fragments

• Dilation and Curettage (D & C) - removal of the retained placenta fragment is necessary to stop the bleeding

• If it cannot be removed, Methotrexate may be prescribed to destroy the retainer placental fragment

• Balloon occlusion and embolization of the internal iliac arteries may be necessary to minimize blood loss in some instances of placenta accrete which is so deeply attached to the myometrium

• In others , hysterectomy (removal of the uterus)must be performed

Thrombin: Coagukopathy

Cause:

• Presistent coagulation disorder: thombocytopenic purpura

• Acquired disorder: Preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count)

• Dilution coagulopathy is which clotting factors are significantly reduced with aggressive transfusion of crystalloid and packed red blood cells

Thrombin: Coagulopathy | Predisposing Factors

• Abruptio placenta

• Amniotic fluid embolisnm

• Endotoxic shock

• Eclampsia and pre-eclampsia

• Hyatidiform mole

• IUFD and missed abortion

• Incompatible blood transfusion

• Prolonged shock of whatever the cause

• Placenta accreta

• Rupture of uterus

Thrombin: Coagulopathy | Clinical Features

• Unexplained spontaneous bleeding from any site

• Oozing of blood

• Bruising

• Epistaxis

• Hematuria

• Hematoma formation especially at wound and venipuncture sire

• Postpartum hemorrhage

Thrombin: Coagulopathy | Management

• Elimination of the underlying cause

• Fresh blood transfusion: contains clotting factors esp F II, V, and VII

• Fresh frozen plasma contains 3gm fibrinogen/L in addition to F V and VIII

• Fibrinogen

• Heparin

• Antifibrinolytic

Subinvolution

• Incomplete return of the uterus to its pre-pregnant size and shape

• With sub involution at 4 to 6 weeks pospartal best, the uterus is still enlarge and soft. Local discharge is still present.

• Subinvolution may result in small retained placenta fragments, a mild endometritis, or an accompanying problem such as a uterine myopia that is interfering with complete contraction

Therapeutic Management for Subinvolution

• Oral administration of Methylergonovine: 0.2 mg 4x daily to improve uterine tone and complete involution

• Oral antibiotic: If uterus feels tender upon palpation suggesting endometritis

• Be certain the women are able to recognize the normal process of involution and local discharge, this helps the women identify subinvolution and seek early care if it occurs

• A chronic loss of blood from sub involution will result in anemia and a lack of energy, conditions that possible could interfere with infant bonding or lead to infection