Week 9-Postpartum Hemorrhage

Postpartum Hemorrhage (PPH)

Definition of Postpartum Hemorrhage

  • Postpartum hemorrhage (PPH) refers to excessive bleeding following childbirth.

  • Quantitative Definitions:

    • Excessive bleeding is defined as:

    • 500 mL after a vaginal delivery.

    • 1000 mL after a cesarean section.

  • Clinical Definition: Any blood loss that leads to signs and symptoms of hypovolemia such as tachycardia, hypotension, and pallor is considered a hemorrhage, regardless of the quantity of blood lost.

Incidence and Importance

  • Occurs in 5-10% of births worldwide.

  • Leading cause of maternal morbidity and mortality globally, accounting for 25% of maternal deaths, especially in low-resource settings.

Causes of Postpartum Hemorrhage: The Four T's

  • Tone (80%):

    • Uterine atony: Failure of the uterus to contract, identified as the most common cause of PPH.

  • Tissue:

    • Retained placenta or fragments.

    • Abnormal placental adherence (accreta, increta, previa).

  • Trauma:

    • Lacerations in the genital tract (cervical, vaginal, perineal), uterine rupture, or inversion.

  • Thrombin:

    • Coagulation disorders (e.g., DIC, preeclampsia, inherited coagulopathy).

Risk Factors for Postpartum Hemorrhage

  • Tone-related:

    • Overdistended uterus due to: twins, polyhydramnios, or macrosomic infant.

    • Prolonged or rapid labor.

    • Chorioamnionitis, magnesium sulfate use.

  • Tissue-related:

    • Retained placenta, previous cesarean delivery.

  • Trauma-related:

    • Instrumental deliveries (forceps, vacuum), episiotomy, cesarean section, or uterine rupture.

  • Thrombin-related:

    • Preeclampsia, placental abruption, stillbirth, sepsis, known bleeding disorders.

  • Note: PPH can still occur without identifiable risk factors.

Prevention of Postpartum Hemorrhage

  • Active management of the third stage of labor:

    • Administer uterotonics (oxytocin) immediately after delivery of the anterior shoulder or baby (typically 10 units IV/IM).

    • Controlled cord traction to prevent premature cord separation from the placenta.

    • Immediate uterine massage following placenta delivery, monitored by nursing staff.

Signs and Symptoms of Postpartum Hemorrhage

  • Early Signs:

    • Tachycardia, rising respiratory rate, anxiety, pallor.

  • Late Signs:

    • Hypotension, altered mental status, oliguria.

  • Heavy bleeding may include:

    • Soaking through at least one pad within an hour.

    • Passing large clots (size of a baseball or larger).

  • Change in mental status can occur, dizziness, lightheadedness, risk of fainting when getting up.

  • Fever greater than 100.4°F, swelling, or pain in vaginal or abdominal areas may indicate retained placental tissue.

Hemorrhagic Shock

  • A life-threatening condition from significant blood loss causing inadequate tissue perfusion and oxygen delivery.

  • Blood loss in women may be underestimated due to their young and healthy status, leading to sudden deterioration.

  • Average blood volume:

    • 100 mL/kg (6-7 liters total).

    • Blood volume increases 30-50% during pregnancy, allowing some tolerance for blood loss.

Classification of Hemorrhagic Shock

  • Class 1:

    • ≤15% blood loss (≤1000 mL).

    • Vital signs typical, may have mild anxiety.

  • Class 2:

    • 15-30% blood loss (1000-1500 mL).

    • Tachycardia (100-120 bpm), tachypnea, narrowed pulse pressure, pale and cool skin.

  • Class 3:

    • 30-40% blood loss (1500-2000 mL).

    • Increased HR (>120 bpm), hypotension, oliguria, confusion, agitation.

  • Class 4:

    • >40% blood loss (>2000 mL).

    • HR >140 bpm, profound hypotension, anuria, possible coma, cold clammy skin.

Physiological Response to Hemorrhagic Shock

  • Compensation:

    • Catecholamine surge leading to tachycardia and vasoconstriction, shunting blood to vital organs.

  • Decompensation:

    • Microcirculatory failure, cellular hypoxia, lactic acidosis, worsened coagulopathy.

  • Lethal triad: acidosis, hypothermia, and coagulopathy.

Diagnosis and Management of PPH

  • Diagnosis is primarily clinical.

  • Do not wait for hypotension; tachycardia and rising respiratory rate are early HM indicators.

  • Immediate Actions in Management:

    • Call for help and activate the massive obstetric hemorrhage protocol.

    • Ensure the patient has two large-bore IV lines (14-16 gauge).

    • Provide oxygen via a non-rebreather mask.

    • Continuous monitoring of BP, HR, SpO2, urinary output (via Foley catheter).

Fluid Resuscitation and Monitoring Guidelines

  • Fluid and blood resuscitation:

    • Begin with 1-2 liters of warmed isotonic saline or Ringer's lactate; avoid excess crystalloids to prevent dilutional coagulopathy.

  • Administer blood products (packed red blood cells, plasma, platelets) in a balanced ratio of 1:1:1 or 2:1:1.

  • Consider fibrinogen replacement and TXA (1 g IV within 3 hours of bleeding onset).

  • Maintain temperature with warm fluids and blankets to prevent hypothermia.

  • Frequent vitals every 5 minutes if unstable.

  • Goal urine output: ≥30 mL/hour.

  • Monitor CBC, coagulation profiles, fibrinogen, lactate regularly.

Complications of Severe Shock

  • Disseminated intravascular coagulation (DIC).

  • Acute kidney injury due to hypoperfusion.

  • Ischemic organ damage (heart, brain, liver).

  • Sheehan syndrome (pituitary ischemia).

  • Potential maternal death.

Lochia Assessment

  • Lochia is the postpartum vaginal discharge comprised of blood, mucus, and uterine tissue as the uterus involutes.

  • Stages of Lochia:

    1. Lochia Rubra: Birth to days 3-4; bright red, bloody, may contain small clots.

      • Normal: Heavy initially, decreasing daily.

      • Abnormal: Saturating a pad hourly, foul odor, large clots (plum size or greater).

    2. Lochia Serosa: Days 4-10 to 14; pinkish-brown, more watery.

      • Return to bright red bleeding suggests secondary postpartum hemorrhage.

    3. Lochia Alba: Days 10 up to 4-6 weeks postpartum; yellowish-white, creamy discharge.

      • Abnormal if foul odor or lasts beyond six weeks.

  • Document lochia’s color (rubra, serosa, alba), amount (scant, light, moderate, heavy), odor, consistency, and any changes over time.

Clinical Red Flags in Lochia Assessment

  • Saturation of a pad in less than an hour.

  • Passage of large clots (plum to baseball-sized).

  • Lochia flow increasing instead of decreasing.

  • Foul-smelling discharge.

  • Lochia rubra persisting beyond day 7.

Nursing Interventions and Education

  • Encourage frequent pad changes for hygiene.

  • Instruct the mother to track lochia (amount, color, odor).

  • Teach the patient when to seek help (heavy bleeding, foul odor, fever, dizziness, large clots).

  • Document findings at each postpartum check-up.

Perineal Lacerations and Their Association with PPH

  • Perineal lacerations can occur during childbirth, either spontaneously or following operative deliveries (forceps, vacuum, episiotomy).

  • Significant source of PPH when bleeding is brisk and arterial.

  • Classifications of Perineal Lacerations:

    1. First Degree: Vaginal mucosa and perineal skin only.

    2. Second Degree: Extends into perineal muscle but not anal sphincter.

    3. Third Degree: Involves anal sphincter; may be divided into 3A, 3B, 3C based on extent.

    4. Fourth Degree: Extends through rectal mucosa.

  • Risk Factors: Instrument delivery, episiotomy (especially midline), advanced maternal age, and multiparity.

  • Important to examine the cervix, vagina, and perineum for laceration or hematoma when PPH is suspected.

Management of Perineal Lacerations

  • Control the hemorrhage with direct pressure; visualize vaginal canal, cervix, and perineum well.

  • Repair first/second degree lacerations with absorbable sutures.

  • Third and fourth degree lacerations often require layered closures in the operating room.

  • Post-op care includes stool softeners, antibiotics, and pain management.

  • Hematomas: Observe if small/stable; incise and evacuate if expanding, ligate bleeding vessels if necessary.

Complications of Severe Lacerations

  • Ongoing hemorrhage leading to hypovolemic shock.

  • Infection risks and long-term complications like anal incontinence, dyspareunia, and fistula formation.

  • Emphasize firm uterus plus bright red bleeding indicates trauma (laceration).

Treatment Steps for PPH

  • Initial Steps:

    • Call for help, assess ABCs (Airway, Breathing, Circulation).

    • Ensure patient has two large bore IVs for blood/fluid administration.

    • Assess and massage uterus if atonic; identify cause using the four T's.

  • Medical Management:

    • Administer oxytocin (IV/IM).

    • Second-line uterotonics if needed (Methergine, Hemabate, Misoprostol).

    • Mechanical interventions include uterine massage and bimanual compression.

    • Surgical interventions: uterine artery ligation, B-Lynch sutures, hysterectomy as a last resort when bleeding is uncontrolled.

  • Blood and coagulopathy management:

    • Activate the massive transfusion protocol early, monitor labs (CBC, coagulation, fibrinogen), administer TXA within three hours of bleeding onset.

Recognizing Signs of Improvement Post-PPH

  • Stabilization of vital signs (HR <100 bpm, BP >90 systolic or MAP ≥65).

  • Improvement in circulation indicators: warm, pink skin, strong pulse quality.

  • Increased urine output (>30 mL/hour).

  • Normalization of lab values (stable hemoglobin, hematocrit, normalizing coagulation profile).

  • General improvement in appearance and mental state: less anxious, better energy, less dizziness/lightheadedness.

  • Ongoing Reassessment: Recovery is continuous; monitor for recurrences of bleeding or instability.