Post Partum Hemorrhage

Definition:

Hemorrhage in the postpartal period is described as either early or the immediate and late or the delayed postpartal hemorrhage. Early postpartal hemorrhage occurs in the first 24 hours after childbirth while the late postpartal hemorrhage occurs from 24 hours to 6 weeks after birth. The traditional definition of hemorrhage has been a loss of more than 500 mL of blood following childbirth and the average blood loss after cesarean childbirth exceeds 1000 mL. As the amount of blood loss increases, as in the case of hemorrhage, estimates are likely to be even less accurate.

Predisposing Factors:

• Overdistention of uterus due to large baby, multiple gestation or multiparity
• Rapid or prolonged labor
• Oxytocin induction of labor
• Precipitous delivery
• C-section
• PROM
• Urinary catheterization

Signs and Symptoms:

• Excessive or bright red vaginal bleeding

Rationale: Assess lochia during the postpartum period, noting any excessive amount, any large blood clots, or any foul odors emitted from the lochia. Saturating 1 pad in less than an hour, a constant trickle of lochia, or the presence of large blood clots is indicative of more serious complications (eg, retained placental fragments, hemorrhage) and should be investigated immediately.

• A boggy fundus that does not respond to massage

Rationale: As with all other body systems, the musculoskeletal system undergoes changes during the postpartum period. Relaxin is the hormone responsible for the relaxation of the pelvic ligaments and joints during pregnancy

• Abnormal clots

Rationale: It will indicate retained placental fragments.

• Any unusual pelvic discomfort or backache

Rationale: Afterpains, intermittent uterine contractions, are a normal occurrence during the postpartum period. Afterpains are caused by the release of the hormone oxytocin and the subsequent relaxation and contraction of the uterine muscles.

• Decreasing blood pressure and increasing pulse

Rationale: Immediately after delivery, the blood pressure should remain the same as it was during delivery. An increase in blood pressure could indicate pregnancy-induced hypertension, while a decrease could indicate shock or orthostatic hypotension. Bradycardia is normal immediately after delivery; however, tachycardia could indicate hemorrhage or infection and should be monitored carefully.

• Persistent bleeding in the presence of a firmly contracted uterus

Rationale: If a patient has a significant amount of bleeding despite a firm fundus, there may be a laceration in the birth canal, which would need to be addressed immediately. Furthermore, foul-smelling lochia typically indicates an infection and needs to be addressed immediately.

• Decreasing urinary output

Rationale: The bladder, urethra, and urinary meatus are edematous after delivery as a result of the fetal head passing through the birth canal. Bladder tone is diminished, and many patients are unable to feel the need to void, despite the rapid diuresis that occurs following delivery.

• Decreased level of consciousness

Diagnostic Exams:

• Physical examination
  • Temperature – elevated temperature may indicate endometritis (infection of the lining of the uterus) which may cause secondarypostpartum hemorrhage.
  • Blood pressure and Pulse rate to help determine presence of shock
  • Feel abdomen to determine how much the uterus has contracted down into the pelvis and establish if the uterus is tender
  • Vaginal examination to determine if opening of the cervix is open or closed and to determine if vaginal discharge is offensive
  • Examine the genital area to look for any lacerations, tears or episiotomy wounds which may contribute to postpartum hemorrhage
• Blood test
  • Full blood count
  • Coagulation profile including INR, PT, APTT
  • More sophisticated bleeding disorder tests depending on suspicion – e.g. Hemophilia screening, von Willebrand’s disease, platelet function studies, platelet antibodies.
• Swab of vaginal discharge – for microscopy and culture.
• Radiological investigations
  • Pelvic ultrasound scan to exclude retained products and clots in the uterus

Medical Management:

• Oxytocin
• Methergine
• Ergonovine Maleate
• Prostaglandin
• Oxygen Therapy
• Intravenous Fluid  (Normal saline solution)

Surgical Management:

• Dilatation and Curettage
• Total hysterectomy

Nursing Diagnosis:

• Defficient Knowledge related to lack of information about signs of delayed postpartal hemorrhage
• Fluid Volume deficit related to blood loss secondary to uterine atony, lacerations, or retained placental fragments

Nursing Management:

1. Monitor amount of bleeding by weighing the perineal pads

Rationale: To measure amount of blood loss

2.  Frequently monitor vital signs

Rationale: Early recognition of possible adverse effects and allows for prompt intervention

3.  Massage the uterus

Rationale: To help expel the blood clots and to check the tone of the uterus

4. Provide comfort measure like back rubs and deep breathing

Rationale: Promotes relaxation and may enhance patients’ coping

5. Administer oxygen as ordered

Rationale: To supply adequate oxygenation for the fetus and mother

6. Administer medications as indicated

Rationale: To promote contraction and prevent bleeding

7. Examine perineal area for signs of hematoma

Rationale: To prevent further complications

8. If there is hematoma, provide hot sitz bath for the client

Rationale: To relax muscle and prevent infection

9. Maintain bedrest

Rationale: Systematic rest is mandatory and important throughout all phases of diseases and to reduce fatigue

10. Monitor type of bleeding

Rationale: Provide objective evidence of bleeding

11. Monitor uterine contractions

Rationale: To assess if the cause of bleeding is not well contracted uterus

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