Chapter 16: Postpartum Hemorrhage (PPH)

Question 1

Post-partum Hemorrhage (PPH)

Answer 1

blood loss greater than 500 mL after vaginal birth; 1000 mL or more after cesarean birth

• hematocrit levels decrease 10% from pre to post-birth
• may be a need for a red blood cell transfusion because of anemia or hemodynamic instability

Question 2

Recognizing Obstetric Hemorrhage in a timely manner: Indicators

Answer 2

nurse should quantify blood loss immediately after birth and remain alert to indicators

• maternal heart rate >110 bpm
• 15% drop in blood pressure
• oxygen saturation < 95%

Question 3

Accurately Determining Blood Loss

Answer 3

after childbirth, the nurse weighs all pads, linens, clothing, and clots in the placental basin on a gram scale
>worksheet can be used to facilitate the process of tracking cumulative blood loss

Question 4

An early (primary) postpartal hemorrhage

Answer 4

occurs within first 24 hours after childbirth
-likely within first 4 hours; the blood flow to the uterus is between 500 and 800 mL/min, and the placental site contains multiple exposed venous areas and low resistance
>4 T’s
-tone
-trauma
-tissue
-thrombin
>lack of uterine tone (atony) and genital tract trauma are most common conditions that cause PPH

Question 5

Late (secondary) post-partal hemorrhage

Answer 5

usually within first 2 weeks after birth

• retained placental fragments most common cause
• other causes: subinvolution, uterine infection, and inherited coagulation defects such as von Willebrand (vW) disease (deficiency of von Willebrand factor, protein required for platelet adhesion)

Question 6

4 T’s: Tone

Answer 6

uterine atony; failure of the uterine myometrium to contract and retract following birth

• results in non-compression of uterine arteries and veins at the placental implantation site, thereby preventing hemostasis
• hallmark: soft uterus filled with clots and blood

Question 7

4 T’s: Tone

Answer 7

uterine atony; failure of the uterine myometrium to contract and retract following birth

• results in non-compression of uterine arteries and veins at the placental implantation site, thereby preventing hemostasis
• hallmark: soft uterus filled with clots and blood (evident by soft, blood filled uterus)

Question 8

4 T’s: Trauma

Answer 8

during second stage of labor, soft tissue trauma (from rapid labor, operative delivery, and episiotomy) can result in genital tract lacerations
-if the source of hemorrhage is from genital tract lacerations, the uterus is firm and midline

Question 9

Clinical for post-partal blood loss

Answer 9

in the presence of a firm uterus, continual vaginal bleeding in a slow but steady trickle, with or without clots, can result in significant blood loss
>most maternal deaths from PPH result from ineffective management of slow, steady blood loss

Question 10

Clinical Alert for post-partal blood loss

Answer 10

in the presence of a firm uterus, continual vaginal bleeding in a slow but steady trickle, with or without clots, can result in significant blood loss
>most maternal deaths from PPH result from ineffective management of slow, steady blood loss

Question 11

4 T’s: Tissue

Answer 11

careful examination of the placenta is component standard of care; hence, retained placental tissue is an uncommon cause of early PPH
-if lobe of the placenta are missing, midwife or physician explore the patients uterus to remove them

Question 12

Risk Factors for Postpartum Hemorrhage from Tissue Trauma

Answer 12

• rapid second stage labor
• rapid/precipitous labor (less than 3 hours from onset to delivery)
• operative vaginal deliveries
• fetal manipulation (extrauterine or intrauterine version, corkscrew maneuver for shoulder dystocia; a progressive 180 degree manual rotation of the babies posterior shoulder to release the impacted anterior shoulder)
• large episiotomies
• fetal macrosomia
• cesarean birth
• uterine rupture

Question 13

Recognizing causes of retained placenta

Answer 13

bedside transabdominal ultrasound used to locate the retained products, and manual removal under anesthesia
-risk factors: previous retained placenta, preterm birth, grand multiparity, previous dilation and curettage, previous abortions, induced labor, older maternal age, preeclampsia, and oxytocin use

Question 14

4 T’s: Thrombin

Answer 14

refers to problems with coagulation
-disorders of the coagulation system and platelets usually do not result in excessive bleeding during immediate post-partum period
>preexistent maternal factors such as low fibrinogen levels and idiopathic thrombocytopenia (ITP) and acquired pathology such as HELLP syndrome, disseminated intravascular coagulation (DIC), sepsis, and abruptio placentae require vigilant care and possible hemorrhage after birth

Question 15

Treatment

Answer 15

ergonovine medication (Ergotrate or Methergine), antibiotics, and if necessary, dilation and curettage to remove placental fragments

Question 16

Signs and Symptoms of Subinvolution

Answer 16

lower abdominal (uterine) tenderness with or without fever

• continuation of red vaginal drainage beyond 1 week
• foul-smelling vaginal drainage, regardless of color

Question 17

Recognizing characteristics that point to the source of post-partal bleeding

Answer 17

• color, character, and consistency
• When bleeding is associated with uterine atony or retained placental fragments= blood is dark red with clots and the uterus is soft and boggy
• When bleeding is associated with lacerations= blood is bright red, often without clots, and uterus remains firmly contracted

Question 18

Hypovolemic Shock

Answer 18

can occur if PPH is not managed
-signs of shock: restlessness, anxiety, pallor, cool, clammy skin, increased pulse, tachypnea, shaking, and decreased BP; may not been seen until 30% to 40% of total circulating blood volume has been lost

Question 19

Nursing Diagnosis for Postpartum Hemorrhage

Answer 19

• fluid volume deficit r/t decreased circulating blood volume secondary to uterine atony
• altered tissue perfusion r/t hypovolemia
• fear r/t threat to health and powerlessness
• risk for infection r/t invasive procedures

Question 20

Goals for Patient experiencing a Post-partum hemorrhage

Answer 20

• patient’s circulating blood volume will be maintained and/or the blood volume will be restored to a physiologically adequate level
• peripheral pulses and oxygenation will be maintained
• patient/family express their fears
• patient’s pain will be managed at a level acceptable to her
• patient will maintain normal vital signs and laboratory values

Question 21

Collaborative Management of PPH

Answer 21

standard care requires frequent measurement of vital signs and fundal massage to check the location and condition of the uterine fundus (q 15 in for first hour; thereafter by policy)
-be cognizant of patients prenatal hx
-after locating the uterine fundus and fundal massage, begin frequent vital signs with an automatic device
-palpate the bladder for distention
>the length of time it takes for blood to saturate a perineal pad is a important parameter to record
-total intake and output
-pulse and BP may remain unchanged until a large volume of blood has been lost; pat attention to the mean arterial pressure (MAP) = first indicator of hypovolemia
>note patients behavior, level of consciousness, restlessness, vague complaints, and pain level

Question 22

Medical Management of PPH

Answer 22

administration of uterotonics: Oxytocin (Pitocin)
>others: misoprostol (Cytotec), methylergonovine (Methergine) or ergonovine (Ergotrate), carboprost (Hemabate), and Dinoprostone (Prostin E2)

Question 23

Immediate Intervention for Uterine Atony

Answer 23

begin fundal massage
-support the lower uterine segment by placing a hand in a slight “C” position just above the symphysis pubis
>do not express clots if the uterus does not become firm with massage; clots may protect the patient from an even greater blood loss

Question 24

DIC

Answer 24

a diffuse clotting pathology that involves the consumption of large amounts of clotting factors including platelets, fibrinogen, prothrombin, and factors V and VII
-may cause both internal and external bleeding
-diagnosis is made clinical findings and lab results:
low hemoglobin, low hematocrit, low platelets, low fibrinogen, elevated fibrin split/degradation products

Question 25

Nursing Care

Answer 25

- if patient has a distended bladder, an indwelling urinary catheter needs to be inserted and all intake and output recorded - weigh pads, linens, and other bloody items on a gram scale to obtain an accurate picture of blood loss - can administer 10-12 L/min of O2 to treat compromised tissue perfusion - baseline information: CBC and coagulation studies (PT, PTT, fibrinogen, and fibrin degradation products) - physician orders blood tests with type and cross match for replacement blood - carefully assess for indicators of DIC

Question 26

Oxytocin (Pitocin)

Answer 26

oxytocic -stimulates uterine smooth muscle and produces contractions similar to those that occur during spontaneous labor -Contraindications: hypersensitivity -Nursing Considerations: monitor uterine response, DO NOT administer a bolus of undiluted oxytocin; can cause hypotension and cardiac arrhythmias >consider administration of pain medication for uterine cramping

Question 27

Methylergonovine maleate (Methergine)

Answer 27

ergot alkaloid - causes uterine contractions by stimulating uterine and vascular smooth muscles - used for prevention and treatment of postpartum and post-abortion hemorrhage caused by uterine atony or subinvolution - Contraindications: hypersensitivity, history of or current elevation of blood pressure - Nursing Considerations: keep refrigerated. DO NOT add it to IV solutions or mix in a syringe with other medications. Take precaution to prevent inadvertent administration to the newborn

Question 28

Carboprost tromethamine (Hemabate)

Answer 28

stimulates contractions of the myometrium - Contraindications: asthma, hepatic, renal, and cardiac disease - Nursing Considerations: DO NOT administer if patient demonstrated shock because it will not be well absorbed. Keep refrigerated. Expensive

Question 29

Misoprostol (Cytotec)

Answer 29

stimulates powerful contractions of the myometrium - Contraindications: hypersensitivity to prostaglandins - Nursing Considerations: stable at room temperature. Rectal absorption is likely slower than IV medication

Question 30

Dinoprostone (Prostin E2)

Answer 30

stimulates powerful contractions of the myometrium - Contraindications: hypersensitivity to prostaglandins. AVOID in severe hypotension - Nursing Considerations: monitor uterine response. if vaginal bleeding is brisk, the use of vaginal suppositories is not likely to be effective. Fever is common. Stored frozen, must be thawed to room temperature