Nursing Care 109: Post-Partum Hemorrhage

• Nursing Care Management 109 focuses on care for mother and child at risk.
• Students will learn to identify the causes of post-partum hemorrhage and dystocia.
• Students will also learn to identify nursing care management for both complications and design a nursing care plan.

Post-Partum Hemorrhage (PPH)

• Post-partum hemorrhage(PPH)remains a major cause of maternal mortality and morbidity worldwide.
• Approximately half a million women die annually from causes related to pregnancy and childbirth.
• PPH refers to any amount of bleeding from or into the genital tract following birth of the baby up to the end of puerperium impacting the mother's general condition, presenting as increased pulse rate and falling blood pressure.
• PPH is generally defined as blood loss greater than or equal to 500ml within 24 hours after birth.
• Severe PPH is defined as blood loss greater than or equal to 1000ml within 24 hours.

Types of PPH:

• Primary post-partum hemorrhage is the hemorrhage occurring during the third stage of labor and within 24 hours of delivery.
• Secondary post-partum hemorrhage is hemorrhage occurring after 24 hours of delivery and within 6 weeks of delivery; it is also referred to as puerperal hemorrhage.

Causes of Primary PPH:

• Atonic uterus.
• Trauma Mixed (combination of both atonic and trauma).
• Retained product of conception.
• Uterine rupture.
• Uterine inversion.
• Blood coagulopathy.

Causes of Secondary PPH:

• Retained bits of cotyledon or membranes.
• Infection.
• Cervico-vaginal laceration.
• Endometritis.
• Subinvolution of the placental site.
• Secondary hemorrhage from caesarean section.
• Rare causes include: chorion epithelioma, carcinoma cervix, placental polyp, fibroid polyp and puerperal inversion of.

Risk Factors for PPH:

• Prolonged third stage of labor.
• Multiple delivery.
• Episiotomy Fetal macrosomia.
• History of postpartum hemorrhage.
• Grandmultiparity.
• Placenta previa.
• Placental abruption.
• Pregnancy induced hypertension.

Symptoms of PPH:

• Massive blood loss.
• Passing large clots.
• Dizziness.
• Lightheadedness or fatigue.
• Decreased blood pressure.
• Increased heart rate.
• Swelling and pain in tissues in the vaginal and perineal area.

Etiology of PPH (The 4 T's):

• Tone: Uterine atony.
• Tissue: Retained placenta.
• Trauma: Lacerations, uterine rupture.
• Clotting: Coagulopathy.

Further Explanation of the 4 T's:

• Tone (Abnormality of Uterine Contraction):
  • Over distended uterus.
  • Uterine muscle exhaustion / Uterine Atony [90%].
  • Intra amniotic infection.
  • Functional/anatomic distortion of the uterus.
• Tissue (Retained Product Of Conception):
  • Retained products.
  • Abnormal placenta.
  • Placenta Praevia /Abruptio Placenta.
  • Blood clots and cotyledon.
• Trauma [At Genital Tract]:
  • Cervix, vagina, perineum laceration.
  • Caesarean section laceration.
  • Uterine rupture.
  • Uterine inversion.
• Thrombin (Abnormality Of Coagulation):
  • Coagulopathy.
  • Therapeutic.

Atony:

• Retained products of conception, most often a retained placenta or retained placental fragments, require removal to stop the bleeding.
  • Management includes:
    • Uterine massage.
    • Medications (oxytocin,carboprost).
    • Gauze packing.
  • Surgical options:
    • Uterine Curettage.
  • Uterine Artery Ligation.
  • Hysterectomy.

Retained Products of Conception:

• Most often a retained placenta or retained placental fragments, must be removed to stop the bleeding.
  • Management:
    • Oxytocin.
  • Surgical:
    • D&C.
  • Administration of prophylactic antibiotics.

Trauma:

• Trauma resulting from the birth process can result in significant blood loss therefore, the source of trauma must be quickly identified and treated.
• Vaginal bleeding is visible outside, either as slow trickle or rarely a copious flow.
• Rarely, the bleeding is concealed either remaining inside the uterovesical canal or in the surrounding tissue space resulting in hematoma.
  • Management:
    • Emergency laparotomy.
    • Resuscitation.
    • Broad spectrum antibiotics.
    • Observation for about two hours after delivery to make sure that the uterus is hard and well contracted before sending women to ward.
    • Adequate post-operative care.

Clotting:

• Any derangement of hemostasis resulting in either excessive bleeding or clotting, although most typically it is defined as impaired clot formation.
  • Examples:
    • Abruptio placenta.
    • Amniotic fluid embolism.
    • Retained dead fetus.
    • Inherited coagulopathy.

Prevention of PPH:

• Antenatal:
  • Improvement of the health status.
  • Managing high risk patients.
  • Knowing the Blood group.
• Intranatal:
  • Slow delivery of the baby.
  • Expert obstetric anesthetist needed.
  • Spontaneous separation and delivery of placenta during caesarean section.
  • Active management of third stage of labor.
  • Examination of placenta.
  • Induced or accelerated labor by oxytocin.
  • Exploration of utero-vaginal canal.
  • Observation of the patient for about two hours after delivery.

FIGO Recommendations for Prevention and Treatment of PPH:

• Prevention: Active management of the third stage of labor requires:
  • Administration of uterotonic agents (oxytocin 10 IU IM or misoprostol 600 µg orally if oxytocin is neither available nor feasible).
  • Controlled cord traction.
  • Uterine massage after delivery of the placenta, as appropriate.
• PPH is indicated with:
  • Vaginal delivery >500 mL of blood loss.
  • Cesarean delivery >1L of blood loss.
  • Any volume of blood loss with unstable woman.
• If ongoing bleeding:
  • Monitor maternal status, Airway, Breathing, and Circulation, IV access.
  • Give a Fluid bolus (aim to keep blood pressure >100/50mm Hg).
  • Oxytocin 20-40 IU/L IV fluid infusion.
  • Give blood products if available.
• Control bleeding by:
  • Aortic compression.
  • Uterine tamponade for atony.
  • Secure IV access.
  • Uterine massage.
  • Empty bladder.
  • Examination to determine cause of bleeding (there may be multiple causes).

Algorithms for Trauma, Tissue, Thrombin, and Tone:

• Trauma: Address episiotomy, hematoma, or ruptured uterus, and consider surgical repair; for uterine inversion, focus on immediate reinversion, recognizing it as life-threatening, and seek immediate consult.
• Tissue: For retained tissue, remove manually or with curettage, and prepare for D&C or possible surgery; for invasive tissue (placenta accreta).
• Thrombin: Address coagulopathy with coagulation studies (PT, PTT, platelet, fibrinogen) followed by FFP, RBC, or Cryoprecipitate administration.
• Tone: Address uterine atony
  • Administer 15-methyl prostaglandin F2 alpha (Hemabate) 0.25 to 1 mg IM or intramyometrially; may repeat in 15 min
• If hemorrhage still not controlled:
  • Transfer to operating room for:
    • :Intrailiac artery ligation/embolization or vasoconstriction
• *If at any time a patient has unstable vital signs or severe hypotension, consider:
  • Central IV line
  • MAST trousers (ABD and legs).
  • Prepare for emergency surgery
• Uterine artery ligation
• Hysterectomy

Active Treatment of PPH:

• Rub the uterus to stimulate contraction and retraction.
• Administer ergometrine (0.2mg) intramuscularly.
• Syntometrine (1 ml) intramuscularly may be given instead of ergometrine.
• Expel the placenta with the next uterine contraction by fundal pressure or controlled cord traction.
• Empty the urinary bladder by catheterization.
• A second dose of syntometrine or ergometrine may be given in ten minutes if bleeding is not controlled.

Treatment of True PPH:

• Uterine Massage:
• If the uterus is soft, massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall and the posterior aspect of the uterus is massaged with the abdominal hand and the anterior aspect with the vaginal hand.
• Uterotonic agents include oxytocin, ergot alkaloids, and prostaglandins.
• Oxytocin - 10 international units (IU) should be injected intramuscularly, or 20 IU in 1 L of saline may be infused at a rate of 250 mL per hour; As much as 500 mL can be infused over 10 minutes without complications.
• Methylergonovine (Methergine) and ergometrine, a typical dose of methylergo-novine, 0.2 mg administered intramuscularly, may be repeated as required at intervals of two to four hours.
• Carboprost can be administered intramyometrially or intramuscularly in a dose of 0.25 mg; this dose can be repeated every 15 minutes for a total dose of 2 mg.
• Misoprostol is another prostaglandin; It can be administered sublingually, orally, vaginally, and rectally. Doses range from 200 to 1,000 mcg and, the dose recommended by FIGO is 1,000 mcg administered rectally.
• Lacerations and hematomas resulting from birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair.
• Uterine Rupture - Symptomatic uterine rupture requires surgical repair of the defect or hysterectomy.
• Uterine inversion is rare.

Hysterectomy

• A surgical operation to remove all or part of the uterus in case of life threatening condition of the women i.e., menorrhagia, post-menopausal period.
• Types of Hysterectomy: Partial, Total, and radical.

Dystocia:

• Defined as long, difficult or abnormal labor, is a term used to identify poor labor progression.
• May arise from any of the three major components of the labor process: the powers (uterine contractions), the passenger (fetus), or the passageway (maternal pelvis).
• May be related to maternal positioning during labor, as well as fetal malpresentation, anomalies, macrosomia and multiple gestation.
• Maternal psychological responses to the labor, based on past experiences, cultural influences, and the woman's present level of support may play a role in the normal progress of labor.

Factors Associated with an Increased Risk for Uterine Dystocia:

• Uterine abnormalities, such as congenital malformations and overdistention (e.g., hydramnios, multiple gestation).
• Fetal malpresentation or malposition.
• Cephalopelvic disproportion (CPD).
• Maternal body build (30 lbs. [13.6 kg] overweight, short stature).
• Uterine overstimulation with oxytocin.
• Inappropriate timing of administration of analgesic/anesthetic agents.
• Maternal fear, fatigue, dehydration, electrolyte imbalance.

Pelvic Dystocia:

• Occurs when contractures of the pelvic diameters reduce the capacity of the bony pelvis, the midpelvis, the outlet, or any combination of these planes.
• Contractures of the maternal pelvis may result from malnutrition, neoplasms, congenital abnormalities, traumatic spinal injury, or spinal disorders.
• Immaturity of the pelvis may predispose some adolescent mothers to pelvic dystocia.
• During labor, contractures of the inlet, midplane, or outlet can cause interference in engagement and fetal descent, necessitating cesarean birth.

Soft Tissue Dystocia:

• Occurs when the birth passage is obstructed by an anatomical abnormality other than that involving the bony pelvis.
• The obstruction, which prevents the fetus from entering the bony pelvis, may be caused by placenta previa, uterine fibroid tumors (leiomyomas), ovarian tumors, or a full bladder or rectum.
• Bandl ring is a pathological retraction ring that develops between the upper and lower uterine segments.
• It is associated with protracted labor, prolonged rupture of the membranes, and an increased risk of uterine rupture.