Postpartum Hemorrhage High Risk

Postpartum High Risk

• Postpartum complications can include hemorrhage, venous thromboembolic disease (DVT, pulmonary embolism), infection, postpartum mood disorder, and gestational diabetes.
• Postpartum care is important to reduce the risk of complications.
• Nursing assessments can identify potential complications so prompt interventions can occur.

Hemorrhage

• Postpartum hemorrhage is a blood loss of >500 mL for vaginal delivery and >1000 mL after a cesarean section.
• Early postpartum hemorrhage occurs within 24 hours after birth.
• Late postpartum hemorrhage occurs from 24 hours to 6 weeks after birth.
• Postpartum Hemorrhage is a leading cause of maternal death globally (WHO, 2015).
• Any amount of bleeding that places the mother in hemodynamic jeopardy could be hemorrhage.
• Active management during the third stage of labor with placenta delivery is essential.
• Postpartum Hemorrhage occurs in 18% of births and is the most common maternal morbidity in developed countries.
• Risk factors for postpartum hemorrhage include neonatal macrosomia (birth weight >4,000 g) and previous cesarean sections or operative vaginal delivery.
• Prolonged first and second stages of labor with ineffective contractions and weakened muscles may lead to PP hemorrhage.
• Other risk factors for hemorrhage are placenta previa or accreta, multiple gestations/high parity with frequent uterine stretching, polyhydramnios with large amounts of amniotic fluid, and augmented or induced labor.

Pathophysiology

• The "4Ts" includes tone (uterine atony), tissue (retained placental fragments), trauma (during labor and birth), and thrombin disorders (coagulopathy).
• Uterine atony is the most common reason for postpartum hemorrhage.
• Indications of postpartum hemorrhage include a 10% decrease in hemoglobin/hematocrit, saturation of peripad within 15 minutes (weigh pad), and a boggy fundus after fundal massage.
• Late signs of postpartum hemorrhage include tachycardia (compensates for hypotension) and decreased blood pressure (hypovolemia).
• Causes for uterine atony include a large baby, multiples, high parity, prolonged labor, induction of labor, or fever.
• Signs/symptoms of uterine atony present with slow and steady or profuse bleeding and a large, boggy uterus.
• Nursing actions for uterine atony involve fundal massage, weighing pads (1 gm = 1 mL), monitoring vital signs and labs, as well as administering oxygen.

Retained Placenta

• Retained or abnormal placenta are the primary causes for hemorrhage related to retained tissue.
• The uterus may not respond to interventions with a retained placenta.
• Signs/symptoms include uterus not responding to interventions, larger fundus, prolonged lochia rubra, and strings of tissue in blood.
• Nursing actions for retained placenta involve calling the provider (dilation and curettage may be needed), monitor signs of shock, and consider oxygen at 10-12 L per mask.

Placenta Accreta

• Placenta accreta is the abnormal adherence of the placenta to the myometrium of the uterine wall, which increases risk for postpartum hemorrhage.
• Diagnosis typically occurs after birth when the placenta does not separate.
• This can by diagnosed antenatally via ultrasound and MRI.
• Risk factors include advanced maternal age, smoking, and previous cesarean birth.
• Approximately 1 in 2,500 pregnancies experience placenta accreta, increta, or percreta.
• Placenta accreta is assessed in stage 3 of labor if the placenta does not deliver.
• Management/nursing actions include monitoring for increased risks of postpartum hemorrhage and hysterectomy, which depend upon the severity.
• Placenta Accreta involves the placenta attaching too deep in the uterine wall but not penetrating the uterine muscle, and accounts for 75% of cases.
• Placenta Increta involves the placenta attaching even deeper into the uterine wall and penetrating into the uterine muscle; it accounts for 15% of cases.
• Placenta Percreta involves the placenta penetrating through the entire uterine wall and attaching to another organ like the bladder, and accounts for 5% of all cases.

Trauma

• Trauma includes lacerations, which may result from birth trauma.
• Signs/symptoms for trauma include a firm uterus with continued bleeding and a steady trickle of unclotted, bright red blood, which is new blood that is not coming from the uterus.
• Nursing actions are to call the provider to evaluate, locate, and repair the laceration, monitor vital signs and lochia, and weigh pads and underpads to monitor blood loss.
• Inversion of the uterus may be a cause of postpartum hemorrhage that requires emergency management.
• Hematoma include vulvar, vaginal, cervical, or retroperitoneal.
• Signs/symptoms can include a firm uterus, sudden onset of painful perineal pressure, and a bulging area just under the outer layer of skin with difficulty voiding or sitting due to blood pooling.
• Nursing actions involve assessing visible hematoma, calling the provider, monitoring vital signs, anticipating possible excision, and include an ice pack to the perineum for pain management.

Coagulopathies

• Patient may experience postpartum hemorrhage due to coagulopathies.
• Risk factors include preeclampsia and stillbirth.
• Signs/symptoms may include disseminated intravascular coagulopathy (DIC), oozing from IV sites, bleeding gums, nose bleeds, petechiae, hypotension, signs of shock, and abnormal clotting lab values.
• Nursing actions involve early recognition and prompt interventions and focus on confirming blood loss estimates, monitoring labs and vital signs, managing systemic symptoms, and administering IV fluids, platelets, and by using a mask for oxygen administration.
• Preventative measures for venous thromboembolic events are key.
• Risk factors include smoking and use of oral contraceptives before pregnancy.
• Signs and symptoms of thromboembolic events include calf swelling, erythema, and a positive Homan's sign.
• The nursing actions for such events include adequate circulation via antiembolism stockings, early ambulation, assessing lung sounds, and educating about anticoagulation therapy if indicated.
• It is necessary to avoid aspirin and ibuprofen if a patient is taking anticoagulants to prevent increasing the risk of bleeding with anti-coagulation therapy.
• Therapeutic management of postpartum hemorrhage involves focusing on the underlying cause such as uterine massage, removal of retained placental fragments, antibiotics for infection, repairing lacerations, a uterine tamponade, interventional radiology for ablation, and a hysterectomy as a last resort.

Medications

• Medications for postpartum hemorrhage include uterotonics can be given to all patients postpartum.
• Oxytocin (Pitocin) is a hormone/oxytocic, promotes uterine smooth muscle contractions, route/dose: 10-20 units IV or 10 units IM, and can never be given as bolus IV undiluted.
• Side effects of Oxytocin include nausea, vomiting, and water intoxication.
• Methylgonovine (Methergine), an oxytocic/ergot alkaloid, causes contraction only given postpartum.
• It involves direct stimulation of the smooth muscles for sustained uterine contractions
• The route/dose: 0.2mg IM or oral every 2-4 hours for up to 5 doses. Monitor vaginal bleeding and uterine tone.
• Methylgonovine is contraindicated in patients with hypertension because it could increase HTN.
• Misoprostol (Cytotec) is an antiulcer/prostaglandin which causes uterine contractions. The route/dose is 500-1,000 mcg X1 rectal or oral and works faster than other medications.
• Carboprost (Hemabate) are synthetic prostaglandins that control postpartum hemorrhage due to uterine atony, but should be avoided if patient has asthma because it has a potential for bronchospasm.
• The route/dose is 250 mcg IM or intrauterine injection with Asthma.
• The use of Carboprost is contraindicated for patients who have active cardiac, pulmonary, or hepatic disease.
• Tranexamic Acid (TXA) is an antifibrinolytic agent which improves blood clotting.
• The route/dose is 1 gm slow IV injection or diluted in 50-100 mL IV fluid and administered over 10 minutes, which is used if other medical interventions are not effective.

Postpartum Infections

• Postpartum infections are a temperature of >38°C or 100.4°F after the first 24 hours, related to dehydration.
• The organisms involved are usually those of normal vaginal flora (aerobic and anaerobic). They also include endometritis (infection of endometrium, decidua and adjacent myometrium).
• Additional infections include wound infections from episiotomy, lacerations, or C-section wounds, urinary tract infections due to a Foley catheter, and mastitis inflammation of the breast.
• Therapeutic management includes prescription broad-spectrum antibiotics for metritis, wound care for wound infections, fluids and antibiotics for UTIs, and breast emptying and antibiotics for mastitis.
• Nursing assessment includes risk factors such as surgical birth, PROM, long labor, and multiple vaginal exams.
• Other signs and symptoms include increased temp, uterine tenderness, foul-smelling lochia, reddened or palpable mass to the breast, and acute pain.
• Depending on the type of infection, nursing actions include hand hygiene and educating on peri care, frequent changing of peri pads to decrease risk for endometritis, breasts latching properly for neonates to prevent cracked or sore nipples, and encouraging frequent feeding to improve mastitis with continual breast feed with antibiotics.
• In addition, wound care is necessary, plus it is important to increase fluids as well as protein in diet and educating the patient about signs and symptoms of infection with a prescription of antibiotics as ordered.

Postpartum Mood Disorders

• Postpartum or baby blues occur in 50-80% of women in the first few days after birth up to 10 days postpartum.
• Symptoms include tearfulness, irritability, sadness, fatigue, and feeling overwhelmed, but this condition is self-limiting with resolves with sleep.
• Postpartum depression occurs within 6 months following birth in 10-15% new mothers.
• Not self-limiting, postpartum depression usually requires intervention. Signs of postpartum depression are persistent feelings of sadness, intense mood swings, and withdrawal from family and friends.
• Postpartum psychosis develops within the first 3 weeks postpartum, requiring immediate psychiatric intervention.
• Signs and symptoms of postpartum psychosis are hallucinations, hypomania, sleep disturbance, and severe depression.
• Nursing includes assessments and screening for depression during pregnancy and postpartum with interventions to recognize signs/symptoms and use tools such as the Edinburgh postnatal depression scale to provide support and discharge education with referrals.

Women with Disabilities

• An increased number of women with disabilities want to become pregnant.
• Adequate healthcare must be provided to these women throughout their pregnancy because healthcare professionals are not properly trained to treat women with physical disabilities (WWPD).
• Health care workers lack confidence in treating women with disabilities. Negative clinical encounters therefore cause women with disabilities to be less likely to seek out necessary care from an Ob-Gyn or midwife during the prenatal and postnatal period.
• Suboptimal health-seeking behavior is a serious concern as WWPD are at a higher risk for Cesarean section and adverse pregnancy outcomes such as early labor, preterm birth, pre-eclampsia, autonomic dysreflexia, and offspring with low birthweight.
• A lack of knowledge about pregnancy in women with ID and barriers, such as healthcare provider attitudes toward disability, puts the pregnant woman at a higher risk for complications of pregnancy.
• Women with spinal cord injuries and IDD are especially at risk.
• The needs of women with IDD in pregnancy are varied, and they may need significant support with feeding skills and other care related to the health and baby's safety.

Case Study

• A.W. is a 34 year-old G4P4 who delivered a female vaginally 2 hours ago. the baby weighed 8 pounds and had APGARs of 8 and 9. The patient has a history of hypertension, does not void since before delivery, and the nurse enters the room to assist her to the bathroom.
• The nurse takes the following vital signs and the patient is dizzy: Pulse 100, BP 100/68, RR 20, T 98.9. The first thing to assess is the fundus.
• When performing a fundal assessment, the patients fundus is palpable 2cms above the umbilicus and deviated to the right side; it is not firm, a large amount of blood and clots are saturating the pads.
• Priority nursing interventions at this time include massaging the fundus, assessing lochia, and weighing pads.

Therapeutic Management

• When a fundus is massaged and it remains boggy, a provider is to be called to order medication.
• In the setting, Methylgonovine (Methergine), cannot be used due to the patient's history of hypertension.
• Interventions to manage postpartum include uterine massage, administration of IV fluids and oxygen, weighing peri pads, and emptying the patients bladder.

Summary

• The most common causes of severe maternal morbidity and mortality postpartum are preventable.
• Most complications can occur after discharge, yet only 60% of women receive follow-up care postpartum.
• Nurses have a key role in prevention, early identification, and postpartum follow-up.