Postpartum Hemorrhage Overview

Postpartum Hemorrhage

• Definition: Bleeding more than 500 ml of blood within 24 hours after delivery.
• Normal Blood Loss Ranges:
  • Normal labor: Less than 500 ml
  • Cesarean section: Less than 1000 ml
• Effect of Excessive Blood Loss: More than 600 ml can impact a patient's overall condition.
• Types of Postpartum Hemorrhage:
  • Primary: Bleeding during the third stage of labor.
  • Secondary: Bleeding 24 hours or more after delivery, up to six to eight weeks postpartum.

Causes of Primary Hemorrhage

• Placental Site Bleeding:
  • Uterine Atony: The most common cause (90% of cases). This refers to a uterus that is unable to contract properly after delivery.
  • Factors Contributing to Uterine Atony:
    • Antepartum hemorrhage
    • Severe anemia
    • Prolonged labor and anesthesia
    • Uterine fibroids (myomas)
    • Over-distended uterus
    • Retained portions of the placenta
    • Coagulation factor deficiencies (e.g., hypo-fibrinogenemia)

Causes of Traumatic Postpartum Hemorrhage

• Definition: Bleeding due to lacerations of the vulva, vagina, cervix, or uterus.
• Diagnosis: Assessment relies on observed blood loss and associated bodily responses, such as shock (hypotension, rapid pulse).
• Physical Examinations: (General examination)
  • Assessing vital signs and color/pallor.
    • (Abdominal Examination)
      • Size & feel of the uterus. (atony vs trauma)
    • (Vaginal examination)
      • Nature & amount of bleeding
      • Location of potential injuries

Management of Postpartum Hemorrhage

• During Pregnancy:
  • Detecting and treating anemia.
  • Ensuring hospital delivery with crossmatched blood.
  • Addressing antepartum hemorrhage.
• Labor and Postpartum:
  • Using oxytocin appropriately to prevent prolonged labor.
  • Avoiding unnecessary lacerations (proper anesthesia).
  • Monitoring for and managing the placenta’s expulsion
  • Routine examination of the placenta and membranes.
  • Exploration of the birth canal (cervix) in cases of difficult deliveries.
  • Careful monitoring for the first 1-2 hours post-delivery.
• Treatment:
  • Immediate Anti-shock Measures: Managing blood loss.
  • Depending on the cause:
    • Placenta Site Bleeding:
      • Immediate delivery of the placenta if in progress.
      • Administering ergometrine (and other uterotonic drugs) with gentle pressure to contract the uterus.
      • Brandt-Andrews maneuver, Credé's method (pressure to uterus).
      • Manual removal of the retained placenta pieces.
    • Traumatic Postpartum Hemorrhage: Repairing lacerations.

Secondary Postpartum Hemorrhage

• Causes:
  • Uterus not shrinking down after birth.
  • Infections, especially after C-section or other abdominal wounds.
  • Retained placental fragments.
  • Malignant tumors associated with trophoblastic disease (like choriocarcinoma).
  • Infective conditions.
• Management:
  • Treat the cause.
  • Use uterotonic medications.
  • Consider hysterectomy if bleeding is severe and resistant to other treatments.
  • Use blood products. Avoid excess blood loss.
  • Manage shock.

Clinical Presentation & Nursing Management of Postpartum Hemorrhage

• Clinical Pictures:
  • Sudden estrogen withdrawal
  • Bright red bleeding
  • Uterus not shrinking down, or atonic uterus
  • Sepsis / Infection
  • Anemia
• Treatment dependent on cause:
  • Retained placenta parts >> antibiotics
  • Infection >> antibiotics and possibly the uterotonic medication, ergometrine
  • Other causes >> treat the root cause
• Nursing Assessment:
  • Vital signs and general condition
  • Condition of the uterus
  • Nature of bleeding (color, amount)
  • Signs and symptoms of blood loss
  • Amount and color of blood loss

Complications

• Maternal Death: Approximately 10% of cases.
• Acute Renal Failure
• Sepsis
• Embolism
• Anemia
• Failure of Lactation
• Sheena’s syndrome