Postpartum Hemorrhage (PPH)

Postpartum Hemorrhage (PPH)

• Cumulative blood loss of ≥ 1000 ml defines PPH
• PPH can also be defined by signs/symptoms of hypovolemia within 24 hours of birth
• PPH is an obstetric emergency and a leading cause of maternal morbidity worldwide
• Early recognition, readiness to act, and appropriate management are essential for good outcomes

PPH Statistics

• Approximately 127,000 women die annually worldwide from postpartum hemorrhage
• PPH accounts for nearly 25% of all maternal deaths
• 14 million women globally experience an obstetric hemorrhage annually, with most being postpartum hemorrhages
• 70% of hemorrhage deaths were preventable

Types of PPH

• Early (acute or primary) PPH occurs within 24 hours of birth
• Late (secondary) PPH occurs more than 24 hours but less than 12 weeks after birth

Risk Factors of PPH

• Uterine atony
• Overdistended uterus (polyhydramnios, LGA, clots, multiples)
• Uterine inversion, subinvolution
• Incomplete placental separation
• Retained products of conception such as placental fragments and fetal membranes
• Morbidly adherent placenta (placenta accrete syndrome)
• Obesity
• Trauma during birth (forceps, vacuum, C/S)
• Administration of Magnesium sulfate or oxytocin
• Chorioamnionitis
• Prolonged labor
• Precipitous delivery
• Lacerations/hematomas
• Coagulopathies (DIC)

Causes of PPH

Subinvolution of the Uterus

• The uterus remains enlarged with continual lochia discharge
• This can be related to retained placenta fragments or infection
• Signs include fundal height higher than expected, boggy uterus, and prolonged lochia discharge
• Testing includes CBC, cultures (blood, intrauterine/intracervical), and ultrasound
• Treatment involves Dilation & Curettage (D&C), antibiotics, and potentially methylergonovine (methergine) to stimulate the uterus

Inversion of the Uterus

• The uterus turns inside out, either partially or completely
• This is an EMERGENCY
• It can be related to vigorous traction on the umbilical line after delivery, vigorous fundal pressure, prolonged labor, fundal implantation of the placenta (accreta), oxytocin use, or a short umbilical cord
• Signs include pain in the lower abdomen, visualization of the prolapsed uterus, vaginal bleeding, dizziness, low blood pressure, increased pulse, and pallor (shock)
• Treatment involves manual replacement of the uterus to the uterine cavity, possible surgery, and administration of terbutaline
• Nursing care involves assisting with the procedure, IVF, stopping oxytocin, and preparing for surgery if manual replacement is unsuccessful

Retained Placenta

• The placenta has not been expelled after 30 minutes of birth
• Fragments of the placenta may remain in the uterus
• Risk factors include incomplete separation of placenta, entrapment on the placenta by a uterine ring, excessive traction of the umbilical cord, placental tissue abnormally adherent to the uterine wall (accreta), and preterm birth (20-24 weeks)
• Signs include uterine atony, subinvolution or inversion, excessive bleeding or clot larger than a quarter, return of lochia rubra (after progression to serosa alba), malodorous discharge, or elevated temperature
• Testing involves HgB and HCT
• Treatment involves manual removal of the placenta, or D&C; consider administering oxytocin

Lacerations and Hematomas

• Lacerations are tears of soft tissue in and around the birth canal, including episiotomies
• Hematomas are collections of blood within tissues in or around the birth canal
• Risk factors include vacuum or forceps-assisted delivery, precipitous birth, cephalopelvic disproportion (CPD), LGA, malposition infant, prolonged pressure from the fetal head, or previous scarring around the birth canal
• Lacerations present as oozing or trickling of blood with a firm and midline fundus
• Hematomas present as persistent perinatal or rectal pain, bluish/red/purple or bulging mass in or around the birth canal
• Lacerations are treated with repair with sutures
• Hematomas are treated with ligation of the bleeding vessel or surgical incision to evacuate blood

Assessment of PPH

• Assess vital signs, especially pulse, blood pressure, and oxygen saturation
• Hypotension is not usually the first sign of hypovolemic shock
• Diaphoresis, tachycardia, tachypnea, and dizziness are indicators
• Fundal massage
• Quantification of blood loss (QBL)
• Urinary output (UOP) should be assessed with a Foley catheter with urometer inserted hourly
• UOP should be at least 30 mL/hour
• Monitor skin/mucous membrane/lip color, presence/absence of pulses in extremities, and capillary refill
• Passage of clots (clots may be enormous in size)
• Level of consciousness
• Anxiety, apprehension, restlessness, or disorientation

Management of PPH

• Determine the cause of bleeding
• Apply oxygen at 10 liters
• Maintain IV fluids, replacing 1 mL of blood loss with 3 mL of fluid
• Start a 2nd IV (large bore)
• Lab work
• Elevate legs 20°-30° angle to increase perfusion
• Administer medications as prescribed
• Prepare for procedures or surgery
• Reassure the client and family

Postpartum Hemorrhage Medications

• Uterine stimulants:
  • Oxytocin: Administered IV/IM, watch for water intoxication by monitoring UOP and CNS changes
  • Methylergonovine (Methergine): A prostaglandin E derivative; administered IM, do not give to clients with hypertension
  • Misoprostol (Cytotec): A prostaglandin E derivative; administer rectally/sublingually/buccally
  • Carboprost tromethamine (hemobate): Administered IM/intramyometrial/intraabdominal; do not give to clients with asthma
• Antifibrinolytics:
  • Tranexamic acid (TXA): Administered IV, improves blood clotting
• Tocolytics:
  • Terbutaline: Administered IV/IM, relaxes the uterus

Nursing/Medical Management of Early PPH

• Bimanual compression

Other Management:

• Bakri balloon tamponade
• Jada Device

Surgical Management of PPH

• Uterine Packing
• Hysterectomy

Discharge Teaching

• Fatigue and exhaustion are likely, limit physical activities
• Increase iron and protein intake to rebuild RBC volume
• There is potential for delayed and reduced milk production (delayed lactogenesis), consult with a lactation consultant
• You may need assistance with childcare and housekeeping
• Watch for signs/symptoms of worsening anemia

Potential Nursing Diagnoses

• Deficient fluid volume related to loss of intravascular fluid secondary to postpartum hemorrhage AEB urine output of < 30 ml/hour, peripheral pulses < 2+, falling BP (from 132/74 before hemorrhage to 90/60 post-hemorrhage), increased pulse (from 94 to 126), muscle weakness, lowered level of consciousness.