Postpartum Hemorrhage

• Complications can occur in the postpartum period, requiring immediate intervention to prevent long-term disability and interference with parent-child relationships
• This module provides information on how to care for a woman and her family when a complication occurs

Postpartum Hemorrhage

• Defined as bleeding of 500 mL or more after delivery
• Can occur early (primary) within the first 24 hours after delivery or later (secondary) after the first 24 hours
• Hemorrhage is a primary cause of maternal mortality associated with childbearing
• Four main reasons are uterine atony, trauma, retained placental fragments, and disseminated intravascular coagulation (DIC)
• Known as the "Four Ts": tone, trauma, tissue, thrombin

Conditions Increasing Risk of Postpartum Hemorrhage

• Conditions that over-distend the uterus beyond average capacity such as multiple gestation, polyhydramnios, a large baby (>9 lb), and uterine myomas
• Conditions that may cause cervical or uterine lacerations
• Conditions that are a variant placental site or attachment, such as placenta previa, placenta accreta or premature separation of the placenta
• Conditions that leave the uterus unable to contract readily, such as deep anesthesia or analgesia
• Labor initiated or assisted with an oxytocin agent
• High parity or maternal age over 35 years of age
• Previous uterine surgery
• Prolonged and difficult labor
• Chorioamnionitis or endometritis
• Secondary maternal illness such as anemia
• Prior history of postpartum hemorrhage
• Prolonged use of magnesium sulfate or other tocolytic therapy or Fetal death
• Conditions that lead to inadequate blood coagulation

Consequences of Postpartum Hemorrhage

• Circulatory collapse leading to shock and death
• Puerperal anemia and morbidity
• Damage to the pituitary blood supply (Sheehan's syndrome will affect FSH, LH, Prolactin, oxytocin)
• Fear of further pregnancies

Uterine Atony

• Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartal hemorrhage
• The uterus must remain contracted after birth to keep the open vessels at the placental site from bleeding
• Factors that predispose to poor uterine tone or inability to maintain a contracted state include a soft (boggy) uterus noted on palpation of the uterine fundus
• Signs of shock and hypovolemia, persistent significant bleeding (perineal pad soaked within 15 minutes), and Complaints of weakness, lightheadedness, dyspnea
• Also, restlessness, increased pulse rate, decrease in blood pressure, cool and clammy skin, ashen or grayish color
• Interventions include massaging the uterus until firm, elevating woman's extremities, administering Oxygen by mask at 10-12lpm
• Monitoring VS, elevating woman's extremities, emptying the bladder, notifying the health care provider is interventions do not resolve the atony
• Administering medications such as bolus or dilute IV Oxytocin, Carbopost tromethamine every 15 – 90 minutes x 8 doses, Methylergonovine maleate q 2-4 hours x 5 doses, Misoprostol x 2 doses
• Bimanual massage, blood transfusion

Lacerations

• Small lacerations or tears of the birth canal are common and may be considered a normal consequence of childbearing, while large lacerations can cause complications
• Causes include difficult or precipitate births, primigravidas, Birth of a large infant (>9 lb), and Use of a lithotomy position during the stage 2 of labor
• Types include cervical, vaginal, and perineal lacerations
• Cervical are usually found on the sides of the cervix,
• Vaginal lacerations are easier to locate and assess than cervical lacerations because they are much easier to view.
• Lacerations of the perineum are apt to occur when a woman is placed in a lithotomy position

Retained Placental Fragments

• Fragments of the placenta may separate and be left behind, preventing the uterus from contracting fully and leading to uterine bleeding
• Detection is done through Ultrasound, Inspection of placenta carefully after birth, Blood serum sample contains gonadotropin hormone
• Risk factors include succenturiate placenta (placenta with an accessory lobe), placenta accreta (placenta that fuses with the myometrium because of an abnormal decidua basalis layer), previous cesarean birth, and in vitro fertilization
• Intervention involves removal of the retained placental fragment with dilation and curettage (D&C)

Uterine Inversion

• Uterine inversion is a prolapse of the fundus of the uterus through the cervix to where the uterus turns inside out with either the fetus or placenta
• Risk factors include traction applied to the umbilical cord to remove the placenta, pressure is applied to the uterine fundus when the uterus is not contracted, the placenta is attached at the fundus
• Never attempt to replace an inversion because handling of the uterus intensifies bleeding
• Administer oxytocin after manual replacement to assist the uterus to contract and remain in its natural place

Disseminated Intravascular Coagulation (DIC)

• Deficiency in clotting ability caused by vascular injury, associated with premature separation of the placenta or fetal death in utero

Subinvolution

• Incomplete return of the uterus to its prepregnant size and shape
• Causes small retained placental fragment and mild endometritis
• Subinvolution, at a 4 to 6 week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present
• Intervention is to prevent excessive blood loss, infection, other complications by massaging the uterus

Perineal Hematomas

• Collection of blood in the subcutaneous layer of tissue of the perineum
• Such blood collections can be caused by injury to blood vessels in the perineum during birth
• Tend to occur more after rapid, spontaneous births and in women who have perineal varicosities
• Severe pain in the perineal area or a feeling of pressure between the mother's legs

Puerperal Infection

• Any infection of the reproductive organs that occurs within 28 days of delivery or abortion
• Bacterial may have started while in utero, tissue necroses, or may be weakened
• Theoretically, the uterus is sterile during pregnancy and until the membranes rupture thus Pathogens can then invade

Mastitis

• Infection of the breast, usually unilateral, frequently caused by cracked nipples in the nursing mother
• Causative organism is usually hemolytic S. Aureus; if untreated, may result in breast abscess Mastitis occurs primarily in breast-feeding mothers 2 to 3 weeks after delivery but may occur at any time lactation.
• Elevated vital signs and importance of stress, tenderness, and redness are other possible Symptoms
• Handwshing is a key intervention

Endometritis

• Infection of the lining of the uterus occurring in the postpartum period and caused by bacteria that invade the uterus at the placental site
• Foul odor to lochia or reddish-brown lochia; tender, large uterus
• Provide antibiotics prescribed by the provider

Thrombophlebitis

• Phlebitis is inflammation of the lining of a blood vessel
• Results in the formation of blood clots
• The level of fibrinogen is still elevated from pregnancy, leading to increased blood clotting

Superficial Thrombophlebitis

• Assess with patient in bed or sitting with legs dangling
• Causes pain, heat, redness, and hardened vein

Femoral Thrombophlebitis

• Also called deep thrombophlebitis
• Causes edema, pain, and change in limb color
• Absent pedal pulse and calf tenderness are often present

Pelvic Thrombophlebitis

• Involves ovarian, uterine, or hypogastric veins
• Usually occurs about the 14th to 20th day postpartum
• Dramatic symptoms include high fever, chills, abdominal pain, general malaise, and eventual pulmonary emboli

Supervision of Newborn Responsibilities

• Emotional and Psychological Complications of the Puerperium happen when a woman is extremely stressed or gives birth to an infant who in any way does not meet her expectations
• It is referred to as Postpartal Depression

Comparison of Postpartal Blues, Depression, and Psychosis

• Postpartal Blues onset is 1 - 10 days after birth due to withdrawal and is Normal. The symptoms are sadness and tears which occurs 70% of the time
• Postpartal Depression, onset is 1-12 months after birth, trigger is the dati symptoms are increased anxiety, feelings of loss and sadness which occurs 10% of the time
• Postpartal Psychosis, onset is within first year after childbirth, and may hear voices, and experience delusion or hallucinations

Explore the classifications, concerns, and causes of postpartum hemorrhage. Review immediate management and the impact of DIC on hemorrhage. Test your knowledge of postpartum hemorrhage causes and management.