Postpartum Hemorrhage: Types, Risks and Causes

Postpartum Hemorrhage

• Refers to excessive blood loss during or after the third stage of labor
• Vaginal delivery blood loss exceeds 500ml
• C-section blood loss exceeds 1000ml
• A 10% decrease in hematocrit level between admission and postpartum may indicate the need for transfusion because of secondary blood loss
• Postpartum hemorrhage is a leading cause of maternal mortality

Types of Postpartum Hemorrhage

• Early postpartum hemorrhage happens during the first 24 hours after delivery
  • Common causes include uterine atony, lacerations of the birth canal, and inversion of the uterus
• Late postpartum hemorrhage happens from 24 hours after birth to 4 weeks postpartum
  • Common causes include retained placental fragments, subinvolution of the uterus, and infection
    • Subinvolution is when the uterus does not return to its normal size after childbirth

Risk Factors for Postpartum Hemorrhage

• Previous history of postpartum hemorrhage
• Antepartum hemorrhage
• Grand multiparity
• Multiple pregnancy
• Polyhydramnios
• Fibroids
• Placenta previa
• Prolonged labor
• Labor augmentation with oxytocin

Causes of Postpartum Hemorrhage

• The causes can be remembered using the 5 T's: Tone, Tissue, Trauma, Thrombin, and Traction

TONE: Uterine Atony

• Uterine atony is the most common cause of PPH
• It involves relaxation of the uterus or inability of the uterus to contract and retract effectively
• In uterine atony, the uterine muscle fibers do not contract sufficiently to compress blood vessels, resulting in continuous bleeding
• Normally, the vessels of the placental bed are compressed by the contracted muscle fibers after delivery, preventing bleeding
• Predisposing factors contributing to uterine atony are: prolonged labor, trauma related to obstetrical procedures, overdistention of the uterus, grandmultiparity, intrapartum stimulation with ritocin, and excessive use of analgesia/anesthesia
• Signs and symptoms of uterine atony include a boggy uterus that doesn't respond to massage, a fundus located higher than usual, bright red bleeding, abnormal blood clots, and/or unusual pelvic discomfort or backache

Management of Postpartum Hemorrhage

• Assess and document bleeding
• Fundal massage and express clots
• Bimanual compression
• Initiate breastfeeding
• Assess vital signs and signs of shock
• Administer medications such as Oxytocin, Methylergometrine (Methergin), Carboprost tromethamine (hemabate), and Misoprostol per rectum
• Replace blood/fluids
• Perform D&C/ Hysterectomy

TISSUE: Retained Placenta or Membranes, Subinvolution

• Failure of placental delivery 30 minutes after the birth of the fetus
• The placenta is normally expelled within 15-20 minutes
• Signs include a boggy, relaxed uterus and dark red bleeding
• This can be caused by adherence of the placenta: Placenta Acreta (into the decidua), Placenta Increta (into the myometrium), and Placenta Percreta (through the myometrium to the peritoneal), uterine abnormality, a full bladder, adherence of placenta (previous cesarean delivery, prior uterine curettage), and succenturiate placenta
• Subinvolution symptoms: Lochia fails to progress, prolonged lochial flow, large flabby uterus, backache and infection, and profuse vaginal bleeding
• Treatment: Methergine, curretage, and antibiotics

TRAUMA: Injury to Vagina, Perineum and Uterine Tears

• Suspect this cause if bleeding continues despite a firm and contracted uterine fundus
• Bleeding is slow trickle, an oozing or frank hemorrhage
• Occurs more often in women with primigravida, difficult or precipitate birth, the use of the lithotomy position, and instrumental delivery: forceps, Ventouse or CS
• Predisposing factors: Spontaneous or precipitous delivery, the size, presentation and position of the baby, a contracted pelvis, and vulvar, perineal, vaginal varices
• Signs and symptoms: Bright red bleeding when there is a steady trickle of blood and uterus remains firm, and hypovolemia
• Treatment and nursing care: Meticulous inspection of the entire lower birth canal, suture any bleeders, vaginal pack - nurse may remove and assess bleeding after removal, and blood replacement

Hematomas

• A collection of blood under the surface of the skin at the edge of the anal opening
• Caused by a traumatic rupture of a small blood vessel in the vagina or vulva; develop rapidly; may contain 300-500ml blood
• Symptoms: Severe pain, Difficulty voiding, Mass felt on vaginal exam, Flank pain, Abdominal distension, Shock
• Treatment: Ice, I & D (incision and drainage) and Packing

TROMBIN: Clotting Disorder

• Disorders of the clotting system should be suspected when bleeding persists without an identifiable cause.
• Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body’s small blood vessels.
  • It is associated with abruptio placenta, septic abortion, fetal death in utero
• Von Willebrand’s disease is an inability to form a stable blood clot in the placental site and susceptible to immediate hemorrhage

TRACTION: Uterine Inversion

• The uterus inverts or turns inside out after delivery
  • Complete inversion is a large red rounded mass protrudes from the vagina
  • Incomplete inversion is when the uterus cannot be seen, but felt
• Predisposing factors: traction applied on the cord before the placenta has separated, incorrect traction/ pressure applied to the fundus, when the uterus is flaccid, and using the fundus to push the placenta out
• Treatment: Replace the uterus – manually and pack uterus, combat shock, blood and fluid replacement, give oxytocin, and initiate brad spectrum antibiotics

Nursing Interventions

• Assess the fundus
• Initiate uterine massage
• Weigh perineal pads (1gm of weight = 1ml of fluid)
• Turn patient to her side to inspect buttocks for pooling
• Facilitate voiding every 4 hours to empty the bladder
• Assess vital signs every 5 to 15 minutes
• Prepare for IV infusion of oxytocin & blood transfusion, Administer Methergin IM as ordered, Administer oxygen per face mask, Measure & record fluid intake and output, Be prepared for a possible D &C (Postpartum curettage), Hysterectomy, bimanual and fundal massage

Prevention

• Active Management of the Third Stage (AMTSL)
  • Administration of uterotonic within one minute of delivery of the baby
  • Controlled cord traction with counter traction on the uterus and uterine massage
• Uterine Contraction-First Line Drugs: Oxytocin 5IU, Oxtocin infusion – 40IU in 500mls, Ergometrine 0.5mg, Carboprost (Haemabate©) 0.25mg IM every 15 minutes x 8 doses, and Misoprostol 600 mcg

Postpartum Puerperal Infection

• A puerperal infection, also known as postpartum infection, is an infection of the uterus and surrounding tissues
• Usually happens after the trauma of vaginal birth or cesarian delivery
• There are three distinct areas where postpartum infections may occur:
  • Endometritis: uterine lining
  • Myometritis: uterine muscle
  • Parametritis (also called pelvic cellulitis): supporting tissue around the uterus
• The most frequent postpartum infection is endometritis since the lining of the uterus can undergo trauma and tears during the birthing process/ provides an entrance for infection to develop
• Infection in the uterus muscle or the structures supporting the uterus may form at the incision or tear sites, such as in an episiotomy or a cesarean delivery (C-section)

General Symptoms of Postpartum Infection

• Fever
• Chills
• Body aches
• Loss of appetite
• Overall discomfort

More Severe Symptoms Specific to Postpartum Infection

• Pain below the waist or in the pelvic bone area caused by an inflamed uterus
• Pale, clammy skin related to a large amount of blood loss
• Foul-smelling vaginal drainage revealing an infection
• Increased heart rate from blood loss

Risk Factors for Puerperal Infection

• Infection risk is 1-3% of standard vaginal deliveries
• Infection risk is 5-15% of scheduled cesarean deliveries performed before labor begins
• Infection risk is 15-20% of non-scheduled cesarean deliveries performed after labor begins
• Females with no previous pregnancy
• Extremes in age, such as very young or older
• Prior medical conditions (obesity, diabetes, high blood pressure, anemia, and immune system problems)
• Multiple vaginal exams during labor
• Monitoring the fetus inside the uterus
• Delay between amniotic sac rupture and delivery or prolonged labor
• Manual removal of the placenta
• Having remains of the placenta in the uterus after delivery
• Excessive bleeding after delivery
• Baby’s stool found in amniotic fluid
• Use of a catheter to soften the opening of the uterus for birth
• Other infectious conditions that may contribute to postpartum infections, namely overgrowth of “bad” bacteria in the vagina, group B Streptococcus (GBS) bacteria naturally living in the vaginal tract, and sexually transmitted infections

Complications of Puerperal Infection

• Abscesses, or pockets of pus
• Peritonitis, or an inflammation of the abdominal lining
• Pelvic thrombophlebitis, or blood clots in the pelvic veins
• Pulmonary embolism, a blood clot that blocks an artery in the lungs
• Septic shock, bacteria get into the bloodstream and cause dangerously low blood pressure

Treatment of Puerperal Infection

• Broad-spectrum antibiotics given intravenously (IV) for patients in the hospital
• Oral antibiotics may include Augmentin (amoxicillin and clavulanate), Vibramycin (doxycycline) plus Flagyl (metronidazole), and Levaquin (levofloxacin) plus Flagyl (metronidazole)
• In addition to antibiotics, the treatment also includes IV fluids and bed rest

Endometritis

• Inflammation of the endometrium (the inner lining of the uterus) due to infection
• It can be acute (starts suddenly and is short-term) or chronic (lasts a long time or occurs repeatedly)
• Acute endometritis can happen after childbirth or miscarriage, or after a surgical procedure involving the cervix or uterus
• Chronic endometritis is more common after menopause or with an infection like chlamydia or gonorrhea
• Endometritis is one of the most common infections after giving birth
• Could start as chorioamnionitis in labor and progress to endometritis after giving birth, or begin after childbirth (postpartum)
• Slightly more common on C-section
• Common in people with pelvic inflammatory disease (PID)
• Many different bacteria cause PID, but infection from unprotected sex is most common
• Symptoms include fever, pelvic pain, vaginal bleeding or discharge, constipation or pain with bowel movement, swelling in your abdomen, and general unwell feeling
• Diagnosis and Tests- Testing fluid from the vagina for bacterial or sexually transmitted infections (STIs) like chlamydia and gonorrhea, removing tissue from the uterus and testing it for bacteria (biopsy), performing laparoscopy to get a closer look at the uterus, blood tests to look at white blood counts (WBC) or erythrocyte sedimentation rate (ESR). High levels can indicate infection or inflammation, and looking at vaginal fluid under a microscope
• Complications: Infertility, Pelvic infection, Pelvic or uterine abscesses (a collection of pus) and Septicemia (inflection in the blood)
• Management includes antibiotics, IV fluids, and bed rest

Wound Infection

• Postpartum surgical site infection (SSI), wound infection and endometritis is a major cause of prolonged hospital stay and poses a burden to the health care system
• Presents with erythema, discharge, and induration of the incision, complicates 2-7% of patients and generally develops 4 to 7 days after CD
• When wound infection develops within 48 h, the offending organisms usually are groups A or B-hemolytic Streptococcus
• Other common pathogens are Ureaplasma urealyticum, Staphylococcus epidermidis, Enterococcus facialis, Staphylococcus aureus, Escherichia coli, and Proteus mirabilis
• Risk Factors (Maternal): tobacco use; limited prenatal care; obesity; corticosteroid use; nulliparity; twin gestations; and previous CD), intrapartum and operative factors (such as chorioamnionitis; premature rupture of membranes; prolonged rupture of membranes; prolonged labor, particularly prolonged second stage; large incision length; subcutaneous tissue thickness > 3 cm; subcutaneous hematoma; lack of antibiotic prophylaxis; emergency delivery; and excessive blood loss
• Interventions- include prophylactic antibiotic use (preoperative first generation cephalosporin and intravenous azithromycin), chlorhexidine skin preparation instead of iodine, hair removal using clippers instead of razors, vaginal cleansing by povidone-iodine, placental removal by traction of the umbilical cord instead of by manual removal, suture closure of subcutaneous tissue if the wound thickness is >2 cm, and skin closure with sutures instead of with staples

Urinary Tract Infection during Pregnancy

• Pregnancy increases the risk of developing urinary tract infections
• During pregnancy — especially weeks six to 24 — the urinary tract changes as the uterus grows
• The increased weight and pressure of the uterus on the bladder can block urine from flowing, making it an ideal environment for bacteria
• Pregnancy also suppresses the immune system, which is the body’s natural defense against illness. This can increase the risk of infection, including UTIs
• Types of Urinary Tract Infections: Asymptomatic bacteriuria (ASB)- is usually caused by bacteria that were in the body before became pregnant. Because it has no symptoms, healthcare providers usually screen for ASB through a urine test at the first prenatal appointment, Urethritis- involves your urethra, the tube that carries pee out of the body, Cystitis- involves your bladder, which holds the pee, and Pyelonephritis- affects the kidneys
• Most Common S/S of UTI during Pregnancy: Pain when peeing (dysuria), blood in your pee, abnormal urine color (cloudy appearance) with a strong smell, incontinence (leaking pee), increased and urgent need to pee, and pain during sex
• Less common UTI symptoms during Pregnancy- Fever (temperature above 100 degrees Fahrenheit or 37.77 degrees Celsius), chills, mental changes or confusion, vomiting, and pain in the side (flank)
• Diagnosis and Tests: Urinalysis checks the urine for white blood cells, red blood cells and bacteria/ The amount of white and red blood cells may indicate an infection and a urine culture looks at the type of bacteria in the urine. Knowing the type of bacteria causing the infection helps the provider determine the best treatment
• Prevention- includes drink plenty of fluids (six to eight glasses per day), especially water and unsweetened cranberry juice, pee before and after having sex, pee at the first sign of having to go and empty bladder completely, talk to healthcare provider about the right prenatal vitamins and supplements to take/ But in general, for UTI prevention, take at least 250 to 500 milligrams of vitamin C, 25,000 to 50,000 IU of beta- carotene and 30 to 50 milligrams of zinc each day, wipe front to back and keep your genital area clean and dry, and change your underwear every day and wear cotton or cotton-crotch underwear

Thromboembolic Disorders

• Blood clot (thromboembolic) disorders—deep venous thrombosis (DVT) or pulmonary embolism (PE)—are a leading cause of death in pregnant women
• Diagnosis and Treatment- In thromboembolic disorders, blood clots (thrombi) form in blood vessels/ An embolus is a blood clot that travels through the bloodstream and blocks an artery, the risk of developing a thromboembolic disorder is higher in pregnant than nonpregnant people and continues to be increased for about 6 weeks after delivery/ Cesarean delivery, like other surgeries, also increases risk, symptoms may be similar to those in people who are not pregnant/ Thromboembolic disorders can occur without symptoms, with only minimal symptoms, or with significant symptoms, clot in the deep veins (deep vein thrombosis) causes symptoms such as calf or thigh swelling, pain, and tenderness/ Usually, the symptoms are only in one leg/ Foot and ankle swelling is common in pregnancy, but if this is accompanied by other symptoms, a blood clot may be present, and deep vein thrombosis may also develop in the pelvis/ The clot may block one or more lung (pulmonary) arteries/ This blockage, called pulmonary embolism, can be life threatening
• Diagnosis of Blood Clot Disorders During Pregnancy:
  • Doppler ultrasound to check for blood clots in the legs
  • Computed tomography to check for pulmonary embolism.
  • During pregnancy, if women have symptoms suggesting a blood clot, Doppler ultrasound (used to evaluate blood flow) may be done to check the legs or pelvis for clots.
  • If pulmonary embolism is suspected, computed tomography (CT) may be done to confirm the diagnosis/ It is done after a radiopaque contrast agent (which can be seen on x-rays) is injected in a vein/ The contrast agent flows through blood vessels and outlines them/ This procedure is called CT angiography/ If the diagnosis of pulmonary embolism is still uncertain, a procedure called pulmonary angiography (angiography of the lung's blood vessels may be done
• Treatment of Blood Clot Disorders During Pregnancy: If a blood clot is detected, heparin (an anticoagulant, a medication that inhibits blood clotting) is started without delay/ Heparin may be injected into a vein (intravenously) or under the skin (subcutaneously)/ Heparin does not cross the placenta and cannot harm the fetus/ Treatment is continued for 3 to 6 months/ After delivery, warfarin may be used instead of heparin, particularly if women require treatment for more than 6 to 8 weeks/ Warfarin can be taken by mouth, has a lower risk of complications than heparin, and can be taken by women who are breastfeeding

Post Partum Psychiatric Disorders

• Postpartum Psychosis (PPP) is a mental health emergency.
  • Affects a person’s sense of reality, causing hallucinations, delusions, paranoia or other behavior changes
  • Severe cases involving people attempting to harm themselves or their newborn
  • It is treatable, and early treatment increases the odds of a good outcome
• Rare condition- Experts estimate that it affects between 0.089 and 2.6 out of every 1,000 births
  • It can affect anyone who recently gave birth/ While it usually happens within several days of giving birth, it can happen up to six weeks after
• PPP can happen to anyone, but the odds of having it are higher for people with certain mental health conditions/ While experts don’t know if these conditions contribute to or cause PPP- Family history of mental health conditions, especially PPP/ People with PPP often have family members with a history of PPP or related mental health conditions/ History of mental health conditions- About one-third of people with PPP have a previously diagnosed mental health condition/ The most common include bipolar disorder (especially bipolar I disorder)/ Other mental health conditions that may increase the risk include major depressive disorder and schizophrenia spectrum conditions, number of pregnancies- PPP is more common in people who just gave birth to their first child/ However, for people with a history of PPP, there’s a 30% to 50% chance that it will happen again after future childbirths, and sleep deprivation- Experts know that not getting enough sleep can trigger mania in people with bipolar disorder
• Symptoms includes hallucinations, delusions, disorganized thinking or behavior, insomnia, irritability or agitation, and thoughts of self-harm or harming others (especially their newborn). The depressive subtype of PPP is the most common, making up about 41% of cases. It’s also the most dangerous, also the rate of harm to a child is about 4.5% with this subtype, about four or five times greater than with the other subtypes. The rate of dying by suicide is about 5%. Manic symptoms is the next most common of the types, affecting about 34% of cases/ Symptoms include agitation and irritability, disruptive or aggressive behavior, talking more or faster than usual (or both), needing less sleep, and delusions of greatness or importance (such as believing your child to be a holy or religious figure). It's risk of self-harm or harm to children is lower but still possible, happening in about 1% of cases. Mixed Symptoms- This subtype makes up about 25% of cases/ This can mix the symptoms of manic and depressive subtypes/ It can also involve symptoms where a person seems much less aware (or completely unaware) of the world around them/ Symptoms: Disorganized speaking or behavior, disorientation or confusion, disturbance of consciousness (where a person doesn’t appear to be awake or isn’t aware of activities or things taking place nearby), hallucinations or delusions, and inappropriate comments, behaviors or emotional displays
• Causes of Postpartum Psychosis: Hormone changes and other medical conditions
• Diagnosis and Test- Tests on blood, urine or other body fluids may look for signs of a medical problem, especially with your body’s internal chemistry processes/ Also includes imaging scans
• Management and Treatment- Medications (Antipsychotic medications, Mood stabilizers, Anti-seizure drugs, Lithium, and Electroconvulsive therapy (ECT)