Postpartum Haemorrhage PDF

Chapter 28 The Woman with a Postpartum Complication Post Partum Hemorrhage 1 1 Post Partum Hemorrhage Postpartum hemorrhage: it is the loss of blood that exceeds 500ml after vaginal delivery or 1000ml after C/S. A drop in hemat...

Chapter 28 The Woman with a Postpartum Complication Post Partum Hemorrhage 1 1 Post Partum Hemorrhage Postpartum hemorrhage: it is the loss of blood that exceeds 500ml after vaginal delivery or 1000ml after C/S. A drop in hematocrit of 10% after delivery or a need for blood transfusion. 2 2  Classifications of postpartum hemorrhage: 1. Early(Primary) Postpartum Hemorrhage : when the hemorrhage occurs in the first 24 hrs after delivery. 2. Late(Secondary)Postpartum Hemorrhage: when hemorrhage occurs after 24 hours up to 6- 12 weeks after birth 3 3 Early postpartum hemorrhage: Major causes of the early post partum hemorrhage: ❑ Uterine atony ❑ Trauma to the birth canal during labor and delivery ❑ Hematomas ❑ Retained Placental fragments ❑ Abnormalities of coagulation ❑ Inversion of uterus 4 4 Common Predisposing Factors for Postpartum Hemorrhage ❑Overdistention of the uterus ❑Multiparity (>5) ❑Use of tocolytic drugs ❑Precipitate labor or delivery ❑Prolonged labor ❑Use of forceps or vacuum extractor ❑Cesarean birth ❑Manual removal of the placenta 5 5 Common Predisposing Factors for Postpartum Hemorrhage. Cont. ❑Previous postpartum hemorrhage ❑General anesthesia ❑Low implantation of placenta, placenta previa ,placenta accreta ❑Administration of certain drugs( Oxytocin, MgSo4) ❑Chorioamnionitis ❑Clotting disorders ❑Disseminated intravascular clotting DIC ❑Uterine fibriods 6 1. Uterine Atony ❑Most often cause of early postpartum hemorrhage ❑Atony define as lack of muscle tone that results in failure of the uterine muscle fibers to contract firmly a round blood vessels when placenta separates 7 7 Predisposing factors of uterine atony Overdistension of uterus from any cause( e.g.large fetus) Multiparity Intrapartum factors such as Prolonged labor Precipitate labor Labor induced or augumented with oxytocin Retention of large segment of placenta 8 8 Signs and symptoms of uterine atony: ❑ A uterine fundus that is difficult to locate ❑ A soft or “boggy” feel when the fundus is located A uterus that becomes firm as it is massaged but loses its tone when massage is stopped ❑ A uterine fundus that is located above the expected level ❑ Excessive lochia or clots expelled 9 9  Intervention: ❑Assessment and management of uterine atony, If the uterus is not firmly contracted, massage the fundus until it is firm and to express the clots that may have accumulated in the uterus (gentle but firmly massage the fundus in a circular motion) To prevent uterine inversion, one hand placed above symphysis pubis and the other hand above the fundus Note: it is critical not to attempt to express clots until the uterus is firmly contracted. 10 10  Assess for full bladder (empty bladder or catheterize if full bladder is the cause) ❑Medication: - a rapid IV infusion of dilute oxytocin (pitocin), increase tone of the uterus and control bleeding. - - If oxytocin is ineffective give prostaglandin F (carboprost Tromethamine) (prostin) I.M or into the uterine muscle. 11 11 ❑Methylergonovine (Methergine) I.M but its side effect is increase BP so it is contraindicated for women with hypertension. ❑Prostin E2 given rectaly or misoprostol(Cytotec) may be used 12 12 ❑Uterine packing or bimanual compression (one hand inserted into the vagina and the other hand compresses the uterus through abdominal wall. 13 13 ❑Woman should be transferred to the delivery room to explore uterus for retained placenta tissue, ❑Ligation of the uterine arteries or emobilization (occlusion) of pelvic arteries if other measures are not effective, 14 14 ❑Hysterectomy (last solution), ❑Replacement of intravascular fluid volume (R/L and whole blood) ❑Assess urine output (should be >30 ml/hr or preferably > 60 ml/hr. 15 15 2.Trauma: Second most common cause of early post partum hemorrhage 1.vaginal, cervical, or perineal lacerations. 2.Hematomas. 16 16 Predisposing factors of laceration: ❑Large infant ❑Rapid labor ❑Induction/ Augmentation of labor ❑Use of assistive devices (forceps or vacuum) 17 17 Signs indicate Laceration ❑If the fundus is contracted well but there is bleeding laceration is suspected ❑Color of blood from uterus is dark red ❑Color of blood from laceration is bright red. 18 18  Hematomas: It is a localized collection of blood in a space or tissue. It is result from spontaneous delivery, forceps or vacuum delivery. Location: vulva, vagina, retroperitoneal areas. 19 19 Types of Hematomas 1. Visible vulvar hematoma: appears discolored bulging masses sensitive to touch. 2. Un visible hematoma: hematoma in the upper vagina and peritoneal area. produce deep ,severe, unrelieved pain and feeling of pressure that are unrelieved by pain relieved measures 20 20  Signs and symptoms indicate Hematomas Deep, severe, unrelieved pain, feeling of pressure. Falling in blood pressure or increase in pulse. 21 21 Management of both hematoma and laceration: ❑ Surgical treatment of laceration and hematoma ❑Return woman to delivery room for repair of lacerations ❑Small hematoma reabsorb naturally ❑Large hematoma needs incision and evacuation of clots and ligation of blood vessels. 22 22 Late postpartum Hemorrhage Causes 1. Subinvolution of uterus( delayed return of the uterus to its nonpregnant size and consistency) 2. Fragments of placenta that remains attached to the myometrium when the placenta is delivered 23 23 Predisposing factors for retained fragments of placenta Previous C/S Placenta accreta Uterine liomyomas (bening single cell divided repeatedly creating a firm, rubbery mass. Growth of uterine fibrosis vary may slow or rapidly) 24 24 Preventive Measures The nurse and Physician should inspect placenta after delivery to be sure that it is intact 25 25 Therapeutic Managements Control excessive bleeding Oxytocin, methylergonovine or prostaglandin are the most commonly used Sonograghy can identify placental fragments that retained D&C if bleeding continue to remove any fragments Broad spectrum antibiotic if infection developed 26 26 2. Subinvolution of uterus Causes –Retained placental fragments –Pelvic infections 27 27 Signs of Subinvolutions ❑Prolonged discharge of lochia ❑Irregular or excessive uterine bleeding ❑Sometimes profuse hemorrhage ❑Pelvic pain , pelvic heaviness, backache , fatigue and persistent malaise might be reported by some woman ❑The uterus feels larger and softer than normal for that point in time postpartum 28 28  Therapeutic management –Correct the cause –Oral methylergonovine provide contraction in the uterus –Antibiotics if infection is present 29 29 Nursing consideration Teaching of mother before discharge about normal involution process and how to assess fundus level Teaching regarding normal lochia flow and types Instruct mother to report any deviation from normal 30 30 Nursing Assessment Chart review to determine if there is any risk factors is present and may expose client to postpartum hemorrhage such as prolong labor , placenta previa and others mentioned before For uterine atony Assess fundus ,bladder, lochia, vital signs, skin temperature and color and note abnormal data that may indicate hemorrhage 31 31 For Trauma If the fundus is firm and there is excessive bleeding inspect the perineum to determine whether a laceration is visible If the mother complains of deep , severe pelvic or rectal pain or if vital signs suggest hemorrhage but excessive bleeding is not visible, the cause may be concealed bleeding and hematoma Examine for bulging mass or discoloration of vulva which may indicate visible hematoma in vulva 32 32 Interventions 1. Preventing Hemorrhage Early and frequent assessment play a big role in preventing postpartum hemorrhage, especially when there is a predisposing factor present 33 33 2.Collaborating with health care provider Begin with uterine massage if fundus is soft Determine amount of blood lost from pads and soaked linen If bleeding not controlled notify physician or midwife 34 34  Initiate some lab studies such as hemoglobin, hematocrite, blood type and RH, and coagulation studies IV fluid Keep the woman in bed rest to increase cardiac output and venous return Administer medication and fluids ordered by health care provider If these measures not effective , a surgical preparation might be needed 3.Providing family support 35 35