OB Report (Ianne Merh Tuazon LD05)

POSTPARTUM HEMORRHAGE
Postpartum hemorrhage is a serious complication of childbirth that can result in hypovolemic shock. It is the leading cause of
maternal morbidity and mortality in the United States.
Postpartum hemorrhage is defined by:

Greater than 500 mL of blood loss after a vaginal birth.

Greater than 1,000 mL of blood loss after a cesarean birth.

Complications:
a. Anemia can result from postpartum hemorrhage and the nurse should:
Monitor the clients hemoglobin and hematocrit levels and coagulation profile (e.g prolonged PTT)
Educate the client about dietary sources of iron and folic acid.
b.

Hypovolemic shock resulting from low fluid volume is a potential complication of postpartum hemorrhage and the
nurse should:
Monitor the client for signs of hypovolemic shock
o hypotension
o rapid shallow respirations
o tachycardia with a weak and
o oliguria
thready pulse

Major Signs and Symptoms of PPH:

Uterine atony.
Blood clots larger than a quarter.
Perineal pad saturation in 15 min or less.
Return of lochia rubra once lochia has
progressed to serosa or alba.
Constant oozing, trickling, or frank flow of bright
red blood from the vagina.

A rising pulse rate and decreasing blood

pressure (often first warning of inadequate blood
volume).
Skin that is pale, cool, and clammy with poor
turgor and pale mucous membranes.
Oliguria.

Early Postpartum Hemorrhage

- Hemorrhage in the first 24 hours after childbirth
Risk Factors/ Causes:
Tone: Uterine Atony
Trauma: Lacerations and Hematoma
Thrombin: coagulation abnormalities (DIC)
Placenta accreta (abnormal adherence of the placenta to the uterine wall)
Inversion of the uterus
A. UTERINE ATONY
- ("boggy uterus") is a failure of the uterine myometrium (muscle) to contract firmly around the blood
vessels when the placenta separates. The relaxed muscles allow rapid bleeding from the endometrial
arteries at the placental site. The hallmark of uterine atony is soft uterus filled with clots and blood.
Risk factors:
o Overdistention of the uterine muscle (e.g., multiparity, multiple gestations, polyhydramnios, LGA)
o Prolonged labor or Precipitate labor.
o Oxytocin induction or augmentation of labor.
o Magnesium sulfate administration as a tocolytic.
o Anesthesia and analgesia administration.
o Trauma (e.g., forceps-assisted or vacuum-assisted birth, cesarean birth).
o Retained placental fragments
S/SX:

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 fundus that is located above the expected level
Excessive lochia, especially if it is bright red

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Excessive clots expelled, either with or without uterine massage
Therapeutic Management:
1. Ensure urinary bladder is empty.
2. Massage the fundus until it is firm and to express clots that may have accumulated in the uterus.
- It is critical that the uterus is contracted firmly before attempting to express clots. Pushing on a
uterus that is not contracted could invert the uterus and cause massive hemorrhage and rapid shock.
3. Administer oxytocics.
Oxytocin (Pitocin)
Methylergonovine maleate (Methergine)
Ergonovine maleate (Ergotrate)
Prostaglandin F (Hemabate, Prostin 15M)

If uterine atony persists: Call physician.

4. Bimanual compression by the primary care provider
- Insertion of a fist into the vagina applying pressure with the knuckles against the anterior side
of the uterus and then placing the other hand on the abdomen and massaging the posterior
uterus.
5. Manual exploration of the uterine cavity for retained placental fragments is performed by the primary care
provider.
6. Surgical management such as a hysterectomy (last resort)
7. Lactated Ringers solution, whole blood, packed red blood cells, normal saline, or other plasma extenders
are also used for prompt replacement of intravascular fluid volume.
Prevention:
a. Prophylactic administration of uterotonic drugs (oxytocin) after the delivery of the placenta. An
intravenous solution of oxytocin may be started to contract the uterus.
b. Early clamping of the umbilical cord and assisted delivery of the placenta may also prevent uterine atony
and postpartum hemorrhage.

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B. TRAUMA
-

Trauma to the birth canal is the second most common cause of early postpartum hemorrhage.
Trauma includes vaginal, cervical, or perineal lacerations and hematomas.

a.

Lacerations sustained during labor and birth consist of the tearing of soft tissues in the birth canal and
adjacent structures including the cervical, vaginal, vulvar, perineal, and/or rectal areas. Perineal
lacerations are the most frequent, occurring in the lower genital tract.

b.

Hematoma is a collection of 250 to 500 mL of clotted blood within tissues that is usually the result of a
breakage of blood vessels in the soft tissues of the vagina or perineum. Hematomas typically appear as a
bulging bluish mass.

Risk factors
o Operative vaginal birth (e.g., forceps-assisted, vacuum assisted birth).
o Precipitate birth.
o Cephalopelvic disproportion.
o Size (macrosomic infant) and abnormal presentation or position of the fetus.
o Prolonged pressure of the fetal head on the vaginal mucosa.
o Previous scarring of the maternal birth canal from infection, injury, or operation
Interventions:
1. Identifying the source of the bleeding. (Lithotomy position)
- Visually or manually inspecting the cervix, vagina, perineum, and rectum for lacerations
and/or hematomas.
- Assessing an episiotomy for extension into a third- or fourth-degree laceration.
- Evaluating lochia.
Continuing to assess the clients vital signs and hemodynamic status.
Treating small vulvar hematomas with the application of ice packs or alternate hot and cold applications.
Encouraging sitz baths.
Encouraging cleansing of the perineal area with a water bottle filled with warm tap water after voiding and
defecation.
6. Assisting the primary care provider with repair procedures.
- Repair and suturing of episiotomy or lacerations
- Ligation of bleeding vessel/surgical incision for evacuation of large hematoma.
2.
3.
4.
5.

C. THROMBIN
a. Disseminated intravascular coagulation (DIC) is a condition in which clotting and anticoagulation
stimulation occur at the same time.
- The release of thromboplastin uses up available fibrinogen and platelets, which results in
profuse bleeding and intravascular clotting.
- It often is a secondary condition associated with abruptio placenta, gestational hypertension,
missed abortion, or fetal death in utero.
- DIC is suspected when the usual measures to stimulate uterine contractions fail to stop
vaginal bleeding.
b. Idiopathic thrombocytopenic purpura (ITP) is a coagulopathy that is an autoimmune disorder in which
the life span of platelets is decreased by antiplatelet antibodies.
Risk factors
o Genetic factors inherited from parents
(ITP)
o Abruptio placenta.
o Abortion.

o
o
o

Severe preeclampsia or eclampsia

Septicemia.
Cardiopulmonary arrest.

S/SX:
Oozing from an intravenous insertion
site
Petechiae
Ecchymosis

Oliguria
Restlessness
Decreasing pulse pressure with
continued bleeding.

OB Report (Ianne Merh Tuazon LD05)

Diagnostics:
a. Laboratory tests include: CBC with differential. Blood typing and crossmatch.
b. Clotting factors.
o Platelet levels (thrombocytopenia)
o Fibrinogen levels (decreased)
o Prothrombin time (increased)
o Fibrin split product levels (increased)
Nursing Interventions
For ITP:
1. Transfuse platelets
2. Assist in preparing the client for splenectomy if ITP does not respond to medical management and
provide postsurgical care.
For DIC:
1. Administering fluid volume replacement.
2. Administering blood component therapy.
3. Monitoring for complications from the administration of blood and blood products.
4. Administering pharmacologic interventions including antibiotics, vasoactive medications, and
uterotonic agents as prescribed.
5. Administering supplemental oxygen.
6. Providing protection from injury.

D. Inversion of the uterus

-

the turning inside out of the uterus

Uterine inversion is an emergency situation that can result in postpartum hemorrhage and
requires immediate intervention.
occurs most frequently in multiparous women with placenta accreta or increta.

Complete inversion as evidenced by a large, red, rounded mass that protrudes 20 to 30 cm

outside the introitus (vaginal opening).
b. Partial inversion as evidenced by the palpation of a smooth mass through the dilated cervix.
Risk factors
a.

o
o

o
o
o
o
o
o

Retained placenta.
Abnormally adherent placental tissue.
Placenta accreta a slight penetration of the placenta into the myometrium.
Placenta increta a deep penetration by the placenta into the myometrium.
Placenta percreta a perforation by the placenta into the uterus.
Multiparity.
Fundal implantation of the placenta.
Vigorous fundal pressure.
Excessive traction applied to the umbilical cord.
Uterine atony.
Leiomyomas (a benign uterine fibroid tumor).

Nursing Interventions
1. Assess vaginal opening
2. Performing a pelvic exam.
3. Prevent uterine inversion by the avoidance of strong pulls on the umbilical cord unless the placenta
has definitely separated.
4. Administering tocolytics or anesthetics to relax the uterus prior to the primary care providers attempt at
replacement of the uterus into the uterine cavity and uterus repositioning.
5. Following replacement of the uterus into the uterine cavity:
- Closely observe the clients response to treatment and assess for stabilization of
hemodynamic status.
- Avoid aggressive fundal massage.
- Administer oxytocics as prescribed.
- Administer broad spectrum antibiotics for infection prophylaxis.
- Anticipate surgery if nonsurgical interventions and management are unsuccessful.

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LATE POSTPARTUM HEMORRHAGE
-

hemorrhage occurring between 24 hours and 6 weeks after birth.

The most common causes of late postpartum hemorrhage are subinvolution and placental
fragments.
Uterine infection can also be the cause.

A. SUBINVOLUTION
-

failure of the uterus to resume its prepregnant

uterus remains enlarged with continued lochial discharge.

Risk factors
o Pelvic infection and endometritis.
o Incomplete expulsion of the placenta leaving retained placental fragments.
o Excessive vigorous massaging of the uterus.
S/SX:
A uterus that is enlarged and higher than normal in the abdomen relative to the umbilicus
A boggy, noncontracted uterus.
Prolonged lochia discharge with irregular or excessive bleeding.

Nursing Interventions
1. Assessments fundal height, position and consistency and assess for lochia.
2. Encourage the client to utilize factors that can enhance uterine involution
- Breastfeeding.
- Early and frequent ambulation.
- Frequent voiding.
3. Administer oxytocics as prescribed to promote uterine contractions and expel the retained fragments of
placenta.
- ergonovine (most common) as prescribed to stimulate uterine contractions. Therapy includes
0.2 mg IM every 4 hr lasting 2 to 3 days.
4. Administer antibiotic therapy as prescribed to prevent or treat infection.
5. Dilation and curettage (D&C) last resort

B. RETAINED TISSUES
-

A retained placenta prevents the uterus from contracting, resulting in uterine atony or
subinvolution of the uterus as well as possible uterine inversion, hemorrhage, or endometritis.
Placental retention because of poor separation is common in preterm births.

Risk factors
o Partial separation of a normal placenta.
o Entrapment of a partially or completely separated placenta by a constricting ring of the uterus.
o Mismanagement of the third stage of labor with excessive traction on the umbilical cord prior to
complete separation of the placenta.
o Abnormally adherent placental tissue to the uterine wall.
S/SX:

Uterine atony, subinvolution, or inversion.

Excessive bleeding or blood clots larger than a quarter.
The return of lochia rubra once lochia has progressed to serosa alba.
Malodorous lochia or vaginal discharge.
Elevated temperature.

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Interventions:
1. Assessing the uterus for fundal height, consistency, and position. Assessing for lochia color, amount,
consistency, and odor. Monitoring vital signs and temperature.
2. Administering oxytocics to expel retained fragments of the placenta.
3. Administering tocolytic to relax the uterus prior to D&C if placental expulsion with oxytocics is
unsuccessful.
4. Anticipating surgical intervention such as a hysterectomy if postpartum bleeding is present and
continues.

General Assessment for Postpartum Hemorrhage:

GENERAL Management of Postpartum Hemorrhage:

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Uterine massage (avoid potential uterine inversion): Avoid excessively vigorous massage.
Maintenance of large-bore intravenous catheters.
Administration of intravenous fluids (e.g., rapid volume expanders, blood products).
Insertion of Foley catheter to maintain accurate measurement of urine output and to assess the clients
kidney function.
Providing oxygen to the client at 2 to 3 L per nasal cannula as prescribed to increase red blood cell
saturation and monitor oxygen saturation with a pulse oximeter.
Elevation of legs at a 20- to 30-degree angle to increase venous return.
Avoid the use of the Trendelenburg position (unless ordered), since it may interfere with cardiac and
respiratory function.
Assess blood loss by weighing the perineal pads (1g of pad weight = 1ml (cc) blood loss volume,
subtracting the weight of dry pad from saturated pad).
Monitor vital signs every 15 minutes until stabilized.
Provide emotional support for the mother and her family.
Provide discharge instructions: instruct the client to limit physical activity to conserve strength and to
increase iron and protein intake to promote the rebuilding of RBC volume.