Postpartum Hemorrhage (PPH)

von Willebrand Disease (vWD)

A congenital bleeding disorder that is inherited as an autosomal dominant trait Characterized by prolonged bleeding time, deficiency of vW factor, and impairment of platelet adhesion Most cases are undiagnosed due to lack of awareness, difficulty of diagnosis, and tendency to attribute bleeding to other causes (i.e. menorrhagia)

Disseminated Intravascular Coagulation

Acquired coagulopathy where clotting system is abnormally activated resulting in widespread clotting in small vessels which leads to depletion of platelets and coagulation factors Known as a consumption coagulopathy NOT a specific illness, secondary diagnosis

Uterine rupture

Tear in uterus that cause famage to genital tract and is more common in women with previous c-sections or those who have undergone any procedure disrupting the uterine wall A catastrophic complication that requires rapid diagnosis and intervention

Uterine relaxants (Tocolytics)

Terbutaline, Magnesium Sulfate, Nifedipine, Indomethacin, Atosiban, Retrodine

Peripartum hysterectomy

The last-resort lifesaving measure with postpartum hemorrhage and carries with it a higher mortality rate compared with nonobstetric hysterectomy Last line of defense if intrauterine balloon tamponade, or uterine compression sutures do not stop the bleeding

Mild Shock (blood loss)

20% Blood Loss S&S: diaphoresis, increased capillary refill, cool extremities, maternal anxiety

Moderate Shock (blood loss)

20-40% blood loss S&S: tachycardia, postural hypotension, oliguria

Tone (4 T's of PPH)

Altered uterine muscle tone most commonly results from overdistention of uterus which is a major risk factor for uterine atony A distended bladder can also displace uterus from midline which impedes ability to contract to reduce bleeding

Idiopathic Thrombocytopenic Purpura (ITP)

An autoimmune disorder of increased platelet destruction caused by autoantibodies, which can increase a woman's risk of hemorrhaging Most common in young women during childbearing age and associated with maternal and fetal complications Glucocorticoids and immune globulin are used for medical therapy

Vaginal wall lacerations

Associated with operative vaginal births but may occur spontaneously, especially if fetal hand is presented with head

Delayed postpartum hemorrhage (late)

Blood loss that occurs 24 hours to 12 weeks after birth May have tachycardia: investigate any HR higher than 100 bpm

Primary postpartum hemorrhage (immediate or early)

Blood loss that occurs within 24 of birth 80% is due to uterine atony

Thrombin (bleeding disorders PPH)

Blood product administration

Prevention of hematomas

Can be prevented with gentle, controlled birth, appropriate inspection and repair of lacerations or episiotomies

Check Vital Signs (PPH)

Check every 15-30 minutes, depending on health status of mother Monitor CBC to identify any deficit Assess LOC and any changes Assess bladder status to prevent uterine displacement

Cervical Lacerations

Commonly occur during forcep delivery or in mothers who cannot resist bearing down before cervix is fully dilated Can arise during manipulations to resolve shoulder dystocia Should always be suspected in contracted uterus with bright red blood continuing to trickle out of vagina

Illnesses leading to DIC

Complications or diagnoses associated with development of DIC: abruptio placentae, amniotic fluid embolism, intrauterine fetal death with prolonged retention, acute fatty liver of pregnancy, severe preeclampsia, HELLP, septicemia, and PPH

Trauma (4 T's of PPH)

Damage to genital tract may occur spontanesouly or through manipulations used during birth Lacerations and hematomas can cause significant blood loss Typically uterus is firm, steady stream of unclotted bright-red blood in perineum

PPH

Defined as blood loss greater than 500 mL after vaginal birth or more than 1,000 mL after cesarean birth Very subjective - s/s may be hidden by normal plasma volume increases from pregnancy Any amount of bleeding that places mother in hemodynamic jeopardy

Major obstetric hemorrhage

Defined as blood loss of more than 1,500-2,500 mL or bleeding that requires more than 5 units of blood to be transfused

Subinvolution Treatment (uterus)

Directed toward stimulating uterus to expel fragments with a uterine stimulant and antibiotics given to prevent infection

Retained placental tissue (PPH)

Evacuation and oxytocics

Massaging the Fundus (procedure)

Explain procerdure to woman. Place gloved hand above symphysis pubis and other gloved hand on the fundus Gently massage in circular manner until firm Apply gentle firm pressure downward to express clots (only if firm) Assist with perineal care and apply new peri-pad Remove gloves and wash hands

Uterine atony

Failure of uterus to contract and retract after birth Most common cause of PPH Overdistention of uterus is a major risk factor for this

Fundal massage

First step if excessive bleeding and uterine tone is diminished Before initiation, nurse places hand over symphysis pubis to anchor uterus and prevent possible uterine inversion

Thrombin (4 T's of PPH)

Formation of blood clots that helps prevent PPH immediately after birth by providing hemostasis Disorders that interfere with this can lead to PPH

Subinvolution signs and symptoms (uterus)

Fundal height higher than expected with boggy uterus Lochia does not change from rubra to serosa to alba within a few weeks Condition usually identified at postpartum exam at 4-6 weeks with a bimanual vaginal exam or ultrasound

Abnormal Coagulation Studies

Generally include decreased platelet and fibrinogen levels, increased PT, increased PTT, fibrin degradation products, and a prolonged bleeding time

Uterine inversion (PPH)

Gentle replacement of uterus and oxytocics

ITP Treatment

Glucocorticoids and IV immunoglobulin, IV anti-RhoD, and platelet transfusions may be given

DIC Treatment Goals

Goals: maintain tissue perfusion through aggressive administration fluid therapy, oxygen, heparin, and blood products Most important = treating underlying condition that leads to DIC; after treating underlying disorder DIC will disappear and coagulation status will normalize

Classic signs of placental separation

Gush or trickle of blood, lengthening of umbilical cord, and slight rise of uterus in pelvis with a change in shape

Readiness Actions for PPH

Having a hemorrhage cart with supplies and instruction cards on every OB unit Having immediate access to medications used to treat a massive hemorrhage Establishing a response team within the hospital that can be called Developing emergency-release transfusion protocols in the blood bank Educating all staff on protocols and holding unit-based drills frequently

Uterine rupture signs and symptoms

Initial symptoms are often nonspecific May be a combination of pain, fetal heart rate abnormalities, and vaginal bleeding

Institute Emergency Measures If DIC Develops (PPH)

Institute emergency measures to control bleeding and impending shock and prepare to transfer her to the intensive care unit Replace fluid volume, administer blood component therapy, and optimize oxygenation and perfusion Continuously assess coagulation status via labs

Subinvolution of Uterus Complications

Hemorrhage, pelvic peritonitis, salpingitis, and abscess formation

From 4 L to 6 L, about 50% increase

How many liters does blood volume increase during pregnancy

Conditions associated with coagulopathies in postpartum client

Idiopathic thrombocytopenic purpura, von Willebrand disease, and DIC Diagnosis of a coagulation disorder often requires a high index of suspicion and should not be overlooked in the evaluation of obstetric hemorrhage

von Willebrand Disease S&S

Include bleeding gums, easy bruising, menorrhagia, blood in urine and stools, nosebleeds and hematomas GI bleeding is rare but prolonged bleeding from small wounds, oral cavity bleeding, and menorrhagia are common During pregnancy the vWD factor increases in most women and labor usually proceeds normally but all women should be monitored for excessive bleeding - esp. first week postpartum

Uterine Inversion Treatment

Includes giving uterine relaxants and immediate manual replacement by HCP

Subinvolution of Uterus

Incomplete involution of uterus or failure to return to normal size and condition after birth Usually occurs when myometrial fibers do not contract effectively and causes relaxation

Other PPH causes

Lacerations of genital tract, episiotomy, retained placental fragments, uterine inversion, coagulation disorders, LGA newborn, failure to progress during 2nd stage, placenta accreta, induction with pitocin, surgical birth, and hematomas

Signs of Postpartum Hemorrhage

Low BP, high HR, low urine output - do not appear till 1,800-2,100 mL of blood has been lost due to about 50% blood volume increase with pregnancy

Von Willebrand Disease Treatment

Mainstays of therapy include desmopressin and plasma concentrates with von Willebrand factor included

Maintain Primary IV infusion (PPH)

Maintain this site and be prepared to start a second infusion at another site if blood transfusion is required

Uterine atony (2 PPH)

Massage and oxytocics

Nursing Management of PPH (2)

Massage uterus Administer uterotonic drug Maintain Primary IV Infusion Check vitals Prepare for Removal of Retained Fragments Continually assess for S&S of hemorrhagic shock Institute emergency measures if DIC develops Prevent PPH

Uterine inversion

Occurs when top of uterus collapses into inner cavity due to excessive fundal pressure or pulling of umbilical cord when placenta is still firmly attached to fundus after infant is born

Uterine Stimulants

Oxytocin - 1st line Misoprostol (Not by FDA) Dinoprostone Methylergonovine maleate Prostaglandin or Carboprost

Hematomas

May present as pain or change in vitals disproportionate to amount of blood loss Formation usually associated with episiotomy, instrumental birth or nulliparity Observe for localized bluish bulging area - may need to be incised and pressure dressing applied

Hematoma s&S

May report severe perineal or pelvic pain and difficulty voiding. May have hypotension, tachycardia, and anemia Assess for bulging bluish area just under skin in perineal area

Severe Shock (blood loss)

More than 40% blood loss S&S: hypotension, agitation or confusion, and hemodynamic instability

Postpartum hemorrhage pathophysiology

Most common cause is uterine atony - 80% of primary or immediate PPH Obstetric lacerations, uterine inversion, and rupture compromise about 20% of primary PPHs Even a full bladder can displace

Postpartum hemorrhage (ICU)

Most common reason postpartum women are admitted to ICU

Nursing Assessment of PPH

Most women will not have identifiable risk factors but assessment for these is required anyway Period after birth and first hours of postpartum are crucial for preventing, assessing, and managing bleeding

Uterine overdistention causes

Multiple gestation, fetal macrosomia, hydramnios, fetal abnormality, placenta previa, precipitous birth, or retained palcental fragments Other causes include: prolonged/rapid or forceful labor, bacterial toxins, use of anesthesia, Mag Sulf

Procedures with risks for uterine rupture

Myomectomy, perforation of uterus during dilation and curettage, biopsy, or intrauterine system insertion (IUS)

Retained placental fragments S/S

No lacerations but painless dark red bleeding mixed with clots and the uterus remains large Prevent hemorrhage from this by carefully inspecting placenta for intactness

Retained placental fragments

Occurs due to failure of complete placental separation and expulsion These occupy space and prevent uterus from contracting fully to clamp down on vessels which may lead to hemorrhage Treatment includes manually separating and removing and administering a uterine stimulant to expel and antibiotics are given

DIC Clinical Manifestations or S&S

Petechiae, ecchymoses, bleeding gums, fever, hypotension, acidosis, hematomas, tachycardia, proteinuria, uncontrolled bleeding during birth, and acute renal failure

Contraindications of Uterine Stimulants in PPH

Pitocin - never give undiluted as bolus IV Cytotec - allergy, active CVD disease, pulmonary or hepatic disease Prostin E2 - active cardiac, pulmonary, renal, or hepatic disease Methergine - do not give with HTN Hemabate - asthma increases risk of bronchial spasm

Postpartum Hemorrhage

Potentially life-threatening complication after births. Leading cause of maternal death -- about 35% of all maternal deaths Majority of deaths occur within 4 hours after birth = 3rd stage consequence

Risk Factors for PPH

Precipitous labor (less than 3 hours) Uterine atony Placenta previa or abruptio placenta Labor induction or augmentation Operative procedures (vacuum extraction, forceps, cesarean birth) Retained placental fragments Prolonged third stage of labor (more than 30 minutes) Multiparity, more than three births closely spaced Uterine overdistention (large infant, twins, hydramnios)

Therapeutic Management of PPH

Prompt diagnosis and understanding underlying triggers is essential

Subinvolution causes (uterus)

Retained placental fragments, distended bladders, excessive activity prohibiting proper recovery, uterine myoma, and infection These all contribute to delayed postpartum bleeding

Assessment of PPH

Review helath history and labor and birth history for risk factors Assess uterine tone after birth for firmness and location Assess amount of bleeding via hospital policy Attempt to identify any source of bleeding (trauma, hematoma, retained fragments) Inspect skin for bleeding or bruises Assess lochia Urine output may be diminished with signs of acute renal failure Vitals show increased pulse and low LOC

Perinatal Management of ITP

Should include maintenance of maternal platelet count and regular monitoring of fetal growth with prediction and prevention of fetal passive immune thrombocytopenia

Lacerations or hematoma (PPH)

Surgical repair

Laceration treatment

Sutured or repaired and antibiotics administered to prevent infection

Uterine clots

These aggregations of blood can occupy space inhibiting uterine contraction

Postpartum hemorrhage sequalae

These include: organ failure, shock, edema, thrombosis, acute respiratorterm-0y distress, sepsis, anemia, intensive care admissions, and prolonged hospitalization

4 T's of postpartum hemorrhage

Tone: uterine atony, distended bladder Tissue: retained placenta and clots or uterine subinvolution Trauma: lacerations, hematoma, inversion, and rupture Thrombin: coagulopathy (preexisting or acquired)

Placenta accreta

Uncommon condition where chorionic villi adhere to myometrium, causing placenta to adhere abnormally to uterus and not separate and deliver spontaneously

Prepare Woman for Removal of Retained Placental Fragments (PPH)

Usually manually separated, be sure HCP remains long enough after birth to assess bleeding status and determine etiology Assist with any suturing to control hemorrhage and repair tissue Anticipate and prepare to transfer woman to OR if tamponade techniques fail to achieve hemostasis Blood bank should be notified that transfusions may be required

Tissue (4 T's of PPH)

Uterine contraction & retraction lead to detachment of placenta after birth Failure of complete separation leads to retained fragments, clots, etc.

Ideally during pregnancy, if no prenatal care order coagulation study immediately

When should women receive coagulation studies to determine her status?

Nursing Management of PPH

When there is excess bleeding management is aimed at improving uterine tone, IV fluid resuscitation, and uterotonic medications If these interventions fail, aggressive therapy may include bimanual compression, internal uterine packing and/or balloon tamponade Transfusion should be instituted once bleeding reaches 1,500 mL

To meet perfusion demands of uteroplacental unit and provide reserve for blood loss occurring at delivery

Why does the blood volume increase about 50% during pregnancy?

Continually Assess for S&S of Hemorrhagic Shock

a catabolic state develops, leading to inflammation, endothelial dysfunction, and disruption of normal metabolic processes in vital organs The main goals of treatment of hemorrhagic shock include fluid resuscitation, correction of the imbalance between oxygen delivery and consumption, and treating DIC Monitor the woman's blood pressure, pulse, capillary refill, mental status, and urinary output