Postpartum Hemorrhage

The nurse understands that an early postpartum hemorrhage is defined as an estimated blood loss greater than ______________mL in the first 24 hours after a vaginal delivery. Use numbers only.

500 A postpartum hemorrhage is defined as an estimated blood loss of greater than 500 mL after a vaginal delivery. The nurse should initiate the postpartum hemorrhage protocol and notify the health care provider if the blood loss is greater than 500 mL.

After a vaginal delivery, an estimated blood loss greater than _____________mL would indicate a diagnosis of a postpartum hemorrhage. Use numbers only.

500 Postpartum hemorrhage is defined as blood loss of more than 500 mL after a vaginal birth and blood loss of more than 1000 mL after a cesarean birth.

The nurse understands that which action after the birth of the newborn can prevent a postpartum hemorrhage? Administration of broad-spectrum antibiotics Inspection of the placenta Manual removal of the placenta after birth Pulling on the umbilical cord to hasten delivery of the placenta

Administration of broad-spectrum antibiotics Broad-spectrum antibiotics may be ordered if the uterus is explored for missing placental fragments; however, antibiotics do not prevent a postpartum hemorrhage. Inspection of the placenta If a portion of the placenta is missing, the healthcare provider can explore the uterus, locate the missing fragments, and remove the potential cause of a postpartum hemorrhage. Manual removal of the placenta after birth Manually removing the placenta after birth places the mother at risk for retaining placental fragments. The placenta should naturally deliver within 30 minutes after the birth of the newborn. Pulling on the umbilical cord to hasten delivery of the placenta Pulling on the umbilical cord after birth places the mother at risk for having a severed cord, a manual removal of the placenta, or an inverted uterus. The placenta should naturally deliver within 30 minutes after the birth of the newborn.

A nurse is monitoring a new mother in the postpartum period for signs of hemorrhage. Which sign, if noted in the mother, indicates excessive blood loss? An increase in the pulse from 88 to 110 beats/min A blood pressure change from 130/88 to 124/80 mm Hg An increase in the respiratory rate from 18 to 20 breaths/min A change in the O2 saturation from 99% to 96%

An increase in the pulse from 88 to 110 beats/min Tachycardia is one of the early signs of hypovolemic shock. A change in pulse rate more than 20 beats/min would be a concern for the nurse. A blood pressure change from 130/88 to 124/80 mm Hg A blood pressure change from 130/88 to 124/80 mm Hg is not a significant change. The nurse should be concerned if the patient begins to experience hypotension. An increase in the respiratory rate from 18 to 20 breaths/min A respiratory change from 18 to 20 breaths/min is not a significant change. The nurse should be concerned if the breathing becomes rapid and shallow. A change in the O2 saturation from 99% to 96% A change in O2 saturation from 99% to 96% is not a significant change. The nurse should be concerned if the O2 saturation falls below 90% and the patient is experiencing symptoms such as dizziness and lightheadedness.

A woman delivered a 9-lb, 10-oz baby 1 hour ago. When the nurse arrives to perform the 15-minute assessment, the patient says that she "feels all wet underneath." The nurse discovers that both perineal pads are completely saturated and that the patient is lying in a 6-inch-diameter puddle of blood. After calling for help, which action would the nurse take next? Assess the fundus for firmness. Estimate the blood loss by weighing the perineal pads. Check the perineum for lacerations. Manually remove any contents in the uterus.

Assess the fundus for firmness. Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first attempt to firm the fundus through firm, but not vigorous, massage. Estimate the blood loss by weighing the perineal pads. Estimating the blood loss is important; however, the nurse should prioritize stopping the active bleeding before estimating blood loss. Check the perineum for lacerations. Checking the perineum for lacerations is important, but the nurse should first determine whether uterine atony is the cause for the bleeding before examining the perineum. Manually remove any contents in the uterus. A retained placenta can cause a postpartum hemorrhage; however, the health care provider, not the nurse, is responsible for manually removing any contents from the uterus. The nurse should first massage the fundus to determine if there is uterine atony.

Which risk factor places a woman at risk for subinvolution of the uterus? Chorioamnionitis Forceful traction of the umbilical cord Vacuum extraction Precipitous delivery

Chorioamnionitis Subinvolution of the uterus is the delayed return (longer than 24 hours) of the uterus to normal size after delivery. Pelvic infections, including chorioamnionitis, place a woman at risk for subinvolution. Forceful traction of the umbilical cord Forceful traction of the umbilical cord is not a risk factor for subinvolution but is a risk factor for uterine inversion. Vacuum extraction A vacuum extraction is not a risk factor for subinvolution but is a risk factor for a vaginal laceration or vaginal hematoma. Precipitous delivery A precipitous delivery is not a risk factor for subinvolution but is a risk factor for a laceration.

A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but the fundus remains difficult to find, and the rubra lochia remains heavy. Which action would the nurse take next? Continue to vigorously massage the fundus. Notify the health care provider. Recheck vital signs. Insert a Foley catheter.

Continue to vigorously massage the fundus. Although the patient is showing signs of a postpartum hemorrhage (PPH), vigorously massaging the fundus can cause the uterus to invert and should be avoided until the etiology of the PPH is revealed. Notify the health care provider. Because the patient has a boggy uterus, heavy lochia, had a precipitous delivery, and delivered a large newborn, the treatment requires notification of the health care provider. The patient with these signs of PPH should not be left alone. Recheck vital signs. Rechecking vital signs is important because the patient is showing signs of a PPH. This should be done every 5 minutes when a PPH is suspected; however, the nurse should notify the health care provider before rechecking vital signs. Insert a Foley catheter. Inserting a Foley catheter is important because a full bladder can inhibit the uterus from contracting effectively and may cause uterine atony; however, the nurse should notify the health care provider before inserting a Foley catheter because the patient is showing signs of a PPH.

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage (PPH). Before administration of this medication, which nursing assessment is the priority? Deep tendon reflexes Uterine tone Amount of lochia Blood pressure

Deep tendon reflexes Deep tendon reflexes are affected by magnesium sulfate for preterm labor or preeclampsia. The nurse would not need to check deep tendon reflexes before giving methylergonovine. Uterine tone Uterine tone should be checked before giving oxytocin, misoprostol, or carboprost tromethamine, but it is not a priority to check before giving methylergonovine maleate. Amount of lochia Lochia (vaginal bleeding after childbirth) should be checked before giving oxytocin, misoprostol, or carboprost tromethamine, but it is not a priority to check before giving methylergonovine. Blood pressure Methylergonovine maleate is more likely to cause the diastolic blood pressure to rise when given; therefore before administering methylergonovine maleate for PPH, the nurse would want to check the patient for high blood pressure. Methylergonovine maleate is contraindicated in a patient with high blood pressure.

A nurse is caring for the following labor patients. Which patients would the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply. G1 P0000, delivered a 29-week fetal demise vaginally after 8 hours in labor G2 P1001, delivered a 4200-g neonate vaginally after 4 hours of labor G2 P0010, delivered a 3750-g neonate by cesarean section for breech presentation G4 P3003, delivered a 3500-g neonate by cesarean section with a placenta accreta G3 P0200, delivered a 3900-g neonate vaginally after 36 hours in labor

G1 P0000, delivered a 29-week fetal demise vaginally after 8 hours in labor A fetal demise does not increase the risk for a woman to have a PPH after delivery. G2 P1001, delivered a 4200-g neonate vaginally after 4 hours of labor Fetal macrosomia (birth weight >4000 g) places a woman at higher risk for PPH after delivery due to an overstretched uterus. G2 P0010, delivered a 3750-g neonate by cesarean section for breech presentation An infant at normal weight delivered by cesarean section for breech presentation does not increase the risk for a woman to have a PPH after delivery. G4 P3003, delivered a 3500-g neonate by cesarean section with a placenta accreta A placenta accreta increases the risk for a woman to have a PPH due to the risk for retained placenta, which can lead to uterine atony. G3 P0200, delivered a 3900-g neonate vaginally after 36 hours in labor A prolonged labor, in this case 36 hours, increases a woman's risk for a PPH due to an overworked and "tired" uterus.

When caring for a patient with a postpartum hemorrhage, which interventions would the nurse initiate to improve the patient's status? Select all that apply. Insertion of an indwelling catheter Fundal massage Pad count Administration of tocolytic drugs Intravenous (IV) fluid replacement

Insertion of an indwelling catheter If a full bladder is displacing the uterus and preventing it from contracting, insertion of an indwelling catheter would be an appropriate response. Fundal massage Fundal massage can stimulate the uterus to contract, which can cause the bleeding to decrease. Pad count Because the patient is already hemorrhaging, it is inappropriate to initiate a pad count. Instead, the nurse should weigh the pads to estimate blood loss. Administration of tocolytic drugs Tocolytic drugs cause uterine relaxation, which would further complicate the postpartum hemorrhage. The nurse would want to administer uterotonic drugs to stimulate uterine contractions. Intravenous (IV) fluid replacement IV fluid replacement can assist with hemodynamic changes during a postpartum hemorrhage.

The nurse understands that which conditions are risks for a uterine inversion? Select all that apply. Precipitous delivery Short umbilical cord Polyhydramnios Fundal implantation of the placenta Prolonged labor

Precipitous delivery A precipitous delivery is not a risk factor for uterine inversion but is a risk factor for a laceration. Short umbilical cord A short umbilical cord is a risk factor for a uterine inversion because it places extra traction on the cord during delivery, which could pull the placenta and invert the uterus. Polyhydramnios Polyhydramnios is not a risk factor for uterine inversion but is a risk factor for uterine atony. Fundal implantation of the placenta Fundal implantation of the placenta is a risk factor for a uterine inversion; as traction is placed on the umbilical cord during delivery, there is a higher risk to invert the uterus. Prolonged labor A prolonged labor is a risk factor for uterine inversion because a prolonged labor creates an overworked and "tired" uterus, which makes it vulnerable to inversion after delivery.

Which conditions are risk factors for uterine atony? Select all that apply. Primiparous birth Polyhydramnios Precipitous birth Fetal macrosomia Chorioamnionitis

Primiparous birth A woman who has high parity (multiparity)—more than five pregnancies to 20 weeks' gestation or greater—is more likely to have an overstretched uterus and is at higher risk for uterine atony. A primiparous birth is at a lower risk for uterine atony due to the fact that the uterus has not been stretched multiple times. Polyhydramnios Polyhydramnios is a medical condition describing an excessive amount of amniotic fluid (greater than 2 L of amniotic fluid), which can cause an overstretched uterus and places a woman at higher risk for uterine atony. Precipitous birth A precipitous birth is a birth that occurs in less than 2 hours. Women who have a precipitous birth are at lower risk for uterine atony. A woman who has a prolonged labor (longer than 24 hours) can have an overworked and tired uterus, which places her at higher risk for uterine atony. Fetal macrosomia Fetal macrosomia describes a newborn who has a birth weight of more than 4000 g regardless of his or her gestational age, which can cause an overstretched uterus and places a woman at higher risk for uterine atony. Chorioamnionitis Chorioamnionitis is an infection of the fetal membranes and can lead to prolonged labor and an infected uterus (both of which are associated with uterine atony).

In the fourth stage of labor, the nurse recognizes that a full bladder increases the risk for which postpartum complication? Retained placenta Boggy uterus Infection Shock

Retained placenta A retained placenta is not related to the maternal bladder, but it can be due to a placenta accreta or placenta percreta. Boggy uterus A full bladder displaces the uterus and prevents contraction of the uterus, and uterine atony is the primary cause of postpartum hemorrhage. Infection A full bladder is not related to an increase risk for infection. If the bladder is not emptied and if the uterus is boggy, the health care provider may need to perform a manual exam, which places the mother at risk for infection. Shock A full bladder is not related to an increased risk for shock; however, if the uterus remains boggy and if the bleeding does not subside, the mother is at risk for hemodynamic instability or shock.

A woman, 1 day postpartum, is being carefully monitored after a significant postpartum hemorrhage (PPH). Which finding would the nurse report to the health care provider? Urine output of 160 mL for the past 8 hours Weight loss of 2 lb since delivery Pulse rate of 68 beats/min Fundus firm at the umbilicus

Urine output of 160 mL for the past 8 hours Oliguria (urine output <30 mL/h) should be reported, as this is a late sign of hypovolemic shock. Weight loss of 2 lb since delivery Weight loss after a childbirth is an expected finding and does not need to be reported to the health care provider. Pulse rate of 68 beats/min A pulse rate of 68 beats/min is within normal limits. Any pulse rate that is bradycardic (<60 beats/min) or tachycardic (>100 beats/min) should be reported to the health care provider. Fundus firm at the umbilicus A firm fundus at the level of the umbilicus is a reassuring sign that the uterus in contracting and returning to normal size and location. If the fundus was boggy or rising above the umbilicus, the nurse would report that finding to the health care provider.

The nurse recognizes that a steady trickle of bright red blood from the vagina in the presence of a firm fundus may indicate which condition? Uterine atony Retained placenta Infection of the uterus A laceration within the genital tract

Uterine atony Uterine atony results in a boggy uterus and dark red lochia with or without the presence of clots. Retained placenta Retained placental fragments result in a boggy uterus that is above the umbilicus. Bleeding typically is dark red lochia with large amounts of clots. Infection of the uterus An infection of the uterus results in a boggy uterus due to the inability of the uterus to contract because of the infection. Lochia may be normal, or it may have a foul smell in the presence of pus. A laceration within the genital tract Undetected lacerations bleed slowly and continuously until repaired with sutures. Bleeding from lacerations is uncontrolled by uterine contractions, and it is typically bright red.

Which type of hematoma is most common in vaginal births and is visible from the outside? Vaginal Vulvar Cervical Retroperitoneal

Vaginal A vaginal hematoma is not visible without a speculum, and women often complain of pressure and pain inside the vagina (a feeling of "fullness"). Vulvar A vulvar hematoma is the most common hematoma and is visible to the outside, painful to the touch, and caused by tissue breakdown during a vaginal birth. Cervical A cervical hematoma is a hematoma on the cervix and is extremely rare. Retroperitoneal A retroperitoneal hematoma is the most uncommon hematoma but is the most life threatening. Retroperitoneal hematomas are usually a result of the rupture of a previous cesarean scar and involve a laceration to the hypogastric artery. These hematomas do not typically cause pain, and the first sign may be symptoms of shock.

On assessment, the postpartum nurse notes a firm fundus, bright red blood oozing from the vagina, and a saturated perineal pad. What diagnosis would the nurse expect based on these assessment findings? Vaginal hematoma Placenta accreta Vaginal laceration Uterine inversion

Vaginal hematoma A vaginal hematoma is not visible without a speculum, and women often complain of pressure and pain inside the vagina (a feeling of "fullness"). A vaginal hematoma may occur due to an operative vaginal delivery (forceps or vacuum extraction), an episiotomy, or a primiparous birth. A vaginal hematoma is trapped blood, and therefore no bleeding will be present. Placenta accreta A placenta accreta is diagnosed when the placenta invades the myometrium of the uterus. With a placenta accreta, the fundus would not be firm; however, there would be bleeding. Vaginal laceration A vaginal laceration that was not discovered or repaired after a vaginal delivery would create an oozing of blood that is typically bright red (frank) in color. Uterine inversion A uterine inversion is diagnosed when the uterus turns inside out followed by a large amount of bleeding. The fundus would not be firm. A uterine inversion is a medical emergency.

A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000-g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but the patient's fundus remains difficult to find and the lochia remains bright red and heavy. Which action would the nurse take next? Vigorously massage the fundus Notify the health care provider Recheck the vital signs Insert an indwelling catheter

Vigorously massage the fundus The nurse should continue to massage the fundus; however, the fundus should never be vigorously massaged because of the risk for uterine inversion. The nurse should initiate the postpartum hemorrhage protocol and notify the health care provider. Notify the health care provider Treatment of a postpartum hemorrhage requires the collaboration of the nurse and the health care provider. The nurse should remain with the patient and call the health care provider. Recheck the vital signs The nurse has already taken vital signs, and they remain unchanged. The nurse should initiate the postpartum hemorrhage protocol and notify the health care provider. Insert an indwelling catheter The nurse has already had the patient void to empty her bladder. The nurse should initiate the postpartum hemorrhage protocol and notify the health care provider.