High Risk Postpartum

Brenda Hanson-Smith, Ph.D,

RNC
Jennifer Malana, MSN, RN

Did You Know?

Postpartum Hemorrhage
Leading cause of morbidity and
mortality in the United States
Diagnosis subjective-difficult to
measure
Underestimated by 50%
Most women giving birth are
healthy and compensate for
blood loss

PPH Defining Criteria

Postpartum hemorrhage defined as:
> 500 ml blood loss for vaginal birth
> 1000 ml blood loss for C-Section
Or 10% change in hematocrit
between admission labs and
postpartum labs

Early or Primary PPH

Early, Acute or Primary Postpartum
Hemorrhage
Occurs first 24 hours after birth
Can occur from time of separation of
placenta to expulsion
Common causes
Uterine Atony, Incomplete placental
separation, Excessive traction of
umbilical cord, over manipulation of
fundus

Late or Secondary PPH

Late or Secondary Postpartum
Hemorrhage
Occurs 24 hours after birth, but
< 6 weeks postpartum
Common causes: Subinvolution
of the Uterus, endometritis,
Retained placental fragments

Character of Blood flow

in PPH

Character and quality of blood flow

suggestive of bleeding origin
Dark blood probably venous
Bright red-arterial deep laceration
Spurts with clots = partial
placental separation
Failure for blood to clot-pathologic
or coagulation problem-DIC

Pregnancy Related Facts

Maternal blood volume increases
approximately 50% (from 4 to 6 L)
during pregnancy
Increase in blood volume serves to
fulfill perfusion demands of the lowresistance uteroplacental unit
provides reserve for blood loss that
occurs with delivery

Uterine Physiology
Estimated blood flow to uterus 500 to
800 ml/min/ 10-15% of cardiac output
Uterine blood vessels that supply
placenta traverse a weave of
myometrial fibers
Fibers contract following delivery
(myometrical retraction)

Uterine Physiology (cont)

Myometrial retraction unique to uterine
muscle.
Maintains shortened length following
each contraction.
Blood vessels compressed and kinked
by interlacing lattice work of uterine
muscle.
Normally, blood flow quickly occludes.

The Long List of Causes &

Predisposing Factors of PPH

Uterine Atony
Laceration of birth canal
Retained placental fragments
Ruptured uterus
Inversion of Uterus
Adherent placental fragments
placenta accreta, increta, preceta

Coagulation disorders
Manual removal of retained placenta
Magnesium sulfate during labor or postpartum
Uterine subinvolution

Uterine Atony
Leading cause early of PPH-complicates one
in 20 births
Usually occurs immediately following
delivery of baby and up to four hours
Failure of the uterine myometrial fibers to
contract and retract
Can lead to severe hemorrhage and
hypovolemic shock
Associated with high parity, hydramnios,
macrosomic fetus, rapid forceful labor, and
multiple gestation

Uterine Atony (cont)

Treatment Based on cause
Fundal Massage
Monitor blood flow 1g = 1ml
Medications
Oxytocin, Methergine, Prostaglandin

IV fluid replacement
Foley catheter if necessary
Bimanual compression-MD or CNM
Manual exploration
Oxygen-increase delivery to cells

Cervical, Vaginal or Perineal

Lacerations
Second most common cause of PPH
Perineal lacerations.
Bleeding usually slow trickle and/or
continuous or frank bleeding
Factors influencing causes:
Operative birth, precipitate birth, size
of fetus, abnormal presentation,
position of fetus, relative size of
presenting part and birth canal,
previous scarring from infection, injury
or operation, vulvar, perineal, and
vaginal varicosities.

Lacerations (cont)
Treatment:
Assessment to identify source of
bleeding
Suture laceration
Monitor blood flow
Fluids and Blood replacement
may be necessary

Retained Placenta
Results from:
Partial separation of normal placenta
Entrapment of partially separated
placenta
Miss management of 3rd stage labor
Abnormal adherence of placenta
Treatment:
Monitor bleeding
Manual or surgical removal of placenta
Fluid replacement
Antibiotic Therapy

Adherent Retained
Placenta
Abnormal adherence of placenta
Cause-zygote implantation in defective
endometrium
Bleeding becomes profuse when delivery of
placenta is attempted
Unable to remove placenta
Placental adherence-recognized in degrees
Placenta acreta-light penetration of
myometrrium by trophobloast
Placenta increta-deep penetration of
myomentrium
Placenta perceta-perforaction of uterus by
placenta

Inversion of Uterus

Occurrence 1 in 2000 to 2500 patients

May reoccur with previous inversion
Classified as partial or complete
May be associated with hemorrhage of 2L
Contributing factors
Fundal implantation
Uterine Atony
Vigorous fundal massage
Excessive traction applied on umbilical
cord
Leiomyomas
Abnormally adherent placenta

Inversion of Uterus
(cont)
Treatment
Based on reason
IV fluid replacement
Medications if necessary

Subinvolution
Late PPH occurs as a result of subinvolution
Causes
Retained Placental Fragments
Pelvic infection

Signs and Symptoms

Prolonged lochial discharge
Irregular or excessive bleeding
Hemorrhage

Treatment
Based on reason for subinvolution
Most common drug Oral Methergine
(methylergonovine maleate) .2mg q 4 hours for 24 to
48 hours (see Table 39-1)
Antibiotic Therapy

Nursing Care
Management

Assess for Signs and Symptoms of PPH

Review patient history for predisposition
Fundal check
Assess for firmness of fundus and deviation
Turn patient to side to assess bleeding

Bleeding assessment
Color, amount, odor

Frequent vital signs

Not reliable but can identify trend
Increasing tachycardia, tachypnea
Body rids itself of excess acids by increasing
respiratory rate

Nursing Care Management

(cont)
Assessment for bladder distention
Distended bladder can displace uterus
Skin
Warmth and dryness
Check nail beds color and capillary refill
In hemorrhage skin is sacrificed to maintain
blood flow to important organs
Laboratory studies
Hematocrit, Hemoglobin, Platelets,
Fibrogen, Fibrin

Nursing Care Management

(cont)
Nursing Education
Inform patient about condition and
treatment plan
Patient education regarding PPH
when discharged
Normal involution
Excessive vaginal bleeding
Resumption of bright red bleeding
Fever > 100.4

Hemorrhagic(Hypovolemic)
Shock
PPH can develop into Hemorraghic shock
Organ systems shut
Physiologic compensatory mechanisms
are activated
Prolonged Shock - reduction of cellular
oxygenation results with build of lactic
acid and acidosis
Acidosis causes arteriolar vasodilation
& venule vasoconstriction
Creates circular

Hemorrhagic Shock
(cont)
Medical Management
Restore Circulating Blood volume
Rapid infusion of IV crystalloid
solution
Rate 3ml infused for every 1 ml estimated blood loss
Packed Red Blood Cells
Possible fresh-frozen plasma
Treat cause of hemorrhage

Hemorrhagic Shock
(cont)
Nursing Interventions
Continued assessment
Pulse, Blood Pressure, Respiratory rate
Patient color
Monitor and provide oxygen
10-12 L/min preferably nonrebreathing
face mask
Level of Consciousness
Seeing stars, feeling dizzy
Restlessness or orthopneic
Confusion
Reacts to stimuli slowly

Hemorrhage Shock (cont)

Continuous EKG monitoring
Hypotensive or tachycardic
Foley Catheter
Assess hourly output
Minimum 30 ml/hr
Fluid or Blood Replacement
Large bore IV catheter
Possibly establish two IV lines
Fluid resuscitation
Careful observation for fluid overload
Transfusion reaction
Assess for complications of replacement
therapy

Hypovolemic Shock Grid

BloodPressur
e(systo
lic)

Blood
Volume
Loss

Symptoms and
Signs

Degree of
Shock

Normal

500-1000 ml
(10-15%)

Palpitations
Tachycardia,
Dizziness

Compensate

Slight fall
(80100
mm/Hg
)

1000-1500 ml
(15-25%)

Weakness,
tachycardia,
Sweating

Mild

Moderate fall
(70-80
mm/Hg
)

1500-2000 ml
(25-35%)

Restlessness,
Pallor,
oliguria

Moderate

Marked fall
(50-70
mm/Hg
)

2000-3000 m;
(35-50%)

Collapse,
air hunger,
anuria

Severe

Coagulaopathies
Idiopathic Thrombocytopenia
Autoimmune disorder
Antiplatelet antibodies
von Willebrand disease
Type of hemophilia-most common
hereditary bleeding disorder
Disseminated Intravascular Coagulation
Pathologic form of clotting
Diffuse & consumes large amount of
clotting factors

Coagulopathies (cont)
Disseminated Intravascular Coagulation
Clotting problem that uses large amounts of
clotting factors
External & Internal bleeding can occur
Small vascular occlusions can occur
Cause
Abruptio Placenta, Amniotic fluid
embolism, dead fetus syndrome, severe
preeclampsia, septicemia,
cariopulmonary arrest, & hemorrhage

Thromboembolic Disease
Formation of blood clot or clots inside of blood
vessel
Incidence 1 in 500-750 women
Risk factors
Increasing maternal age
Increasing parity
Previous thromboembolism
Congestive cardiac failure
Obesity
Operative delivery

Clinical Manifestations of
Thromboembolic Disease
Major cause
venous stasis & hypercoagulation

Three conditions
Superficial venous thrombosis
Deep venous thrombosis
Pulmonary embolism

Characterized by pain & tenderness

Deep vein more common in pregnancy
Physical exam
warmth, redness & enlarged hardened vein

Thrombolembolic Disease
(cont)
Medical management
Superficial
analgesia,nonsteroidal
antiinflammatory agents, rest &
elevation of effected leg
Deep vein
anticoagulant therapy, bed rest,
analgesia

Postpartum Infections
Definition-fever > 38 or more on 2 successive
days of the first 10 days postpartum (Cunningham
et al., 2001)
Major cause of morbidity & mortality throughout
world-6% in US
Intrapartal factors contribute to infections
PROM, prolonged labor, maternal fever (Varner,
1998)

Types of Infections
Overall postpartum infection rate 1-8%
Motality .6 maternal deaths per
100,000 liver birth
Types of infections
Endometritis
Mastitis
Urinary Tract Infections
Sepsis

Endometritis
Most common source of postpartum
infection
Characterized by lower abdomen pain
Temperature > 38.3
Foul-smelling lochia
Risk increases after cesarean
delivery (10-20%)

Mastitis
Fever & chills
Tender engorgement breasts
Frequently occurs in first time mothers
Most common organismstaphylococcus aureus
Infants mother or throat
Treatment

Urinary Tract Infection

Fever, Chills
Frequency on urinations
Most common bacteria-normal bowel flora
E. Coli & Enterobacter species
Common cause
Foley catherization
Hygiene
Treatment

Septic Shock
Signs & symptoms
Tachypneas > 20 breaths/min
Tachycardia > 90 beats/min
Hypotension
Hypothermia < 35 degrees C
Hyperthermia > 38 degrees C
Evidence of inadequate organ perfusion
Oliguria
+ Blood cultures
Usual cause Gram-negative organisms
Early shock- receptive to IV fluids & antibiotics
Septic shock with sepsis poor prognosis- 28%
mortality

Case Study
C.R. is a 40 years old Gravid 7 Para 6 who
delivered a 9 lb 11oz boy, after 24 hours of labor
induction. She stated to the nurse that she felt of
gush of blood and seems to be upset and fearful.
Her vital signs are stable. C. R.s lochia is bright
red and heavy and her fundus is deviated to the
right.

Case Study (conti)

1. Which of the following assessments is the most
important for the nurse to perform?
A. Continue to check her vital signs every 15
minutes.
B. Charting the amount of blood flow and deviation
of the uterus
C. Check the bladder for distention
D. Massage the uterus vigorously until firm

Case Study (cont)

C.R. is considered to at high risk for uterine atony
because of the following reasons?

A.
B.
C.
D.

She is a grand multipara

Her baby weighed 9 lbs 11ozs
The length of her labor
D. All of the above

Case Study (conti)

G.R. has saturated 3 pads in one hour with bright
red blood. Her vital signs continue to be stable.
Which condition is her early postpartum bleeding
attributed to?

A.
B.
C.
D.

Subinvolution related to placental fragments

Ruptured Hematoma
Uterine Atony
Laceration of the Cervix

Case Study (cont)

Which is the first nursing action you should
perform following your findings?

A. Chart your finding

B. Run through the halls asking for help
C. Open the IV to increase the level of Oxytocin
D. Massage the Fundus
E. Check her bladder for distention
F. Turn the patient to the side

Case Study (cont)

Which is the main cause of early postpartum
hemorrhage?

A.
B.
C.
D.
E.

DIC
Retained Placental Fragment
Hematomas and Lacerations
Uterine Atony
Subinvolution

Case Study (conti)

Which is the main cause of late postpartum
hemorrhage?

A. DIC
B. Uterine Atony
C. Retained placental fragments
D. Overdistended bladder
E. Hematomas and Lacerations
F. Subinvolution

Case Study (cont)

Which of the following nursing actions help to
stabilize the mothers condition and relate to
uterine atony?
A. Massage the fundus
B. Assess the bladder and if necessary
insert a foley catheter
C. Increase the IV infusion of oxytocin
D. Report finding to provider
E. All of the above

Take Home
Evaluate patients for predisposition to
PPH
Clear communication with Providers
Assess for signs and symptoms of PPH
Develop Nursing Care plan based on
cause of PPH
Educate patients regarding PPH and
treatment plan