Postpartum Hemorrhage

Description

Postpartum hemorrhage is blood loss of more than 500 mL following the birth of a newborn.

Etiology

Early postpartum hemorrhage, which is usually due to uterine atony, lacerations, or retained placental fragments, occurs in the first 24 hours after delivery.
Late postpartum hemorrhage occurs after the first 24 hours after delivery and is generally caused by retained placental fragments or bleeding disorders.

Pathophysiology

Delayed uterine atony or placental fragments prevent the uterus from contracting effectively. The uterus is unable to form an effective clot structure and bleeding ensues or continues.

Assessment Findings

Common clinical manifestations include:

Vaginal bleeding is the obvious sign of postpartum hemorrhage; amount and character vary with cause.
Signs of impending shock include changes in skin temperature and color, and altered level of consciousness.

Nursing Management

1. Prevent excessive blood loss and resulting complications.

Massage the uterus, facilitate voiding, and report blood loss.
Monitor blood pressure and pulse rate every 5 to 15 minutes.
Prepare for intravenous infusion, oxytocin and blood transfusion, if needed.
Administer medications and oxygen as prescribed. ( Drug Chart )
Measure and record fluid intake and output.
Be prepared for possible dilation and curettage (D&C).

2. Assist the client and family to deal with physical and emotional stresses of postpartum complications.

Drug Chart Medications Used for Postpartum Complications

Classifications	Used for	Selected Interventions
Anticoagulants Heparin sodium injection (Hepalean) Lovenox	Blocks the conversion of prothrombin to thrombin and fibrinogen to fibrin thus decreasing clotting ability Inhibits thrombus and clot formation	Heparin IV should be administered as a “piggy back” infusion. Heparin SQ is given deep into the site (abdomen), sites are rotated, do not aspirate, apply pressure (do not massage). Used to prevent and treat pulmonary embolism and thrombosis.
Warfarin sodium (Coumadin, Warfilone)	Interferes with hepatic synthesis of vitamin K –dependent clotting factors (II,VII, IX, X)	Women on anticoagulopathy therapy should no be given estrogen or aspirin. Obtain baseline coagulation studies. Obtain serial coagulation studies while the client is on therapy. Keep protamine sulfate readily available in case of heparin overdose. Assess client for bleeding from nose, gums, hematuria, and blood in stool. Observe color and amount of lochia. Institute pad count. Avoid IM injections to avoid formation of hematomas. Inform the client that this drug does not pass into breast milk. Monitor for the following side effects; hemorrhage, bruising urticaria, and thrombocytopenia. Women on anticoagulant therapy should not be given estrogen or aspirin. Obtain baseline coagulation studies while on therapy. Keep AquaMEPHYTON (vitamin K) on hand in case of Coumadin overdose. Assess client for bleeding from nose, gums, hematuria, and blood in stool. Observe color and amount of lochia. Institute a pad count. Avoid IM injections to avoid formation of hematomas. Inform the client that this drug passes into breast milk and its use is contraindicated during pregnancy. Monitor the following side effects: hemorrhage, fever, nausea, and cramps.
Oxytoxic methylergonovine maleate (methergine) (PO, IM, IV)	Directly stimulates uterine and vascular smooth muscle Promotes uterine contraction Used for prevention and treatment of postpartum or postabortion hemorrhage caused by uterine atony or subinvolution.	Obtain a baseline calcium level. Advise the client that this medication will cause menstrual-like cramps. Assess for numb fingers and toes, cold, chest pain, nausea, vomiting, muscle pain, and weakness. May cause decreased serum prolactin. IV administration is used for emergency dosage only. Administer at a rate of 0.2 mg over at least 1 minute. DO NOT MIX THIS DRUG WITH ANY OTHER DRUG. Use solution only if it is clear and colorless, with no precipitate. May store at room temperature for 60 days. The drug deteriorates with age. Monitor for the following side effects: dyspnea, palpitations, diaphoresis, chest pain, hypotension, and headache.

Exam

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Nursing Care Plan

Ineffective Tissue Perfusion

Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.

May be related to

Hypovolemia (a decreased volume of circulating blood in the body).

Possibly evidenced by

Diminished arterial pulsations, cold extremities.
Decreased capillary refill.
Decreased milk production.
Changes in the vital signs.
Changes in the neurologic status.

Desired Outcomes

Patient will demonstrate blood pressure, pulse, arterial blood gasses (ABGs), and Hematocrit/hemoglobin level within the expected range.
Patient will demonstrate normal hormonal functioning by adequate milk supply for lactation (as appropriate) and resumption of normal menstruation.

Nursing Interventions	Rationale
Monitor vital signs closely; record the degree and duration of any hypovolemic episodes.	Extent of pituitary involvement may be related to the degree and duration of hypotension. A respiratory difficulty may indicate an effort to combat metabolic acidosis.
Observe the color of the nail beds, gums, tongue and buccal mucosa; Note the temperature of the skin.	With the vasoconstriction compensation and shunting to vital organs, circulation in the peripheral blood vessels is diminished, resulting in cyanosis and cold skin temperatures.
Evaluate the neurologic status and observe for any behavioral changes.	Changes in the mentation is an early sign of hypoxia. Cyanosis, on the other hand, is a late sign which may not appear until the PO2 levels drop below 50 mm Hg,
Check the breast at least daily; Inspecting for changes in breast size and the presence or absence of lactation.	Sheehan’s syndrome, also known as postpartum hypopituitarism reduces prolactin levels, resulting in agalactorrhea (absence of lactation) and a decrease in breast tissue.
Monitor Hemoglobin and hematocrit values before and after blood loss. Check for the height and weight; Assess the nutritional status of the client.	Such values indicate the severity of blood losses. Preexisting poor health status increases the extent of injury brought about by the oxygen deficits.
Monitor arterial blood gasses (ABGs) and PH levels.	To determine the degree of tissue hypoxia or acidosis, indicating the build uo of lactic acid resulting anaerobic metabolism.
Administer sodium bicarbonate as indicated.	To correct metabolic acidosis.
Insert airway; suction as indicated.	Facilitates oxygen administration in presence of retained secretions.
Provide supplemental oxygen as indicated.	Maximizes available oxygen for circulatory transport to tissues.

Risk For Infection

Risk For Infection: At increased risk of being invaded by pathogenic organisms.

Risk factors

Decreased hemoglobin.
Invasive procedures.
Stasis of body fluids (lochia).
Traumatized tissues.

Possibly evidenced by

[Not applicable]

Desired Outcomes

Patient will state an understanding of individual causative/risk factors.
Patient will display white blood cell count and vital signs within expected ranges.
Patient will display a lochia free odor.

Nursing Interventions	Rationale
Monitor rate of uterine involution and nature and the amount of lochial discharge.	Infection of the uterus delays involution and lengthen the flow of the lochia.
Observe for signs of fever, chills, body malaise, anorexia, pelvic pain or uterine tenderness.	These symptoms reflect systemic involvement, possibly leading to bacteremia, shock or even death if left untreated.
Check the episiotomy site and abdominal wound (for caesarian) for signs of edema, erythema, separation of wound edges, purulent drainage.	These indicates localized infection requiring immediate intervention to prevent systemic involvement.
Check for other possible sources of infection such as urinary tract infection(urinary frequency/pain, cloudy and odoriferous urine), mastitis (swelling, erythema, pain) or respiratory infection (productive cough, purulent sputum, fever).	Differential diagnosis is critical for effective management.
Teach and demonstrate proper hand-washing and self-care techniques. Review appropriate handling and disposal of contaminated materials (eg., dressings, peripads, linens).	To prevent the spread of infectious organisms.
Review WBC count, hemoglobin and hematocrit levels.	Increased white blood cell count indicates an infection. Anemia often accompanies infection, delays the wound healing, and weaken the immune system.
Administer iron supplement as indicated.	To correct anemia. And possibly improves wound healing.
Obtain a gram’s stain or culture and sensitivity if lochia is noted to have an odiferous smell or purulent wound discharge is observed.	Gram stain identifies the type of infection while cultures and sensitivity identify the specific pathogen and can indicate which antibiotic is suitable to fight the organism.
Administer IV antibiotics as ordered.	Broad spectrum antibiotic may be ordered until the results from culture and sensitivity is available at which time organism-specific antibiotic may be started.