postpartum hemorrhage


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hemorrhage

 [hem´ŏ-rij]
the escape of blood from a ruptured vessel; it can be either external or internal. Blood from an artery is bright red in color and comes in spurts; that from a vein is dark red and comes in a steady flow. Aside from the obvious flow of blood from a wound or body orifice, massive hemorrhage can be detected by other signs, such as restlessness, cold and clammy skin, thirst, increased and thready pulse, rapid and shallow respirations, and a drop in blood pressure. If the hemorrhage continues unchecked, the patient may complain of visual disturbances, ringing in the ears, or extreme weakness.
capillary hemorrhage oozing of blood from minute vessels.
cerebral hemorrhage a hemorrhage into the cerebrum; one of the three main causes of cerebral vascular accident (stroke syndrome).
concealed hemorrhage internal hemorrhage.
fibrinolytic hemorrhage that due to abnormalities of fibrinolysis and not hypofibrinogenemia.
internal hemorrhage that in which the extravasated blood remains within the body.
intracranial hemorrhage bleeding within the cranium, which may be extradural, subdural, subarachnoid, or cerebral.
petechial hemorrhage subcutaneous hemorrhage occurring in minute spots.
postpartum hemorrhage that which follows soon after labor.
primary hemorrhage that which soon follows an injury.
secondary hemorrhage that which follows an injury after a considerable lapse of time.

post·par·tum hem·or·rhage

hemorrhage from the birth canal in excess of 500 mL after a vaginal delivery or 1000 mL after a cesarean delivery during the first 24 hours after birth.

postpartum hemorrhage

Etymology: L, post, after, partus, birth; Gk, haima, blood, rhegnynai, to burst forth
excessive bleeding (a loss of more than 500 mL of blood) after childbirth.

post·par·tum hem·or·rhage

(pōst-pahr'tŭm hem'ŏr-ăj)
Hemorrhage from the birth canal in excess of 500 mL after a vaginal delivery or 1000 mL after a cesarean delivery during the first 24 hours after birth.

Postpartum Hemorrhage

DRG Category:765
Mean LOS:4.8 days
Description:SURGICAL: Cesarean Section With CC or Major CC
DRG Category:774
Mean LOS:3.3 days
Description:MEDICAL: Vaginal Delivery With Complicating Diagnoses

A postpartum hemorrhage (PPH) is frequently defined as a blood loss of greater than 500 mL after giving birth vaginally or a blood loss of greater than 1,000 mL after a cesarean section. Because many women lose at least 500 mL of blood during childbirth and do not experience any symptoms, a more accurate way to define PPH is losing 1% or more of the body weight after delivering a baby (1 mL of blood weighs 1 g). For example, a patient weighing 175 lb (80 kg) would need to lose 800 mL of blood to be classified as having a PPH. Greater than a 10% decrease in the prenatal hematocrit is another means used to suggest that PPH has occurred; this value needs to be used cautiously because hematocrit is affected by factors other than blood loss such as dehydration. It is estimated that 2% to 4% of all deliveries end in PPH, and it is a major contributor to maternal morbidity and mortality.

PPH is classified as either an early hemorrhage (occurring during the first 24 hours after delivery) or a late hemorrhage (occurring more than 24 hours after delivery). With the current trend in obstetric practice of sending postpartum patients home in 48 hours or less after delivery, the significance of PPH, particularly late hemorrhage, is profound. Often, the severity of the hemorrhage depends on the expediency with which it is diagnosed and treated; if the patient hemorrhages at home, her risk increases significantly.

Causes

There are several causes of PPH, particularly uterine atony, trauma, and retained placental fragments. Several predisposing factors related to these causes can be found in Box 1. The number one cause of early PPH is uterine atony, a condition in which the uterus does not adequately contract, allowing increased blood loss from the placental site of implantation. After the placenta is delivered, the uterus needs to contract to seal off the iliac arteries. If the uterus is contracted, the placental site is smaller, causing less bleeding.

Predisposing Factors to Postpartum Hemorrhage

Table .
  • Overdistention of the uterus (multiple gestation and delayed-interval delivery in twin and triplet pregnancies, hydramnios)
  • Grand multiparity; use of anesthetic agents, especially halothane
  • Delivery of large infant
  • Manual removal of the placenta
  • Placenta previa
  • Placenta accreta (separation of the placenta is difficult or impossible)
  • Mismanaged/prolonged (> 30 min) third stage of labor
  • Forceps or vacuum delivery; prolonged or rapid labor
  • Extended used of oxytocin (Pitocin) during labor
  • Maternal malnutrition or anemia
  • Uterine infections
  • Pregnancy-induced hypertension
  • Maternal history of hemorrhage or blood coagulation problems
  • Hypopituitarism (rate of PPH increases to 8.7%)

Lacerations of the perineum, vagina, and cervix can occur during a vaginal birth. Lacerations of the cervix occur with rapid dilation or with pushing before complete dilation. During the second stage of labor, vaginal, perineal, and periurethral tears occur. Failure to repair these lacerations adequately can result in a slow, steady trickle of blood.

The most common cause of late PPH is retained placental fragments. If parts of the placenta remain in the uterus after delivery, small clots form around the retained parts, sealing off the bleeding. After a while, the clots slough, and heavy bleeding occurs. Subinvolution (delayed involution) can also be a causative factor in a late PPH.

Genetic considerations

Several genetic coagulopathies could predispose a woman to PPH, including familial hypofibrinogenemia or Scott’s syndrome. Von Willebrand’s disease is the most commonly inherited bleeding disorder. It is usually transmitted in an autosomal dominant fashion but can rarely be transmitted autosomal recessively. It results in mild to moderate risk of bleeding, but in some cases, bleeding can be severe and similar to that of hemophilia. Von Willebrand’s disease affects men and women equally.

Gender, ethnic/racial, and life span considerations

PPH is linked not to age but to risk factors (see Box 1). Jehovah’s Witnesses are at a 44-fold increased risk of maternal death owing to hemorrhage because of decisions against blood transfusion when it is recommended. Asians and Hispanics also have a higher rate of PPH than whites.

Global health considerations

Although rates of PPH have declined in the developed regions of the globe, it is the leading cause of maternal mortality in the world, accounting for 25% of all maternal deaths. Experts at the World Health Organization and other agencies estimate that 100,000 to 140,000 women die from PPD each year, with the majority of them from developing and underresourced regions. Reasons for the high rates of maternal death in developing regions include availability of medication and blood transfusion, lack of experienced caregivers present during birth, lack of operating room services, and increased prevalence of nutritional deficiencies.

Assessment

History

Because PPH can be repeated in subsequent pregnancies, always ask a multipara if she had a previous PPH. Inquire about a family history of coagulation disorders or excessive bleeding with surgical procedures or menses. Ask if the patient has perineal pain. Although some discomfort is expected after a vaginal delivery, severe pain or pressure is uncommon and often indicates a hematoma.

Physical examination

The most common symptom is heavy vaginal bleeding. Observe the amount and characteristics of blood loss; sometimes there is a pooling of blood and the passage of large clots. Usually, complete saturation of one perineal pad within 15 minutes or saturation of two or more pads in 1 hour suggests hemorrhage. A bimanual examination may be done to determine tone, uterine enlargement, or presence of pelvic hematomas. Palpate the fundus, noting if it is firm or boggy, if it is midline or deviated laterally, and if it is above or below the umbilicus. Normally, after delivery, the fundus is firm, midline, and at the level of the umbilicus. A fundus above the umbilicus and deviated laterally may indicate a full bladder. A boggy uterus is indicative of uterine atony and, if it is not corrected, results in a PPH. If the fundus is firm, midline, and at or below the umbilicus and if there is steady, bright red bleeding, further assessment for trauma is necessary. Inspect the perineum carefully to discern any unrepaired lacerations or bleeding from a repaired episiotomy. If a hematoma is suspected, the patient is placed in lithotomy position and the vagina and perineal area are carefully inspected. A bulging and discoloration of the skin is noted if a hematoma is present. Assess the patient’s vital signs. A temperature above 100.4°F may indicate uterine infection, which decreases the myometrium’s ability to contract and makes the patient more susceptible to PPH. Note any foul vaginal odor that may accompany the fever with infection. Elevated heart rate, delayed capillary refill, decreased blood pressure, and increased respiratory rate may be noted if PPH is occurring. Assess the patient’s color and skin temperature; pallor and cool, clammy skin also indicate hypovolemic shock.

Psychosocial

PPH is a traumatic experience because medical complications are unexpected during what is anticipated as a happy time. Assess the anxiety level of the patient; the patient going into hypovolemic shock is highly anxious and then may lose consciousness. The significant others experience a high level of anxiety as well and need a great deal of support.

Diagnostic highlights

General Comments: Diagnosis of PPH is usually based on the estimated blood loss, which eventually is reflected in serum laboratory tests. Coagulation studies and typing and crossmatching are done if bleeding remains excessive.

TestNormal ResultAbnormality With ConditionExplanation
Red blood cell count4–5.4 million/μLDecreases several hours after significant blood loss has occurredActive bleeding causes decrease
Hemoglobin12–16 g/dLDecreases several hours after significant blood loss has occurredActive bleeding causes decrease
Hematocrit37%–47%Decreases several hours after significant blood loss has occurredActive bleeding causes decrease

Primary nursing diagnosis

Diagnosis

Fluid volume deficit related to blood loss

Outcomes

Fluid balance; Hydration; Circulation status

Interventions

Bleeding reduction; Blood product administration; Intravenous therapy; Shock management

Planning and implementation

Collaborative

The goal of treatment is to correct the cause and replace the fluid loss. Resuscitation occurs first, followed by identification and management of the underlying cause of PPH. Patients should have nothing by mouth until hemostasis is established. Expedient diagnosis and treatment of the cause reduce the likelihood of a blood transfusion. Treatment for uterine atony involves performing frequent fundal massage, sometimes bimanual massage (by the medical clinician only), and pharmacologic therapy. Fluid replacement with normal saline solution, lactated Ringer’s injection, volume expanders, or whole blood may be necessary. Multiple venous access sites, 100% oxygen, and a Foley catheter are often needed. If uterine atony is not corrected quickly, a life-saving hysterectomy is indicated.

Monitor the hematocrit and hemoglobin to determine the success of fluid replacement and the patient’s intake and output. If an infection is the cause of the atony, the physician prescribes antibiotics. PPH caused by trauma requires surgical repair with aseptic technique. Hematomas may absorb on their own; however, if they are large, an incision, evacuation of clots, and ligation of the bleeding vessel are necessary. Administer analgesics for perineal pain. If retained fragments are suspected at the time of delivery, the uterine cavity should be explored. If manual removal or expression of clots/placental fragments is unsuccessful, cervical dilation and curettage is indicated to remove retained fragments. A type of compression suture, Meydanli, may decrease PPH of cesarean deliveries with abnormal placental attachments or atony. The suture is placed from the lower end of the uterus to the top on both sides to assist in uterine compression.

Pharmacologic highlights

Medication or Drug ClassDosageDescriptionRationale
Oxytocin (Pitocin)Mix 10–40 U in 1,000 mL, give 20–40 mU/minOxytocicControls bleeding by producing uterine contractions
Methylergonovine (Methergine)0.2 mg IMOxytocicControls bleeding by producing uterine contractions
Carboprost, misoprostol (recent studies suggest use)Varies by drugProstoglandinUsed when oxytocin and methylergonovine are not effective in producing contractions

Independent

Be alert for PPH in any postpartum patient, especially those who have any of the predisposing factors. It is often the nurse who discovers the hemorrhage. For the first 24 hours postpartum, perform frequent fundal checks. If the fundus is boggy, massage until it feels firm; it should feel like a large, hard grapefruit. When massaging the fundus, keep one hand above the symphysis pubis to support the lower uterine segment, while gently but firmly rubbing the fundus, which may lose its tone when the massage is stopped. Explain that cramping or feeling like “labor is starting again” is expected with liberal administration of the oxytocic drugs used to manage the bleeding. Monitor for hypertension if oxytocics and prostaglandins are used. Encourage the patient to void; a full bladder interferes with contractions and normal uterine involution. If the patient is unable to void on her own, a straight catheterization is necessary.

Monitor vaginal bleeding; the lochia is usually dark red and should not saturate more than one perineal pad every 2 to 3 hours. Notify the physician if the bleeding is steady and bright red in the presence of a normal firm fundus; this usually indicates a laceration. Ice packs and sitz baths may relieve perineal discomfort. The patient is usually on complete bedrest. Rooming in with the infant may be difficult; provide for safe care for the infant while it is in the mother’s room. Assist the patient and significant others as much as possible with newborn care to facilitate quality time between the mother and her newborn. Assist the patient with ambulation the first few times out of bed; syncope is common after a large blood loss. Ensure adequate rest periods.

Evidence-Based Practice and Health Policy

Biguzzi, E., Franchi, F., Ambrogi, F., Ibrahim, B., Bucciarelli, P., Acaia, B., …Mannucci, P.M. (2012). Risk factors for postpartum hemorrhage in a cohort of 6011 Italian women. Thrombosis Research, 129(4), e1–e7. doi 10.1016/j.thromres.2011.09.010

  • In a study among 6,011 women who gave birth vaginally, 24% of women lost ≥ 500 mL of blood and 4.8% lost ≥ 1,000 mL of blood.
  • The risk of postpartum hemorrhage increased by 9.21 times among women with retained placenta (95% CI, 5.09 to 16.68; p < 0.0001), 1.65 times among women with genital tract lacerations (95% CI, 1.32 to 2.07; p < 0.0001), and 1.45 times among women in which a vacuum extractor was used (95% CI, 1.13 to 1.87; p = 0.004).
  • Each 100-g increase in placenta weight was associated with a 1.24 times increased risk of postpartum hemorrhage (95% CI, 1.13 to 1.36; p < 0.0001), each 5-kg increase in maternal weight was associated with a 1.04 times increased risk (95% CI, 1.01 to 1.08; p = 0.036), and each 5-year increase in maternal age was associated with a 1.15 times increased risk (95% CI, 1.06 to 1.24; p = 0.001).
  • Each 1 g/dL increase in hemoglobin was associated with a 16% decreased likelihood of postpartum hemorrhage (95% CI, 0.78 to 0.90; p < 0.0001), and each 30,000/µL increase in platelets was associated with a 4% decreased likelihood (95% CI, 0.93 to 0.99; p = 0.04).

Documentation guidelines

  • Bleeding: Amount, characteristics, precipitating factors
  • Fundus: Location (above or below umbilicus, midline or lateral) and firmness
  • Vital signs and any signs and symptoms of hypovolemic shock
  • Appearance of the perineum, episiotomy, laceration repair (use REEDA [redness, edema, ecchymosis, drainage, approximation] to guide the documentation); fluid intake and output
  • Absence or presence of vaginal odor

Discharge and home healthcare guidelines

teaching.
Teach the patient how to check her own fundus and do a fundal massage; this is especially important for patients at risk who are discharged early from the hospital. Advise the patient to contact the physician for the following: a boggy uterus that does not become firm with massage, excessive bright red or dark red bleeding, many large clots, fever above 100.4°F, persistent or severe perineal pain or pressure.

medications.
If iron supplements are provided, teach the patient to take the drug with orange juice and expect some constipation and dark-colored stools. If oxytocics are ordered, emphasize the importance of taking them around the clock as prescribed. If antibiotics are ordered, teach the patient to finish the prescription, even though the symptoms may have ceased.

hemorrhage

the escape of blood from a ruptured vessel. Hemorrhage can be external, internal, or into the skin or other tissues. Blood from an artery is bright red in color and comes in spurts; that from a vein is dark red and comes in a steady flow.
Hemorrhages in particular anatomical sites may be found under their specific anatomical headings.

alimentary tract hemorrhage
includes hematochezia, melena.
cancer-associated hemorrhage
see paraneoplastic hemorrhage (below).
capillary hemorrhage
oozing of blood from minute vessels.
cerebral hemorrhage
see brain hemorrhage.
concealed hemorrhage
internal hemorrhage.
ecchymotic hemorrhage
exercise-induced pulmonary hemorrhage
see exercise-induced pulmonary hemorrhage.
fibrinolytic hemorrhage
that due to abnormalities in the fibrinolytic system and not dependent on hypofibrinogenemia.
internal hemorrhage
that which occurs into cavities, e.g. hemoperitoneum, or into tissues, e.g. vulvar hematoma in mares. The only evidence of illness may be extreme pallor and weakness. There may be moderate dyspnea and other signs related to the distention of individual organs.
hemorrhage intra-abdominal
intra-articular hemorrhage
see hemarthros.
intracranial hemorrhage
bleeding within the cranium, which may be extradural, subdural, subarachnoid or cerebral.
intraocular hemorrhage
see hyphema.
mesenteric hemorrhage
uncommon syndrome caused by leakage of blood into the potential space between the two serosal layers of the mesentery. An extensive hemorrhage causes severe abdominal pain, shock, some blood-staining of peritoneal fluid and leakage of blood into the intestinal lumen.
paraneoplastic hemorrhage
a variety of hemostatic disorders develop in association with neoplasia in animals and may result in disseminated intravascular coagulation and hemorrhage. Called also cancer-associated hemorrhage.
peritoneal hemorrhage
petechial hemorrhage
subcutaneous hemorrhage occurring in minute spots.
postpartum hemorrhage
that which follows soon after parturition.
primary hemorrhage
that which soon follows an injury.
secondary hemorrhage
that which follows an injury after a considerable lapse of time.
subcutaneous hemorrhage
causes a soft, painless fluctuating swelling capable of being moved easily. Paracentesis reveals the presence of whole blood.
References in periodicals archive ?
This could be the answer" for preventing many cases of postpartum hemorrhage in rural areas, he says.
This real-time information will help us save lives, especially in some of the most severe cases we see in obstetrics involving postpartum hemorrhages, and dramatically reduce the morbidity associated with early active intervention.
Key Words: cesarean delivery, postpartum hemorrhage, risk factors
Postpartum hemorrhage (PPH) is responsible for 25% of the 515,000 maternal pregnancy-related deaths reported by the World Health Organization.
The expert panelists addressed the risk factors, causes, and treatment options for postpartum hemorrhage (PPH), which causes the death of 140,000 women annually, and equates to one death every four minutes across the globe1.
28, 2015 /PRNewswire/ -- Postpartum hemorrhage (PPH) can be defined as blood loss in excess of 500 mL after vaginal delivery or more than 1,000 mL after cesarean delivery.
The common practice of immediate cord clamping, which generally means clamping within 15-20 seconds after birth, was fueled by efforts to reduce the risk of postpartum hemorrhage, a leading cause of maternal death worldwide.
This set of techniques, aimed at preventing postpartum hemorrhage, was used correctly in only 1-32% of deliveries in the seven study countries, while potentially harmful practices occurred in 48-94% of deliveries.
PATH will work on the Prevention of Postpartum Hemorrhage Initiative (PoPPHI), as part of USAID's Special Initiative to reduce PPH.
BARCELONA -- Cook Medical has invitedexperts in women's health and postpartum hemorrhage from North America, Europe, Middle East and Africa to participate in a roundtable discussion with the world press to explore the causes, risk factors and prevalence of postpartum hemorrhage (PPH) a fatal complication of childbirth that affects approximately 14 million women annually.
According to a new market report published by Transparency Market Research "Postpartum Hemorrhage (PPH) Treatment Devices Market - Global Industry Analysis, Size, Growth, Trends and Forecast, 2015 - 2023", the global postpartum hemorrhage treatment devices market was valued at USD 604.
There also was "adequate evidence" that the risks of placental abruption, postpartum hemorrhage, and fetal intracranial bleeding were not increased with low-dose aspirin, the USPSTF statement said.

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