POSTPARTUM HAEMORRHAGE
Definitions:
• Primary PPH – blood loss of 500ml or more ===> within 24hours of delivery.
• Secondary PPH – significant blood loss ===> between 24 hours and 6 weeks after
birth.
Risk Factors:
•
Most cases have no risk factors.
1. Previous PPH.
2. Antepartum haemorrhage.
3. Grand multiparity.
4. Multiple pregnancy.
5. Polyhydramnios.
6. Fibroids.
7. Placenta praevia.
8. Prolonged labour (& oxytocin).
Causes 4 T’s:
1. Tone.
2. Tissue.
3. Thrombin.
4. Trauma
A. Tone:
1. Previous PPH.
2. Prolonged labour.
3. Age > 40 years.
4. Big baby.
5. Multiple pregnancy.
6. Placenta praevia.
7. Obesity.
8. Asian ethnicity.
B. Tissue:
1. Retained placenta/membrane/clot.
C. Thrombin:
1. Abruption.
2. PET.
3. Pyrexia.
4. Intrauterine death.
5. Amniotic fluid embolism. ===> DIC.
D. Trauma:
1. .Caesarean section: (emergency > elective).
2. Perineal trauma.
3. Operative delivery.
4. Vaginal and cervical tears.
5. Uterine rupture.
Management:
Nursing Management of Postpartum Hemorrhage:
Assessment:
•
Identify Risk Factors in the Patient’s History.
•
Assess:
-
Vital signs and general condition.
-
State of uterus.
-
Nature of bleeding.
-
Signs and symptoms of blood loss.
-
Amount of blood loss.
-
Compare laboratory reports.
Nursing Interventions:
•
If atonic uterus:
-
Inform the obstetrician. Feel consistency of the uterus.
-
Massage the uterus to express clots and make it hard as follows. The fundus is
first gently felt with the fingertips to assess its consistency. If it is soft and relaxed
the fundus is massaged with a smooth circular motion, applying no undue
pressure. When a contraction occurs the hand is held still.
-
Assess the general physical condition of the mother. (face, skin...).
-
Monitor PR and blood pressure.
-
Put the infant to the breast to suck or stimulate the nipple manually.
-
Prepare instruments and equipment such as sterile gloves, cannula # 18, IV set,
catheter set.... etc.
-
Administer oxytocics as ordered.
-
Start IV infusion and oxytocin drip.
-
Empty the bladder.
-
Examine the expelled placenta and membranes for completeness.
-
Administer medications as ordered.
•
Reassure the mother:
-
Never leave the mother alone.
-
Touch the mother’s hand and talk to her.
•
In cases of traumatic bleeding:
-
Press on the tear or laceration.
-
Prepare equipment and instruments, sterile gloves, sterile needles and catgut,
sterile needle holder, forceps, sterile kidney basin, scissors, sterile gauze etc.
Secondary Postpartum Hemorrhage:
•
Commonly occurs between 10 to 14 days after delivery.
•
Common causes:
-
Retained bits of cotyledon or membranes.
-
Separation of a slough exposing a bleeding vessel.
-
Subinvolution at the placental site due to infection.
Clinical Manifestations:
•
Sudden episodes of bleeding with bright red blood of varying amounts.
•
Subinvolution of uterus.
•
Sepsis.
•
Anemia.
Nursing Management:
•
Follow the same steps as in the case of postpartum hemorrhage due to retained
parts of placenta.
•
In cases of postpartum hemorrhage due to infection the following should be done:
-
Reassure the mother.
-
Monitor TPR and blood pressure.
-
Start IV infusion and blood transfusion according to doctor’s orders.
-
Prepare sterile instruments and equipment needed for examination.
-
Empty the bladder.
-
Administer medications as ordered (broad spectrum antibiotic).
-
Follow strict aseptic technique while providing care to the woman.
-
Frequent changing of sanitary pads.