Postpartum Hemorrhage

Hemorrhage is the most common complication mothers face in the postpartum period. It usually occurs within the first 24 hours after giving birth, but it can occur later on during the postpartum period.

In pregnancy, the uterus had to grow to accommodate the fetus: the uterus' muscle fibers stretch and, in between the fibers, blood vessels enlarge to supply and accommodate the growth. The placenta, which is basically network of blood vessels and capillaries (albeit with a little barrier between the mom and the baby) that supplies nutrients to the growing fetus, it is attached to and fed from the uterus' blood supply.

After childbirth the uterus is basically a big bleeding wound, and it's up to hormones and mechanical changes to cut of circulation to the wound so it can stop bleeding.  

Postpartum Mom's bodies do have advantages that normal women don't, though. Even though their blood is expanded to almost double it's original volume, most of the extra blood volume exists as plasma. That the part of the blood that contains the clotting factors that are activated in injury, protect against excess bleeding, and promote healing. 

However, it also means Mom's blood is hemodiluted: there are fewer red blood cells circulating, mom is already anemic before birth even happens. So a large amount of blood loss at birth, or shortly thereafter can have a big impact on cardiovascular stability. 

That's why its important for the postpartum nurse to get a time of birth estimated blood loss (EBL), so total blood loss can continue to be monitored. 

There are several reasons Postpartum Hemorrhage can occur:

Sometimes the uterus muscle becomes atonic doesn't clamp up like it's supposed to, and blood continues to flow as if it's still supplying a baby there. 

Other times there's a mechanical obstruction, such as a full urinary bladder, or clots that prevents the uterus from contracting and getting smaller like it's supposed to.

There can be a retained placental fragment still in the uterus after the rest of the products of conception have been delivered. 

A multiparous mom (a mom who's had a lot of kids), or a multigestational mom (a mom who has been carrying more than one fetus), is also at increased risk for postpartum hemorrhage just because her uterus has had to stretch more.

A mom who experienced a traumatic birth; laceration or epistotomy along the birth canal is also a source of bleeding. 

There are also medications that can increase the mom's risk for developing hemorrhage, such as magnesium sulfate (given to moms who have preeclampsia or eclampsia, and are at risk for having seizures).

Sometimes clotting factors can activate when they're not supposed to and deplete: forming tiny little clots in some areas of mom's capillary bed and extremely thin blood that bleeds very easily everywhere else. This is a very ominous condition called dissiminated intravascular coagulation (DIC)

It's important to monitor the patient's uterus and lochia flow. Palpate the patient's abdomen, while supporting the neck of the uterus at the pubic bone, and locate the fundus (the thick, top part of the uterus) of the uterus in relation to the patient's umbilicus (belly button). Note if the fundus feels firm or boggy. If the fundus is boggy, perform a fundal massage until it is firm.

If the fundus is deviated to the left or right of the umbilicus, it may mean the patient's bladder is full, and the uterus is being displaced. Assist the patient to the restroom to void and then re-assess.

If clots or excess lochia are expelled on fundal massage, weigh the soiled linens. It is also important to assess the patient's pad and peritoneal area. If patient is on bedrest, have the patient lift or turn to assess bed pad, if patient is ambulatory make sure the patient is not saturating 1 peri-pad per hour or more, if this occurs it is important to weigh the pad

(To weigh soiled linens: First place clean linens of the same type on scale and zero the scale, then remove and place the soiled linens. (If you weigh in grams, you can convert easily to ml because 1gram=1ml))

and calculate the patient's total blood loss.

IF

The cumulative (added together) blood loss is greater than 500 ml (for a vaginal birth)

The cumulative blood loss is greater than 1000 ml (for Cesarean birth)

OR

Vital signs are unstable:

 a 15 percent change in vital signs is noted

• HR 110 tachycardia
• BP less than 85/45 Hypotension
• O2 saturations less than 95 percent Hypoxia
  

OR

There is even more bleeding in the recovery or postpartum period, which when weighed increases the patient's total blood loss above 500/1000ml respectively. 

• The patient is in Stage 1 of Postpartum Hemorrhage.
  

It's important that a nurse (usually the primary nurse) stay with the patient and call for the assistance of the charge nurse, or another nurse. Continue fundal massage, and (if patient's IV has been removed) start another one, preferably 18 gauge or larger because those are the ones suitable for fluid resuscitation.

Call the doctor and notify of EBL at birth, current loss in MLs, presence of clots, lochia color (bright, dark, pale red) vital signs, and most recent hemoglobin and hematocrit level.

Receive orders, which may include:

• Oxytocin 10-40 units IV (Oxytocin is a hormone is released in a pregnant woman's body when the placenta disconnects from the uterus, and when the infant starts to breastfeed. It can also be given as an IV infusion.)
  

• Hemabate 250mg IM (NOT IV) Q15-90 minutes. Not to exceed 8 doses/24 hours. May cause nausea, vomiting, hypertension.
  

• Methergine 0.2 mg IM (NOT IV) Q 2-4 hours. Do not give to patients who have high blood pressure, primary hypertenstion or pre-ecclampsia/ecclampsia because it can make their blood pressure go even higher and they can have a stroke or seizure.
  

• Misoprostol 800-1000 mcg PR once. Causes diarrhea (sorry mom D: ) Nausea, vomiting, transient fever and headache.
  

• Type and screen for 2 units of blood
  

• Oxygen administration, frequent V/S, LOC checks, keep patient warm, insert foley catheter for strict I/O and to depress bladder, continue vigorus fundal massage.
  

These medications are available on the hemorrhage crash cart located in L&D.

It's also important to review the patient's history and consider the potential cause of the bleeding (For instance: atony, trauma/laceration, retained placenta amniotic fluid emboli, uterine inversion, coagulopathy etc.)

If Vital sign instability continues, or bleeding continues to greater than 1500ml

• The patient is now in Stage 2 of Postpartum Hemorrhage.

This is where a team effort really comes into play, as everyone prepares to take the patient to Labor and Delivery, OR, or recovery room.

You'll need another nurse to help perform a bimanual uterine massage (which is basically a uterine massage with two sets of hands).

The charge nurse will call a code OB

Labs are drawn for STAT CBC with platelets, CMP, Coagulation panel, ABGs.

Additional doses of medications listed above will be given,

Blood products are administered

A second large bore IV site will need to be inserted, the primary nurse will need to communicate the total blood loss and vital signs to team members.

Prepare for massive transfusion protocol.

Some of the procedures the doctor may perform include:

• Repair of laceration or episiotomy
• D&C to remove retained placenta fragments
• Intrauterine balloon
• selective embolization
• B-Lynch suture
• Bilateral uterine relaxation drugs
• Hysterectomy
• Aggressive respiratory, vasopressor, and blood products support (if DIC)
  

If blood loss continues beyond 1500ml, 2 PRBCs have been given but V/S are still unstable or disseminated intravascular coagulation (DIC) is suspected:

• Initiate massive transfusion protocol
• Move patient to OR (prepare for artery ligation or hysterectomy)
• Call ICU for bed
  

Other considerations:

The patient will probably be really cold through all of this, do your best to keep patient warm and if possible warm blood products before infusion using designated device.

Re assign staffing for infant

Support for other family members.

Resources:

http://www.ncbi.nlm.nih.gov/pubmed/4075604

https://www.hon.ch/Dossier/MotherChild/preg_changes/circulation.html

http://www.open.edu/openlearnworks/mod/oucontent/view.php?id=279&printable=1

My hospital's policy and procedure

Notes:

I had this all printed up and the text flowed all pretty, but I forgot to save BOOOOOOOOOOO!!!!!

Serves me right for typing up on blogger.