Postpartal hemorrhage is the postpartum loss of blood totaling 500 ml or more within a twenty-four hour period.
After bladder distention is ruled out, the three main causes of postpartal hemorrhage are uterine atony, lacerations, and retained placental fragments in the uterus.
a. Uterine Atony.
This is the inability of the myometrium to contract and constrict the blood vessels within the muscle fibers, resulting in open sinuses at the site of placental separation. Decreased muscle tone causes slow, insidious loss of blood.
(1) Factors usually leading to uterine atony.
(a) Conditions which result on overextension of uterine musculature (multiple pregnancy – two or more fetuses and hydramnios – excessive amniotic fluid).
(b) Conditions resulting in exhaustion of the uterine musculature are large fetuses, prolonged or difficult labor, Pitocin® induced or augmented labor (this may result in decreased response to postpartal administration of pitocin) and precipitous or forceful delivery.
(2) Situations resulting in drug related relaxation of uterine musculature are the use of MgSO4 for preeclampsia and the use of general anesthesia for cesarean delivery. Conditions resulting in abnormal bleeding or uterine tissue damage are cesarean section, placenta previa, abruptio placenta, uterine rupture, and retained placental fragments.
(3) Signs and symptoms of uterine atony.
(a) Signs of shock–decreased blood pressure, increased pulse, and increased and anxiety and irritability.
(b) Bleeding-usually dark with clots present.
(c) Noncontracted, boggy uterine fundus.
(4) Medical treatment.
(a) Intervenously fluids administered to increase fluid and blood volume.
(b) Oxytocin administration.
(c) Methergine/prostin may be administered to stimulate uterine contractions when oxytocin is ineffective.
(d) Blood transfusion if the patient’s hematocrit drops too low and/or if she is symptomatic.
(5) Nursing interventions.
(a) Palpate the fundus frequently to determine continued muscle tone.
(b) Massage the fundus, if boggy, until firm (do not over massage, this fatigues the muscle).
(c) Monitor patient’s vital signs every 15 minutes until stable.
(d) Prevent bladder distention. Bladder distention displaces the uterus and prevents effective uterine contractions.
b. Lacerations.
(1) Common sites. Sites of lacerations are the vaginal side wall, the cervix, the lower uterine segment, and the perineum.
(2) Degrees of perineal lacerations.
(a) First degree-tear of the vaginal and perineal mucous membranes.
(b) Second degree-tear of the vaginal and perineal mucous membrane and the perineal muscles.
(c) Third degree-tear of the vaginal and perineal mucous membrane, the perineal muscles, and the capsule of the rectal sphincter.
(d) Fourth degree-tear of the vaginal and perineal mucous membrane, the perineal muscles, and through the rectal sphincter and anterior wall of the rectum.
(3) Possible causes.
(a) Rapid descent of the fetus.
(b) Pushing prior to complete cervical effacement and dilatation.
(c) Large fetus.
(d) Forceps application.
(e) Uncontrolled, forceful extension of the fetal head.
(4) Signs and symptoms.
(a) Obvious body injury after delivery of the infant–if perineal laceration.
(b) Bright red bleeding despite a well toned fundus-if vaginal or cervical laceration and not detected at time of delivery.
(c) Signs of shock-rapid, thready pulse, falling blood pressure, increasing anxiety of the patient.
(5) Medical treatment.
(a) Suturing of the laceration.
(b) Vaginal packing.
(c) Blood transfusions if the patient’s hematocrit is low and the patient is symptomatic.
(6) Nursing interventions.
(a) Observe closely for continued vaginal bleeding.
(b) Monitor the patient’s vital signs.
(c) Flag the patient’s chart for vaginal packing in place. This is helpful to the nurse who is checking for vaginal bleeding doesn’t mistake a lack of obvious signs of blood for no bleeding. The vaginal packing could “hide” a hemorrhagic episode of bleeding.
c. Retained Placental Fragments in the Uterus.
These fragments are the major cause of late postpartum hemorrhage.
(1) Signs and symptoms.
(a) Large amount of bright red bleeding or persistent trickle type bleeding.
(b) Uterus may be boggy due to its inability to contract properly.
(c) Signs of shock.
(d) Sudden rise in uterine fundal height indicating the formation of clots inside the uterine cavity.
(2) Medical treatment.
(a) Manual removal of the remaining placenta is done by the physician, if it is a result of incomplete separations of the placenta with increased vaginal bleeding.
(b) A D&C is performed, if it is retained fragments.
(c) Intravenous fluids are administered.
(d) Oxytocic drugs are given immediately after either procedure.
(3) Nursing interventions.
(a) Check the uterine fundus tone frequently (every 15 minutes the first hour, then every 30 minutes for 2 hours, and every hour until stable).
(b) Check the nature and amount of lochia flow (every 15 minutes the first hour, then every 30 minutes for 2 hours, and every hour until stable).
(c) Keep accurate count of perineal pads used.
(d) Monitor the patient’s vital signs and blood pressure every 15 minutes or more frequently as necessary.
(e) Observe for signs of shock.
(f) Turn the patient on her side to prevent pooling of blood under her.
(g) Provide emotional support to the patient and family.