Postpartum Hemorrhage
Current definitions include blood loss of more than 500 mL after vaginal birth or 1000 mL after cesarean birth, a decrease in hematocrit level of 10% or more since admission or the need for a blood transfusion (Cunningham, et al., 2010) and continued blee
early post partum hemorrhage
Early postpartum hemorrhage usually occurs during the first hour after delivery and is most often caused by uterine atony (Cunningham et al., 2010). Atony refers to lack of muscle tone that results in failure of the uterine muscle fibers to contract firml
Major signs of uterine atony
�A uterine fundus that is difficult to locate
�A soft or "boggy" feel when the fundus is located
�A uterus that becomes firm as it is massaged but loses its tone when massage is stopped
�A fundus that is located above the expected level
�Excessive lochia,
BOX 28-1 COMMON PREDISPOSING FACTORS FOR POSTPARTUM HEMORRHAGE
�Overdistention of the uterus (multiple gestation, large infant, hydramnios)
�Multiparity (five or more)
�Precipitate labor or delivery
�Prolonged labor
�Use of forceps or vacuum extractor
�Cesarean birth
�Manual removal of the placenta
�Uterine inversion
first 24 hours after birth
For the first 24 hours after childbirth, the uterus should feel like a firmly contracted ball roughly the size of a large grapefruit. It should be easily located at about the level of the umbilicus. Lochia should be dark red and scant to moderate in amoun
DRUG GUIDE: Methylergonovine (Methergine)
Classification: Ergot alkaloid, uterine stimulant
Action: Stimulates sustained contraction of the uterus and causes arterial vasoconstriction.
Indications: Used for the prevention and treatment of postpartum or postabortion hemorrhage caused by uterine at
DRUG GUIDE: Carboprost Tromethamine (Hemabate, Prostin/15M)
Classification: Prostaglandin, oxytocic.
Action: Stimulates contraction of the uterus.
Indications: Used for the treatment of postpartum hemorrhage caused by uterine atony. Also used for abortion.
Dosage and Route: Postpartum hemorrhage: 250 mcg intramusc
Therapeutic Management
Nurses are with the mother during the hours after childbirth and are responsible for assessments and initial management of uterine atony. If the uterus is not firmly contracted, the first intervention is to massage the fundus until it is firm and to expre
Trauma
Trauma to the birth canal is the second most common cause of early postpartum hemorrhage. Trauma includes vaginal, cervical, or perineal lacerations as well as hematomas.
Predisposing Factors
Many of the same factors that increase the risk of uterine aton
lacerations
The perineum, vagina, cervix, and the area around the urethral meatus are the most common sites for lacerations. Small cervical lacerations occur frequently and generally do not require repairs. Lacerations of the vagina, perineum, and periurethral area u
Hematoma
Hematomas occur when bleeding into loose connective tissue occurs while overlying tissue remains intact. Hematomas develop as a result of blood vessel injury in spontaneous deliveries and deliveries in which vacuum extractors or forceps are used. Hematoma
Therapeutic Management of trauma
Therapeutic Management
When postpartum hemorrhage is caused by trauma of the birth canal, surgical repair is often necessary. Visualizing lacerations of the vagina or cervix is difficult, and it is necessary to return the mother to the delivery area, wher
late post partum hemorrhage
The most common causes of late postpartum hemorrhage are subinvolution (delayed return of the uterus to its nonpregnant size and consistency) and fragments of placenta that remain attached to the myometrium when the placenta is delivered. Clots form aroun
Predisposing Factors to late post partum hemmorrhage
Attempts to deliver the placenta before it separates from the uterine wall, manual removal of the placenta, placenta accreta (see Chapter 27), previous cesarean birth, and uterine leiomyomas are primary predisposing factors for retention of placental frag
Therapeutic management of late post partum hemorrhage
Initial treatment for late postpartum hemorrhage is directed toward control of the excessive bleeding. Oxytocin, methylergonovine, and prostaglandins are the most commonly used pharmacologic measures. Placental fragments may be dislodged and swept out of
Hypovolemic shock
During and after giving birth, the woman can tolerate blood loss that approaches the volume of blood added during pregnancy (approximately 1500 to 2000 mL). A woman who was anemic before birth has less reserve than a mother with normal blood values. The a
pathophysiology of hypovolemic shock
Recognition of hypovolemic shock may be delayed because the body activates compensatory mechanisms that mask the severity of the problem. Carotid and aortic baroreceptors are stimulated to constrict peripheral blood vessels. This shunts blood to the centr
SAFETY ALERT: Signs of Postpartum Hemorrhage
� A uterus that does not contract, or does not remain contracted
� Large gush or slow, steady trickle, ooze, or dribble of blood from the vagina
� Saturation of one peripad per 15 minutes
� Severe, unrelieved perineal or rectal pain
� Tachycardia
initial postpartum assessment
The initial postpartum assessment includes a chart review to determine whether prolonged labor, birth of a large infant, use of vacuum extractor or forceps, or other risk factors for hemorrhage are present. This alerts the nurse to women at increased risk
Uterine atony assesments
Priority assessments for uterine atony include the fundus, bladder, lochia, vital signs, skin temperature, and color. Assess the consistency and the location of the uterine fundus. The fundus should be firmly contracted, at or near the level of the umbili
Chart Review
Presence of predisposing factors
Perform more frequent evaluations.
Fundus
Soft, boggy, displaced
Massage, express clots, and assist to void or catheterize; notify primary health care provider if measures are ineffective.
Lochia
Bleeding (steady trickle, dribble, oozing, seeping, or profuse flow); heavy: saturation of 1 pad/hr; excessive: 1 pad/15 min
Assess for trauma; save and weigh pads, linen savers, and bed linens so estimation of blood loss will be more accurate. Notify hea
vital signs
Tachycardia, decreasing pulse pressure, falling blood pressure, decreasing oxygen saturation level
Report signs of excessive blood loss.
urine output
Decreased urine output
Report decrease in output.
Should be at least 30 mL/hr
Comfort level
Severe pelvic or rectal pain
Assess for signs of hematoma, usually perineal or vaginal; examine vulva for masses or discoloration; report findings.
Skin
Cool, damp, pale
Look for signs of hypovolemia; vigilant assessment and management by entire health care team is necessary.
Planning should reflect the nurse's responsibility to:
Monitor for signs of postpartum hemorrhage.
�Perform actions that minimize postpartum hemorrhage and prevent hypovolemic shock.
�Notify the health care provider if signs of excessive blood loss are observed or if the woman does not respond as desired.
preventing hemorrhage
The key to successful management of early postpartum hemorrhage is early recognition and response. All postpartum women are at risk for hemorrhage. However, always be aware of factors that increase this risk further and be particularly vigilant in monitor
colloboration with hcp
Administer medications, fluids, and treatments as ordered by the health care provider or as stated in the facility's protocol. Note the effects and relay the information to the health care provider. Physicians and nurse-midwives depend on the nurse for ac
Providing support for the family
Acknowledge the anxiety and provide simple appropriate explanations of the activity. "I know all this activity must be frightening. She is bleeding a little more than we would like and we are doing several things at once.
subinvolution of the uterus
Subinvolution refers to a slower-than-expected return of the uterus to its nonpregnant size after childbirth. Normally the uterus descends at the rate of approximately 1 cm or one fingerbreadth per day. By 14 days, it is no longer palpable above the symph
Therapeutic management of subinvolution
Treatment is tailored to correct the cause of subinvolution. Methylergonovine maleate (Methergine) given orally provides long, sustained contraction of the uterus. Infection responds to antimicrobial therapy.
Nursing consideration rt subinvolution
The mother is taught how to locate and palpate the fundus and how to estimate fundal height in relation to the umbilicus. The uterus should become smaller each day (by approximately one fingerbreadth). Also, explain the progressive changes from lochia rub
Thromboembolic Disorders
A thrombus is a collection of blood factors, primarily platelets and fibrin, on a vessel wall. Thrombophlebitis occurs when the vessel wall develops an inflammatory response to the thrombus. This further occludes the vessel. An embolus is a mass that may
Incidence and Etiology of thromboembolic disorders
Thromboembolic disorders are the leading cause of maternal mortality in the United States (Rhode, 2011). Thrombi can form whenever the flow of blood is impeded. Once started, the thrombus can enlarge with successive layering of platelets, fibrin, and bloo
Venous Stasis
During pregnancy, compression of the large vessels of the legs and pelvis by the enlarging uterus causes venous stasis. Stasis is most pronounced when the pregnant woman stands for prolonged periods of time. It results in dilated vessels that increase the
BOX 28-2 FACTORS THAT INCREASE THE RISK OF THROMBOSIS
� Inactivity
� Prolonged bed rest
� Obesity
� Cesarean birth
� Sepsis
� Smoking
� History of previous thrombosis
� Varicose veins
� Diabetes mellitus
� Trauma
� Prolonged labor
� Prolonged time in stirrups in second stage of labor
� Maternal age older tha
Hypercoagulation
Pregnancy is characterized by changes in the coagulation and fibrinolytic systems that persist into the postpartum period. During pregnancy, the levels of many coagulation factors are elevated. In addition, the fibrinolytic system, which causes clots to d
Additional risk factors for thrombus
Women with varicose veins, obesity, a history of thrombophlebitis, and smoking are at additional risk for thromboembolic disease (Box 28-2). Age older than 35 years doubles the risk
SVT
Manifestations
SVT is most often associated with varicose veins and limited to the calf area. It can also occur in the arms as a result of IV therapy. Signs and symptoms include swelling of the involved extremity as well as redness, tenderness, and warmth
DVT
Signs and symptoms of DVT or PE are absent in 75% of those affected (Lockwood, 2009). When present, they may be attributed to normal benign changes of pregnancy (Farquharson & Greaves, 2011). Those that occur are caused by an inflammatory process and obst
Preventing thrombus formation
Women who have had a previous DVT or PE are at risk for another. These women and others at high risk may receive prophylactic heparin, which does not cross the placenta. Either standard unfractionated heparin (UH) or a low-molecular-weight heparin (LMWH),
Initial treatment to prevent thrombus
Anticoagulant therapy is started to prevent extension of the thrombus. Therapy may begin with a continuous infusion of IV UH that is later changed to subcutaneous UH. The activated partial thromboplastin time (aPTT) should be monitored, and the heparin do
subsquent treatment for thrombus prevention
The long-term management of DVT depends on whether the woman is pregnant or in the postpartum period. The pregnant woman with a DVT receives anticoagulation therapy until labor begins. It is resumed 6 to 12 hours after birth and continued for 6 weeks to 6
WOMEN WANT TO KNOW: How Do I Prevent Thrombosis (Blood Clots)?
Methods to improve peripheral circulation will help prevent the occurrence of thrombophlebitis:
�Improve your circulation with a regular schedule of activity, preferably walking.
�Avoid prolonged standing or sitting in one position.
�When sitting, elevate
Nursing Diagnosis rt thrombus
Risk for Bleeding related to lack of understanding of anticoagulant therapy precautions.
antidote for anticoagulants
Protamine sulfate, which is the antidote for UH and is partially effective against LMWH, should be available. The antidote for warfarin is vitamin K.
pathophys of PE
PE is a serious complication of DVT and a leading cause of maternal mortality. As many as 15% to 25% of DVTs will lead to PE if not recognized and treated (Martin & Foley, 2008). PE occurs when fragments of a blood clot dislodge and are carried to the lun
Manifestations of PE
Clinical signs and symptoms depend on how much the flow of blood is obstructed. Dyspnea, chest pain, tachycardia, and tachypnea are the most common signs (Cunningham, et al., 2010). Syncope (fainting) is uncommon and may indicate massive emboli (Lockwood,
Therapeutic Management of PE
Treatment of PE is aimed at dissolving the clot and maintaining pulmonary circulation. Oxygen is used to decrease hypoxia, and narcotic analgesics are given to reduce pain and apprehension. Bed rest with the head of the bed elevated is used to help reduce
Nursing Considerations for PE
Monitoring for Signs
When caring for a woman with DVT, nurses must be aware of the danger of PE and focus the assessment for early signs and symptoms. This includes frequent assessment of respiratory rate as well as thorough and frequent auscultation of b
Pueperal infection
Puerperal infection is a term used to describe bacterial infections after childbirth. Until the advent of antibiotics, puerperal infection often resulted in death. Even today, it is a cause of maternal death, especially in developing nations. The most com
definition of puerperal infection
The definition of puerperal infection is a temperature of 38� C (100.4� F) or higher after the first 24 hours and occurring on at least 2 of the first 10 days following childbirth. Although a slight elevation of temperature may occur during the first 24 h
TABLE 28-2 RISK FACTORS FOR PUERPERAL INFECTION
History of previous infections (urinary tract infection, mastitis, thrombophlebitis)
May be more vulnerable to infectious process
Colonization of lower genital tract by pathogenic organisms
Infections usually caused by several microbes that have ascended
Endometritis
Etiology
Endometritis is usually caused by organisms that are normal inhabitants of the vagina and cervix. Most infections are polymicrobial with both aerobic and anaerobic organisms involved. Organisms most often found include aerobic and anaerobic strep
Therapeutic Management of endo
Administration of IV antibiotics is the initial treatment for endometritis. The goal is to confine the infectious process to the uterus and to prevent spread of the infection throughout the body. Broad-spectrum antibiotics such as the cephalosporins, clin
Nursing Considerations for endo
The woman with endometritis should be placed in a Fowler's position to promote drainage of lochia. She should be medicated as needed for abdominal pain or cramping, which may be severe. Monitor the woman's response to treatment and note signs of improveme
Wound Care
Wound infections are common types of puerperal infection because any break in the skin or mucous membrane provides a portal of entry for organisms. The most common sites are cesarean surgical incisions, episiotomies, and lacerations. Infection of the inci
Wound Care Nursing Considerations
Despite their small size, wound infections are painful and annoying to the mother. Perineal infections cause discomfort during many activities, such as walking, sitting, or defecating, and are particularly troublesome because they are not expected by the
UTI
Manifestations
Symptoms typically begin on the 1st or 2nd postpartum day. They include dysuria (a burning pain on urination), urgency, frequency, and suprapubic pain. Hematuria may also occur. A low-grade fever is sometimes the only sign. In some women, a
Nursing considerations for UTI
The woman with a urinary tract infection must be instructed to take the medication for the entire time it is prescribed and not to stop when symptoms abate. In addition, she must drink at least 2500 to 3000 mL of fluid each day to help dilute the bacteria
Mastitis
Mastitis, an infection of the breast, occurs most often 2 to 4 weeks after childbirth, although it may develop at any time during breastfeeding. Approximately 5% to 10% of lactating women are affected (Duff et al., 2009). It usually affects only one breas
Septic pelvic thrombophlebitis
Septic pelvic thrombophlebitis is the least common of the puerperal infections, occurring in 1 of 3000 pregnancies (Ambrose & Repke, 2011). It usually is not seen until 2 to 4 days after childbirth. It occurs when infection spreads along the venous system
SAFETY ALERT: Signs and Symptoms of Postpartum Infection
� Fever, chills
� Pain or redness of wounds
� Purulent wound drainage or wound edges not approximated
� Tachycardia
� Uterine subinvolution
� Abnormal duration of lochia, foul odor
� Elevated white blood cell count
� Frequency or urgency of urination, dys
Assessment of woman with infectioon
Pay particular attention to signs that may be expected in infection, such as fever, tachycardia, pain, or unusual amount, color, or odor of lochia. Generalized symptoms of malaise and muscle aching may also be significant. Examine all wounds each shift fo
Affective disorders
The postpartum period is a time of change and adjustment for the mother and the family. Postpartum women have an increased risk for mood disorders (blues, depression and psychoses, and rarely, bipolar disorders) and for anxiety disorders (obsessive-compul
SAFETY ALERT: Signs and Symptoms of Postpartum Depression
� Feelings of sadness, crying
� Loss of pleasure in usual activities
� Anxiety, agitation or irritability
� Feelings of guilt
� Fatigue, sleep disturbances
� Difficulty concentrating or making decisions
� Depression (may not be present at first)
� Suicida
Postpartum mood disorders
Mood disorders are disturbances in function, affect, or thought processes that can affect the family after childbirth as severely as physiologic problems. Postpartum blues ("baby blues") is a transient, self-limiting mood disorder (discussed in Chapter 20
PPD
PPD is a period of depression that begins after childbirth and lasts at least 2 weeks. It includes depressed mood or loss of interest in almost all activities. It also includes at least four of the following: changes in appetite or weight, sleep, and psyc
PPD therapeutic management
Depression responds best to a combination of psychotherapy, social support, and medication. Psychotherapy may be helpful to assist the woman to cope with changes in her life. The woman's partner and immediate family must be included in counseling sessions
Postpartum pychosis
Psychosis is a mental state in which a person's ability to recognize reality, communicate, and relate to others is impaired. Postpartum psychosis can be classified as depressed or manic types (Stuart, 2009). It is a rare condition that affects 1 or 2 wome
Bipolar II Disorder
Women with bipolar disorder suffer from periods of irritability, hyperactivity, euphoria, and grandiosity. They exhibit little need for sleep and are seldom aware they have a problem. The poor judgment and confusion they experience make self-care and infa
postpartum anxiety disorders
Postpartum anxiety disorders include panic disorder, postpartum obsessive-compulsive disorder (OCD), and posttraumatic stress disorder. Panic disorder manifests as episodes of tachycardia, palpations, shortness of breath, chest pain, and fear of dying or