Postpartum Hemorrhage (Maternal-Newborn) - CE

ALERT

Quickly identify a patient experiencing postpartum hemorrhage and treat as an emergency.^{undefined#ref7">7} Postpartum hemorrhage is a potentially life-threatening complication that may have a rapid, unexpected onset⁷ and is the number one cause of maternal mortality worldwide.²

OVERVIEW

All organizations with obstetric services should be well prepared to manage postpartum hemorrhage and have policies and procedures in place to ensure optimal management, which includes the availability of blood products for transfusion. Postpartum hemorrhage requires a multidisciplinary team approach of nurses, practitioners, anesthesia providers, and blood bank personnel.^8,10

Primary postpartum hemorrhage occurs within the first 24 hours after birth; in many cases, it is associated with uterine atony.^2,7 Postpartum hemorrhage is defined as a cumulative blood loss of 1000 ml or more, or blood loss that occurs along with signs and symptoms of hypovolemia within 24 hours after the birth process (including intrapartum loss).^2,8 Blood loss greater than 500 ml in a vaginal delivery should trigger heightened surveillance and interventions as clinically indicated.^2,8 Secondary postpartum hemorrhage is excessive bleeding that occurs 24 hours to 6 weeks after birth.⁷ Secondary postpartum hemorrhage is associated with subinvolution of the uterus; in some cases, it is related to retained placental fragments, infection, and inherited coagulation defects (e.g., von Willebrand disease [VWD]).^2,7

Studies have shown that visual estimation of blood loss in an obstetric patient has been underestimated by 33% to 50%, which delays recognition and treatment of postpartum hemorrhage.^2,3,7 Postpartum hemorrhage is the leading cause of maternal morbidity and mortality related to the lack of recognizing and quantifying the amount of blood loss;³ for this reason, quantification of blood loss (QBL) is recommended.^3,5,7 Obstetric nurses in labor and delivery and postpartum units should be able to recognize the signs of postpartum hemorrhage and, through risk assessment scoring and routine drills, be prepared to initiate emergency interventions as they become necessary.^2,7,8,11

Factors that increase a patient’s risk of developing postpartum hemorrhage include:^2,5,7

• Any condition that causes an overdistended uterus (e.g., multiple gestations, macrosomia, hydramnios)
• Trauma during labor and birth, which may be related to the use of forceps or vacuum-assisted delivery (e.g., lacerations of the birth canal, uterine inversion)
• High parity
• Uterine rupture
• Prolonged labor
• Cesarean delivery
• History of uterine atony
• Complications involving the placenta (e.g., placental abruption, placenta previa, placenta accrete syndrome or morbidly adherent placenta, manual removal of the placenta, retained placenta or placental fragments, placental implantation in lower uterine segment)
• Induction of labor using oxytocin
• History of postpartum hemorrhage
• General or halogenated anesthesia
• Magnesium sulfate administration during labor or postpartum
• Chorioamnionitis
• Coagulopathies, including idiopathic (immune) thrombocytopenia purpura, VWD, and disseminated intravascular coagulation (DIC)⁷

Postpartum hemorrhage may be prevented with active third stage of labor management. Evidence-based data has shown a strong association between the use of oxytocin administration, uterine massage, and umbilical cord traction in the third stage of labor, and reduction in maternal hemorrhage.^2,5

The most frequent cause of postpartum hemorrhage is uterine atony, which is more likely to occur when the uterus has been overdistended.^2,5 Early recognition of the initial signs of postpartum hemorrhage is critical. Because of the increased blood volume in pregnancy, a change in the patient’s vital signs may not be apparent until there is a significant loss of the total circulating blood volume. Vital sign changes of more than 15%, or heart rate 110 beats per minute or higher; blood pressure 85/45 mm Hg or lower; and peripheral oxygen saturation (SpO₂) less than 95% should trigger interventions for postpartum hemorrhage.⁵ Rather than relying solely on vital signs, nurses must begin treatment with presentation of other signs and symptoms,² including:

• A boggy or uncontracted uterus
• Vaginal bleeding that gushes or slowly trickles
• Vaginal bleeding that frequently saturates perineal pads

Once postpartum hemorrhage is suspected, the nurse’s goal is to identify the underlying cause of bleeding, monitor and minimize blood loss, and prevent or manage hemorrhagic (hypovolemic) shock and DIC.⁷ Hemorrhagic shock and DIC are life-threatening emergencies that, if not treated effectively, may lead to multisystem organ failure and eventually death.⁷ An algorithm for the assessment of and intervention in postpartum bleeding may be helpful in recognizing the underlying cause and initiating the appropriate intervention (Figure 1).⁷

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Ensure that the patient and support person understand the risks of postpartum hemorrhage, if appropriate.
• Review the plan of care and necessary interventions with the patient and support person.
  • Frequent monitoring of vital signs
  • Fundal assessment and massage
  • Bladder catheterization
  • Administration of oxygen
  • Administration of IV fluids
  • Administration of ordered medications, including uterotonics (e.g., oxytocin, methylergonovine, 15-methyl prostaglandin F2 alpha, and misoprostol), and antifibrinolytics (e.g., tranexamic acid)
  • Administration of blood products
  • Laboratory studies
  • Laceration repair
  • Manual examination of the genital tract
  • Use of a tamponade device or surgery
  • Electrocardiogram (ECG) monitoring
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact.
2. Introduce yourself to the mother and support person.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s medical and obstetric history for risk factors for postpartum hemorrhage.

   Rationale: Antepartum assessment is essential to help identify patients at risk for obstetric hemorrhage. Using an approved risk scoring tool or order preset helps to determine maternal risk. ^2,5

5. Assess the patient for any conditions that contraindicate the use of specific uterotonic medications.
6. Assess the patient for signs of postpartum hemorrhage.
   1. Vaginal bleeding that is heavy or suddenly gushes, a slow constant flow, or an oozing of blood⁷

   Rationale: A perineal pad saturated within 15 minutes and a pooling of blood under the buttocks are indications of excessive blood loss. ¹

   2. QBL of 1000 ml or more, or blood loss between 500 and 999 ml with clinical indications for treatment^2,8
   3. Change in mentation
   4. Tachycardia, tachypnea, hypotension, or other change in vital signs (late signs)
   5. Change in level of consciousness (alertness, confusion, lethargy, obtundation, stupor, coma)
   6. Persistent, severe perineal pain or pressure, possibly accompanied by a discolored swollen mass in the vulvar or perineal area

Preparation

1. Ensure that adult resuscitation equipment and other needed supplies, such as a postpartum hemorrhage cart, are readily available.

   Rationale: A postpartum hemorrhage cart with the appropriate supplies and equipment may reduce delays in locating needed items.

PROCEDURE

1. Perform hand hygiene and don gloves.
2. Verify the correct patient using two identifiers.
3. Explain the procedure to the mother and support person and ensure that they agree to treatment.
4. If evidence of postpartum hemorrhage exists, initiate obstetric hemorrhage protocol. Call for help and notify additional health care team members, including the practitioner and a second labor and delivery nurse.⁵

Rationale: Interventions to manage postpartum hemorrhage may occur simultaneously with a multidisciplinary team approach.

5. If QBL is excessive, attempt to identify the source of bleeding. Use “the 4 T’s” mnemonic to consider whether the bleeding is related to tone (uterine atony), trauma (lacerations, hematomas, or uterine rupture), tissue (retained placental tissue), or thrombin (coagulation factors).²
1. If blood is dark red, assess for superficial lacerations.
2. If blood is bright red, assess for deep lacerations (i.e., lacerations in the cervix).
3. If blood spurts and clots, assess for uterine atony or partial placental separation.
4. If blood does not clot, assess for coagulopathies, including idiopathic or immune thrombocytopenic purpura (ITP), VWD, or DIC.⁷
6. Establish IV access in two sites using large-bore catheters. Begin IV infusions with 0.9% sodium chloride solution or lactated Ringer solution.⁷

Rationale: One IV line is used to administer IV fluids; the other is used to administer blood products. ⁵ The establishment of two IV lines facilitates fluid resuscitation. ⁷

7. Obtain specimens for necessary laboratory studies as ordered.
1. Complete blood count (CBC) with platelet count
2. Coagulation studies (fibrinogen, fibrin split products, prothrombin time, partial thromboplastin time)

Rationale: These laboratory values are necessary to assist with determining the extent of postpartum hemorrhage and any underlying causes. ⁷

3. Blood type and antibody screen for blood products if not already performed
8. In the presence of the patient, label the specimens per the organization’s practice.⁶
9. Place the labeled specimens in a biohazard bag and transport them to the laboratory immediately per the organization’s practice.
10. Assess vital signs, including SpO₂, at least every 5 minutes.^4,5

Rationale: Classic signs of shock may be absent until the postpartum patient has lost 30% to 40% of her blood volume. ⁷ Tachycardia and hypotension should alert the practitioner to the possibility of significant loss of blood volume. ^4,5

Initiate continuous ECG monitoring if profuse bleeding continues or if the patient exhibits signs of shock, specifically tachycardia or hypotension.⁷

11. Calculate cumulative blood loss using quantification methods and communicate the amounts to the practitioner (Box 1) (Box 2). Methods for quantification may include:³
1. Using calibrated underbuttocks drapes (Figure 2)
2. Weighing blood-saturated items (1 gm = 1 ml)
3. Calculating blood loss by obtaining the wet item gram weight and subtracting the dry item gram weight to obtain QBL
4. Using formulas, which may be inserted into the electronic charting, to deduct the dry weight from the wet weight of items such as perineal pads and underpads
5. Placing scales to weigh blood-soaked items in all labor and operating rooms

Rationale: Visual estimation of blood loss as compared with weight or collection devices is 33% to 50% lower than the measured loss. ³

12. Perform interventions specific to the source of the bleeding.
1. Assess the patient for boggy fundus as a sign of uterine atony, and respond as follows:
1. Perform a fundal massage (Figure 3).
2. Once the uterus is firm, express clots by applying firm but gentle pressure on the fundus toward the vagina.^2,5

Ensure that the uterus is firm before attempting to express clots to prevent uterine inversion, which is a life-threatening emergency. If uterine inversion occurs with the placenta still attached to the uterine wall, the placenta is normally delivered after replacement of the uterus to avoid excessive blood loss. Tocolytics, such as terbutaline, magnesium sulfate, halogenated general anesthetics, and nitroglycerin, may be used to help relax the uterus to facilitate uterine replacement.²

Rationale: Compression or massage may decrease bleeding, help to expel clots, and allow time for other interventions. ^2,5,7

3. Administer oxytocin or other uterotonic agents (e.g., methylergonovine, 15-methyl prostaglandin F2 alpha, dinoprostone, misoprostol) as ordered.

Rationale: Uterotonic agents are critical to facilitating contraction of the uterus after delivery of the placenta.

Do not use methylergonovine if the patient has hypertension or cardiovascular disease. Do not administer 15-methyl prostaglandin F2 alpha if the patient has a history of asthma because it may cause bronchoconstriction; avoid the use of this medication if the patient has a history of hypertension, because it may cause hypertension.⁷

4. Ensure that the patient’s bladder is empty. If it is distended, catheterize if needed.

Rationale: A full bladder causes uterine displacement, prevents the uterus from contracting normally, and is a common cause of bleeding. ⁷

5. Assist the practitioner with performing a bimanual examination or perform fundal massage if indicated.
2. Assist the practitioner with a perineal and vaginal examination for lacerations and hematomas if indicated.
1. Assist with the repair of lacerations or hematoma drainage (if necessary) by providing a spotlight, supplying the requested suture and instruments, and cleansing the perineum after repair.
2. If the patient experiences a fourth-degree laceration or if a large hematoma is observed, remove gloves; perform hand hygiene; don sterile gloves, gown, and mask; and assist the practitioner with holding retractors and passing instruments and gauze sponges as requested.

Rationale: Hematoma formation may be extremely painful and is more common with forceps delivery. The developing hematoma may be visible and located in the vulva or hidden and located in the vagina or retroperitoneal area.

3. Assist the practitioner with assessing for retained placenta and assist with removal as needed.
1. Notify the anesthesia provider about the retained placenta.

Rationale: If the patient did not receive regional anesthesia during labor, administration of light nitrous oxide and oxygen inhalation anesthesia or IV pain medications should be considered for the removal of the retained placental fragments. ⁷

2. Administer oxytocin or other uterotonic agents as ordered after the placenta is removed.
13. Administer oxygen by nonrebreather mask as ordered.

Rationale: Blood loss and hypovolemia cause decreased oxygenation of the organs; therefore, supplemental oxygenation is critical. ⁵

14. Administer IV fluids and blood products as ordered to replace lost fluid and blood volume. Use warming devices as indicated.

Rationale: Fluid volume replacement is critical to prevent hypovolemic shock. ⁷ Poor perfusion of organs can increase lactate levels and acidosis. Without blood volume replacement, the body eventually loses the ability to perfuse the heart and brain; permanent damage or death may occur. ⁵

15. Keep the patient warm. Use warm blankets or a forced-air warming blanket device and a blood and fluid warming device as indicated.

Rationale: Euthermia is necessary to help avoid added coagulopathy, which can be exacerbated by hypothermia.

16. Insert an indwelling urinary catheter and maintain strict monitoring of intake and output with the use of an attached urometer.

Rationale: Intake and output must be monitored closely so that volume replacement remains adequate. In addition, DIC may result in renal failure; therefore, urine output must be monitored on an hourly basis to ensure an output of at least 30 ml/hr, preferably greater than 50 ml/hr. ⁷

17. Assist with bimanual compression of the uterus.
18. Assist with uterine packing or insertion of a tamponade device.
19. Prepare the patient for surgery as needed. Provide ongoing reassurance to her and the support person.
20. Provide interventions as ordered for specific causes of any identified coagulopathy.⁷
1. Idiopathic thrombocytopenia purpura: Corticosteroids, IV immunoglobulin, and platelet transfusions may be administered. If unsuccessful, the patient may require a splenectomy.
2. VWD: Desmopressin, cryoprecipitate, and concentrates of factor VIII may be administered.
3. DIC: Treatment of the underlying cause may include antibiotic therapy for existing infection, treatment of preeclampsia or eclampsia, or removal of an abrupted placenta. Usual treatment measures include volume expansion, rapid replacement of blood products and clotting factors, optimized oxygenation, achievement and maintenance of euthermia, and continued reassessment of laboratory values. Additional therapies, including administration of vitamin K, recombinant activated factor VIIa, fibrinogen concentrate, and hemostatic agents, may be considered.⁹
21. Discard supplies, remove personal protective equipment (PPE), and perform hand hygiene.
22. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Monitor the patient closely for signs of recurring postpartum hemorrhage.
2. Monitor the patient for infection if internal interventions were used.
3. Monitor the patient for signs of DIC and other coagulopathies.
   1. Excessive vaginal bleeding with a firm uterus and no clots
   2. Bleeding from the eyes and nose
   3. Petechiae around the site where the blood pressure cuff is applied
   4. Excessive bleeding from any puncture sites, such as an IV site
   5. Tachycardia and diaphoresis
   6. Abnormal coagulation studies, decreased platelet count
4. Assess, treat, and reassess pain.
5. Perform other recovery care.

EXPECTED OUTCOMES

• Early and effective treatment of postpartum hemorrhage
• No adverse outcomes or complications
• Identification and management of coagulopathy, if present

UNEXPECTED OUTCOMES

• Emergency hysterectomy
• DIC
• Permanent damage to vital organs
• Maternal death

DOCUMENTATION

• Vital signs
• Uterine tone and fundal location
• Subjective and objective signs of postpartum hemorrhage
• Color and consistency of blood loss or any blood clots
• QBL
• Six rights of medication safety for administration of all medications and blood products
• Verification of blood product numbers and expiration dates
• Patient’s response to administration of blood products
• Interventions specific to the source of bleeding and outcomes of interventions
• IV fluid administration
• Intake and output
• Time of placenta delivery
• Specimens collected per the organization’s practice
• Health care team members notified and present during interventions
• Unexpected outcomes and related interventions
• Education

REFERENCES

1. Alderman, J.T. (2020). Chapter 21: Nursing care of the family during the postpartum period. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 424-440). St. Louis: Elsevier.
2. American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins—Obstetrics. (2017, reaffirmed 2019). ACOG practice bulletin no. 183: Postpartum hemorrhage. Obstetrics & Gynecology, 130(4), e168-e186. doi:10.1097/AOG.0000000000002351 Retrieved January 19, 2020, from https://clinicalinnovations.com/wp-content/uploads/2017/10/ACOG_Practice_Bulletin_No_183_Postpartum-Hemorrhage-2017.pdf (Level VII)
3. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2015). Quantification of blood loss: AWHONN practice brief number 1. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 44(1), 158-160. doi:10.1111/1552-6909.12519 (Level VII)
4. Behling, D.J., Renaud, M. (2015). Development of an obstetric vital sign alert to improve outcomes in acute care obstetrics. Nursing for Women’s Health, 19(2), 128-141. doi:10.1111/1751-486X.12185
5. California Maternal Quality Care Collaborative (CMQCC). (2015). Maternal Quality Improvement Toolkit: Improving health care response to obstetric hemorrhage, version 2.0. Retrieved January 19, 2020, from https://www.cmqcc.org/ (Level VII)
6. Joint Commission, The. (2020). National patient safety goals: Hospital accreditation program. Retrieved January 19, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_hap_jan2020.pdf (Level VII)
7. Lanning, R.K. (2020). Chapter 33: Postpartum complications. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 721-732). St. Louis: Elsevier.
8. Main, E.K. and others. (2015). National partnership for maternal safety: Consensus bundle on obstetric hemorrhage. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 44(4), 462-470. doi:10.1111/1552-6909.12723 (Level VII)
9. Montgomery, K.S. (2020). Chapter 28: Hemorrhagic disorders. In D.L. Lowdermilk and others (Eds.), Maternity & women’s health care (12th ed., pp. 598-614). St. Louis: Elsevier.
10. Shields, L.E. and others. (2015). Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. American Journal of Obstetrics & Gynecology, 212(3), 272-280. doi:10.1016/j.ajog.2014.07.012 (Level II)
11. Skupski, D.W. and others. (2017). Improvement in outcomes of major obstetric hemorrhage through systematic change. Obstetrics & Gynecology, 130(4), 770-777. doi:10.1097/AOG.0000000000002207 (Level VI)

ADDITIONAL READINGS

Dahlke, J.D. and others. (2015). Prevention and management of postpartum hemorrhage: A comparison of 4 national guidelines. American Journal of Obstetrics & Gynecology, 213(1), 76.e1-76.e10. doi:10.1016/j.ajog.2015.02.023

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports