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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
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
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:
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
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.
Rationale: A perineal pad saturated within 15 minutes and a pooling of blood under the buttocks are indications of excessive blood loss.
Rationale: A postpartum hemorrhage cart with the appropriate supplies and equipment may reduce delays in locating needed items.
Rationale: Interventions to manage postpartum hemorrhage may occur simultaneously with a multidisciplinary team approach.
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.
Rationale: These laboratory values are necessary to assist with determining the extent of postpartum hemorrhage and any underlying causes.
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.
Initiate continuous ECG monitoring if profuse bleeding continues or if the patient exhibits signs of shock, specifically tachycardia or hypotension.7
Rationale: Visual estimation of blood loss as compared with weight or collection devices is 33% to 50% lower than the measured loss.
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.
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
Rationale: A full bladder causes uterine displacement, prevents the uterus from contracting normally, and is a common cause of bleeding.
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.
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.
Rationale: Blood loss and hypovolemia cause decreased oxygenation of the organs; therefore, supplemental oxygenation is critical.
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.
Rationale: Euthermia is necessary to help avoid added coagulopathy, which can be exacerbated by hypothermia.
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.
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
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