Postpartum Hemorrhage

A postpartum hemorrhage (PPH) is frequently defined as a blood loss of greater than 500 mL after giving birth vaginally or a blood loss of greater than 1,000 mL after a cesarean section. Because many women lose at least 500 mL of blood during childbirth and do not experience any symptoms, a more accurate way to define PPH is losing 1% or more of the body weight after delivering a baby (1 mL of blood weighs 1 g). For example, a patient weighing 175 pounds (80 kilograms) would need to lose 800 mL of blood to be classified as having a PPH. Greater than a 10% decrease in the prenatal hematocrit is another means used to suggest that PPH has occurred; this value needs to be used cautiously because hematocrit is affected by factors other than blood loss, such as dehydration. It is estimated that 2% to 4% of all deliveries end in PPH, and it is a major contributor to maternal morbidity and mortality.

PPH is classified as either an early hemorrhage (occurring during the first 24 hours after delivery) or a late hemorrhage (occurring more than 24 hours after delivery). With the current trend in obstetric practice of sending postpartum patients home in 48 hours or less after delivery, the significance of PPH, particularly late hemorrhage, is profound. Often, the severity of the hemorrhage depends on the expediency with which it is diagnosed and treated; if the patient hemorrhages at home, the risk increases significantly. Complications include anemia, hemorrhagic/hypovolemic shock, and death.

Causes ⬆ ⬇

There are several causes of PPH, particularly uterine atony, trauma, retained placental tissue, and thrombosis. Several predisposing factors related to these causes can be found in Box 1. The number one cause of early PPH is uterine atony, a condition in which the uterus does not adequately contract, allowing increased blood loss from the placental site of implantation. After the placenta is delivered, the uterus needs to contract to seal off the iliac arteries. If the uterus is contracted, the placental site is smaller, causing less bleeding.

Box 1 Predisposing (risk) Factors for Postpartum Hemorrhage

Overdistention of the uterus (multiple gestation and delayed-interval delivery in twin and triplet pregnancies, hydramnios)
Use of anesthetic agents, especially halothane
Delivery of large infant
Manual removal of the placenta
Placenta previa
Placenta accreta (separation of the placenta is difficult or impossible)
Mismanaged/prolonged (> 30 min) third stage of labor
Lacerations

Obesity
Forceps or vacuum delivery; prolonged or rapid labor
Extended used of oxytocin (Pitocin) during labor
Maternal malnutrition or anemia
Uterine infections
Pregnancy-induced hypertension
Maternal history of hemorrhage or blood coagulation problems
Hypopituitarism (rate of PPH increases to 8.7%)

Lacerations of the perineum, vagina, and cervix can occur during a vaginal birth. Lacerations of the cervix occur with rapid dilation or with pushing before complete dilation. During the second stage of labor, vaginal, perineal, and periurethral tears occur. Failure to repair these lacerations adequately can result in a slow, steady trickle of blood.

The most common cause of late PPH is retained placental tissue. If parts of the placenta remain in the uterus after delivery, small clots (thrombosis) form around the retained parts, sealing off the bleeding. After a while, the clots slough, and heavy bleeding occurs. Subinvolution (delayed involution) can also be a causative factor in a late PPH.

Genetic Considerations ⬆ ⬇

Several genetic coagulopathies could predispose a woman to postpartum hemorrhage (PPH), including familial hypofibrinogenemia or Scott syndrome. Von Willebrand disease is the most commonly inherited bleeding disorder. It is usually transmitted in an autosomal dominant fashion but can rarely be transmitted autosomal recessively. It results in mild to moderate risk of bleeding, but in some cases, bleeding can be severe and similar to that of hemophilia. Von Willebrand disease affects men and women equally and is caused by mutations in the VWF gene.

Sex and Life Span Considerations ⬆ ⬇

PPH is linked not to age but to risk factors (see Box 1).

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

Jehovah's Witnesses are at a 44-fold increased risk of death owing to hemorrhage during and after delivery because of decisions against blood transfusion when it is recommended. Black, Asian, and Hispanic women have a higher rate of PPH than White women. Women with severe maternal complications are more likely to be Black, multiparous, and/or 35 years or older. They are also likely to have public health insurance and receive inadequate prenatal care. The most common causes of severe maternal morbidity are hemorrhage (48%) and preeclampsia/eclampsia (20%). Sexual and gender minority status has no known effect on the risk for PPH (Geller et al., 2021).

Global Health Considerations ⬆ ⬇

Although rates of PPH have declined in the developed regions of the globe, it is the leading cause of maternal mortality in the world, accounting for 25% of all maternal deaths. Experts at the World Health Organization and other agencies estimate that 100,000 to 140,000 women die from PPD each year, with the majority of them from developing and underresourced regions. Reasons for the high rates of maternal death in developing regions include availability of medication and blood transfusion, lack of experienced caregivers present during birth, lack of operating room services, and increased prevalence of nutritional deficiencies.

Assessment ⬆ ⬇

ASSESSMENT

History

Take a complete reproductive history. Because PPH can be repeated in subsequent pregnancies, always ask if a multipara had a previous PPH. Inquire about a family history of coagulation disorders or excessive bleeding with surgical procedures or menses.

Physical Examination

The most common symptom is heavy vaginal bleeding. Observe the amount and characteristics of blood loss; sometimes there is a pooling of blood and the passage of large clots. Usually, complete saturation of one perineal pad within 15 minutes or saturation of two or more pads in 1 hour suggests hemorrhage. A bimanual examination may be done to determine tone, uterine enlargement, or presence of pelvic hematomas. Palpate the fundus, noting if it is firm or boggy, if it is midline or deviated laterally, and if it is above or below the umbilicus. Normally, after delivery, the fundus is firm, midline, and at the level of the umbilicus. A fundus above the umbilicus and deviated laterally may indicate a full bladder. A boggy uterus is indicative of uterine atony and, if it is not corrected, results in a PPH. If the fundus is firm, midline, and at or below the umbilicus and if there is steady, bright red bleeding, further assessment for trauma is necessary. Inspect the perineum carefully to discern any unrepaired lacerations or bleeding from a repaired episiotomy. If a hematoma is suspected, the patient is placed in lithotomy position and the vagina and perineal area are carefully inspected. Ask if the patient has perineal pain. Although some discomfort is expected after a vaginal delivery, severe pain or pressure is uncommon and often indicates a hematoma. A bulging and discoloration of the skin is noted if a hematoma is present. Assess the patient's vital signs. A temperature above 100.4°F (38°C) may indicate uterine infection, which decreases the myometrium's ability to contract and makes the patient more susceptible to PPH. Note any foul vaginal odor that may accompany the fever with infection. Elevated heart rate, delayed capillary refill, decreased blood pressure, and increased respiratory rate may be noted if PPH is occurring. Assess the patient's color and skin temperature; pallor and cool, clammy skin also indicate hypovolemic shock.

Psychosocial

PPH is a traumatic experience because medical complications are unexpected during what is anticipated as a happy time. Assess the anxiety level of the patient; the patient going into hypovolemic shock is highly anxious and then may lose consciousness. The significant others experience a high level of anxiety as well and need a great deal of support.

Diagnostic Highlights

General Comments: Diagnosis of PPH is usually based on the estimated blood loss, which eventually is reflected in serum laboratory tests. Coagulation studies and typing and crossmatching are done if bleeding remains excessive. Serial monitoring of serum electrolytes, blood urea nitrogen, and creatinine is important.

Test	Normal Result	Abnormality With Condition	Explanation
Complete blood count	Red blood cells (RBCs): 3.6–5.8 million/mcL; hemoglobin (Hgb): 11.7–17.3 g/dL; hematocrit (Hct): 36%–52%; white blood cells: 4,500–11,100/mcL; platelets: 150,000–450,000/mcL	RBC count, Hgb, and Hct decrease several hours after significant blood loss has occurred	Active bleeding causes decrease

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisRisk for bleeding as evidenced by frank or occult hemorrhage, thirst, oliguria, hypotension, and/or tachycardia

Outcomes

OutcomesBlood loss severity; Fluid balance; Hydration; Circulation status; Shock severity: Hypovolemic; Vital signs

Interventions

InterventionsBleeding reduction: Postpartum uterus; Blood product administration; Fluid resuscitation; IV therapy; Shock prevention; Shock management: Volume; Vital signs monitoring

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

The goal of treatment is to correct the cause and replace the fluid loss. Resuscitation occurs first, followed by identification and management of the underlying cause of PPH. Patients should have nothing by mouth until hemostasis is established. Expedient diagnosis and treatment of the cause reduce the likelihood of a blood transfusion. Treatment for uterine atony involves performing frequent fundal massage, sometimes bimanual massage (by the medical clinician only), and pharmacologic therapy. Fluid replacement with normal saline solution, lactated Ringer injection, or volume expanders is essential, and administration of blood may be necessary. Raising the patient's legs will improve venous return. Multiple venous access sites, 100% oxygen, and a Foley catheter are often needed. If uterine atony is not corrected quickly, a life-saving hysterectomy is indicated.

Serial laboratory measures to monitor the patient's hemoglobin and RBC count are essential, along with ensuring that blood products are readily available for transfusion. Monitor the hematocrit and hemoglobin to determine the success of fluid replacement and the patient's intake and output. If an infection is the cause of the atony, the physician prescribes antibiotics. PPH caused by trauma requires surgical repair with aseptic technique. Hematomas may absorb on their own; however, if they are large, an incision, evacuation of clots, and ligation of the bleeding vessel are necessary. Administer analgesics for perineal pain. If retained fragments are suspected at the time of delivery, the uterine cavity should be explored. If manual removal or expression of clots/placental fragments is unsuccessful, cervical dilation and curettage is indicated to remove retained fragments. A type of compression suture, Meydanli, may decrease PPH of cesarean deliveries with abnormal placental attachments or atony. The suture is placed from the lower end of the uterus to the top on both sides to assist in uterine compression.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Oxytocin (Pitocin)	Mix 10–40 units in 1,000 mL, give 20–40 milliunit/min	Oxytocic	Controls bleeding by producing uterine contractions
Methylergonovine (Methergine)	0.2 mg IM	Oxytocic	Controls bleeding by producing uterine contractions
Carboprost	259 mcg IM	Prostaglandin	Controls bleeding by producing uterine contractions
Misoprostol	1,000 mcg PR	Prostaglandin	Causes sustained uterine contraction

Independent

Be alert for PPH in any postpartum patient, especially those who have any of the predisposing factors. It is often the nurse who discovers the hemorrhage. For the first 24 hours postpartum, perform frequent fundal checks. Fundal check should be every 15 minutes for the first hour, then every 30 minutes the next hour, then every 2 hours for 4 hours, then every 4 hours and progressing to every 8 hours if there are no problems with involution. If the fundus is boggy, massage until it feels firm; it should feel like a large, hard grapefruit. When massaging the fundus, keep one hand above the symphysis pubis to support the lower uterine segment, while gently but firmly rubbing the fundus, which may lose its tone when the massage is stopped. Explain that cramping or feeling like “labor is starting again” is expected with liberal administration of the oxytocic drugs used to manage the bleeding. Monitor for hypertension if oxytocics and prostaglandins are used. Encourage the patient to void; a full bladder interferes with contractions and normal uterine involution. If patients are unable to void on their own, straight catheterization is necessary.

Monitor vaginal bleeding; the lochia is usually dark red and should not saturate more than one perineal pad every 2 to 3 hours. Blood loss is frequently underestimated. If unsure, weigh the perineal pads and any blood-soaked underpads or sheets. One gram of weight is equal to 1 mL of blood loss volume. Notify the physician if the bleeding is steady and bright red in the presence of a normal firm fundus; this usually indicates a laceration. Ice packs and sitz baths may relieve perineal discomfort. The patient is usually on complete bedrest. Rooming in with the infant may be difficult; provide for safe care for the infant while it is in the birthing parent's room. Assist the patient and significant others as much as possible with newborn care to facilitate quality time between the parent and the newborn. Assist the patient with ambulation the first few times out of bed; syncope is common after a large blood loss. Ensure adequate rest periods.

Evidence-Based Practice and Health Policy

Almutairi, W., Ludington, S., Griffin, M., Burant, C., Al-Zahrani, A., Alshareef, F., & Badr, H. (2021). The role of skin-to-skin contact with breastfeeding on atonic postpartum hemorrhage. Nursing Reports, 11, 1–11.

The authors aimed to conduct a retrospective chart review using codes for atonic postpartum hemorrhage to determine the incidence of PPH, the amount of estimated blood loss, and the duration of the third stage of labor in women with and without PPH. The cases were from medical records of patients who received care in a large university-based tertiary healthcare setting.
The postpartum hemorrhage rate due to atonic uterus increased by 47.5% from 2009 to 2015, and the third stage of labor was longer for the postpartum hemorrhage patients. Women who had skin-to-skin contact and breastfed their newborns immediately after birth had a shorter third stage of labor, and estimated blood loss was lower than for women who did not have that experience.

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DRG Information ⬇

Introduction ⬆ ⬇