Etiology and Risk Factors

Considering the problem of excessive bleeding with reference to the stages of labor is helpful. From birth of the infant until separation of the placenta the character and quantity of blood passed may suggest excessive bleeding. For example, dark blood is probably of venous origin, perhaps from varices or superficial lacerations of the birth canal. Bright blood is arterial and may indicate deep lacerations of the cervix. Spurts of blood with clots may indicate partial placental separation. Failure of blood to clot or remain clotted indicates a pathologic condition or coagulopathy such as disseminated intravascular coagulation (DIC) (Francois & Foley, 2007).

Excessive bleeding may occur during the period from the separation of the placenta to its expulsion or removal. Commonly, such excessive bleeding is the result of incomplete placental separation, undue manipulation of the fundus, or excessive traction on the cord. After the placenta has been expelled or removed, persistent or excessive blood loss is usually the result of atony of the uterus or inversion of the uterus into the vagina. Late PPH may be the result of subinvolution of the uterus, endometritis, or retained placental fragments (Francois & Foley, 2007). Risk factors for PPH are listed in Box 23-1.

Uterine Atony

Uterine atony is marked hypotonia of the uterus. Normally, placental separation and expulsion are facilitated by contraction of the uterus, which also prevents hemorrhage from the placental site. The corpus is in essence a basket weave of strong, interlacing smooth-muscle bundles through which many large maternal blood vessels pass (see Fig. 2-3). If the uterus is flaccid after detachment of all or part of the placenta, brisk venous bleeding occurs, and normal coagulation of the open vasculature is impaired and continues until the uterine muscle is contracted.

Uterine atony is the leading cause of PPH, complicating approximately 1 in 20 births (Francois & Foley, 2007). It is associated with high parity, hydramnios, a macrosomic fetus, and multifetal gestation. In such conditions the uterus is “overstretched” and contracts poorly after the birth. Other causes of atony include traumatic birth, use of halogenated anesthesia (e.g., halothane) or magnesium sulfate, rapid or prolonged labor, chorioamnionitis, and use of oxytocin for labor induction or augmentation (Francois & Foley). PPH in a previous pregnancy is a predominant risk factor for recurrent PPH (Kominiarek & Kilpatrick, 2007).

Lacerations of the Genital Tract

Lacerations of the cervix, vagina, and perineum are also causes of PPH. Hemorrhage related to lacerations should be suspected if bleeding continues despite a firm, contracted uterine fundus. This bleeding can be a slow trickle, an oozing, or frank hemorrhage. Factors that influence the causes and incidence of obstetric lacerations of the lower genital tract include operative birth, precipitate birth, congenital abnormalities of the maternal soft parts, and contracted pelvis. Size, abnormal presentation, and position of the fetus; relative size of the presenting part and the birth canal; previous scarring from infection, injury, or operation; and vulvar, perineal, and vaginal varicosities also can cause lacerations.

Extreme vascularity in the labial and periclitoral areas often results in profuse bleeding if laceration occurs. Hematomas also may be present.

Lacerations of the perineum are the most common of all injuries in the lower portion of the genital tract. These lacerations are classified as first, second, third, and fourth degree (see Chapter 12). An episiotomy may extend to become either a third- or fourth-degree laceration.

Prolonged pressure of the fetal head on the vaginal mucosa ultimately interferes with the circulation and may produce ischemic or pressure necrosis. The state of the tissues in combination with the type of birth may result in deep vaginal lacerations, with consequent predisposition to vaginal hematomas.

Pelvic hematomas may be vulvar, vaginal, or retroperitoneal in origin. Vulvar hematomas are the most common. Pain is the most common symptom, and most vulvar hematomas are visible. Vaginal hematomas occur more commonly in association with a forceps-assisted birth, an episiotomy, or primigravidity (Francois & Foley, 2007). During the postpartum period, if the woman reports a persistent perineal or rectal pain or a feeling of pressure in the vagina, a thorough examination is made. However, a retroperitoneal hematoma may cause minimal pain, and the initial symptoms may be signs of shock (Francois & Foley).

Cervical lacerations usually occur at the lateral angles of the external os. Most lacerations are shallow, and bleeding is minimal. More extensive lacerations may extend into the vaginal vault or into the lower uterine segment.

Retained placenta may result from partial separation of a normal placenta, entrapment of the partially or completely separated placenta by an hourglass constriction ring of the uterus, mismanagement of the third stage of labor, or abnormal adherence of the entire placenta or a portion of the placenta to the uterine wall. Placental retention because of poor separation is common in very preterm births (20-24 weeks of gestation).

Management of nonadherent retained placenta is by manual separation and removal by the primary health care provider. Supplementary anesthesia is not usually needed for women who have had regional anesthesia for birth. For other women, administration of light nitrous oxide and oxygen inhalation anesthesia or intravenous (IV) thiopental facilitates uterine exploration and placental removal. After this removal the woman is at continued risk for PPH and for infection.

Inversion of the Uterus

Inversion of the uterus after birth is a potentially life-threatening but rare complication. The incidence of uterine inversion is approximately 1 in 2500 births (Francois & Foley, 2007), and the condition may recur with a subsequent birth. Uterine inversion may be partial or complete. Complete inversion of the uterus is obvious; a large, red, rounded mass (perhaps with the placenta attached) protrudes 20 to 30 cm outside the introitus. Incomplete inversion cannot be seen but must be felt; a smooth mass will be palpated through the dilated cervix. Contributing factors to uterine inversion include uterine malformations, fundal implantation of the placenta, manual extraction of the placenta, short umbilical cord, uterine atony, leiomyomas, and abnormally adherent placental tissue (Francois & Foley). The primary presenting signs of uterine inversion are hemorrhage, shock, and pain in the absence of a palpable fundus abdominally.

Prevention—always the easiest, cheapest, and most effective therapy—is especially appropriate for uterine inversion. The umbilical cord should not be pulled on strongly unless the placenta has definitely separated.

Subinvolution of the Uterus

Late postpartum bleeding may occur as a result of subinvolution of the uterus. Recognized causes of subinvolution include retained placental fragments and pelvic infection.

Signs and symptoms include prolonged lochial discharge, irregular or excessive bleeding, and sometimes hemorrhage. A pelvic examination usually reveals a uterus that is larger than normal and that may be boggy.

Early recognition and acknowledgment of the diagnosis of PPH are critical to care management. The first step is to evaluate the contractility of the uterus. If the uterus is hypotonic, management is directed toward increasing contractility and minimizing blood loss.

Nursing interventions

PPH may be sudden and even exsanguinating. The nurse must therefore be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss (Fig. 23-1 and Box 23-3). Immediate assessments, nursing diagnoses, expected outcomes of care, and interventions are listed in the Nursing Process box: Postartum Hemorrhage.

BOX 23-3   Noninvasive Assessments of Cardiac Output in Postpartum Patients Who Are Bleeding

• Palpation of pulses (rate, quality, equality)

• Arterial

• Blood pressure

• Auscultation

• Heart sounds and murmurs

• Breath sounds

• Inspection

• Skin color, temperature, turgor

• Level of consciousness

• Capillary refill

• Neck veins

• Mucous membranes

• Observation

• Presence or absence of anxiety, apprehension, restlessness, disorientation

• Measurement

• Urinary output

• Pulse oximetry

Nursing Process

Postpartum Hemorrhage

Assessment

• Review the woman’s history for factors that cause a predisposition to postpartum hemorrhage (PPH) (see Box 23-1).

• Assess the fundus to determine whether it is firmly contracted at or near the level of the umbilicus.

• Assess bleeding for color and amount.

• Inspect the perineum for signs of lacerations or hematomas.

• Assess vital signs every 15 minutes during the first 2 hours after birth to identify trends related to blood loss (e.g., tachycardia, tachypnea, decreasing blood pressure). However, vital signs may not be reliable indicators of shock immediately postpartum because of the physiologic adaptations of this period.

• Assess for bladder distention because a distended bladder can displace the uterus and prevent contraction.

• Assess the skin for warmth and dryness; nail beds should be checked for color and promptness of capillary refill.

• Collect specimens or review reports of laboratory studies, specifically hemoglobin and hematocrit levels.

Nursing Diagnoses

Nursing diagnoses for women experiencing PPH include the following:

• Deficient fluid volume related to:

• Excessive blood loss secondary to uterine atony, lacerations, or uterine inversion

• Risk for imbalanced fluid volume related to:

• Blood and fluid volume replacement therapy

• Risk for infection related to:

• Excessive blood loss or exposed placental attachment site

• Multiple invasive procedures

• Risk for injury related to:

• Attempted manual removal of retained placenta

• Administration of blood products

• Operative procedures

• Fear or anxiety related to:

• Threat to self

• Deficient knowledge regarding procedures and operative management

• Risk for impaired parenting related to:

• Separation from infant secondary to treatment regimen

• Ineffective (peripheral) tissue perfusion related to:

• Excessive blood loss and shunting of blood to central circulation

Expected Outcomes of Care

Expected outcomes of care for the woman experiencing PPH may include that the woman will do the following:

• Maintain normal vital signs and laboratory values.

• Develop no complications related to excessive bleeding.

• Express an understanding of her condition, its management, and discharge instructions.

• Identify and use available support systems.

Plan of Care and Interventions

Immediate nursing care of the woman with PPH includes:

• Assessing vital signs, bleeding, and fundus

• Administering medication per protocol or orders

• Establishing or maintaining venous access

• Notifying the primary health care provider

• Providing explanations about interventions to woman and her family

(Care for specific problems that caused the bleeding as well as discharge instructions, are discussed in the text beginning on p. 726.)

Evaluation

The nurse can be reasonably assured that care was effective to the extent that the expected outcomes were achieved.

After the bleeding has been controlled the care of the woman with lacerations of the perineum is similar to that of women with episiotomies (analgesia as needed for pain and hot or cold applications as necessary). The need for increased roughage in the diet and increased intake of fluids is emphasized. Stool softeners may be used to assist the woman in reestablishing bowel habits without straining and putting stress on the suture lines.

Nursing Alert

To prevent injury to the suture line a woman with third- or fourth-degree lacerations is not given rectal suppositories or enemas or digital rectal examinations.

The care of the woman who has experienced an inversion of the uterus focuses on immediate stabilization of hemodynamic status. This situation requires close observation of her response to treatment to prevent shock or fluid overload. If the uterus has been repositioned manually, care must be taken to avoid aggressive fundal massage.

Discharge instructions for the woman who has had PPH are similar to those for any postpartum woman. In addition, the woman should be told that she will probably feel fatigue, even exhaustion, and will need to limit her physical activities to conserve her strength. She may need instructions in increasing her dietary iron and protein intake and iron supplementation to rebuild lost red blood cell (RBC) volume. She may need assistance with infant care and household activities until she has regained strength. Some women have problems with delayed or insufficient lactation and postpartum depression. Referrals for home care follow-up or to community resources such as support groups may be needed. (See Nursing Care Plan: Postpartum Hemorrhage.)

Nursing Care Plan

Postpartum Hemorrhage

Nursing Diagnosis Deficient fluid volume related to postpartum hemorrhage

Expected Outcome Woman will demonstrate fluid balance as evidenced by stable vital signs, prompt capillary refill time, and balanced intake and output.

Nursing Interventions/Rationales

• Monitor vital signs, oxygen saturation, urine specific gravity, and capillary refill to provide baseline data.

• Measure and record amount and type of bleeding by weighing and counting saturated pads. If woman is at home, teach her to count pads and save any clots or tissue. If woman is admitted to the hospital, save any clots and tissue for further examination to estimate the type and amount of blood loss for fluid replacement.

• Provide a quiet environment to promote rest and decrease metabolic demands.

• Give an explanation of all procedures to reduce anxiety.

• Begin intravenous access with an 18-gauge or larger needle for infusion of isotonic solution as ordered to provide fluid or blood replacement.

• Administer medications as ordered, such as oxytocin, methylergonovine, or prostaglandin F_2a, to increase contractility of the uterus.

• Insert an indwelling urinary catheter to provide most accurate assessment of renal function and hypovolemia.

• Prepare for surgical intervention as needed to stop the source of bleeding.

Nursing Diagnosis Ineffective tissue perfusion related to hypovolemia

Expected Outcome Woman will have stable vital signs, oxygen saturation, arterial blood gases, and adequate hematocrit and hemoglobin.

Nursing Interventions/Rationales

• Monitor vital signs, oxygen saturation, arterial blood gases, and hematocrit and hemoglobin to assess for hypovolemic shock and decreased tissue perfusion.

• Assess for any changes in level of consciousness to assess for evidence of hypoxia.

• Assess capillary refill, mucous membranes, and skin temperature to note indicators of vasoconstriction.

• Give supplementary oxygen as ordered to provide additional oxygenation to tissues.

• Suction as needed, insert oral airway, to maintain clear, open airway for oxygenation.

• Monitor arterial blood gases to provide information about acidosis or hypoxia.

• Administer sodium bicarbonate if ordered to reverse metabolic acidosis.

Nursing Diagnosis Anxiety related to sudden change in health status

Expected Outcome Woman will verbalize that anxious feelings are diminished.

Nursing Interventions/Rationales

• Using therapeutic communication, evaluate the woman’s understanding of events to provide clarification of any misconceptions.

• Provide calm, competent attitude and environment to aid in decreasing anxiety.

• Explain all procedures to decrease anxiety about the unknown.

• Allow the woman to verbalize feelings to permit clarification of information and promote trust.

• Continue to assess vital signs or other clinical indicators of hypovolemic shock to evaluate if the psychologic response of anxiety intensifies physiologic indicators.

Nursing Diagnosis Risk for infection related to blood loss and invasive procedures as a result of postpartum hemorrhage

Expected Outcomes Woman will verbalize understanding of risk factors. Woman will demonstrate no signs of infection.

Nursing Interventions/Rationales

• Maintain Standard Precautions, and use good handwashing technique when providing care to prevent the introduction or spread of infection.

• Teach the woman to maintain good handwashing technique (particularly before handling her newborn) and to maintain scrupulous perineal care with frequent change and careful disposal of perineal pads to prevent the spread of microorganisms.

• Monitor vital signs to detect signs of systemic infection.

• Monitor level of fatigue and lethargy, evidence of chills, loss of appetite, nausea and vomiting, and abdominal pain, which are indicative of extent of infection and serve as indicators of the status of infection.

• Monitor lochia for foul smell and profusion as indicators of the infection state.

• Assist with collection of intrauterine cultures or other specimens for laboratory analysis to identify the specific causative organism.

• Monitor laboratory values (i.e., white blood cell count, cultures) for indicators of the type and status of infection.

• Ensure adequate fluid and nutritional intake to fight infection.

• Administer and monitor broad-spectrum antibiotics if ordered to prevent infection.

• Administer antipyretics as ordered and necessary to reduce elevated temperature.

Vigorous treatment is necessary to prevent adverse sequelae. Medical management of hypovolemic shock involves restoring circulating blood volume and treating the cause of the hemorrhage (e.g., lacerations, uterine atony, or inversion). To restore circulating blood volume a rapid IV infusion of crystalloid solution is given at a rate of 3 ml infused for every 1 ml of estimated blood loss (e.g., 3000 ml infused for 1000 ml of blood loss). Packed RBCs are usually infused if the woman is still actively bleeding and no improvement in her condition is noted after the initial crystalloid infusion. Infusion of fresh-frozen plasma may be needed if clotting factors and platelet counts are below normal values (Cunningham et al., 2005; Francois & Foley, 2007).

Nursing Interventions

Hemorrhagic shock can occur rapidly, but the classic signs of shock may not appear until the postpartum woman has lost 30% to 40% of blood volume. The nurse must continue to reassess the woman’s condition, as evidenced by the degree of measurable and anticipated blood loss, and mobilize appropriate resources.

Most interventions are instituted to improve or monitor tissue perfusion. The nurse continues to monitor the woman’s pulse and blood pressure. If invasive hemodynamic monitoring is ordered, the nurse may assist with the placement of the central venous pressure (CVP) or pulmonary artery (Swan-Ganz) catheter and monitor CVP, pulmonary artery pressure, or pulmonary artery wedge pressure as ordered (Gilbert, 2007).

Additional assessments to be made include evaluating skin temperature, color, and turgor, as well as assessing the woman’s mucous membranes. Breath sounds should be auscultated before fluid volume replacement, if possible, to provide a baseline for future assessment. Inspection for oozing at the sites of incisions or injections and assessment of the presence of petechiae or ecchymosis in areas not associated with surgery or trauma are critical in the evaluation for DIC.

Oxygen is administered, preferably by nonrebreathing facemask, at 10 to 12 L/min to maintain oxygen saturation. Oxygen saturation should be monitored with a pulse oximeter, although measurements may not always be accurate in a woman with hypovolemia or decreased perfusion. Level of consciousness is assessed frequently and provides an additional indication of blood volume and oxygen saturation (Gilbert, 2007). In early stages of decreased blood flow the woman may report “seeing stars” or feeling dizzy or nauseated. She may become restless and orthopneic. As cerebral hypoxia increases, she may become confused and react slowly or not at all to stimuli. Some women complain of headaches (Curran, 2003). An improved sensorium is an indicator of improved perfusion.

Continuous electrocardiographic monitoring may be indicated for the woman who is hypotensive or tachycardic, continues to bleed profusely, or is in shock. A Foley catheter with a urometer is inserted to allow hourly assessment of urinary output. The most objective and least invasive assessment of adequate organ perfusion and oxygenation is urinary output of at least 30 ml/hr (Cunningham et al., 2005). Blood may be drawn and sent to the laboratory for studies that include hemoglobin and hematocrit levels, platelet count, and coagulation profile.