• This is any blood loss from the uterus greater than 500 mL. It may be classified as early postpartum hemorrhage when it occurs on the remaining days of the 6-week puerperium period.
• Common causes include the following:
1. Uterine Atony - term used to describe a lax uterus and the most common cause of postpartum hemorrhage.
Risk factors include the following:
- Conditions, which distend the uterus to beyond its capacity such as conditions of multiple gestations, hydramnios, macrosomia, or LGA babies, and presence of fibroid tumors.
- Conditions that could have caused cervical or uterine tears such as operative delivery.
- Pregnancy with placental anomalies such as abruptio placenta, placenta previa, and placenta accreta.
- Conditions that exhausts the uterus such as deep anesthesia and analgesia, high parity, endometritis, etc.
Assessment:
- Positive gush of blood from the placental site.
- Positive signs and symptoms of hypovolemic shock.
- Estimate blood loss from “saturated perineal pads”. More accurate method is weigh the pads (1 gram = 1 mL).
- Uterus is not well contracted upon palpation.
- Check for lochia and vital signs if within normal range.
Management:
- First step is to massage the uterus to promote involution to stop the bleeding. If the uterus is unable to remain contracted, administer Methergine as ordered. A diluted IV infusion of Oxytocin can also be ordered. Both medications help maintain the uterine tone.
- Administer an intravenous Oxytocin agent. Pitocin is the most common with a usual dose of 10-40 units per 1000Ml of Dextrose solution. Oxytocin action is not continuous therefore, an oral Methergine 0.2 mg is also given as ordered. Both medications have a hypertensive side effect therefore, woman’s blood pressure must first be checked before administration of the medications. It is contraindicated in women with a blood pressure reading of 140/90.
- Prepare for blood transfusion as ordered and observe all precautions.
- Bimanual massage.
- Prostaglandin administration as ordered because prostaglandin promotes strong and sustained uterine contractions. Observe for side effects such as nausea, diarrhea, tachycardia, hypertension, etc and take necessary actions.
- Hysterectomy is indicated for an extremely atonic uterus.
- Nursing interventions include the following:
- - gentle massage
- - close observation for the next 4 hours
- - encourage voiding to avoid displacement of uterus leaving it in a more uncontracted state
- - monitor for signs and symptoms of shock and act accordingly.
2. Lacerations – when the uterus is firm upon palpation postpartally, but bleeding still occurs, lacerations may be suspected. Immediately arrange for the attending physician or midwife to repair lacerations.
3. Retained Placental Fragments – bleeding may persist when the placenta is not completely delivered.
Assessment:
- If the retained fragment is large, bleeding may be apparent on immediate postpartum.
- Upon palpation, uterus is not firm and contracted.
- There can still be high HCG results secondary to retained placental fragments.
Management:
- Remove retained fragments.
- Dilation and curettage may be indicated.
- In cases of placenta accreta, methotrexate may be given as ordered.
- Instruct woman regarding the characteristics of normal lochia discharges and ask her to report certain deviations from normal immediately.
4. Disseminated intravascular coagulation.
5. Other less common causes of postpartal hemorrhage are:
- Sub-involution
- Perineal hematomas
- Postpartal anterior pituitary gland necrosis (Sheedan syndrome)