POSTPARTAL HEMORRAHGE

 Hemorrhage, one of the most important causes of maternal mortality associated

with childbearing, poses a possible threat throughout pregnancy and is also a
major potential danger in the immediate postpartal period
 Traditionally, postpartal hemorrhage has been defined as any blood loss from the
uterus greater than 500 mL within a 24-hour period
 In specific agencies, the loss may not be considered hemorrhage until it reaches 1000
mL
 Hemorrhage may occur either early (within the first 24 hours) or late (anytime
after the first 24 hours during the remaining days of the 6-week puerperium).
 The greatest danger of hemorrhage is in the first 24 hours because of the grossly
denuded and unprotected uterine area left after detachment of the placenta
 There are five main causes for postpartal hemorrhage: uterine atony, lacerations,
retained placental fragments, uterine inversion, and disseminated intravascular
coagulation

UTERINE ATONY
 Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartal
hemorrhage
 The uterus must remain in a contracted state after birth to keep the open vessels
at the placental site from bleeding
 Be especially cautious in your observations and be on guard for signs of uterine
bleeding. This is especially important because many postpartal women are
discharged within 48 hours after birth

Therapeutic Management:
 Uterine massage to encourage contraction
 Uterine massage may not completely resolve uterine atony:
o Stay with the mother even after massaging
o Check if uterus will relax again
o Check for the fundic height, and lochia
 Oxytocin Infusion- drug of choice
o Other drugs: Carboprost tromethamine (Hemabate), a
prostaglandin F2a derivative, or methylergonovine maleate
(Methergine), an ergot compound, given intramuscularly
 empty the bladder- A full bladder pushes an uncontracted uterus into an even
more uncontracted state.
o Empty every 4 hours
o IFC can be inserted
 Continous blood loss- position women on supine position
o O2 admistartion
o Monitor for signs of hypovolemic shock: initial- increase RR, PR, cold
clammy skin, pale color; late- decrese RR, PR, thready pulse, Decrease
BP, changes in LOC
 Bimanual Massage- if there are retained placental fragments, the physician or
nurse-midwife inserts one hand into a woman’s vagina while pushing against the
fundus through the abdominal wall with the other hand:
o Uterine packing may be inserted during this procedure to help halt
bleeding
o Use anesthesia since it is painful
o If uterine packing is used, be certain this is documented in a woman’s
chart so it can be removed before agency discharge. Retained packing
serves as a growth medium for microorganism invasion that could lead to
a postpartal infection
 Prostaglandin Administration- Intramuscular injection of prostaglandin F22 is
another way to initiate uterine contractions. Observe for nausea, diarrhea,
tachycardia, and hypertension, all of which are possible adverse effects of
prostaglandin administration
 Blood Replacement
 Hysterectomy or Suturing- sutures or balloon compression may be used to halt
bleeding
 Embolization of pelvic and uterine vessels by angiographic techniques may be
successful
 Hysterectomy
CERVICAL LACERATIONS
 Lacerations of the cervix are usually found on the sides of the cervix, near the
branches of the uterine artery.
 If the artery is torn, the blood loss may be so great that blood gushes from the
vaginal opening
 occurs immediately after delivery of the placenta

Therapeutic Management
 Repair of a cervical laceration is difficult, because the bleeding can be so intense
that it obstructs visualization of the area
 Suturing
 Stay with the mother and explain properly
  If the cervical laceration appears to be extensive or difficult to repair, it may be
necessary for the woman to be given a regional anesthetic to relax the uterine
muscle and to prevent pain

VAGINAL LACERATIONS
Therapeutic Management
 Suturing
 Some oozing often occurs after a repair, so the vagina may be packed to
maintain pressure on the suture line
 IFC maybe inserted
 If packing is inserted, document in a woman’s nursing care plan when and
where it was placed, so you can be certain it will be removed after 24 to 48
hours or before discharge
 Prolonged packing may cause infection


PERINEAL LACERATIONS
Lacerations of the perineum usually occur when a woman is placed in a lithotomy
position for birth, because this position increases tension on the perineum.
Classification Description of Involvement :
 First degree Vaginal mucous membrane and skin of the perineum to the
fourchette
 Second degree Vagina, perineal skin, fascia, levator ani muscle, and perineal
body
 Third degree Entire perineum, extending to reach the external sphincter of the
rectum
 Fourth degree Entire perineum, rectal sphincter, and some of the mucous
membrane of the rectum.


Therapeutic Management
 Perineal lacerations are sutured and treated as an episiotomy repair.
 Document the degree of lacerations
 Diet high in fluid and a stool softener
 Enema or rectal sppositiry is not recommended for 3rd-4th degree lacaeration
because the hard tips of equipment could open sutures near to or including
those of the rectal sphincters

 RETAINED PLACENTAL FRAGMENTS
 Occasionally, a placenta does not deliver in its entirety; fragments of it separate
and are left behind
 Retained palcenta fragments causes the uterus not to contact effectively
 To detect the complication of retained placenta, every placenta should be
inspected carefully after birth to see that it is complete
 Can be deterdect tru UTZ
 If retained are large enough bleeding may be immidate after delivery
 If the retained are small bleeding may not be detected until postpartum day 6 to
10

Therapeutic Management
 D&C
 Balloon occlusion and embolization of the internal iliac arteries may minimize
blood loss.
 Methotrexate may be prescribed to destroy the retained placental tissue
 be certain a woman knows to continue to observe the color of lochia discharge
and to report any tendency for the discharge to change from lochia serosa or
alba back to rubra

SUBINVOLUTION
 Subinvolution is incomplete return of the uterus to its prepregnant size and shape.
 With subinvolution, at a 4- or 6- week postpartal visit, the uterus is still enlarged
and soft
 result from a small retained placental fragment, a mild endometritis (infection of
the endometrium), or an accompanying problem such as a uterine myoma that is
interfering with complete contraction
Therapeutic Management
 Oral administration of methylergonovine
 Oral antibiotic for endometritis
 Instruction of discharges