POSTPARTUM HEMORRHAGE

• 2020 National Health Goals Related to a Family Experiencing a Postpartum Complication

  • Reduce the maternal mortality rate to no more than 11.4 per 100,000 live births from a baseline of 12.7 per 100,000
  • Increase the proportion of infants who are breastfed to at least 81.9% from a baseline of 74%.
  • Increase the proportion of infants who are breastfed at 6 months from a baseline of 43.5% to 60.6%.
• Postpartum hemorrhage


  Blood loss of 500 ml or more following a vaginal birth, or blood loss of 1,000 ml or more or 10% decrease in hematocrit level after cesarean birth
• Early postpartum hemorrhage


  Occurring within the first 24 hours after delivery
• Late postpartum hemorrhage


  Occurring between 24 hours and 6 weeks after delivery
• Postpartum hemorrhage occurs in 5% to 8% of postpartal women
• The greatest danger of postpartum hemorrhage is in the first 24 hours
• The "4 T's" - causes of postpartum hemorrhage

  • Tone - uterine atony
  • Trauma
  • Tissue - retained placental fragments
  • Thrombin
• Uterine atony


  
  

  A cause of postpartum hemorrhage

  Deficient fluid volume r/t excessive blood loss after birth
• Management of postpartum hemorrhage


  1. Control hemorrhage (fundal massage)

  2. Pitocin (oxytocin)

  3. Hemabate (carboprost tromethamine)

  4. Methergine (methylergonovine maleate)

  5. Cytotec (misoprostol)

  6. Monitor blood pressure

  7. Elevate lower extremities

  8. Offer a bedpan every 4 hours

  9. Provide oxygen

  10. Obtain vital signs
• Therapeutic management of perineal lacerations


  1. Protect suture site from stress or infection

  2. Push fluids, high fiber diet, stool softeners

  3. No enema/rectal suppository
• Immediate nursing actions for postpartum hemorrhage: perform fundal massage, notify healthcare provider if fundus does not become firm, count pads to estimate blood loss, assess and record vital signs, increase IV fluids, administer oxytocin infusion as prescribed
• Puerperal infection


  Infection occurring in the postpartum period
• Assessment of puerperal infection


  1. Temperature above 100.4°F or 38°C orally for two consecutive 24-hour periods

  2. Unusual odor and color of lochia

  3. Fundal pain on palpation on days 3 to 4 (endometritis)

  4. Abdominal rigidity and pain, abdominal guarding (peritonitis)

  5. Visual inspection of perineal suture lines for inflammation or drainage (perineal infection)
• Management of puerperal infection

  1. Cesarean section

  2. Antibiotics
• Clindamycin


  Broad-spectrum antibiotic used to treat postpartum endometritis
• Ampicillin-sulbactam


  Broad-spectrum antibiotic used to treat postpartum endometritis
• Gentamicin sulfate


  Aminoglycoside antibiotic used for serious puerperal infections
• Cephalexin


  Broad-spectrum antibiotic used to treat lactational mastitis
• Endometritis


  Endometrial lining infection
• Endometritis


  • Usually associated with chorioamnionitis & C/section
• Onset of fever on 3rd or 4th day postpartial, ↑ WBC, chills, loss of appetite, malaise, uterus not well contracted & painful, strong afterpains, foul smelling dark brown lochia
• Management of endometritis


  1. C/S

  2. Antibiotics: Cleocin (clindamycin)

  3. Oxytocic agent: methylergonovine

  4. Analgesics

  5. Increase PO fluids

  6. Good handwashing
• Thrombophlebitis


  • Femoral thrombophlebitis
  • Pelvic thrombophlebitis
  • Pulmonary embolus
• Initial treatment of deep-vein thrombosis


  1. Heparin IV (Monitor aPTT) X 3-5 days

  2. Warfarin X 3 months (Monitor PT & INR)
• Antidote for Heparin is Protamine Sulfate
• Antidote for Warfarin is Phytonadione
• Femoral thrombophlebitis


  • Check legs for mottling, "drained appearance", localized redness and warmth, and leg swelling below a hard and inflamed vessel
  • Check for Homans sign
  • Compare calf and/or thigh diameters of both legs
• Pelvic thrombophlebitis


  • Check for high fever and chills, abdominal pain, and malaise
• Pulmonary embolus


  • Check for sharp, sudden chest pain; tachypnea; tachycardia; orthopnea and cyanosis
  • High risk for cardiopulmonary arrest
• Pulmonary embolus patients are transferred to ICU
• Preventing thrombophlebitis


  • Ask for side-lying or back-lying position for birth rather than lithotomy
  • Ask for padding on stirrups if using lithotomy
  • Drink adequate fluids to avoid dehydration
  • Do not sit with knees crossed or wear constricting clothing
  • Ambulate as soon as possible after birth
  • Ask for support stockings in immediate postpartal period
  • Quit smoking
• Low-molecular weight heparin


  • Heparin is a common anticoagulant
  • Blocks conversion of prothrombin to thrombin and of fibrinogen to fibrin, decreasing clotting ability and inhibiting thrombus and clot formation
• Pregnancy Risk Category for low-molecular weight heparin is B
• Mastitis


  Organism enters via cracked/fissured nipples
• Mastitis


  • Unilateral, painful, appears swollen & reddened
  • Fever
  • Scant breast milk
• Management of mastitis


  1. Antibiotics: Dicloxacillin, cephalosporin, cephalexin

  2. Keep breast feeding

  3. Cold/ice compresses, good support bra
• Mastitis can sometimes be confused with a blocked milk sinus, which is treated by nursing closer to the lump and by rotating the baby on the breast
• Breastfeeding is not contraindicated for women with mastitis unless pus is in the breast milk or the antibiotic of choice is harmful to the infant
• Primary bladder overdistention


  • Time to first voiding (>8 hours)
  • Fundus check for tone and position related to midline
• Examples of Nursing Diagnoses for a Family Experiencing a Postpartum Complication


  • Deficient fluid volume related to blood loss
  • Ineffective breastfeeding related to development of mastitis
  • Decreased uterine tone related to bladder distention
  • Knowledge deficit of symptoms of retained placental fragments and subinvolution of the uterus for which to monitor related to manual removal of the placenta