Republic of the Philippines

ISABELA STATE UNIVERSITY

Ilagan City, Isabela
HANDOUT in NUR 221
2nd sem. SY 2021- 2022
“Walang Nanay ang mamamatay sa pagbibigay Buhay”
POST PARTAL HEMORRHAGE
 Postpartum hemorrhage is a major cause of maternal death and morbidity in the United States
and the world (Berg, Callaghan, Syverson, et al., 2010).
 Blood loss is frequently underestimated, especially when bleeding is brisk or hemorrhage is
concealed. Estimates are frequently only about half the actual loss (Cunningham, Leveno,
Bloom, et al., 2010).
 Current definitions include blood loss of more than 500 mL after vaginal birth or 1000 mL after
cesarean birth, a decrease in hematocrit level of 10% or more since admission or the need for
a blood transfusion (Cunningham, et al., 2010) and continued bleeding even with the “usual
treatment” (Belfort & Dildy, 2011)

Hemorrhage in the first 24 hours after childbirth is called early postpartum hemorrhage. 

Hemorrhage after 24 hours or up to 6 to 12 weeks after birth, is called late postpartum hemorrhage. 

A. Early Postpartum Hemorrhage

 Early postpartum hemorrhage usually occurs during the first hour after delivery and is most often
caused by uterine atony (Cunningham et al., 2010). 
 The two major causes of early post-partum hemorrhage are uterine atony and trauma to the
birth canal during labor and delivery, hematomas (localized collections of blood in a space or
tissue), retention of placental fragments, and abnormalities of coagulation are other causes.
UTERINE ATONY
o Atony refers to lack of muscle tone that results in failure of the uterine muscle fibers to
contract firmly around blood vessels when the placenta separates.
o With uterine atony, the relaxed muscles allow rapid bleeding from the endometrial
arteries at the placental site. Bleeding continues until the uterine muscle fibers contract
to stop the flow of blood

. 
FIG 28-1 A, When the uterus remains contracted, the placental site is smaller, so
bleeding is minimal. B, If uterine muscles fail to contract around the endometrial arteries
at the placental site, hemorrhage occurs.

 Predisposing Factors
COMMON PREDISPOSING FACTORS FOR POSTPARTUM HEMORRHAGE
• Overdistention of the uterus (multiple gestation, large infant, hydramnios)
• Multiparity (five or more)
• Precipitate labor or delivery
• Prolonged labor
• Use of forceps or vacuum extractor
• Cesarean birth
Jonalyn Cielito Uy- Francisco, MSN
Subject Instructor
 • Manual removal of the placenta
• Uterine inversion
• Placenta previa, placenta accreta, or low implantation
• Drugs: oxytocin, prostaglandins, tocolytics, or magnesium sulfate
• General anesthesia
• Chorioamnionitis
• Clotting disorders
• Previous postpartum hemorrhage or uterine surgery
• Disseminated intravascular coagulation
• Uterine leiomyomas (fibroids)
 Signs and Symptoms
Major signs of uterine atony include:
• A uterine fundus that is difficult to locate
• A soft or “boggy” feel when the fundus is located
• A uterus that becomes firm as it is massaged but loses its tone when massage is stopped
• A fundus that is located above the expected level
• Excessive lochia, especially if it is bright red
• Excessive clots expelled
 Therapeutic Management
o If the uterus is not firmly contracted, the first intervention is to massage the fundus until
it is firm and to express clots that may have accumulated in the uterus. One hand is
placed just above the symphysis pubis to support the lower uterine segment while the
other hand gently but firmly massages the fundus in a circular motion. Figure 28-
2 illustrates fundal massage.

FIG 28-2 Technique for fundal massage.

o If the uterus does not remain contracted as a result of uterine massage, or if the fundus
is displaced, the problem may be a distended bladder. A full bladder lifts the uterus,
moving it up and to the side, preventing effective contraction of the uterine muscles.
Assist the mother to urinate, or catheterize her to correct uterine atony caused by
bladder distention. Note urine output then reassess the uterus.
o Pharmacologic measures also may be necessary to maintain firm contraction of the
uterus. A rapid intravenous (IV) infusion of dilute oxytocin (Pitocin) often
increases uterine tone and controls bleeding
o Methylergonovine (Methergine) may be given intramuscularly (IM), but it elevates blood
pressure and should not be given to a woman who is hypertensive. The usual route of
administration is IM; IV use is reserved for life-threatening emergencies only
o Analogs of prostaglandin F2-alpha (PGF2α; carboprost tromethamine [Hemabate;
Prostin/15M]) are very effective when given IM or into the uterine muscle if oxytocin is
ineffective in controlling uterine atony (Kim, Hayashi, & Gambone, 2010
o Prostaglandin E2  (dinoprostone [Prostin E2]) or misoprostol (Cytotec) given rectally may
also be used to control bleeding.
o If uterine massage and pharmacologic measures are ineffective in stopping uterine
bleeding, the physician or nurse-midwife may use bimanual compression of the uterus.
In this procedure, one hand is inserted into the vagina, and the other compresses the
uterus through the abdominal wall (Figure 28-3). A balloon may be inserted into the
uterus to apply pressure against the uterine surface to stop bleeding (Belfort & Dildy,
2011; Thorp, 2009). Uterine packing may also be used. It may be necessary to return the
woman to the delivery area for exploration of the uterine cavity and removal of placental
fragments that interfere with uterine contraction.
Jonalyn Cielito Uy- Francisco, MSN
Subject Instructor
 FIG 28-3 Bimanual compression. One hand is inserted in the vagina, and the other compresses
the uterus through the abdominal wall.

o A laparotomy may be necessary to identify the source of the bleeding. Uterine

compression sutures may be placed to stop severe bleeding. Ligation of the uterine or
hypogastric artery or embolization (occlusion) of pelvic arteries may be required if other
measures are not effective. Hysterectomy is a last resort to save the life of a woman with
uncontrollable postpartum hemorrhage.
o Hemorrhage requires prompt replacement of intravascular fluid volume. Lactated
Ringer’s solution, whole blood, packed red blood cells, normal saline, or other plasma
extenders are used. Enough fluid should be given to maintain a urine flow of at least 30
mL/hour and preferably 60 mL/hour (Cunningham et al., 2010). Typically, the nurse is
responsible for obtaining properly typed and cross-matched blood and inserting large-
bore IV lines that are capable of carrying whole blood.
o
TRAUMA
o Trauma to the birth canal is the second most common cause of early postpartum
hemorrhage. Trauma includes vaginal, cervical, or perineal lacerations as well as
hematomas.
 Predisposing Factors
o Many of the same factors that increase the risk of uterine atony increase the risk of soft
tissue trauma during childbirth. For example, trauma to the birth canal is more likely to
occur if the infant is large or if labor and delivery occur rapidly. Induction and
augmentation of labor and use of assistive devices, such as a vacuum extractor, increase
the risk of tissue trauma.
 Lacerations
o The perineum, vagina, cervix, and the area around the urethral meatus are the most
common sites for lacerations. Small cervical lacerations occur frequently and generally
do not require repairs. Lacerations of the vagina, perineum, and periurethral area usually
occur during the second stage of labor, when the fetal head descends rapidly or when
assistive devices such as a vacuum extractor or forceps are used to assist in delivery of
the fetal head.
o Lacerations of the birth canal should always be suspected if excessive uterine bleeding
continues when the fundus is contracted firmly and is at the expected location. Bleeding
from lacerations of the genital tract often is bright red, in contrast to the darker red color
of lochia. Bleeding may be heavy or may appear to be minor with a steady trickle (dribble
or oozing) of blood that continues.
 Hematomas
o Hematomas occur when bleeding into loose connective tissue occurs while overlying
tissue remains intact. Hematomas develop as a result of blood vessel injury in
spontaneous deliveries and deliveries in which vacuum extractors or forceps are used.
Hematomas may be found in vulvar, vaginal, and retroperitoneal areas.
o The rapid bleeding into soft tissue may cause a visible vulvar hematoma, a discolored
bulging mass that is sensitive to touch. Hematomas in the vagina or retroperitoneal areas
cannot be seen. Hematomas produce deep, severe, unrelieved pain and feelings of
pressure that are not relieved by usual pain-relief measures. Formation of a hematoma
should be suspected if the mother demonstrates systemic signs of concealed blood loss,
such as tachycardia or decreasing blood pressure, when the fundus is firm and lochia is
within normal limits.
 Therapeutic Management
Jonalyn Cielito Uy- Francisco, MSN
Subject Instructor
 o When postpartum hemorrhage is caused by trauma of the birth canal, surgical repair is
often necessary. Visualizing lacerations of the vagina or cervix is difficult, and it is
necessary to return the mother to the delivery area, where surgical lights are available.
She is placed in a lithotomy position and carefully draped. Surgical asepsis is required
while the laceration is being visualized and repaired.
o Small hematomas usually reabsorb naturally. Large hematomas may require incision,
evacuation of the clots, and location of the bleeding vessel so that it can be ligated.

B. Late Postpartum Hemorrhage

 The most common causes of late postpartum hemorrhage are subinvolution  (delayed return of
the uterus to its nonpregnant size and consistency) and fragments of placenta that remain
attached to the myometrium when the placenta is delivered.
 Late postpartum hemorrhage, also called secondary postpartum hemorrhage, is defined as
hemorrhage occurring between 24 hours and 6 weeks after birth (Ambrose & Repke, 2011).
 It frequently happens after discharge from the facility and can be dangerous for the unsuspecting
mother. (Women must be taught how to assess the fundus and normal characteristics and
duration of lochia flow. They should be instructed to notify their health care provider if bleeding
persists or becomes unusually heavy.)
RETAINED PLACENTAL FRAGMENT
 Predisposing Factors
 to deliver the placenta before it separates from the uterine wall
 manual removal of the placenta
 placenta accrete
 previous cesarean birth
 uterine leiomyomas
 Therapeutic Management
 Initial treatment for late postpartum hemorrhage is directed toward control of the
excessive bleeding.
 Oxytocin, methylergonovine, and prostaglandins are the most commonly used
pharmacologic measures.
 Placental fragments may be dislodged and swept out of the uterus by the bleeding, and if
the bleeding subsides when oxytocin is administered, no other treatment is necessary.
 Sonography can identify placental fragments that remain in the uterus.
 If bleeding continues or recurs, dilation and curettage, stretching of the cervical os to
permit suctioning or scraping of the walls of the uterus, may be necessary to remove
fragments.
 Broad-spectrum antibiotics may be given if postpartum infection is suspected because of
uterine tenderness, foul-smelling lochia, or fever.
HYPOVOLEMIC SHOCK
o During and after giving birth, the woman can tolerate blood loss that approaches the
volume of blood added during pregnancy (approximately 1500 to 2000 mL).
o A woman who was anemic before birth has less reserve than a mother with normal
blood values. The amount of blood lost can be estimated by comparing the hematocrit
before labor and delivery with one measured after delivery. If the hematocrit is lower
after delivery, the woman lost the amount of blood added during pregnancy and an
additional 500 mL for each 3% drop in the hematocrit value (Cunningham et al., 2010).
o When blood loss is excessive, hypovolemic shock (acute peripheral circulatory failure
resulting from loss of circulating blood volume) can ensue.
o Hypovolemia, abnormally decreased volume of circulating fluid in the body, endangers
vital organs by depriving them of oxygen. The brain, heart, and kidneys are especially
vulnerable to hypoxia and may suffer damage in a brief period.
 Pathophysiology
 Recognition of hypovolemic shock may be delayed because the body activates compensatory
mechanisms that mask the severity of the problem. Carotid and aortic baroreceptors are
stimulated to constrict peripheral blood vessels. This shunts blood to the central circulation and
away from less essential organs, such as the skin and extremities. The skin becomes pale and
cold, but cardiac output and perfusion of vital organs are maintained.
 In addition, the adrenal glands release catecholamines, which compensate for decreased blood
volume by promoting vasoconstriction in nonessential organs, increasing the heart rate, and
Jonalyn Cielito Uy- Francisco, MSN
Subject Instructor
 raising the blood pressure. As a result, blood pressure remains normal initially, although a
decrease in pulse pressure (difference between systolic and diastolic blood pressures) may be
noted. The tachycardia that develops is an early sign of compensation for excessive blood loss.
 As shock worsens, the compensatory mechanisms fail, and physiologic insults spiral. Inadequate
organ perfusion and decreased cellular oxygen for metabolism result in a buildup of lactic acid
and the development of metabolic acidosis. Decreased serum pH (acidosis) results in
vasodilation, which further increases bleeding. Eventually, circulating volume becomes
insufficient to perfuse cardiac and brain tissue. Cellular death occurs as a result of anoxia, and the
mother dies.
 Manifestations
 Early signs of blood loss such as mild tachycardia or hypotension may not appear until 20% to
25% of the woman’s blood volume has been lost (Martin & Foley, 2009).
 Tachycardia is one of the earliest signs of hypovolemic shock, and even gradual increases in the
pulse rate should be noted.
 A decrease in blood pressure and narrowing of pulse pressure occur when the circulating
volume of blood is sufficiently decreased.
 The respiratory rate increases as the woman becomes more anxious and attempts to take in
more oxygen to overcome the need that is created when hemoglobin is inadequate to transport
oxygen adequately.
 Skin changes also provide early clues. Vasoconstriction in the skin causes it to become pale and
cool to the touch. As hemorrhage worsens, the skin changes become more obvious as pallor
increases and the skin becomes cold and clammy.
 As shock progresses, changes also occur in the central nervous system. The mother becomes
anxious, then confused, and finally lethargic as blood loss increases. Urine output also
decreases and eventually stops.
 Therapeutic Management
 The goals of therapy are to control bleeding and prevent hypovolemic shock from becoming
irreversible.
 A second IV line should be inserted with a large-bore (14- to 18-gauge) catheter capable of
carrying whole blood. Central IV catheters may be placed. Sufficient fluid volume is infused to
produce a urinary output of at least 30 mL/hour.
 Vasopressors may be needed for low blood pressure. The health care team makes every effort to
locate the source of bleeding and to stop the loss of blood.
 Interventions may include uterine packing;
 ligation of the uterine, ovarian, or hypogastric artery; or hysterectomy.
 Nursing Considerations
 Immediate Care
 Evaluate and record vital signs.
 Blood pressure and pulse should be assessed every 3 to 5 minutes.
 The location and consistency of the fundus, amount of lochia, skin temperature and color, and
capillary return also are assessed.
 Oxygen may be administered by tight face mask at 8 to 10 L/min to increase the saturation of
fewer red blood cells.
 Oxygen saturation levels are carefully monitored.
 Nurses often follow facility protocols that allow them to draw blood for hemoglobin, hematocrit,
clotting studies, and type and cross match.
 Nurses are responsible for administering fluids, whole blood, and medications as directed and for
reporting their effectiveness.
 A urinary catheter is inserted to measure hourly urinary output, which should be at least 30
mL/hour.
 The catheter is also necessary if a surgical procedure to control the hemorrhage is required.
 In addition, nurses must make every effort to provide information and emotional support to the
woman and her family.

  SAFETY ALERT
 Signs of Postpartum Hemorrhage
• A uterus that does not contract, or does not remain contracted
• Large gush or slow, steady trickle, ooze, or dribble of blood from the vagina
• Saturation of one peripad per 15 minutes
• Severe, unrelieved perineal or rectal pain
Jonalyn Cielito Uy- Francisco, MSN
Subject Instructor
 • Tachycardia

TABLE 28-1
NURSING ASSESSMENTS FOR POSTPARTUM HEMORRHAGE

ASSESSMENTS ABNORMAL SIGNS AND SYMPTOMS NURSING IMPLICATIONS

Chart review Presence of predisposing factors Perform more frequent evaluations.

Fundus Soft, boggy, displaced Massage, express clots, and assist to void or catheterize; notify
primary health care provider if measures are ineffective.

Lochia Bleeding (steady trickle, dribble, oozing, Assess for trauma; save and weigh pads, linen savers, and bed linens
seeping, or profuse flow); heavy: saturation of so estimation of blood loss will be more accurate. Notify health care
1 pad/hr; excessive: 1 pad/15 min provider.

Vital signs Tachycardia, decreasing pulse pressure, falling Report signs of excessive blood loss.
blood pressure, decreasing oxygen saturation
level

Urine output Decreased urine output Report decrease in output.

  Should be at least 30 mL/hr  

Comfort level Severe pelvic or rectal pain Assess for signs of hematoma, usually perineal or vaginal; examine
vulva for masses or discoloration; report findings.

Skin Cool, damp, pale Look for signs of hypovolemia; vigilant assessment and management
by entire health care team is necessary.

Jonalyn Cielito Uy- Francisco, MSN

Subject Instructor