POSTPARTAL HEMORRAGE o Trauma: lacerations cervix, vagina

or perineum, hematomas, uterine

inversion, uterine rupture
Postpartal period  If the uterine contracts
occur yet bleeding is
 first 6 weeks after birth present
 postpartum complications – are always o Tissue: retained placental
potentially serious; many people are fragments or clots
impacted o Thrombin: pre-existing or acquired
 a complication may be so serious it could coagulopathy (DIC)
cause a personal injury- fertility impaired,  The patient has blooding
death factor
 PPH – average blood loss – vaginal – 500ml;  Abruption placenta
cesarean – 1000 ml  Assessment
 Early or primary PPH – excessive blood loss o During immediate PP period, blood
within 24 hours loss should be monitored closely
 Late or Secondary PPH – after 24 – 6 weeks and continuously by assessing:
of blood loss  Check fundus – level of
 Early or Primary PPH- Causes: umbilicus
o Uterine atony – retention of  V/S – BP is low; PR is high
placenta – signs of bleeding
 Placenta must be  Vaginal bleeding
delivered after 30 mins  Hgb (12-16 gms/dl_
after birth of baby  Hct (38% - 46%)
 Uterine prolapse may  Hematocrit is 50%of our
happen when forced rbc
 Hysterectomy o Palpate the fundus
 Late or Secondary PPH – Causes:  Consistency
o Retained placental fragments  Size – we start measuring
o Subinvolution of the uterus – from umbilicus going
multiple gestation, overdistention down using finger
– slow involute/ slow and weak breadths – regressing one
contractions finger breadth per day, 2
o Infection fingerbreadths after two
days
Etiology
 Position – if it is on the
 The causes of PPH have been described as side, it might have been
the four Ts pushed by a distended
o Tone: uterine atony, distended bladder
bladder – level of umbilicus  RANGES OF HEMATOCRIT
(avocado) SLIDE
o Four to six hours- postpartal o Inspect the vagina and Perineal
woman must urinate otherwise the area
uterus relaxes – take note of time  Continuous oozing of
when the baby is delivered as basis blood
for the time of urination  Hematoma formation
 Use of forceps
 If the baby is
large
 o Monitor blood loss per vagina
 Weigh perineal pad
before and after use
weighing of packs and
sponges used to absorb
blood
 1g – 1 ml of blood
 Check under the hips
where blood tends to pool
o Monitor vital signs
o Monitor urine output
 Blood volume decreases,
so does the blood supply
to the kidney and the
amount of urine
formation
o Monitor tissue perfusion
 Pulse oximetry is udeful
for assessing O2
saturation
o Assess level of consciousness
 Alertness
 Low blood level, blood
supply in brain is low as
well
o Lab works
 PPH may be due to DIC,
placenta previa, missed
miscarraige
 CBC level
o Ultrasound
 To detect causes of
hemorrhage
 Nursing Diagnosis:
o Deficient – ambot paspas si miss
 Outcome identification
o BP – 100/60
 Related interventions:
o Place pt in Trendelenburg position
 Increases oxygenated
blood to the brain and
heart
o Keep pt warm by providing extra
blanket
 Cold increases demand for
oxygen – cell metabolism
increases when cold to
produce body heat
o Adm O2 as ordered
o Two IV lines are usually ordered
 For fluids and drugs given
thru IVTT
 For blood transfusion –
more than 2000 ml
o Monitor DIC due to shock
 Hypoperfusion of tissues
cause tissue damage and
stimulates release of
thromboplastins
manifested by:
 Spontaneous
bleeding at IV
puunture sites
 Low fibrogen
Uterine atony
 Less than 3hrs – precipitate labor
 Failure of uterus to contract after delivery
 Most commons cause of PPH
o Risk factors/ causes:
o 1 overdistention – hydramnios,
mavrosomia
o Complicatino of labor
o Uterine relaxing agents
o Oxytocin given during labor
o High parity and advanced maternal
age
o Infection
o Over massage of the uterus – when
uterus is relaxed we should
massage but when overdone, it
causes uterine atony
o Retained placental fragments
o Medical conditions
 Anemia
o Prolonged third stage of labor –
delivery of placenta
o Varied placental site or attachment
 Management:
o Priorities in managing PPH
 Call for help
 Make rapid assessment of
woman’s condition
 Find the cause of bleeding
 Stop the bleeding – send
to OR
  Stabilize or resuscitate the
woman – blood
transfusion - oxytocin
 Prevent further bleeding –
continuous monitoring
o 1st action to take when a relaxed
uterus is palpated is to massage
the uterine fundus
 Prevents uterine inversion
o Keep the bladder empty
o Administer uterotonics to
stimulate uterine contractions
 Oxytocin (1st drug of
choice)
 10 unit IM after
delivery of
placenta
 1L IV fluid
 Add 10 – 40 units
– not to exceed
40 units
 Methylergonovine
maleate (Methergine) – 6-
7 mins to take effect; 45
seconds when IV;
repeated every 2-4 hrs up
to 5 doses
 Carboprost tromethamine
(Hemabate) –
Prostaglandin F2a
derivative ; given if
oxytocin is ineffective ;
given IM
 Misoprostol (cytotec) –
administered rectally
 Administer 02 mask at 10
– 12 mins
 Trendelenburg
o External bimanual compression
o Internal bimanual compression
o Uterine packing – removed after 24
– 36 hours (gauze rolled into balls –
cherry balls); monitor for possible
infection_ fver four vaginal odor
o Blood transfusion
o Laparotomy – making incision on
abdomen to remove large blood
clots
o Hysterectomy (last resort)
LACERATIONS
 Bright red bleeding from vagina
 Usually found on the sides of the cervix,
near the branches of the uterine artery –
blood may gusg from vaginal opening,
brighter red than the IV transfused blood ?
 Therapeutic management
o Suturing of cervical laceration
usually rewuires sutures and can
be difficult because, if the bleeding
is intense, this obstructs
visualization of the area
o Vaginal packing
o Try to maintain an air of calm and,
if possible, stand beside the
woman at the head of the table
o Pen – cutterie? – attach ground
pad to prevent burns
o Give regional anesthetic to relax
uterine muscle to prevent pain
o Explain the need for anesthetic
o Be certain the primary care
provider has adequate space to
work, adequate sponges
VAGINAL LACERATIONS
Easier to locate and assess than cervical
lacerations because they are easier to view
 Therapeutic management
o Suturing
o A balloon tamponade similar to the
type used
o Vaginal pack – maintains pressure
on suture line
o An indwelling catheter may be
placed following the repair –
packing causes pressure on the
urethra that can interfere with
voiding
o Be certain to document the
woman’s electronic record when
and where packing was placed
PERINEAL LACERATIONS
 More apt to occur when a woman is placed endometrium), or an accompanying
in a lithotomy position for birth rather than a supine problem
position  Therapeutic management
o Methylergonovine – 0.2mg four
times daily – improves uterine tone
 Classification and complete involution
o First degree – vaginal mucous o Blood loss from subinvolution
membrane and skin of the results in anemia and lack of
perineum to the fouchette (no energy that can interfere with
need for suturing) infant bonding
o 2nd degree – vagina, perinela skin,
RETAINED PLACENTAL FRAGMENTS
fascis, levator ani muscle, and
perineal body  KAPOOOOY NAAAAA, PASPAS PA GYUD,
o 3rd degree – entire perineuem, AWA NALANG SA SLIDE 48
extending to reach the external
Methotrexate – destroys fragments if not
sphincter of rectum
removed
o 4th degree – entire perineum,
ectending to reach the internal
sphincter of rectum and anal
sphincter
 Management:
o Suturing of 3rd and 4th degree
laceration, bledding lesions of > 2
cm
o After suturing,
o Assess for bladder distention
o Constipaion should be avoided
o Ice compress first 24 hours –tissue
laceration; warm compress after
24 hours

HEMATOMAS

Collection of blood in the subcutaneous

layer of thhe perineum

 Management
o AMBOT PASPASS SI MISS

DISSEMINATED INTRAVASCULAR COAGULATION

SUBINVOLUTION

 The incomplete return of the uterus to its

pre- pregnant size and shape
 Lochial discharge usually is still present – 3
to 4 days normal
 Subinvolution may result from a small
retained placental fragment, a mild
endometritis (infection of the