NUR1213

Nursing Care of the Signs of Pospartal Hemorrhage

Postpartum Client
OUTLINE • Excessive or bright red bleeding
I. Postpartum Hemorrhage • A boggy fundus that does not respond to
II. Uterine Atony massage
III. Lacerations • Abnormal clots
IV. Hematoma • Any unusual pelvic discomfort or backache
V. Uterine Inversion • Persistent bleeding in the presence of a
VI. Retained Placental Fragments in the firmly contracted uterus
Uterus • Rise in the level of the fundus of the uterus
VII. Uterine Subinvolution • Increased pulse or decreased BP
VIII. Disseminated Intravascular • Hematoma formation or bulging/ shiny skin
Coagulation in the perineal area
IX. Puerperal Infection • Decreased level of consciousness
X. Urinary Tract Infection
XI. Postpartal Psychiatric Disorder

Postpartum complications may be serious it could

cause personal injury, leave a. woman with her
future fertility impaired, or even death.

I. Postpartum Hemorrhage

Hemorrhage is a major threat during pregnancy,

and one of the primary cause of maternal mortality.

Primary Post-Partum Hemorrhage

• Blood loss from birth canal of 500 ml or

more Predisposing factors
• Early: within the first 24 hours following
birth • Overdistention of the uterus
- Multiparity
• Greatest danger because of the grossly
- Large babies
denuded and unprotected uterine are left
- Polyhydramnios
after detachment of placenta.
- Multiple pregnancies
- Presence of uterine Myomas (fibroid
Secondary Post-Partum Hemorrhage
tumors)
• Cesarean Section
• Abnormal bleeding after 24 hours to six
weeks after birth. • Prolonged and Difficult labor
• Placental accidents (previa or abruptio)
Conditions that Increase a women’s risk for a
postpartal hemorrhage Four main reasons for postpartum hemorrhage

1. Conditions that distend the uterus beyond 1. Tone: Atonic uterus

average capacity 2. Trauma: Lacerations, hematomas, inversion,
2. Conditions that could have caused cervical or rupture
uterine lacerations 3. Tissue: Retained tissue, Invasive placenta
3. Conditions that leave the uterus unable to 4. Thrombin: Coagulopathies
contract readily
4. Conditions that lead to inadequate blood Consequences of PPH
coagulation
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• Circulatory collapse leading to shock and The uterus, although empty, fails to contract and
death control bleeding from the placental site.
• Puerperal anemia and morbidity
• Damage to the pituitary blood supply also The commonest and potentially most dangerous
known as Sheehan’s syndrome. A cause of post-partum hemorrhage.
hypopituitarism caused by ischemic
necrosis due to blood loss and hypovolemic
shock.
• Fear of further pregnancies

Nursing Management!
• Assist with appropriate treatment
• Prevent excessive blood loss and resulting
complications
• Provide physical and emotional support Predisposing Causes of Uterine Atony
• Provide client and family education
• Excessive uterine distention
Primary Post-Partum Hemorrhage Nursing • Exhaustion of the uterine musculature
Interventions! • Multiparity
• Prolonged labor
1. Identify client at risk for condition
• Labor augmented with Syntocinon
2. Monitor fundus frequently if bleeding occurs;
• General anesthesia
when stable, every 15 minutes for 1-2 hours, than
at appropriate intervals. • Placenta previa
3. Monitor maternal vital signs for indication of • Abruptio placenta – the ‘Couvelaire’ uterus
shock may not be contract
4. Administer medications, IV fluids as ordered5.
5. Measure I&O Situation resulting in drug related relaxation of
6. Remain with client for support and explanations uterine musculature
of procedure
7. Keep client warm a. The use of MgSO4 for preeclampsia
8. Prepare for clients return to delivery room if b. The use of general anesthesia for caesarean
needed for repair of laceration or removal of delivery
placental fragment
9. Monitor for signs of DIC Signs and Symptoms of uterine atony

To be certain, do not rely solely on a woman’s • Signs of shock -  blood pressure,  pulse,
report of perineal healing or amount of lochia.  anxiety and irritability.
Always inspect her perineum yourself. • Bleeding
• Noncontracted, boggy uterine fundus
The patient has no knowledge of “normal” lochia
or fundal height against which to accurately Medical Treatment
compare her own condition.
a. Intravenous fluids
An increased temperature during the first 24 hours b. Oxytocin administration
after birth is an extremely serious finding. Report c. methergine/prostin
greater than 38.0 C. d. Blood transfusion
e. Hysterectomy
Primary Post-Partum Hemorrhage
Nursing Interventions
II. Uterine Atony
a. Palpate the fundus
b. Massage the fundus
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c. Monitor patient’s vital distention
e. Bimanual compression Causes

Bimanual uterine compression – an intervention • Rapid descent of the fetus

performed by a skilled birth attendant, where one • Pushing prior to complete cervical
hand is placed in the vagina and pushed against the effacement and dilatation
body of the uterus. • Large fetus
• Forceps application
III. Lacerations • Uncontrolled, forceful extension of the fetal
head
1. Cervical Lacerations: usually found on the Signs and symptoms
sides of the cervix
• Obvious body injury
2. Vaginal Lacerations: occurs in the vagina and • Bright red bleeding
easier to assess the cervical lacerations, because • Signs of shock-rapid, thready pulse, falling
this position increases tension on the perineum. blood pressure, increasing anxiety of the
patient.
3. Perineal Lacerations: usually occur when a
woman is placed in a lithotomy position for birth, Medical treatment
because this position increases tension on the
perineum.
• Suturing of the laceration
• Vaginal packing
Degrees of perineal lacerations
• Blood transfusion if the patient’s
A. First degree: tear of vaginal mucous membranes hematocrit is low and the patient is
and skin of the perineum to the fourchette. symptomatic.

B. Second degree: tear of the vagina, perineal skin, Nursing Intervention

fascia, levator ani muscle, and perineal body.
• Observe for vaginal bleeding
C. Third degree: tear of the perineum, and reaches • Monitor Vital signs
the external sphincter of the rectum. • Flag the patient’s chart for vaginal packing
in place
D. Fourth degree: tear of the entire perineum, rectal
sphincter, and some of the mucous membrane of IV. Hematoma
the rectum.
Vulvar hematoma – is localized collection of blood
in the connective tissue beneath the skin covering
the external genitalia or vaginal mucosa.

Causes

a. Rapid, Spontaneous delivery

b. Perineal varicosities
c. Episiotomy repairs
d. Laceration of perineal tissues

Signs and Symptoms

• Pain
• Mass
• Swelling
• Inability to void
• Fullness or pressure
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• Check the uterine fundus tone frequently
Medical Treatment • Check the nature and amount of lochia flow
• Keep accurate count of perineal pads
• Analgesics • Monitor patient’s vital signs
• Opening • Observe for signs of shock
• Ligated • Turn the patient on her side to prevent
• Packing pooling blood under her
• Apply ice • Provide emotional support to the patient
• Observe and family
• Flag
VII. Uterine Subinvolution
V. Uterine Inversion
Uterine subinvolution – is a slowing of the process
• Fundus is forced through the cervix so that of involution or shrinking of the uterus; delayed
the uterus is turned inside out. return of the enlarged uterus to normal size and
• Insertion of placenta at the fundus, so that function.
as fetus is rapidly delivered, fundus is
pulled down. Causes
• Strong fundal push, attempts to deliver the
placenta before signs of separation. • Endometritis
• Retained placental fragments
Secondary Post-Partum Hemorrhage • Pelvic infection
• Uterine fibroids
VI. Retained Placental Fragments in the
Uterus Signs and Symptoms

These fragments are the major cause of late • Prolonged lochia flow
postpartum hemorrhage. • Profuse vaginal bleeding
• Large, flabby uterus
Signs and Symptoms
Medical Treatment
• Large amount of bright red bleeding or
persistent trickle type bleeding. a. Administration of oxytocic medication to
• Uterus may be boggy due to its inability to improve uterine muscle tone:
contract properly.
• Signs of shock - Methergine
• Sudden rise in uterine fundal height - Pitocin
indicating the formation of clots inside the - Ergotrate
uterine cavity.
b. Dilation and Curettage
Medical Treatment
c. Antimicrobial
a. Manual removal of the remaining placenta is
done by the physician, if it is a result of incomplete Nursing Intervention
separations of the placenta with increased vaginal
bleeding. • Prevent excessive blood loss, infection,
b. Attempted removal by sharp curettage other complications
c. Intravenous fluids are administered
d. Oxytocic drugs are given immediately after a. Massage uterus
either procedure b. Monitor vital signs
c. Administer medications
Nursing Interventions d. Prepare for possible D & C
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VIII. Disseminated Intravascular
Coagulation Signs of wounds infection

Is a deficiency in clotting ability caused by vascular • Edema, warmth, redness, tenderness,

injury. It may occur in any woman in the postpartal and pain
period, but it is usually associated with premature • Edges of the wound may full apart, and
separation of the placenta, a missed early seropurulent drainage may be present.
miscarriage, or fetal death. • Fever and malaise

IX. Puerperal Infection Therapeutic Management

• Refers to bacterial infections after - Incision and drainage of the affected area
childbirth - Broad spectrum antibiotics
• Occurs in 3% of all women in vaginal birth - Analgesics
• Occurs in 15% to 20% of all woman who - Warm compression or sitz baths
had cesarean births
• It is one of the leading causes of maternal Signs and Symptoms
deaths
• Pain
Most common postpartum infections • Fever
• Localized tenderness and or swelling and
1. Metritis redness
2. Mastitis
3. Wound infections Medical Treatment
4. Urinary tract infections
5. Septic pelvic thrombophlebitis - Antibiotic therapy
6. Peritonitis - Anticoagulant therapy-heparin
- Blood transfusion as needed
TORCH = infections that can be devastating to the
fetus or newborn Nursing Management

Toxoplasmosis - Heparin – Monitor Prothrombin time –

Other infections
Rubella
Cytomegalovirus
Herpes
Means to Prevent the spread of Puerperal infection
in hospitals.
• Restrict personnel with respiratory
infections from working with patients
• Use caps, mask, gowns, and gloves when
working in delivery rooms
• Use sterilized equipment within control
dates
• Wash hands meticulously (staff)
• Correct breaks in sterile techniques
immediately
• Instruct the patient on hand washing and
cleansing her perineum from front to back
• Limit unnecessary organisms from the
rectum and vagina into the uterus.
Protamine sulfate
- Coumadin – Monitor Prothrombin –
Vitamin K
X. Urinary Tract Infection
Symptoms typically begin on the 1st or 2nd
postpartum day.
Dysuria, urgency, and frequency of urination, low-
grade fever
Upper urinary tract infection such as pyelonephritis
may develop on the 3rd or 4th day with chills,
spiking fever, costovertebral angle tenderness,
flank pain, and nausea and vomiting.
XI. Post Partal Psychiatric Disorder
Any woman who is extremely stressed or who
gives birth to an infant who in any way does not
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meet her expectations such as being the wrong sex,
being physically or cognitively challenged, or
being ill may have difficulty bonding with her
infant.
- Bizarre behavior, disorganization of
thought, hallucinations, delusions
- Occurs usually in first 2 weeks

Postpartal Psychosis/Physiologic Maladaptation

• A major psychiatric complication in three

of a thousand pregnant women
• 15% occurs during the prenatal period
• 85% occurs during postpartal
• Appears usually appears the third day after
delivery.

Most common conditions are typically identified

as:

• Maternity blues, postpartum blues, baby

blues, or 3rd, 4th or 10th day blues
• Postpartum or postnatal depression
• Postpartum or puerperal psychosis
• Postpartum panic disorder
• Postpartum obsessive-compulsive disorder

Signs and Symptoms

• Withdrawal
• Depression
• Hostility
• Suspicion
• Denial of existence of infant
• Mood swings

Postpartum Depression

• Begins within 4 weeks after delivery

• Almost every woman notices some
immediate (1 to 10 days postpartum)
feelings of sadness (post partal blues) after
childbirth

A. Baby blues

- Common, transient mood disturbance

- Sadness, weeping, irritability, anxiety, and
confusion
- Occurs in 40-80% of postpartum women

B. Postpartum psychosis

- Psychiatric emergency due to risk of

infanticide or suicide