ANDRES BONIFACIO COLLEGE

COLLEGE PARK. DIPOLOG CITY

SCHOOL OF NURSING

POSTPARTUM
HEMORRHAGE
Submitted By:

Christy M. Alumbro

Sheila Jean Enguito Submitted To:

Jojie Keith F. Rosalem Mr. Art Bryan V. Arcinas

Clinical Instructor
DELIVERY ROOM
WARD CLASS
 Table of Contents

I. ABC Mission and Vision

II. Nursing Mission and Vision

III. Definition
IV. Signs & Symptoms
V. Etiology
VI. Diagnosis
VII. Treatment
VIII. Nursing Management
IX. Pathophysiology
X. Reference
 ANDRES BONIFACIO COLLEGE

Mision Vision
We commit to provide affordable quality A center of excellence
education with values in industry, in instruction ,
intelligence, integrity, and undertake research, technology,
relevant research and socially-responsive extension, athletics
community service using innovative and the arts.
technologies.
 School of Nursing

Mision Vision
The school of nursing shall generate competent, safe and Excellence in nursing education.
compassionate professional nurses
committed to:

a. Practice high standard of nursing care utilizing research

and evidence base practices that are culturally appropriate
and sensitive;

b. Be actively involved in local, national, global issues affecting

nursing, people’s health environment;

c. Ongoing holistic growth and development of the self and

others.
DEFINITION
Postpartum hemorrhage is heavy bleeding after the
birth of your baby. Losing lots of blood quickly can
cause a severe drop in your blood pressure. It may
lead to shock and death if not treated. The most
common cause of postpartum hemorrhage is when the
uterus does not contract enough after delivery. Blood
loss of ≥500 mL for vaginal delivery and ≥1000 mL
for cesarean delivery, after completion of the 3rd stage
of labor
2 Types of PPH:

 Early PPH - happen in the first 24 hours after the delivery

 Late - happen 24 hrs to 6 weeks recovery phase
SIGNS AND SYMPTOMS

 Uncontrolled bleeding
 Decreased blood pressure
 Increased heart rate
 Decrease in the red blood cell count
 Swelling and pain in the vagina and nearby area if
bleeding is from a hematoma 
ETIOLOGY
Early PPH is typically caused by at least one of
following: Tone, tissue, trauma, thrombin.

Tone (Uterine Atony

 Failure of contraction and retraction of myometrial muscle fibers after delivery.
 Most common cause of PPH.
 Causes of uterine atony include the following:
 Overly distended uterus: Multiparity, fetal macrosomia, polyhydramnios.
 Fatigued uterus: Amnionitis, prolonged labor or rapid forceful labor, use of tocolytics,
high parity.
 Obstructed uterus: Retained placenta or fetal parts, placenta accreta, overly distended
bladder, anatomic/functional distortion of uterus.
 Other causes include previous PPH or use of general anesthesia.
ETIOLOGY

Tissue (Retained Products of

Conception)
 Bleeding may occur from retained products, blood
clots, cotyledon or from an abnormal placenta.
ETIOLOGY

Trauma (Genital Tract Trauma)

 Genital tract damage may occur spontaneously or
through manipulations used to deliver the baby, eg.
Episiotomy.
 Lacerations may be present in the cervix, vagina or
perineum.
 Extensions or lacerations at cesarean section.
 Uterine rupture or uterine inversion.
ETIOLOGY

Thrombin (Coagulopathy)
 Can be caused by preexisting disorders (eg. hemophilia A, von
Willebrand’s Disease, factor XI deficiency).
 May be acquired during pregnancy [eg. idiopathic
thrombocytopenic purpura (ITP), thrombocytopenia with
preeclampsia, disseminated intravascular coagulopathy (DIC)] or
from therapeutic anticoagulation (eg. history of thromboembolic
disease).
LATE
PPH Late or secondary PPH occurs between 24 hours and 6
weeks postpartum and occurs in about 1% of women
postpartum. Bleeding most commonly occurs between 8
and 14 days after delivery.

Common causes include:

-Abnormal involution of the placental site,
-Retained placental tissue,
-Infection
-Inherited coagulation defects.
DIAGNOSIS

How is postpartum hemorrhage

diagnosed?
 Estimate of how much blood you have lost
 Assessment of uterine tone and size
 Measuring pulse and blood pressure.
 Red blood cell count.
 Clotting factors in the blood.
TREATMENT

The aim of treatment of postpartum hemorrhage is to find and stop the cause of the bleeding
as soon as possible. Treatment may include:

 External uterine massage and bimanual compression.

 Removing pieces of the placenta that remain in the uterus

 Uterine artery ligation.

TREATMENT
 Uterine hemostatic
compression suturing

 Laparotomy
TREATMENT

Hysterectomy
TREATMENT
There are numerous medications used to treat PPH. The following
uterotonic agents are used to help the uterus contract.

 Oxytocin
 Methergine
 Hemabate
 Cytotec
 Tranexamic acid (TXA)
TREATMENT

 Replacing lost blood and fluids is important in treating postpartum hemorrhage.

You may quickly be given IV (intravenous) fluids, blood, and blood products to
prevent shock. Oxygen may also help.

Postpartum hemorrhage can be quite serious. But when your provider quickly finds
and treats the cause of bleeding, you often will be able to recover fully.
NURSING MANAGEMENT
Initial management includes identifying PPH, determining the
cause, and implementing appropriate interventions based on
the etiology.

 Assess maternal vital signs

 Assess cause of trauma
 Assess the amount of bleeding
 Save all perineal pads used during bleeding and weigh them to
determine the amount of blood loss.
 Place the woman in a side lying position to make sure that no
blood is pooling underneath her.
NURSING MANAGEMENT

 Assess lochia frequently to determine if the amount

discharged is still within the normal limits.
 Massage of uterus / bimanual compression until the
procedure taken over by obstetrician
 Provide psychological care
Arrange the
words!
 UMPORTSTPA
EGEHROMAHR
Postpartum
hemorrhage
COAGULOPATHY
Coagulopathy
OLDOB SSINOUFNTRA
Blood Transfusion
ETEIRNU OYNTA
Uterine Atony
YXOOTNIC
Oxytocin
PATHOPHYSIOLOGY
NEXT SLIDE
 Pathophysiology Mechanism Signs and Symptoms Complications Diagnosis Intervention

Tissue Thrombus Tone Trauma

Delayed Multiple General

Placental Pre- Instrumental
Incomplete pregnancy, anestheti
spontaneous abruption eclampsia Prolonged deliveries risk
delivery of poly- c applied
expulsion of labor, or _ of trauma
placenta hydramnio to
placenta very rapid
Damage to Widespread s, mother Cephalo- Women with
labor
fetoplacenta endothelial macrosom during pelvic scarred
l tissue damage y labor disproportion uteruses (e.g.
Parts of the
: fetal head/ prior C-
placenta may be
shoulder section) _
retained inside the Excessive exposure of
wider than risk of
uterine cavity after tissue factor present in
birth canal trauma
delivery the placental vascular
bed Over- Smooth Uterine
distended muscle muscle Prolonge
Retained tissue Disseminate Pre- uterus relaxation over- d 2nd Ruptured
may be felt d existing weakens persisting worked Stage of uterus
inside the uterus intravascular maternal uterine after and Labor
or seen on U/S coagulation coagulopat muscles labor fatigue
hy: (Von
Depletion Birth canal or uterine
Willebrand
of trauma, bleeding directly
Retained tissue prevent Disease)
thrombin out via vagina
the uterine wall from Inadequate uterine muscle
fully contracting and Elevated INR, PTT, PT tone after delivery
sealing off maternal
blood vessels
Impaired maternal coagulation

• Fluid resuscitation and sometimes transfusion

Postpartum Hemorrhage (PPH) • Uterine massage
• Normal delivery: blood loss > 500 ml • Removal of retained placental tissues and repair of
• Cesarian delivery: blood loss > 1000 ml genital lacerations
Clinical
• Elevated, thready pulse • Uterotonics (eg, oxytocin,
evaluation
• Low blood pressure prostaglandins, methylergonovine)
• Hypovolemia • Sometimes surgical procedures
 SUMMARY
PPH - Blood loss >500 ml after delivery and >1000 ml after
c-section.
Diagnosis:
2 Types of PPH:  Pad saturated every 15 mins
Early PPH - happen in the first 24 hours after the delivery  Vital signs (BP and PR) [ ] RBC count
 Lab values Treatment:
Late - happen 24 hrs to 6 weeks recovery phase
 The main treatment of the PPH is to determine the cause of the bleeding as
soon as possible.
Signs and symptoms:  dministration of uterotonics (Oxytoxin, Methergine, Hemabate, Cytotec,
 A pad saturated every 15 mins
Tranexamic acid (TXA)) as ordered.
 Tachycardia  Blood transfusion and fluid replacement.
 Low BP
 Cool clammy skin
 Constant oozing of blood
 Low Hct
 Low Hgb Nursing Management:
 Monitor/Monitor VS
Etiology/Causes: Four Ts  Assess saturated pads
 Tone  Assess lochia
 Tissue  Firm massage
 Trauma  Elevate leg
 Thrombin
REFERENCES
• https://www.stanfordchildrens.org/en/topic/default?id=postpartum-hemorrhage

• https://
www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P
02486

• https://nurseslabs.com/postpartum-hemorrhage/

• https://
www.stanfordchildrens.org/en/topic/default?id=postpartum-hemorrhage-90-P02486

• https://www.webmd.com/parenting/what-is-a-postpartum-hemorrhage#2-5

• https://
www.msdmanuals.com/professional/gynecology-and-obstetrics/abnormalities-and-com
plications-of-labor-and-delivery/postpartum-haemorrhage

• http://
calgaryguide.ucalgary.ca/wp-content/uploads/2014/09/Post-Partum-Hemorrhage.jpg