13.1 Hemorrhage

Question 1

Post-Partum Hemorrhage

Answer 1

• Cumulative blood loss greater than 1000 mL
• Dark red blood is likely from venous origin (varices or superficial laceration)
• Bright Blood is arterial (deep laceration of cervix)

Question 2

Risk factors of Uterine Atony

Answer 2

• Uterine atony is hypotonia of the uterus
• Great risk is during first hour of birth
• Overdistended uterus
• Large fetus
• Multiple fetuses
• Hydramnios
• Distension with clots

Question 3

Retained Placenta

Answer 3

• Placenta not expelled after 30 minutes of birth

Placenta Accreta - Slight penetration of myometrium
Placenta Increta - Deep penetration of myometrium
Placenta Percreta - Perforation of myometrium and uterine serosa (possibly involving adjacent organs)

TREATMENT
- Blood component replacement therapy or hysterectomy (remove the uterus)

Question 4

Lacerations

Answer 4

• Bleeding continues even if uterus is firm
• Perineum lacerations are the most common injury of the lower genital tract
• Prolonged pressure of fetal head on vaginal mucosa cause ischemia (pressure necrosis)
• This can cause vaginal hematomas

Question 5

Hematoma

Answer 5

• Retroperitoneal hematomas are life threatening
• Pain and pressure is most common symptoms
• Surgically removed (provide pain relief and monitor bleeding)

Question 6

Uterine Inversion

Answer 6

EMERGENCY

• Maternal fluid resuscitation
• Tocolytics or halogenated anesthetics
• Oxytocin after uterus is repositioned
• Broad spectrum antibiotics

Question 7

Subinvolution Uterus

Answer 7

• Delay in return of enlarged uterus to prepregnant size
• CAUSED BY RETAINED PLACENTAL FRAGMENTS AND PELVIC INFECTION

SIGNS
- Prolonged lochia discharge, irregular/excessive bleeding, hemorrhage, large boggy uterus

TREATMENT

• Ergonovine, Methylergonovine
• Dilation and Curettage (D&C)

Question 8

MANAGEMENT OF HEMORRHAGE

Answer 8

• Readiness (hemorrhage cart, immediate access to medications, response team, unit based education drills)
• Recognition and Prevention (assess risk and measure blood loss)
• Response (Emergency management team)
• Reporting and Systems Learning (Huddling and post event debriefs)

Question 9

Medical Management of Hemorrhage

Answer 9

• Fundal massage
• Express clots
• Eliminate bladder distension
• IV Oxytocin
• Oxygen
• Indwelling catheter

Question 10

OUTCOMES OF HEMORRHAGE

Answer 10

• Stable VS (HR and BP)
• Measure Amount of Blood loss
• Oxytocin, misoprostol, methylarginine, prostaglandins

INTERVENTIONS

• Monitor VS for hypovolemic shock
• Assess capillary refill and skin temperature (to check for vasoconstriction)
• Oxygen via Non-rebreather (provide additional oxygenation)

Question 11

Assessment of Hemorrhagic Shock

Answer 11

RR - Rapid and Shallow
Pulse - Weak and Rapid (Irregular) 
BP - Decrease (late sign) 
Skin - Cool, Pale, Clammy
Urinary Output - Minimal
LOC - Lethargy/Coma
Mental Status - Anxiety/Coma
Central Venous Pressure - Decreased