Class 8: Postpartum Hemorrhage Flashcards
what estimated blood loss (EBL) from a vaginal delivery indicates PPH
- EBL >500 mL
what EBL from a c-section indicates PPH
- EBL >1000mL
PPH is classified with respect to?
- respect to time of birth
what is considered early/primary/acute bleeding?
- within 24 h of delivery = most dangerous time for potential PPH
what is considered late/secondary PPH?
- between 24h and 6 weeks postpartum
due to the timing of late/secondary PPH, what is important?
- education since the pt will be at home
late/secondary PPH is usually due to
- subinvolution
what is considered PPH
- ANY blood loss that has the potential to cause hemodynamic instability
what is the leading cause of death globally
- PPH
PPH is an…
- obstetrical emergency
how preventable is PPH?
- highly preventable
describe the identification of PPH
- can go unrecognizable for awhile d/t compensatory mechanisms–> until there are serious symptoms
addressing PPH is facilitated by…
- an interprofessional team approach
what are the 4 main causes of PPH?
- Tone
- Tissue
- Trauma
- Thrombin
what is included under the Tone cause of PPH
- uterine atony
what is included under the Tissue cause of PPH (4)
- retained placental fragments
- placenta accrete/increta/percreta
- placental abruption
- placenta previa
what is included under the trauma cause of PPH (7)
- uterine inversion
- uterine rupture
- lacerations of birth canal
- hematoma
- episiotomy
- trauma during labor & birth (forceps & vacuum assisted birth)
- manual removal of retained placenta
what increases the risk of uterine rupture
- c-section
- VBAC
what is included under the thrombin cause of PPH
- coagulopathies
what can be done to prevent PPH (7)
- be prepared –> know risk factors and communicate them to the team
- active mngmt of 3rd stage of labor
- uterine massage (correct process)
- uterotonics as ordered
- careful inspection of placenta (ensure no pieces missing)
- prevent a full bladder
- close observation of birther
what is included in active mngmt of 3rd stage of labor to help prevent PPH (4)
- admin oxytocin w birth of anterior shoulder
- gentle cord traction (do not be too aggressive)
- consider delayed cord clamping (to allow newborn to get as much blood as possible)
- fundal massage after delivery
birth of the placenta that lasts ____ increases the risk of placenta
> 30 min
fundal massage is done until? why is it important to only do it until then?
- fundus firm, no more than that
- to prevent uterus from becoming too tired
what is uterine atony
- defined as hypotonia or relaxation of the uterus
what is the leading cause of early PPH
- uterine atony
what are risk factors for uterine atony (9)
- uterus overstretched or overdistended
- high parity (>=4)
- over tired uterus
- birth trauma
- mg sulfate admin during labor or PP
- halogenated anaesthetic
- chorioamnionitis
- subinvolution
- history of PPH
how can an “overstretched” or overdistended uterus increase the risk of PPH
- causes muscle layer not to be as effective
how can mg sulphate admin increase risk of PPH
- relaxes muscle layer
what can cause an overstretched or overdistended uterus? (4)
- fetal macrosomia
- multiple gestation
- polyhydramnios
- distention w clots
what can cause an overtired uterus? (2)
- prolonged labor
- includes induction/augmentation w oxytocin
what can cause birth trauma? (2)
- vacuum
- forceps-assisted delivery
what is included in mngmt of uterine atony (9)
- astute assessments –> estimation of blood loss
- frequent VS
- uterine/fundal massage
- empty the bladder
- large bore IV access
- admin of uterotonic meds
- bloodwork
- admin of blood components as ordered
- may require more extensive procedures
what is the first line mngmt for PPH r/t uterine atony
- uterine/fundal massage
what are esp important to assess r/t VS? why?
- HR and RR
- will increase before BP due to compensatory mechanisms
why is it imp to have an empty bladder r/t PPH and uterine atony?
- a full bladder pushes an uncontracted uterus into an even more contracted state
what may be done to empty the bladder
- an indwelling urinary cath may be inserted
what is included in bloodwork for mngmt of uterine atony (4)
- CBC (hgb, plts)
- blood type & antibody screen
- coagulation studies
- other
what are more extensive procedures for uterine atony?
- bimanual compression
- surgical procedures
what is bimanual compression of the uterus
- involves physician using 2 hands to compress uterus
what is imp with the interventions for uterine atony
- ongoing monitoring of effectiveness of each intervention
what could happen if uterine massage is done too aggressively
can cause:
- overtired uterus
- invert/prolapses uterus
what are examples of uterotonic drugs (4)
- oxytocin
-misoprostol - carboprost
- ergometrine (ergonovine)
what is the 1st line uterotonic drug
- oxytocin
what is the onset and duration of oxytocin? what implication does this have?
- rapid onset
- short duration
- keep close eye on IV bag so doesn’t run out
misoprostol can be given via what routes?
- oral
- rectal
describe the effectiveness of misoprostol
- debate about effectiveness
what side effect can misoprostol have
- can increase temperature
what side effect can carboprost have? what implication does this have?
- causes signif diarrhea
- also give an anti-diarrheal
what is a contraindication to carboprost
- asthma –> can cause bronchospasm
what side effect can ergometrine have? what implication does this have?
- can increase BP
- do not give if HTN
describe the difference in oxytocin dosing during L&D vs PP
- dosing difference bc not worried abt gas exchange to fetus
what is retained placenta
- part or all of the placenta remains in the uterus which prevents the uterus from contracting fully
succenturiate lobe
A specific lobe on the maternal side of the placenta which is more likely to be retained
what may be signs of retained placenta? (5)
- prolonged lochia
- pain
- fever
- foul odor
- signs occur later
what is placenta accreta/increta/perceta
- abnormal adherence
what is included in mngmt for retained placenta (5)
- frequent VS
- astute assess
- could require manual removal of placenta by obstetrical care provider
- lab studies as ordered
- admin of blood components as ordered
what is included in nursing care for manual removal of placenta (4)
- requires effective pain control
- IV access w large bore IV
- frequent VS
- ensure correct sponge and needle counts
what may be required in the case of acreta/increta/percreta
- hysterectomy
where is the placenta located w placenta previa?
- placenta covers opening of cervix
how might placenta previa affect PPH?
- implants lower = muscle layer not there to contract/less effective
what is inversion of the uterus
- uterus turns inside out after birth
what is the risk of uterus inversion
- potentially life-threatening
what are 3 types of inversion of the uterus
- incomplete
- complete
- prolapsed
what is incomplete uterus inversion
- cannot see but felt
- feel smooth mass that can be palpated thru slightly dilated cervix
what is complete uterus inversion
- lining of fundus protrudes thru cervical os
what is prolapsed uterus inversion
- thrus introitus
- see large, red, round mass
what are causes of inversion of the uterus (8)
- fundal implantation of the placenta
- vigorous fundal pressure
- excessive traction applied to the cord
- fetal macrosomia
- tocolysis
- prolonged labor
- uterine atony
- abnormally adherent placental tissue
what is included in mngmt of inversion of the uterus? (4)
- emergency situation, call for help!
- large bore IV
- fluid resus as ordered
- uterus must be replaced into pelvic cavity by HCP
what should be avoided in mngmt of inversion of uterus
- aggressive fundal massage
what meds may be given in mngmt of inversion of uterus (2)? what impact do these have?
- tocolytics
- halogenated anesthetics
- may be given to relax the uterus before attempting to replace
what is given after the uterus is replaced into the pelvic cavity in mngmt for inversion of uterus
- oxytocin
lacerations should be suspected when…
- bleeding continues despite a well-contracted (firm) uterus
lacerations to the ___ are most common
- perineum
__ and __ degree extensions to episiotomies possible
- 3rd and 4th
bleeding from lacerations are often described as…
- a slow trickle or oozing
- a constant flow
lacerations occur more often w (4)
- difficult or precipitous births
- fetal size
- abnormal presentation and position
- operative assisted vaginal birth
what is included in nursing mngmt for lacerations (5)
- IV as needed
- pain mngmt
- ensure correct sponge & needle count
- provide explanation and education
- lab studies as needed
if packing is inserted during mngmt of lacerations, what is required? (3)
- clearly document time inserted
- how much used
- where
define: hematoma
- collection of blood in the connective tissue
hematomas can be… which are most common
- vulvar (most common)
- vaginal
- retroperitoneal
what can cause vaginal hematoma?
- forceps assisted birth
what can cause retroperitoneal hematoma
- c-section
what can retroperitoneal hematoma feel like
- pressure, like about to give birth again
hematomas may require… (2)
- surgical evacuation
- lab test as ordered
describe the uterus, bleeding, and characteristics of bleeding with uterine atony
- uterus: boggy
- bleeding: intermittent
- characteristics: clots and dark blood
describe the uterus, bleeding, and characteristics of bleeding with trauma
- uterus: firm
- bleeding: continuous
- characteristics: bright red blood (arterial)
when should we suspect coagulopathies as the cause of PPH?
- if bleeding continues and no identifable source
what are 3 diff types of coagulopathies
- idiopathic thrombocytopenia purpura (ITP)
- von willebrand disease
- DIC
what is ITP
- autoimmune disorder in which antiplt antibodies decrease the lifespan on the plts
what impact does ITP have on bleeding time
- increases it
medical mngmt of ITP focuses on..
- control of plt stability
Idiopathic thrombocytopenia purpura may require what meds?
- corticosteroids
- IV IgG
what is von willebrand disease
- factor VIII deficiency and plt dysfunction which leads to prolonged bleeding time
von willebrand disease is a type of?? the most common ____?
- type of hemophilia
- most common hereditary bleeding disorder
individuals w von willebrand disease are at an increased risk for PPH up to ___ weeks PP
- up to 4 weeks PP
what med is included in mngmt of von willebrand disease
DDAVP
describe use of DDAVP for von willebrand disease
- given 30 min prior to delivery = promotes release of von willebrand & factor 8
what is SIC
- imbalance between the body’s clotting and fibrinolytic systems
- acquired disorder of blood clotting in which the fibrinogen lvl falls to below effective limits
describe clotting in a health pt
- plts seal over a point of bleeding to prevent further blood loss
- fibrin strengthens this “plug”
describe clotting in a pt w DIC
- at one point in their body, there is increased coagulation ( at the site of the initial insult/bleed)
- in the remainder of the body, a bleeding deficit exists = no plts or fibrin left
what are signs of DIC (6)
- spontaneous bleeding from gums, nose, IV, IM, or subcut site
- peteachiae around where BP was placed
- tachycardia
- hypotension
- diaphoresis
- bloodwork changes
what labwork changes are seen w DIC (3)
- decreased plts
- decreased fibrinogen
- decreased prothrombin
what are risk factors for DIC (7)
- acute APH
- acute PPH
- placental abruption
- amniotic fluid embolism
- fetal demise that remains in utero for extended periods
- severe preeclampsia
- sepsis
mngmt of DIC requires… (2)
- correction of the underlying cause
- must be distinguished from other clotting disorders before therapy initiated
what is included in mngmt of DIC (7)
- assessment
- fluid replacement as ordered
- blood component replacement as ordered
- optimize oxygenation & perfusion
- lab studies as ordered
- consider foley
- provide explanation & emotional support
what should foley w urometer placement be considered w DIC
- DIC can cause renal failure
what should urine output be w DIC?
- at least 30mL/hr
what is tranexamic acid
- an antifibrinolytic drug that is given concomitantly w other drugs and procedures for control of bleeding with bleeding disorders
what is included in assessment for PPH (5)
circulatory status:
- palpation of pulses
- inspection
- auscultation
- observation
- measurement
what is included in inspection of PPH (7)
- skin color
- temp
- turgor
- LOC
- cap refill
- mucos membranes
- any oozing sites
- petechiae/ecchymosis
what is included in auscultation of PPH (2)
- heart sounds/murmurs
- breath sounds
what is included in observation for PPH (4)
- anxiety
- apprehension
- restlessness
- disorientation
what is included in measurement for PPH
- pulse oximetry
- BP, HR
- urinary output
what is essential w PPH
- early recognition and intervention
how can we be prepared for PPH
- be aware of risk factors
what is imp to do w PPH
- call for help
what is hemorrhagic shock
- perfusion of organs severely compromised d/t bleeding
what are signs of hemorrhagic shock (7)
- rapid & shallow resps
- rapid, irregular, weak pulse
- decreased BP (late sign)
- pale, cool, clammy skin
- decreased urine output
- increased anxiety & disorientation
- lethargy
the classic signs of shock may not appear until the PP woman has lost ____% of their blood volume
- 30-40%
what is included in mngmt for hemorrhagic shock (5)
- large bore IV, maybe 2
- fluid resus
- blood component admin
- lab studies as ordered
- urinary output –> indwelling cath
what should be monitored closely w hemorrhagic shock (3)
- VS
- breath sounds
- LOC
a massive transfusion is an…
- an emergency situation where there is an expected transfusion of 4 or more RBC within 1 hr and on-going, substantial need is expected
