Postpartum Hemorrhage Flashcards
List the risk factors for PPH (10)
- hx of PPH
- uterine overdistension
- prolonged/dysfunctional labor
- grand multiparity: 5+ pregnancies
- low platelets: preeclampsia/thrombocytopenia
- medications that relax smooth muscle
- obesity
- asian or latin heritage (unclear reasons)
- birth procedures
- pre-existing anemia
PPH can occur without any risk factors!
How is hx of PPH a risk factor for PPH?
it doubles risk
what must be done if a postpartum pt has a hx of PPH?
alert the blood bank and ensure cross-matched blood availability
How is uterine overdistension a risk factor for PPH? (3)
- Multiple gestation (Twins or higher order multiples)
- Macrosomia (Baby >9 lbs)
- Polyhydramnios (Excessive amniotic fluid)
How is prolonged/dysfunctional labor a risk factor for PPH? (2)
- uterine muscle exhaustion
- lactic acid buildup
How is grand multi-parity a risk factor for PPH?
uterus may struggle to maintain tone
How is preeclampsia a risk factor for PPH?
- low platelets (HELLP syndrome)
- tx with uterine relaxants (ex: mag sulfate, nifedipine)
What medications that relax smooth muscle can increase risk for PPH? (3)
- anesthesia
- magnesium sulfate
- nifedipine
How is obesity a risk factor for PPH? (2)
- hormonal changes reduce oxytocin response
- higher likelihood of macrosomia
What birth procedures increase risk for PPH? (3)
- Induction or augmentation with oxytocin (especially prolonged use)
- Operative vaginal deliveries (forceps, vacuum)
- Cesarean section
what is the first intervention for PPH?
fundal massage
Blood clots in the uterus prevent ________ and mask ____ ______
prevent contractions and mask blood loss
Extra _____ ______ in pregnancy can delay detection of PPH
blood volume
What can be misleading?
slow trickling blood loss
What is a bias in maternity care that can put women at risk for PPH?
Young, healthy women may not be seen as “at risk”
What is true about vital signs and PPH?
Vital signs may remain stable until blood loss exceeds 1,000–1,500 mL
Pre-existing anemia increases danger in PPH. What lab values represent this?
Hgb <11
Hct <33%
List ways we can prevent complications from PPH (7)
- identify high risk pts early
- frequent postpartum assessments
- avoid invasive birth procedures if possible
- active management of 3rd stage of labor
- administer oxytocin immediately after delivery
- skin-to-skin contact
- early intervention
What should be done when high risk pts are identified early? (2)
- notify blood bank
- alert all caregivers
how often should postpartum assessments be done after birth?
every 15 mins in the first 1-2 hrs
What does active management of 3rd stage of labor entail? (2)
- Administer oxytocin before placenta delivery
- Gentle traction on placenta to promote detachment
Rapid placenta delivery prevents what?
excessive blood flow
When administering oxytocin immediately after delivery, what happens if there is no IV access?
give 10 units IM
why should oxytocin be given immediately after delivery?
it floods oxytocin receptors to contract uterus effectively
How does skin-to-skin contact prevent complications of PPH?
it stimulates endogenous oxytocin
what is critical if a postpartum woman is having excessive bleeding?
early intervention
What is the number one cause of all PPH? What percentage of PPH is it responsible for?
uterine atony
causes 50% of all hemorrhages
List the four causes of PPH. What is the mnemonic?
Four T’s Mnemonic:
- Tone → uterine atony
- Tissue → retained placenta fragments
- Trauma → lacerations/hematomas
- Thrombin → thrombocytopenia or coagulopathy
List the causes of uterine atony (4)
- Failure to contract
- Overdistended uterus (twins, macrosomia, polyhydramnios)
- Full bladder preventing contraction
- Clots inside uterus
How does retained placenta fragments cause PPH? what is critical to catch this?
the body continues perfusing placenta site, inhibiting contraction
placental inspection post-delivery is critical
What type of lacerations can cause PPH?
Unrepaired lacerations → cervical, vaginal, perineal
What is a perineal hematoma?
collection of blood under tissue
how much blood can a perineal hematoma hold?
250-500 mL
What coagulation disorders can cause PPH? (4)
- Thrombocytopenia
- Von Willebrand’s disease
- Disseminated Intravascular Coagulation (DIC)
- Preeclampsia
postpartum hemorrhage may be the first sign of undiagnosed _______ _______
clotting disorder
How is uterine atony treated? (4)
- fundal massage
- empty bladder
- uterotonic medications
- if less invasive methods fail, prep pt for OR
What is done if the uterus is displaced and causing uterine atony?
straight cath
if less invasive methods fail to tx uterine atony, what things could be done? (6)
- Exploration of uterus for retained placenta & removal if found
- Dilation & Curettage (D&C)
- Bakri balloon
- B-Lynch Suture
- Ligation of uterine arteries
- Hysterectomy
What is a bakri balloon?
placement of balloon for uterine tamponade
What is B-Lynch Suture?
surgical compression of uterus
what is the last resort tx for uterine atony?
hysterectomy
How are retained placental fragments managed? (3)
- Provider should inspect placenta, membranes after every delivery
- Manual removal at bedside by provider
- Dilatation and Curettage in OR if fragments persist
How are small hematomas managed? (2)
apply ice & pressure
How are large hematomas managed? (2)
- incision/drainage
- vaginal packing
What should the nurse monitor for in a postpartum pt with unrepaired lacerations/hematomas?
monitor for hypovolemic shock
laceration tears may require what?
surgery
If a pt has a clotting disorder, what should be minimized?
invasive procedures
What is replaced in pts with PPH caused by clotting disorder?
Replacement of clotting factors as needed → fresh frozen plasma (FFP), platelets
What med is given to pts with PPH caused by clotting disorder?
Tranexamic Acid (TXA)
In pts with PPH caused by clotting disorder, what should the nurse monitor for?
fluid overload
In pts with PPH caused by clotting disorder, what should be avoided until stable?
NSAIDs
In PPH, fluid volume is replaced to support hemodynamic stability. What is the first step?
Get a second IV site → pref. 18 gauge
What type of fluid is used for fluid replacement in PPH?
Crystalloid Fluids → LR or NSS
In pts with PPH, we want to frequently monitor vital signs and look for hypovolemic shock. How would this present in vitals? (3)
- tachycardia
- hypotension
- decreased O2 sat
In pts with PPH, we may need to administer _______
oxygen
In pts with PPH, how should they be positioned?
with legs elevated 30 degrees to perfuse vital organs
In pts with PPH, a ______ _____ is needed and the nurse should monitor ______
foley catheter; output
In pts with PPH, what transfusion may be needed?
blood transfusion if indicated → massive transfusion protocol (MTP) may be needed
During postpartum assessment, how would uterine atony present? (2)
- Uterus will be boggy
- “high” → above umbilicus
in pts with retained placental fragments, what might they have?
“trailing membranes”
During the postpartum assessment, how would unrepaired lacerations/hematomas present? (3)
- Pt. will complain of sudden, excruciating pain
- Continuous trickle with firm fundus at umbilicus, OR s/s perineal hematoma
in pts with unrepaired lacerations/hematomas, what should the nurse monitor for at the site? (3)
- localized swelling
- discoloration
- fluctuant mass
How is thrombin determined to be the root cause of PPH? (3)
- Lab values (e.g., platelets) abnormal
- History of PPH, heavy periods, etc.
- Coagulopathy may be secondary to primary cause
What medications are uterotonic? (4)
- oxytocin (pitocin)
- methylergonovine (methergine)
- misoprostol (cytotec)
- carboprost (hemabate)
what uterotonic meds are prostaglandins? (2)
Misoprostol (Cytotec)
Carboprost (Hemabate)
what med is the first-line agent for PPH?
oxytocin (pitocin)
If a pt is already receiving pitocin but is experiencing uterine atony, what should the nurse anticipate?
anticipate the need for a bolus, depending on the provider’s orders.
what must be checked first before administering methylergonovine (methergine)? why?
blood pressure!!
can cause hypertension and potential risk of stroke, seizure, or hypertensive crisis.
How is methylergonovine (methergine) typically given?
IM injection (0.2 mg or 200 micrograms) into a large muscle (e.g., thigh or ventral gluteal)
What does methylergonovine (methergine) do/used for? (3)
- A potent uterotonic and vasoconstrictor.
- used for uterine contractions
- can be used postpartum to control bleeding if needed
How does misoprostol (cytotec) work/what is it used for in PPH?
- A prostaglandin that induces uterine contractions.
How is misoprostol (cytotec) dosed for PPH?
Used in larger doses than for cervical ripening or labor induction (800-1000 micrograms).
how can misoprostol (cytotec) be given? (3) what method is common for c-section pts?
can be given sublingually, rectally, or orally.
rectal administration common for C-sections.
what side effect does misoprostol (cytotec) have and what is used to manage it?
fever, and sometimes acetaminophen is given to manage
What meds can be given with misoprostol (cytotec)? (2)
Ensure acetaminophen is given to manage temperature spikes, and ibuprofen can be given if no clotting issues are present.
What is the standard of care for any cause of PPH?
Tranexamic Acid (TXA)
what is the mechanism of action of Tranexamic Acid (TXA)?
It inhibits fibrinolysis (the breakdown of blood clots) and promotes normal clotting.
how is Tranexamic Acid (TXA) dosed?
administered as a loading dose followed by a slower dose over 4 to 8 hours.
How does carboprost (hemabate) work/what is it used for in PPH?
prostaglandin that promotes strong uterine contractions
when is carboprost (hemabate) typically used?
when other meds are ineffective / after oxytocics have failed
What severe side effect can carboprost (hemabate) cause?
diarrhea
CUS words are used to be assertive in PPH situations. What are these words? List an example for each
C → concerned
“I’m concerned that my patient is deteriorating”
U → uncomfortable
I’m uncomfortable waiting this long for appropriate care/ the surgeon to see her”
S → safety
“I don’t feel safe managing this situation without appropriate escalation”
After CUS words, how is chain of command used in PPH?
“I hear what you are saying but I am very uncomfortable but I will have to move up the ladder in chain of command”
First → charge nurse
Who will escalate to → nursing supervisor
Who can escalate to → chief of obstetrics; Medical director; director of radiology
how should hemorrhoids present?
soft and flat
what happens if hemorrhoids are swollen, hard or painful?
comfort measures should be provided
