Postpartum Hemorrhage (PPH) [NextGen]

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Causes of Postpartum Hemorrhage (Mnemonic)
Postpartum Hemorrhage Pathochart (Cheat Sheet)
Fundal Massage (Image)
Postpartum Hemorrhage (Picmonic)

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In this lesson I will explain postpartum hemorrhage and your role in providing care to this patient

Let’s dive right in to what a postpartum hemorrhage is. It is blood loss and a lot of blood loss. It can occur early, in the first 24 hours or late which is after 24 hours. It can occur up to 2 weeks after delivery. So the patient is at home and has this happen to her. Which is super scary and dangerous! We had a patient who had gone home after twins which were her 5th and 6th kid. So she was already at risk because her uterus was tired and had been overstretched so more at risk for bleeding. She apparently had been calling over several days saying to the nurse at the office that she was bleeding a lot she thought. Well the nurse didn’t pass it on the way it should have been and so it continued. Then at around 2 in the morning she woke up to go to the bathroom and a clot the size of a frisbee came out. She instantly started to pass out and thankfully before she did she chucked some hair product at her husband to wake him. It would have been a different story if she hadn’t gotten his attention. So she was taken to the hospital and they couldn’t get the bleeding to stop and it ended with a hysterectomy. The doctor said she had never been so close to having a patient die. The patient stayed in ICU for a couple of days and was given blood products and all ended well. This is where we are also so thankful that a pregnant patient has extra blood volume. This is one of the great reasons why. It helps to have excess since bleeding is going to happen. Now how much is too much? A loss of 500 ml of blood or more for vaginal delivery and 1000 ml of blood for c-section are considered a postpartum hemorrhage. Now let me tell you something. The doctors always underestimate their estimated blood loss so unless everything is being weighed to quantify the blood loss it is probably off by a couple hundred. So not just this but you might have a patient pass a clot after delivery that is about 100 ml of blood, which might not seem bad but if she already lost 400ml of blood an hour ago at delivery then we have met that hemorrhage number. So if your patient is saturating a pad in 15 minutes or found in a puddle of blood that is a problem! And don’t forget those chucks pads under the patient, sometimes the blood is collecting behind them and you are not aware if you aren’t checking. Now let’s look at the causes.

There are many reasons that a hemorrhage can occur. So first our number one reason of postpartum hemorrhage is uterine atony. Remember this is the boggy uterus, it is not firm because it is unable to contract. There could be Injury to the birth canal from delivery. So maybe a laceration or episiotomy that is not closed completely or for some reason reopens. There could also being retained pieces of placenta. This retention of tissue is not supposed to be there, right?! So the body is going to bleed, bleed bleed trying to get it out of there. Our other reason is bleeding disorders so they are not clotting properly and DIC will be one of those and the most dangerous.

So who is at risk? Everyone is at risk but some are at a greater risk. So those that have a history of a previous hemorrhage or at risk to do it all over again. Things that will cause the uterus to be overstretched and distended. So this would be pregnant with multiples and a large fetus. Then when the uterus gets tired it is at risk so this is a uterus that has carried multiple pregnancies. It’s always our biggest fear when you get that patient that is a G10P9 come rolling in to have a baby. Labor that is prolonged or even precipitous is going to make this uterus tired. Placenta previa and abruption both cause a lot of bleeding so the patient is at risk because she has already lost a good amount of blood. Preeclampsia increased the risk as well as an assisted delivery so vacuum or forceps. Now let’s look at what you’ll assess in your patient.
So what will this patient look like? What are her symptoms. Increased bleeding is of course our number one symptom. That is what it is all about, right!? There are a lot of different symptoms and depends on severity. You might have a patient completely asymptomatic or a patient with all the symptoms. So depending on the cause will also vary the symptoms so your patient might have a boggy uterus on assessment so it just doesn’t want to firm up. She might be in a puddle of blood just have constant oozing or trickling of blood. The patient might be having symptoms of shock. Now I will tell you that vitals are a late sign that something has happened. The patient will be tachycardic, restless, pale, diaphoretic, hypotensive, tachycardic, weak. The patient being restless and tachycardic are early signs but if you walk in and your patient is hypotensive that is a late sign and you might have missed something.

Our management is always going to be prevention so fundal assessment is done frequently to watch for bleeding. After delivery fundal massage and checking is every 15 minutes for first hour, then every 30 minutes x 2, every hour times 4. At any time that bleeding is heavy fundal height is checked and fundal massage happens. This will help contract those muscle fibers to firm the uterus and stop bleeding. Blood loss is estimated so we know how much is lost. It allows us to quantify the blood loss. Remember we have to watch the pad under her because blood goes behind and under the patient.. To quantify we can weigh pads. 1 g equals 1 ml of blood loss. Lab work is done. Typically an H&H is done at the time but also 6 hours after to see effects. It takes time for the labs to catch up with what has occurred. So if fundal massage is not enough then medications can be given. Oxytocin, Methylergonovine, Carboprost Tromethamine all will cause the uterus to contract to help stop bleeding. Blood products may also be indicated, depending on severity. Interventions might lead to a D&C to clean out retained placenta or even a hysterectomy if bleeding won’t stop and it is severe.
The patient needs to be educated on when to call the provider or even the nurse if she is in the hospital still. So these would be bleeding, soaking a pad in 15 minutes and when they go home in an hour. It can quickly add up to a lot of blood! If she passes any clots we want to know about that. We also want the patient to know that she can hemorrhage up to 2 weeks postpartum.
Clotting and perfusion are our concepts because we are concerned with perfusion because of blood loss and we need clotting to occur to stop it.
Let’s review the key points. Uterine atony is the number one cause of postpartum hemorrhage. It is classified as blood loss of 500 ml or more of blood for a vaginal delivery and 1000 ml or more of a c-section. Symptoms will be of hypovolemia so there is blood loss, tachycardia, and hypotension. It will be treated with medications such as Oxytocin, Methylergonovine and Carboprost Tromethamine to increase uterine contractions and reduce bleeding. The absolute worst case scenario for a patient with a postpartum hemorrhage is they can’t get it under control and have to perform a hysterectomy and remove the uterus all together.

Make sure you check out the resources attached to this lesson and pay attention to who is at risk and how we treat it.. Now, go out and be your best selves today. And, as always, happy nursing.
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