2/12/2016

Postpartum Hemorrhage

Connie Hogewood, MSN RN Cathy Roche, PhD, RN

Disclosure

• We have no actual or potential conflict of interest in relation to this presentation.

Learning Objectives

• Identify causes of postpartum hemorrhage and chorioamnioitis • Define methods for prevention and management of postpartum hemorrhage and chorioamnioitis

1 2/12/2016

Primary Postpartum Hemorrhage

• Occurs within 24 hours after delivery

• Studies show actual blood loss is typically underestimated.

Vaginal Birth Cesarean Birth

> 500 mL blood loss >1000 mL blood loss following a vaginal following a cesarean delivery delivery

Major obstetric hemorrhage More than 1000 mL

Can very rapidly lead to maternal death

2 2/12/2016

 Prolonged second stage  Longer duration of oxytocin exposure  Multiples  Polyhydramnios  Fibroids  Placenta previa  Chorioamnitis

(Grotegut, Paglia, Johnson, Thames, & James, 2011; Lu et al, 2009)

Tone

Trauma

Tissue

Thrombin

3 2/12/2016

Uterine Atony

Nursing Actions Treatment  Assessment  Trendelenburg  #1 Oxytocin  Vital Signs  Methargine – Blood  I & O’s pressure  Evaluate bladder  Cytotec  Recovery period –  Hemabate – side every 15 minutes effects  Fundal massage  Vaginal balloon

Possible Causes Nursing Actions

Monitor bleeding – what is Episiotomy excessive Vaginal tears Assess episiotomy Cervical laceration Long labor Continuous trickle of blood may signal laceration of the Uterine rupture vagina or cervix or an unligated vessel in the episiotomy.

◦ Possible Cause

Retained placenta or other products of conception

◦ Nursing Action Assessment

◦ Treatment Dilation and Curettage (D & C)

4 2/12/2016

◦ Possible Cause

Clotting disorders – preexisting or not

◦ Nursing Action History – Assessment - Communication

◦ Treatment Depends on cause possible hysterectomy

Tone

Trauma

Tissue

Thrombin

Recognition of PPH IV access, crystalloids, colloids

Determination of Baseline laboratory etiology evaluation Administration of blood products

Uterine atony Retained placenta, Lacerations, tears, placental fragments uterine rupture

Uterotonics, uterine Manual removal Surgical exploration massage curettage Laceration repair

Balloon tamponade

Arterial embolization Uterine compression Arterial embolization suture, Arterial ligation, Hysterectomy

Ahoenen, Stefanov & Lassila, 2010

5 2/12/2016

 Occurs during labor  Causes: ◦ AROM ◦ Lengthy labor after rupture ◦ Underlying infection  Treatment – Antibiotics  Nursing Action ◦ Assessment of temperature throughout labor

 New guidelines to be published this spring http://peace-p.org/guidelines/

 California Maternal Quality Care Cooperative https://www.cmqcc.org/resources- tool-kits/toolkits/ob-hemorrhage- toolkit

 Ahonen, J., Stefanovic, V., Lassila, R.(2010). Management of post-partum heamorrhage. Acta Anaesthesiol Scand, 54, 1165-1178.doi:10.1111/j.1399- 6576.2010.02309

 Anderson, J.M., & Duncan, E. (2007). Prevention and management of postpartum hemorrhage. American Family Physician, 75(6). Retrieved from http://www.aafp.org/afp/2007/0315/p875.html

 Alabama Perinatal Excellence Collaborative (n.d.). Retrieved from http://peace-p.org/guidelines/

 Lu, M. C., Muthengi, E., Wakeel, F., Fridmann, M., Korst, L. m., & Gregory, K. D. (2009). Prolonged second stage of labor and postpartum hemorrhage. The Journal of Maternal-Fetal and Neonatal Medicine, 22(3), 227-232. doi:10- 1080/14767050802676709

 Parreira, M. & Gomes, N. (2013). Preventing postpartum haemorrhage: active management of the third stage of labour. Journal of Clinical Nursing, 22. doi:10-1111/jocn.12361

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