Postpartum hemorrhage

Postpartum hemorrhage
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is excessive maternal bleeding after delivery of an infant and has multiple causes. Postpartum hemorrhage is classified into two groups: early postpartum hemorrhage and late postpartum hemorrhage. The most common cause of early postpartum hemorrhage is uterine atony, but it can also be caused by trauma, lacerations, and hematomas. Late postpartum hemorrhage is most commonly caused by retained placental fragments.
Contractions that were minimally effective, resulting in prolonged labor
Contractions that were excessively vigorous, resulting in precipitate labor
Placental abruption: early detachment of the placenta from the uterus
Placenta previa: the placenta covers or is near the cervical opening
Overdistended uterus: excessive enlargement of the uterus due to too much amniotic fluid (polyhydramnios) or a large infant (macrosomia), especially with birthweight of more than 4000 grams (8.8 pounds)
Multifetal gestation
Pregnancy-induced hypertension (PIH)
Multiparity
Prolonged labor
Maternal infection
Endometriosis
Maternal obesity
Induction or augmentation of labor with oxytocin
Tocolytic medications to stop contractions (for preterm labor)
General anesthesia
Vacuum extractor—or forceps-assisted delivery
History of postpartum hemorrhage
HematomasRisk factors include use of vacuum extractors or forceps during delivery, traumatic delivery, or large infant. Bleeding is not visible, but the woman will exhibit signs and symptoms of bleeding, as well as persistent pain in the vagina. Occur when bleeding into loose connective tissue occurs while overlying tissue remains intact. May be found in vulvar, vaginal, and retroperitoneal areas. Vaginal and retroperitoneal hematomas are not visible. Develop as a result of blood vessel injury.Late postpartum hemorrhage, also called secondary postpartum hemorrhage, is defined ashemorrhage occurring between 24 hours and 12 weeks after delivery.Causes and Risk Factors of Late Postpartum HemorrhageCommonly caused by subinvolution (delayed return of the uterus to its nonpregnant size and consistency), which is often the result of retained placental fragments. Frequently happens after the woman has been discharged from the hospital. Women should be educated on the normal amount and characteristics of lochia flow expected after discharge from the hospital and encouraged to call their health care provider if bleeding saturates more than one pad in an hour or if they begin to pass clots. Risk factors include manual removal of the placenta, attempts to deliver a placenta that has not fully detached from the uterine wall, placenta accreta, previous cesarean delivery, uterine myelomas, early postpartum hemorrhage, and advanced maternal age. Retention of placental fragments can be prevented easily. When the placenta is delivered, the health care provider carefully inspects it to determine whether it is intact. If a portion of the placenta is missing, the health care provider manually explores the uterus, locates the missing fragments, and removes them. This procedure may require a dilation and curettage (D&C).Which woman is at greatest risk for late postpartum hemorrhageA 38-year-old woman with placenta accreta Advanced maternal age and placenta accreta are risk factors for development of late postpartum hemorrhage.A woman with a body mass index (BMI) of 30 delivered an infant after 12 hours of labor. The woman has the greatest risk for which complication?Uterine atony Obesity and prolonged labor put the woman at increased risk for uterine atony.A woman with a firm fundus who presents with excessive vaginal bleeding may be at risk for which complication?Laceration Excessive vaginal bleeding with a firm fundus may be a sign of a vaginal, cervical, or perineal laceration.Postpartum hemorrhage can sometimes be prevented bycareful examination of factors that predispose to excessive bleeding.Signs of Postpartum HemorrhageA uterus that does not contract or does not remain contracted; "boggy" or soft-feeling fundus; large gush or slow, steady trickle, ooze, or dribble of blood from the vagina Saturation of one perineal pad per hour Severe, unrelieved perineal or rectal pain TachycardiaAssessment Findings of postpartum hemorrhageThe fundus should be firmly contracted, at or near the level of the umbilicus, and midline. If the fundus is above the level of the umbilicus and displaced, a full bladder may be the cause of uterine atony and excessive bleeding. If the fundus is firm, but bleeding is excessive, the cause may be lacerations of the cervix or birth canal. If the mother complains of deep, severe pelvic or rectal pain, or if vital signs or skin changes suggest hemorrhage but bleeding is not obvious, the cause may be the formation of a hematoma.Aside from heavy bleeding, the first vital sign change the nurse assesses in postpartum hemorrhage istachycardia. It is important to note that the postpartum patient will not usually be hypotensive until she has lost a significant amount of blood due to the increased blood volume of pregnancy. Sometimes she will have lost up to 20% of total blood volume before her blood pressure decreases significantly.Patient-Centered Goals for Postpartum HemorrhageThe patient's vital signs will be within normal limits. The patient will have the appropriate amount of lochia. The patient's hemoglobin and hematocrit will be stable. The patient will not experience any signs or symptoms of hypovolemiaPlanning for Postpartum HemorrhageMonitor for signs of postpartum hemorrhage. Perform actions that minimize postpartum hemorrhage and prevent hypovolemic shock. Notify the health care provider if signs of excessive blood loss are observed or if the patient does not respond to interventions as expected.All patients who have given birth are at risk forhemorrhage. However, be aware of factors that may increase this risk, and be particularly vigilant in monitoring these women so that excessive bleeding can be anticipated and minimized. A delay in assessment could result in excessive blood loss.Nursing Interventions for Patients Experiencing Postpartum HemorrhageWhen excessive bleeding is noted and the fundus is boggy, begin uterine massage. Assess the patient's bladder for distention and have her void or obtain an order for catheterization if necessary. Weigh blood-soaked pads, linen savers, and linens to accurately determine the amount of blood lost. If fundal massage is not effective in controlling bleeding, promptly notify the health care provider. Maintain bed rest for the patient to increase venous return and maintain cardiac output. Assistance is necessary; one nurse must continue to massage the uterus and perform and record assessments while the other notifies the health care provider and obtains necessary medications and equipment. Keeping the family informed is one of the most effective ways to reduce anxiety. Acknowledge the anxiety and provide simple, appropriate explanations of the activity.Postpartum hemorrhage is treated based upon thecause of the hemorrhage. The nurse is often the first to discover the hemorrhage and must troubleshoot the probable cause quickly. A boggy uterus may need medications. However, a perineal or cervical laceration may present with heavy bleeding and a firm uterus. Use your assessment skills to identify the cause and you may save a life!Posthemorrhage CareContinue to assess the patient frequently for a resumption of bleeding. Allow rest periods and organize work to help her conserve energy. Because the patient may experience orthostatic hypotension, assist her in getting out of bed. Encourage intake of fluids and foods high in iron. Iron-rich foods include red meat, poultry, seafood, beans, dark green leafy vegetables (such as spinach), and dried fruit. Inform the patient that iron supplements or blood transfusions may be required. The patient may need assistance feeding her newborn because of weakness, lightheadedness, or fatigue.Home CareIn general, patients who have had postpartum hemorrhage are exhausted, and it may take weeks for them to feel well again. Activity may be restricted until strength returns. Some patients may need assistance with housework and care of the new infant, and fatigue may interfere with attachment. Educate the patient about the specific signs and symptoms of postpartum infectionWhich statements should be included in discharge education for a patient who has experienced a postpartum hemorrhage"You should get out of bed slowly, especially if you feel dizzy." "You may need help caring for your infant while you recover." "If your temperature is elevated, or you start feeling achy, you should call your health care provider immediately."A woman in the immediate postnatal period complains of severe pelvic pain. The fundus is firm, and no excessive bleeding is visible. Which action should the nurse take first?Notify the health care provider. Severe pelvic pain with no signs of excessive bleeding indicates the possibility of a hematoma. The health care provider should be notified immediately.The nurse is caring for a patient recovering from a postpartum hemorrhage. The patient's bleeding is under control, and vital signs are stable. Which action should the nurse take?Perform shift assessments and medication administration at the same time. Patients recovering from a postpartum hemorrhage are often exhausted. Organizing care so that some interventions are done together allows the patient to conserve energy.A woman who has given birth reports severe perineal pain. She had a vacuum extractor delivery. This woman is at risk for which early postpartum complication?HematomaA 37-year-old woman whose placenta was manually removed during delivery is at greatest risk for which complicationSubinvolutionWhich intrapartum factors contribute to an increased risk for uterine atony?Placenta previa Maternal infection Use of forceps during deliveryThe nurse arrives in the obstetric unit and receives the shift report. Which patient should the nurse assess first?A patient whose fundus is firm and who is saturating one perineal pad every hour.A patient's fundus is boggy and rests to the left above the umbilicus. Which action should the nurse take first?Ask the patient to void.While performing fundal massage, the nurse observes that vaginal bleeding has decreased. The fundus was boggy before massage and currently feels firm. Which is the next step in nursing management?Assess the patient's vital signs.