Question

What nursing interventions will you initiate for postpartum Hemorrhage?

Answer 1

Definition: Describes a woman who is experiencing or is at high risk to experience acute blood loss greater than 500ml after vaginal birth or greater than 1000ml after cesarean birth within the first 24 hrs postpartum ( Primary Hemorrhage) or occurring after 24hrs and before the 6th week postpartum ( secondary hemorrhage).

High Risk Population:

- Precipitous labor/birth,

- Problematic third stage of labor,

- Over distended Uterus ( eg: due to polyhydramnios, large fetus, multiple gestation),

- prolonged labor,

- Oxytocin induction / augmentation,

- Drugs ( general anesthesia, magnesium surface),

- Multiparty,

- Maternal exhaustion,

- Trauma to genital tract ( Use of forceps or intravaginal manipulation),

- History of Uterine atony,

- Uterine malformation or uterine fibroids,

- Hx of postpartum hemorrhage,

- Uterine rupture, or uterine surgery,

- excessive analgesic or anesthesia use,

- preeclampsia,

- retained placental fragments,

- Previous placenta prévia, placental a creta, increta or percreta,

- Current placenta previa,

- Maternal Systemic disease,

- chorioaminonitis,

- maternal malnutrition or Anemia,

- Asian or Hispanic ethinicity.

Interventions and Rationales :

1. Assess the Uterine fundus every 15minutes for the first hour postpartum, every 30minutes the second hour postpartum, every hour for third and fourth hour, and every shift thereafter, evaluate

- Height ( normally should be at the level of the umblicus after delivery,

- Size ( when contracted , should be about the size of a large grapefruit ₹,

- Consistency ( Should feel firm)

Rationale : With Uterine atony, a boggy or relaxed uterus will not control bleeding by compression of the uterine muscle fibers,

2. If the Uterus is relaxed or relaxing , massage it with firm but gentle circular strokes until it contracts.

Rationale : Massage stimulates the Uterine muscle to contract,

3. Avoid routine massage or over massaging the uterus

R: Unnecessary massage can cause pain and muscle fatigue, with subsequent Uterine relaxation,

4. Monitor blood pressure and pulse every 15 minutes for one hour, then every 30 minutes for the next hour and then once every hour until the mother's condition stabilises.

R: careful vital sign monitoring provides accurate evaluation of heamodynamic status,

5. Ensure there are two large bore IV lines if actively bleeding or hypovolemic according to policy/protocol.

R: IV access is important for fluid replacement, medication administration and blood product replacement,

6. Monitor perineal blood loss

R: continuous seepage of blood with a firm uterus can indicate cervical or vaginal lacerations . Bleeding after the first 24hrs can indicate retained placental fragments or subinvolution,

- Measure and estimate blood loss

R: record visual blood loss in cucm of blood stained on a pad in a certain period of time or weigh saturated pads, linen protectors.

- administer oxygen by face mask at a rate of 10L per minute as indicated,

7.Obtain Laboratory/ diagnostic studies ( CBC, type & cross match, coagulation profile). Report a decrease to the physician or certified nurse midwife,

R: A decrease in the HB value of 1.0 to 1.5 g per dl and a four point drop in hct Indicate a blood loss of 450 to 500ml,

8. Minister bladder size and urine output with the same frequency as for vital signs,

R: A distended bladder can displace the uterus and increase uterine atony,

- Insert Foley catheter to monitor urinary output according to protocol/ policy,

- If bleeding becomes excessive , if the uterus fails to contract, or if vital sign changes occur, notify the physician or advanced practice nurse,

- If the women exhibits signs of shock, correct the hypovolemia