Postpartum Hemorrhage (PPH): A Comprehensive Guide for Nurses

Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality worldwide. It is defined as excessive bleeding following childbirth and requires prompt identification and management to prevent life-threatening complications. Nurses play a vital role in recognizing the signs, initiating treatment, and providing emotional support to affected patients.

Definition

Quantitative Criteria:

• Blood loss of >500 mL after vaginal delivery.
• Blood loss of >1000 mL after cesarean delivery.

Clinical Criteria:

• Any blood loss causing hemodynamic instability or requiring intervention.

Timing:

• Primary (Early) PPH: Occurs within 24 hours of delivery.
• Secondary (Late) PPH: Occurs from 24 hours to 6 weeks postpartum.

Causes of Postpartum Hemorrhage (The "4 T's")

Tone (Uterine Atony):

• Failure of the uterus to contract adequately after delivery.
• Most common cause (70-80% of PPH cases).

Tissue (Retained Placental Tissue):

• Retention of placental fragments or clots preventing uterine contraction.
• Abnormal placental attachment (e.g., placenta accreta, increta, or percreta).

Trauma (Birth Canal Injuries):

• Lacerations of the cervix, vagina, or perineum.
• Uterine rupture or inversion.

Thrombin (Coagulopathy):

• Pre-existing or acquired clotting disorders (e.g., disseminated intravascular coagulation [DIC], severe preeclampsia, or HELLP syndrome).

Risk Factors

Maternal Factors:

• Multiparity (grand multiparity >5 pregnancies).
• History of PPH in previous deliveries.
• Prolonged labor or precipitous delivery.
• Advanced maternal age.

Obstetric Factors:

• Placenta previa, placenta accreta.
• Overdistended uterus (e.g., twins, polyhydramnios, macrosomia).
• Use of uterine relaxants (e.g., magnesium sulfate, tocolytics).

Intrapartum Factors:

• Induction or augmentation of labor.
• Operative deliveries (forceps, vacuum, cesarean).

Other Factors:

• Infection (e.g., chorioamnionitis).
• Clotting disorders (e.g., thrombocytopenia, DIC).

Clinical Presentation

Symptoms:

• Profuse vaginal bleeding.
• Signs of hypovolemia:
  • Dizziness, fatigue.
  • Palpitations.
  • Cold or clammy skin.

Signs:

• Tachycardia, hypotension.
• Pale or cyanotic appearance.
• Uterine Atony:
  • Soft, boggy uterus on palpation.
  • Fundal height above expected level.
• Visible lacerations or hematomas.

Diagnosis

1. Clinical Assessment:

• Quantify blood loss (use calibrated collection devices).
• Assess uterine tone through fundal massage.
• Examine for visible lacerations or trauma.

2. Laboratory Tests:

• Complete Blood Count (CBC): Assess hemoglobin, hematocrit.
• Coagulation Profile (PT, aPTT, Fibrinogen): For clotting disorders.
• Blood Type and Crossmatch: For transfusion.

3. Imaging Studies:

• Ultrasound: Identify retained placental fragments or uterine abnormalities.

Management of Postpartum Hemorrhage

Goals:

• Control bleeding and stabilize the patient.
• Address the underlying cause.
• Prevent complications such as shock and organ failure.

1. Initial Interventions:

Assess and Stabilize:

• Monitor vital signs (blood pressure, pulse, oxygen saturation).
• Ensure IV access with two large-bore cannulas.

Fluid Resuscitation:

• Administer isotonic crystalloids (e.g., normal saline or lactated Ringer’s).
• Transfuse blood products if indicated (packed red blood cells, fresh frozen plasma, platelets).

2. Medical Management:

Uterotonic Agents (for uterine atony):

• Oxytocin (Pitocin):
  • First-line agent.
  • IV infusion or IM injection.
• Methylergonovine (Methergine):
  • IM injection for uterine contraction.
  • Avoid in patients with hypertension.
• Carboprost Tromethamine (Hemabate):
  • IM injection.
  • Contraindicated in asthma.
• Misoprostol (Cytotec):
  • Rectal or oral administration.
• Tranexamic Acid (TXA):
  • Antifibrinolytic agent to reduce blood loss.
  • Administer within 3 hours of bleeding onset.

Monitor:

• Vital signs, oxygen saturation, and duration of the seizure.

3. Surgical or Endoscopic Intervention:

• Manual Removal: For retained placental fragments.
• Uterine Tamponade: Use of a Bakri balloon or packing to compress bleeding vessels.
• Repair Lacerations: Suture vaginal or cervical tears.
• Arterial Ligation or Embolization: For uncontrolled bleeding.
• Hysterectomy: Last resort for life-threatening hemorrhage.

Nursing Interventions

1. Assessment:

• Monitor vital signs every 5–15 minutes during active bleeding.
• Palpate the uterus for tone and position.
• Assess the amount and color of vaginal bleeding.
• Monitor for signs of hypovolemic shock (e.g., tachycardia, hypotension, decreased urine output).

2. Administer Medications:

• Administer prescribed uterotonics and monitor their effects.
• Administer pain relief as needed.

3. Fluid and Blood Product Management:

• Maintain IV access and administer fluids as ordered.
• Prepare and administer blood products if indicated.

4. Emotional Support:

• Provide reassurance and explain procedures to the patient and family.
• Address fears and concerns about the condition and its management.

5. Documentation:

• Record blood loss (quantitative measurement).
• Document interventions, medications, and patient responses.
• Note any complications or adverse events.

Complications of Postpartum Hemorrhage

• Hypovolemic Shock: Rapid fluid and blood loss leading to organ dysfunction.
• Anemia: May require prolonged recovery or blood transfusion.
• Sheehan Syndrome: Pituitary necrosis caused by severe blood loss, leading to hormonal deficiencies.
• Coagulopathy: Secondary to massive transfusion or DIC.

Prevention of Postpartum Hemorrhage

Active Management of the Third Stage of Labor (AMTSL):

• Administer oxytocin immediately after delivery of the baby.
• Controlled cord traction.
• Uterine massage after placental delivery.

Identify High-Risk Patients:

• Screen for risk factors (e.g., multiparity, history of PPH).
• Plan for close monitoring during and after delivery.

Education:

• Teach patients the importance of reporting heavy bleeding postpartum.
• Promote early breastfeeding to enhance natural uterine contractions.

Conclusion

Postpartum hemorrhage is a medical emergency requiring immediate and coordinated action to prevent maternal mortality and morbidity. Nurses play a critical role in early recognition, prompt intervention, and patient education. By adhering to evidence-based protocols and maintaining vigilant monitoring, nurses can significantly improve outcomes for mothers experiencing postpartum hemorrhage.