Running Head: POSTPARTUM

HERMORRHAGE 1

Postpartum Hemorrhage

Alyssa Gillentine

Jackson College
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Two to three women die each day in the United States as a result of complications while

giving birth. The US is ranked 47th in maternal mortality, despite being a developed country with

some of the highest healthcare costs to consumers worldwide. Postpartum hemorrhage is one of

the leading causes of these mortalities ("Maternal Morbidity & Mortality"). Postpartum

hemorrhage has traditionally been defined as blood loss greater than 500 mL’s following vaginal

birth and greater than 1000 mL’s following cesarean birth. This definition has been problematic

as it has been determine that blood loss at the time of delivery is often greatly underestimated

(Smith, 2019).

During pregnancy, a woman’s blood volume increases by about 50%, from 4 liters to 6

liters. This change is to accommodate the extra blood flow through the placenta to deliver

nutrients and oxygen to the fetus. Following delivery of the fetus, contractions of the uterus work

to facilitate hemostasis and separate the placenta from the uterine wall. This process is mostly

mediated by hormones, namely oxytocin and prostaglandins. One of the most common causes of

postpartum hemorrhage is uterine atony. This is characterized by a failure of the uterus to

contract following delivery of the baby. Without the contractions, the blood vessels in the

myometrium fail to constrict to control bleeding. This form of postpartum hemorrhage is most

common accounting for about 75-90% of all primary PPH cases. Another cause of primary PPH

is retained placental fragments. These fragments act as a physical barrier for the uterus to

contract properly. For this reason, inspection of the placenta after it is delivered is important to

identify if there are any missing pieces. Uterine trauma, such as lacerations or rupture, comprise

about 20% of PPH instances. PPH can also be caused by congenital or acquired clotting

abnormalities, but this is less common (Khan & El-Refaey).

Certain conditions put women at greater risk for postpartum hemorrhage. Some of these

conditions include a history of PPH, fetal macrosomia (fetus weighing over 4000 g), pregnancy

induced hypertension, weight gain over 15 kg during pregnancy, and severe vaginal or perineal

tearing (Fukami et al. 2019). Postpartum hemorrhage can also be a result of certain placental

disorders including placental abruption (early detachment of the placenta from the uterine wall),

placenta previa (placenta obstructs or is near the opening of the cervix), placenta accreta

(abnormal attachment of placenta to uterus), placenta increta (placenta invades the uterine

muscle), and placenta percreta (placenta is all the way in the uterine muscle tissue which can

lead to rupture). Certain medications used to induce labor or slow/stop contractions for preterm

labor have also been shown to increase a woman’s risk of PPH (“Postpartum Hemorrhage”).

While it is important to screen for these conditions and provide extra vigilant care, 20% of

women who experience PPH have no risk factors (Fukami et al. 2019). It is important for

providers and nursing staff to be prepared to treat PPH at each delivery.

The labor and delivery nurse performs a critical role in monitoring for postpartum

bleeding, early detection can be the difference between life and death for many of these cases. It

is important for the nurse to establish a baseline for patient’s vital signs early on, this will help

the nurse determine if there is a deviation that may indicate hemorrhage, such as a drop in blood

pressure or increase in heart rate. These are early signs of hypovolemic shock, and should be

promptly reported to the provider. Other signs of shock include confusion, weakness, cool,

clammy skin, and unconsciousness. Another crucial assessment for the nurse to perform is visual

checks of the perineal pad to observe for bleeding, this can be done while also assessing the

condition of the uterus. Assessing the uterus following delivery is usually done every 15 minutes

for the first two hours (or depending on facility policy). When assessing the uterus, note fundal
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height, tone, and position. After delivery, the uterus begins the process of involution where it

returns to the pre-pregnancy state. The fundus should be firm, midline, and about 2 cm below

the umbilicus. Deviations from this may indicate there is bleeding. A uterine massage should be

performed to expel any retained blood and assess for clots/excessive bleeding. The nurse should

assess the lochia for color and amount, abnormalities should be reported to the provider (Belleza,

2017).

There are several other interventions for the labor and delivery nurse to consider. He/she

should assist the postpartum female to empty her bladder, as a full bladder can give the

impression that the uterus is not midline or filled with blood. Once the bladder has been emptied,

the nurse should reassess fundal height and position. A full bladder can lead to issues with

uterine contractility, which will interfere with the uteruses ability to return to normal size and

expel blood. If the woman is unable to void, a bladder scan may be indicated, and catheterization

may be required if more than 150 mL of urine is in the bladder (Dalton, 2018).

Most patients who experience PPH are treated promptly before major complications

occur. One of the most common complications following PPH is anemia from blood loss which

results in fatigue during the postpartum period. Complications of severe postpartum hemorrhage

are usually associated with hypovolemic shock and blood loss. Hypovolemic shock is often

secondary to rapid blood loss, which can result in multi-system organ failure. The decrease in

blood volume leads to inadequate perfusion. Damage to the respiratory system and renal system

are the most common with PPH, but rare (Smith, 2019). Another rare, but possible complication

of postpartum hemorrhage is Sheehan syndrome. Sheehan syndrome is an acute form of

hypopituitarism that occurs when the pituitary gland is deprived of oxygen due to excessive

blood loss/low blood pressure. The pituitary gland is responsible for stimulating the release of
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several important hormones in the body. Notably for postpartum women is prolactin. Prolactin

stimulates milk production, inadequate amounts can cause difficulty or inability to breastfeed.

Most women who experience Sheehan syndrome will need to be on hormone replacement

therapy for life ("Acute Hypopituitarism", 2019). Other long term complications that can arise

usually are a result of surgical intervention to control bleeding. These include sterility,

perforation of the uterus, bowel or urinary tract injury, pelvic hematoma,

genitourinary/genitointestinal fistula, and sepsis (Smith, 2019).

Postpartum hemorrhage is a very serious, potentially life threatening condition for

mothers after delivery. The labor and delivery nurse is imperative for early detection and

treatment. He/she should be well informed about early signs and symptoms of this condition and

open communication with a provider is of utmost importance. The California Maternal Quality

Care Collaborative has taken steps toward reducing maternal mortality related to postpartum

hemorrhage by putting together an OB Hemorrhage Toolkit. This toolkit contains emergency

readiness plans, checklists, and flowcharts as well as education for nurses and patients ("OB

Hemorrhage Toolkit V 2.0"). Their task force is continuing efforts to improve the toolkit.

Hospitals using their toolkit have seen a 20.8% reduction in severe maternal morbidity from

2014-2016 (“Obstetric Hemorrhage”). More research should be done regarding this condition

and protocols should be put in place in hospitals across the country to help preserve the lives of

our new moms.

References
Acute Hypopituitarism. (2019, February 2). Retrieved from

https://emedicine.medscape.com/article/767828-overview

Belleza, M. (2017, January 18). Postpartum Hemorrhage: A Fatal Yet Common Complication of

Pregnancy. Retrieved from https://nurseslabs.com/postpartum-hemorrhage/

Dalton, J. (2018, November 6). Assessment of the Newly Delivered Mother. Retrieved from

https://obgynkey.com/assessment-of-the-newly-delivered-mother/

Fukami, T. et al. (2019, January 9). Incidence and risk factors for postpartum hemorrhage among

transvaginal deliveries at a tertiary perinatal medical facility in Japan. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326562/

Khan, R. U., & El-Refaey, H. (n.d.). Pathophysiology of Postpartum Hemorrhage and Third Stage of

Labor. Retrieved from http://www.glowm.com/pdf/pph_2nd_edn_chap-13.pdf

Maternal Morbidity & Mortality. (n.d.). Retrieved from http://www.pphproject.org/maternal-morbidity-

mortality.asp

OB Hemorrhage Toolkit V 2.0. (n.d.). Retrieved from https://www.cmqcc.org/resources-tool-

kits/toolkits/ob-hemorrhage-toolkit

Obstetric Hemorrhage. (n.d.). Retrieved from https://www.cmqcc.org/qi-initiatives/obstetric-hemorrhage

Postpartum Hemorrhage. (2014, August 24). Retrieved from https://www.chop.edu/conditions-

diseases/postpartum-hemorrhage

Smith, J. R. (2019, July 18). Postpartum Hemorrhage. Retrieved from

https://emedicine.medscape.com/article/275038-overview#a5

Smith, J. R. (2019, July 18). Postpartum Hemorrhage Treatment & Management: Medical Therapy,

Management of obstetric hemorrhage, Management of massive obstetric hemorrhage. Retrieved

from https://emedicine.medscape.com/article/275038-treatment#d17