1.20.2007

NCP Postpartal Hemorrhage

Postpartal hemorrhage is usually defined as the loss of more than 500 ml of blood during or after delivery. It is one of the leading causes of maternal mortality. Hemorrhage may occur early, within the first 24 hr after delivery, or late, up to 28 days postpartum (the end of the puerperium).

CLIENT ASSESSMENT DATA BASE
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General Findings

Activity/Rest

May report excessive fatigue

Circulation

Blood loss at delivery generally 400–500 ml (vaginal delivery), 600–800 ml (cesarean delivery), although research suggests that blood loss is often underestimated
History of chronic anemia, congenital/incidental coagulation defects, idiopathic thrombocytopenia purpura

Ego Integrity

May be anxious, fearful, apprehensive

Sexuality

Labor may have been prolonged/augmented or induced, precipitous/traumatic; use of forceps/vacuum extractor, general anesthesia, tocolytic therapy.
Difficult or manual delivery of placenta.
Examination of placenta following birth may have revealed missing placental fragments, tears, or evidence of torn blood vessels.
Vaginal birth after cesarean (VABC).

Teaching/Learning

Previous postpartal hemorrhage, PIH, uterine or cervical tumors, grand multiparity
Ongoing/excess aspirin ingestion


Early Postpartal Hemorrhage (Up to 24 Hr Following Delivery)

Circulation

Changes in BP and pulse (may not occur until blood loss is significant)
Delayed capillary refill
Pallor; cold/clammy skin
Dark, venous bleeding from uterus externally evident (retained placenta)
May have excessive vaginal bleeding, or oozing from cesarean incision or episiotomy; oozing from IV catheter, sites of intramuscular injections, or urinary catheter; bleeding gums (signs of disseminated intravascular coagulation [DIC])
Profuse hemorrhage or symptoms of shock out of proportion to the amount of blood lost (inversion of uterus)

Elimination

Difficulty voiding may reflect hematoma of the upper portion of the vagina.
Bladder distension (urinary retention).

Pain/Discomfort

Painful burning/tearing sensations (lacerations), severe vulvar/vaginal/pelvic/back pain (hematoma formation), lateral uterine pain, flank pain (hematoma into the broad ligament), abdominal tenderness (uterine atony, retained placental fragments), severe uterine and abdominal pain (uterine inversion)

Safety

Lacerations of the birth canal: Persistent trickle of bright red blood (may be profuse) with firm, well-contracted uterus; visible tears in labia majora/labia minora, from vaginal introitus to perineum; extended tears from episiotomy, extension of episiotomy into vaginal vault, or tears in cervix
Hematomas: Unilateral, tense, fluctuant, bulging mass at vaginal introitus or encompassing labia majora; firm, painful to touch; unilateral bluish or reddish discoloration of skin of perineum or buttocks; (abdominal hematoma following cesarean delivery may be asymptomatic except for changes in vital signs)

Sexuality

Uterus: Soft, boggy, or enlarging, difficult to palpate; bright red bleeding from vagina (slow or profuse); large clots expressed on massage of uterus (uterine atony)
Firm, well-contracted or partially contracted, and slightly boggy (retained placental fragments, which may necrose and over time form polyps)
Fundus of uterus inverted; comes into close contact with, or may protrude through, the external os (uterine inversion)
Current pregnancy may have involved uterine overdistension (multiple gestation, hydramnios, macrosomia), abruptio placentae, placenta previa

Late Postpartal Hemorrhage (24 to 28 Days Following Delivery)

Circulation

Continued oozing or sudden bleeding
May appear pale, anemic

Pain/Discomfort

Uterine tenderness (retained placental fragments)
Vaginal/pelvic discomfort, backache (hematoma)

Safety

Foul-smelling lochial discharge (infection)
Reported premature rupture of membranes (risk for infection)

Sexuality

Fundal height or uterine body fails to return to prepregnancy size and function (subinvolution).
Leukorrhea may be present.
Continues to pass tissue.

DIAGNOSTIC STUDIES

Blood Typing: Determines Rh, ABO group, and cross-match.
CBC: Reveals decreased Hb/Hct and/or elevated WBC count (shift to the left, and increased sedimentation rate suggests infection).
Platelet Count: Levels below 50,000/┬ÁL can lead to spontaneous bleeding.
Uterine and Vaginal Culture: Rules out/identifies specific postpartal infection.
Urinalysis: Ascertains damage to bladder.
Coagulation Profile: Elevated fibrin degradation product/fibrin split product (FDP/FSP) levels, decreased fibrinogen levels; activated partial thromboplastin time/partial thromboplastin time (APTT/PTT), prothrombin time (PT) prolonged in presence of DIC.
Sonography: Determines presence of retained placental tissue.

NURSING PRIORITIES

1. Maintain or restore circulating volume/tissue perfusion.
2. Prevent complications.
3. Provide information and appropriate support for client/couple.
4. Have plan in place to meet needs after discharge.

DISCHARGE GOALS

1. Tissue perfusion/organ function WNL
2. Complications prevented/resolving
3. Clinical situation and treatment needs understood