Postpartum hemorrhage, or EPP, is defined as abnormal blood loss from the vagina following childbirth. This bleeding can occur within 24 hours after delivery or after a few days. EPP is currently one of the main causes of maternal death, leading to this outcome in 8% of cases. Mortality is much higher in underdeveloped and developing countries. However, it is normal for some blood loss to occur after delivery (known as "lochiaation"). Often, this loss lasts a few weeks. To avoid complications, it is important to learn to quickly distinguish EPP from lochiaation.
Steps
Method 1 of 4: Recognize High Risk Situations
Step 1. You need to know what conditions can cause EPP
EPP can be caused by a variety of conditions that occur before, during or after childbirth. For this to be ruled out, many diseases require close monitoring of the patient during and after delivery. It is important to know about these conditions, because they can increase your chances of suffering from this complication.
- Placenta previa, placental abruption, placental retention and other placental abnormalities.
- Multiple pregnancies.
- Preeclampsia or increased blood pressure during pregnancy.
- History of EPP in a previous birth.
- Obesity.
- Uterine malformations.
- Anemia.
- Emergency caesarean section.
- Blood loss during pregnancy.
- Prolonged labor beyond 12 hours.
- Infant weight over 4 kg.
Step 2. Uterine atony is one of the causes that can lead to massive blood loss
Postpartum hemorrhage, or postpartum blood loss, is a leading cause of maternal death, even in cases that occur after a safe delivery. There are several causes that can cause excessive blood loss after childbirth, i.e. more than 500ml. One of these is uterine atony.
- Uterine atony occurs when the mother's uterus (the part of the female reproductive system that housed the baby) encounters difficulty in returning to its original state.
- The uterus remains sunken, devoid of muscle tone and unable to contract. In this way the blood passes more easily and quickly, thus contributing to post partum hemorrhage.
Step 3. Trauma suffered during childbirth can lead to postpartum bleeding
Another cause that causes excessive blood loss is a trauma or injury that occurs while the baby is exiting the mother's body.
- The trauma can come in the form of cuts, which can be caused by the use of medical tools during childbirth.
- It is also possible for injuries to occur when the baby is older than average and is coming out quickly. This could cause the vaginal opening to tear.
Step 4. In some cases there is no blood leaking from the woman's body
The losses caused by EPP do not always flow out of the body. Sometimes bleeding occurs inside, and if it finds no way out, the blood moves into the small cracks between the tissues of the body, forming a hematoma.
Method 2 of 4: Recognize the Blood Leaks Associated with EPP
Step 1. Pay attention to the amount of blood
The type of blood loss that occurs immediately after delivery, in the following 24 hours or after a few days, is essential to be able to rule out PEP. For this purpose, the most important parameter is the extent of the loss.
- Any blood loss greater than 500ml after vaginal delivery and more than 1000ml after a caesarean section is considered an EPP.
- In addition, blood loss greater than 1000ml is classified as severe EPP, requiring immediate medical attention, especially in the presence of other risk factors.
Step 2. Observe the flow and consistency of the blood
EPP generally occurs in a continuous, abundant stream, with or without several large clots. However, clots are much more common in an EPP that develops a few days after delivery, and this type of leakage may also have a more gradual flow.
Step 3. The smell of blood may help you determine if postpartum bleeding is occurring
Some additional characteristics that can help distinguish it from a physiological blood loss that occurs after childbirth, called lochiation (vaginal discharge consisting of blood, tissues of the uterus's inner lining, and bacteria) are smell and flow. If your licking produces a disgusting odor or if your flow suddenly increases after giving birth, you need to suspect the presence of EPP.
Method 3 of 4: Recognize the Secondary Symptoms
Step 1. If you recognize severe symptoms, seek medical help
Acute EPP is often accompanied by signs of shock, such as low blood pressure, tachycardia or low pulse, fever, tremors, and weakness or fainting. These are the clearest symptoms of a PE, but also the most dangerous. In these cases, immediate medical intervention is required.
Step 2. Look for symptoms that occur a few days after delivery
There are some less serious but still dangerous symptoms of a secondary EPP that tend to occur a few days after delivery. These include fever, abdominal pain, painful diuresis, general weakness and abdominal tension in the suprapubic and related areas.
Step 3. If you get these warning signs, go to the hospital
EPP is a medical emergency and requires hospitalization and immediate steps to stop blood loss. It is not a pathology that can be underestimated. If, after giving birth, you experience any of the following symptoms, contact your obstetrician immediately, as you may be in shock.
- Low blood pressure.
- Low pulse rate.
- Oliguria or decreased urinary secretion.
- Sudden and continuous vaginal blood loss or passage of large clots.
- Fainting.
- Tremors.
- Fever.
- Abdominal pain.
Method 4 of 4: Create a Nursing Care Plan (for Doctors and Nurses)
Step 1. Understand what a nursing care plan is
The most important thing in reducing the chances of death after childbirth is the ability to detect the symptoms of a blood loss as quickly as possible and to accurately determine the cause. A quick identification of the causes of the leak allows for faster intervention.
- To do this, a very useful tool is a nursing care plan. This plan follows five steps: evaluation, diagnosis, planning, intervention and final check.
- In order to apply a nursing care plan to postpartum hemorrhage, it is important to know what to look for and what to do in each of these steps.
Step 2. Pay special attention to mothers who are predisposed to developing postpartum hemorrhage
Before proceeding with an evaluation, it is important to take note of the mother's medical history. There are several factors that predispose the mother to postpartum hemorrhage, just as all women who have just given birth tend to have excessive blood loss.
- These factors include: an enlarged uterus, caused by carrying a very large baby inside or by too much fluid in the placenta (the sac that surrounds the baby); having given birth to more than five children; rapid labor; prolonged labor; the use of medical assistance tools; a caesarean section; manual removal of the placenta; a retroverted uterus.
- Mothers particularly prone to excessive blood loss are: those who have suffered from pathologies such as placenta previa or placenta accreta; those who use drugs such as oxytocin, prostaglandins, tocolytics or magnesium sulfate; those who have undergone general anesthesia, who have clotting problems, who have had bleeding in a previous birth, who have contracted a uterine fibroid, and those who have suffered from a bacterial infection of the fetal membranes (chorioamniositis).
Step 3. Examine the mother's condition frequently
When evaluating the mother, there are some physical aspects that need to be checked regularly to determine if postpartum hemorrhage is occurring and to determine the cause. These physical aspects include:
- The bottom of the uterus (the upper part, opposite the cervix), the bladder, the amount of lochi (the fluid that flows from the vagina, composed of blood, mucus and uterine tissue), the four vital parameters (temperature, pulse rate, respiratory rate and blood pressure) and skin color.
- In evaluating these aspects, it is important to note the observations. For more information, follow the next steps.
Step 4. Keep a watchful eye on the bottom of the uterus
It is important to check the consistency and location of the bottom of the uterus. Normally, the bottom should be firm to the touch and its level should be aligned towards the umbilical area. Any changes (for example, if the bottom of the uterus is soft or hard to find) could indicate postpartum bleeding.
Step 5. Check your bladder
There may be cases where the bladder causes bleeding: this is indicated by the displacement of the bottom of the uterus above the umbilical area.
Make the mother urinate, and if the blood loss stops after diuresis, the bladder is causing the uterus to move
Step 6. Check for the littering
When assessing the amount of vaginal discharge, it is important to weigh before and after the tampons used, in order to obtain accurate information. Excessive blood loss could be indicated by saturating a swab within fifteen minutes.
Sometimes, the emissions may go unnoticed, and can be controlled by asking the mother to turn on her side and check under her, especially in the buttock area
Step 7. Check the mother's vital signs
Vital signs consist of blood pressure, respiratory rate (number of breaths), pulse rate and temperature. In the case of postpartum bleeding, the pulse rate should be lower than normal (60 to 100 per minute), but may vary based on the mother's previous pulse.
- However, vital signs may not show any abnormalities until after the mother has suffered from excessive blood loss. Consequently, you should consider any deviations from what would normally be expected with an adequate amount of blood, such as warmth, dry skin and rosy lips, and mucous membranes.
- The nails can also be examined by pinching and releasing them. It should only take three seconds for the nail bed to turn pink again.
Step 8. Understand that trauma can cause excessive blood loss
If all these changes have been evaluated, the mother may be suffering from postpartum hemorrhage due to the fact that the uterus is unable to contract and return to its original shape. However, if the uterus is contracted and not displaced after being checked, but there is still excessive blood loss, the cause could be trauma. When assessing the presence of trauma, the pain and external color of the vagina must be taken into account.
- Pain: The mother will experience severe, deep pain in her pelvis or rectum. It could indicate the presence of internal bleeding.
- External vaginal orifice: Swollen masses and skin discoloration (usually purplish or bluish-black) will be observed. This could also be an indication of internal bleeding.
- If the laceration or wound is on the outside, it can be easily checked by visual inspection, especially if done under appropriate lighting conditions.
Step 9. Tell other doctors
If there is considerable blood loss and the cause has been determined, the next step in the nursing plan has already been followed: diagnosis.
- As soon as the diagnosis of postpartum haemorrhage is confirmed, the next step is to inform the treating physicians, as nurses cannot apply therapy.
- In these kinds of complications, a nurse's role is to monitor the mother, take steps to minimize blood loss and replace lost blood, and immediately report if there are any significant changes in the previously observed condition and if the reaction of the mother does not correspond to what is desired.
Step 10. Massage the mother's uterus and note the extent of the blood loss
In the event of postpartum hemorrhage, appropriate nursing interventions consist of constantly monitoring vital signs and the extent of the emission, weighing blood-soaked tampons and linens. Massaging the uterus will also help make it contract and firm again. Equally important is to tell doctors and midwives if the blood loss continues (even during the massage).
Step 11. Adjust blood values
The nurse should have already informed the blood bank, in case a blood transfusion is needed. Regulation of intravenous flow is also the responsibility of the nurse.
Step 12. Put the mother in the Trendelenburg position
The mother should also be placed in the Trendelenburg position, where the legs are raised to an inclination of between 10 and 30 degrees. The body is placed horizontally, and the head is also slightly raised.
Step 13. Give the medication to the mother
The mother will generally be given a number of medications, such as oxytocin and Methergin, of which the nurse should be able to determine the side effects, as they could threaten the mother's life.
- Oxytocin is mainly used to induce labor, since its administration is safe at this stage; however, it is also used after childbirth. The action of the drug is to facilitate the contraction of the smooth muscles of the uterus. It is usually given as an intramuscular injection (usually in the upper arm) in doses of 0.2 mg with a frequency of between two and four hours, up to a maximum of five doses after delivery. Oxytocin has an antidiuretic effect, which means that it inhibits diuresis.
- Methergin is a drug that is never given before labor, but can be used afterwards. The reason is due to the fact that Methergin works by stimulating prolonged contractions of the uterus and, consequently, would cause a reduction in oxygen consumption by the baby who is still inside the uterus. Methergin is also administered by intramuscular injection in doses of 0.2 mg, with a periodicity of between two and four hours. The side effect produced by Methergin is an increase in blood pressure. It should be observed if the pressure rises to levels above normal.
Step 14. Monitor the mother's breathing
The nurse should pay attention to any accumulation of fluid within the body, constantly listening to the sound of breathing, in order to identify the presence of any fluid in the lungs.
Step 15. When the mother is in safer condition, check her out
The last step in the nursing process is the final evaluation. As during the initial one, the affected areas of a mother suffering from excessive blood loss will be checked.
- The uterus should be placed along the midline centered on the navel. To the touch, the uterus should appear firm.
- The mother shouldn't change tampons as often as before (using only one every hour or so), and there shouldn't be any loss of blood or fluids on the sheets.
- The mother's vital signs should have returned to normal values prior to delivery.
- Her skin shouldn't be clammy or cold and her lips should have a rosy color.
- Since he is no longer expected to excrete fluids in large quantities, his urine output should again be between 30 and 60 ml every hour. This shows that there is enough fluid inside your body to allow for adequate circulation.
Step 16. Check for any open wounds the mother may have
If her blood loss was due to trauma, any open wounds will have been sutured by the doctor. These wounds will require constant observation, to make sure they do not reopen.
- There should be no severe pain, although there may be some localized pain originating from the sutured wound.
- If there has been a buildup of blood in the mother's muscles or tissues, the treatment should have cleared the purplish or bluish-black complexion of the skin.
Step 17. Check for side effects of medications
The side effects of the above drugs should be checked regularly until their administration has been stopped. Even if postpartum haemorrhage is dealt with in collaboration with a doctor, the nurse is still able to evaluate the effectiveness of the interventions by observing a constant improvement in the mother's condition.
