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HistoryThe clinical history should be taken as a primary survey (ABCs) of the patient. This should include collecting an initial set of vital signs to guide the patient’s management, as the patient is positioned to begin the physical examination. Keep in mind, that if the bleeding is very brisk, the patient’s mental status may wane. As a result, this first set of questions should include queries about signs and symptoms that are most crucial in managing potential circulatory collapse, identifying the cause of postpartum hemorrhage (PPH), and selecting appropriate therapies. [10] Severity of bleedingConsider the following:
Intervention guidesObtain the following information:
Predisposing factors and potential etiologyObtain the following information:
PhysicalAs mentioned earlier, patients with postpartum hemorrhage (PPH) should be managed like all emergency department resuscitation situations, with the history and physical examination occurring simultaneously while following acute life support algorithms. The physical examination should focus on determining the cause of the bleeding. The patient may not have the typical hemodynamic changes of shock early in the course of the hemorrhage due to physiologic maternal hypervolemia. Important organ systems to assess include the pulmonary system (evidence of pulmonary edema), the cardiovascular (heart murmur, tachycardia, strength of peripheral pulses), and neurological systems (mental status changes from hypovolemia).The skin should also be checked for petechiae or oozing from skin puncture sites, which could indicate a coagulopathy, or a mottled appearance, which can be indicative of severe hypovolemia. Looking for occult postpartum hemorrhage—in the form of a pelvic, vaginal, uterine, or abdominal wall hematoma, or intra-abdominal or perihepatic bleeding—is always an important consideration when unstable hemodynamic findings are present without evidence of excessive vaginal blood loss. Having a gynecologic examination bed is helpful but not necessary. The patient's pelvis can always be elevated on an inverted bedpan (thick-side toward the patient's feet) cushioned with towels and a sheet for comfort. Ensure that good lighting and suction are available before beginning the following evaluations:
CausesThe 4Ts of postpartum hemorrhage (PPH) +1: tone, trauma, tissue, thrombosis, and traction. More than one of these can cause postpartum hemorrhage in any given patient. Uterine atony"Tone" Atony is by far the most common cause of postpartum hemorrhage. Uterine contraction is essential for appropriate hemostasis, and disruption of this process can lead to significant bleeding. Uterine atony is the typical cause of postpartum hemorrhage that occurs in the first 4 hours after delivery. Risk factors for atony include the following:
Laceration or hematoma"Trauma" Trauma to the uterus, cervix, and/or vagina is the second most frequent cause of postpartum hemorrhage. Injury to these tissues during or after delivery can cause significant bleeding because of their increased vascularity during pregnancy. Vaginal trauma is most common with surgical or assisted vaginal deliveries. It also occurs more frequently with deliveries that involve a large fetus, manual exploration, instrumentation, a fetal hand presenting with the head, or spontaneously from friction between mucosal tissue and the fetus during delivery. Cervical lacerations are rarer now that forceps-assisted deliveries are less common. They are more likely to occur when delivery assistance is provided before the cervix is fully dilated. Risk factors for trauma include the following:
Retained placenta"Tissue" Retained placental tissue is most likely to occur with a placenta that has an accessory lobe, deliveries that are extremely preterm, or variants of placenta accreta. Retained or adherent placental tissue prevents adequate contraction of the uterus allowing for increased blood loss. Risk factors for retained products of conception include the following:
Clotting disorder"Thrombosis" During the third stage of labor (after delivery of the fetus), hemostasis is most dependent on contraction and retraction of the myometrium. During this period, coagulation disorders are not often a contributing factor. However, hours to days after delivery, the deposition of fibrin (within the vessels in the area where the placenta adhered to the uterine wall and/or at cesarean delivery incision sites) plays a more prominent role. In this delayed period, coagulation abnormalities can cause postpartum hemorrhage alone or contribute to bleeding from other causes, most notably trauma. These abnormalities may be preexistent or acquired during pregnancy, delivery, or the postpartum period. Potential causes include the following:
Uterine inversion"Traction": The traditional teaching is that uterine inversion occurs with an atonic uterus that has not separated well from the placenta as it is being delivered, or from excessive traction on the umbilical cord while placental delivery is being assisted. Studies have yet to demonstrate the typical mechanism for uterine inversion. However, clinical vigilance for inversion, secondary to these potential causes, is generally practiced. Inversion prevents the myometrium from contracting and retracting, and it is associated with life-threatening blood losses as well as profound hypotension from vagal activation.
 Author Maame Yaa A B Yiadom, MD, MPH Staff Physician, Department of Emergency Medicine, Cooper University Hospital, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School Maame Yaa A B Yiadom, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, National Medical Association, Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Coauthor(s) Daniela Carusi, MD, MSc Instructor, Obstetrics and Gynecology and Reproductive Biology, Harvard Medical School; Consulting Physician, Department of Obstetrics and Gynecology, Medical Director, Department of General Ambulatory Gynecology, Brigham and Women's Hospital Daniela Carusi, MD, MSc is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Reproductive Health Professionals, Massachusetts Medical Society Disclosure: Nothing to disclose. Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Mark L Zwanger, MD, MBA, FACEP Emergency Medicine Physician Mark L Zwanger, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians Disclosure: Nothing to disclose. Chief Editor Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE Chief, Department of Emergency Medicine, Sentara Norfolk General Hospital; Medical Ditector, Sentara Transfer Center; Professor and Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School; Board Member, American Academy of Emergency Medicine Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Additional Contributors Acknowledgements Special thanks to Dr. Donnie Bell for his assistance with the "Imaging" section for this topic. The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author, Michael P Wainscott, MD, to the development and writing of this article. Which condition in the client may lead to uterine atony?Higher risk factors for developing uterine atony include placental disorders, such as placenta accreta or placenta previa, and bleeding diathesis (i.e., increased tendency of the pregnant individual to bleed or bruise).
Which is the most common kind of placental adherence seen in the pregnant client?Placenta accreta: The placenta firmly attaches to the wall of your uterus. It doesn't pass through the wall of the uterus or impact the muscles of the uterus. This is the most common type.
Which nursing intervention would be beneficial for a client who has postpartum hemorrhage caused by uterine atony?The best safeguard against uterine atony is to palpate the client's fundus at frequent intervals to ensure her uterus remains contracted. The fundus should be firm to compress the bleeding vessels at the placenta site. 5. Assess for additional risk factors for postpartum hemorrhage.
What management is required for a client experiencing a postpartum hemorrhage?Nursing Interventions
Save all perineal pads used during bleeding and weigh them to determine the amount of blood loss. Place the woman in a side lying position to make sure that no blood is pooling underneath her. Assess lochia frequently to determine if the amount discharged is still within the normal limits.
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The ultrasonography report of a pregnant client reveals the presence of polyhydramnios
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