Postpartum Hemorrhage

Postpartum hemorrhage is a major cause of maternal morbidity and mortality, second only to cardiovascular disease. In the United States, the overall rate of postpartum hemorrhage increased by 26% between 1994 and 2006. Postpartum hemorrhages (PPH) is a low volume, high-risk event that labor and delivery (L&D) nurses need to be prepared for. Rapid recognition and response are necessary to prevent the progression of hemorrhage as women can lose large volumes of blood very quickly due to the physiologic changes of pregnancy (OB Hemorrhage Toolkit, 2019).

Early identification of abnormal blood loss helps to prevent major hemorrhage. The 4 areas that need to be addressed for all women giving birth are:

1. Recognition
2. Preparation
3. A standardized approach to measuring cumulative blood loss
4. Recognition of clinical findings suggesting hypovolemia (OB Hemorrhage Toolkit, 2019)

Hemorrhages can occur prior to birth, early postpartum (within the first 24 hours), or late postpartum (≥ 24 hours postpartum), but there is no single definition of hemorrhage.

A commonly used definition of > 500 mL for a vaginal birth and > 1,000 mL for a cesarean birth is inconsistent and not related to morbidity but may be useful as an alert for concern. In healthy women, blood loss is generally tolerated without vital sign changes until the total loss exceeds 1,000 mL (OB Hemorrhage Toolkit, 2019). In 2017, the American College of Obstetricians and Gynecologists (ACOG) revised their definition of PPH from the classic one described above to cumulative blood loss ≥1000 mL or bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process regardless of the delivery route (Committee on Practice Bulletins, 2017).

It is difficult to determine the exact incidence because of varying criteria, and it may occur in up to 5% of all deliveries (Sheldon et al., 2014). The rate of postpartum hemorrhage in the United States increased by 26% between 1994 and 2006.

In late pregnancy, uterine artery blood flow is 500-700mL/min. This blood flow is 15% of the woman's cardiac output. In a normal delivery, once the placenta detaches from the uterus (and delivers), the myometrium contracts, which compresses blood vessels and maintains hemostasis. Hemostatic factors cause clotting at this time. An interruption to either of these processes can cause a hemorrhage (Lockwood, 2001).

There are numerous causes of PPH. Consider the 4 "Ts" when evaluating a postpartum hemorrhage:

• Tone
• Trauma
• Tissue
• Thrombin

Uterine atony (lack of uterine tone) is the largest cause of hemorrhage, accounting for 70-80% of all postpartum hemorrhages. When looking for lacerations, hematoma, or a ruptured uterus, trauma should be considered. The third "T," tissue, refers to retaining placental tissue, and the last "T," thrombin, refers to coagulopathy. The patient may have an undiagnosed bleeding disorder or may have disseminated intravascular coagulation (DIC) (Nationwide Sample of Deliveries, 2010).

Many factors can raise the risk of PPH, although there can be PPH without risk factors. Up to 40% of PPH occurs in low-risk women. The risk factors are (Committee on Practice Bulletins, 2019):

A history of severe postpartum hemorrhage puts the woman at the highest risk for a subsequent postpartum hemorrhage (Nyfløt et al., 2017).

Postpartum hemorrhage risk assessments should be performed upon admission, pre-birth, and post-birth (Pphproject.org, 2019). The Association for Women's Health, Obstetric, and Neonatal Nursing (AWHONN) created one version of a PPH risk assessment that can be used to assess women for their risk of PPH.

This tool is comprehensive because it looks at admission, pre-birth, and post-birth factors, all of which can affect a woman's risk of hemorrhage. The tool even gives suggestions for interventions based on the woman's risk. For example, a woman who is low-risk only needs a "type and hold" order from the blood bank, but a woman who is medium-risk should have a "type and screen" from the blood bank, and certain personnel should be notified of the risk (provider, charge RN, anesthesia, blood bank). A high-risk woman should have a "type and cross," notify personnel and possibly deliver at a tertiary care center (Pphproject.org, 2019).

The California maternal quality care collaborative (CMQCC) also has a postpartum hemorrhage risk assessment similar to the AWHONN tool. With any risk assessment, it is important to remember that admission risks will remain, but labor and delivery can impose new risks to the woman.

Special consideration must be given to women who choose not to accept blood products, such as a woman who is a Jehovah's witness. These women should be identified and counseled prenatally. The woman should be given information and a checklist to fill out, stating which products she wishes to receive or not. The woman should have a designated healthcare proxy. Some women will accept certain products, such as her blood, from a cell salvage system. It is important to have a care plan for this woman and have the information available at the hospital. It is also important that these women have their hematocrit measured regularly near the end of pregnancy so the woman can take iron and vitamin C as needed to maintain their hematocrit. Erythropoietin is a medication used to maximize red blood cell production and may be given to these women (Massiah et al., 2007). These women are at high risk and have special needs before delivering their babies.

Accurate measurement of blood loss is essential for recognizing potentially life-threatening hemorrhages and the management of blood product replacement (OB Hemorrhage Toolkit, 2019). Visual identification of blood loss has been used in the past. There are serious problems with the visual estimation of blood loss. Amniotic fluid can impact the volume that is being identified. Providers tend to underestimate large blood loss volumes, leading to delayed treatment and increased complications for the woman.

As soon as PPH is recognized, treatment must begin. The evidence shows it works best for unit-standard, stage-based obstetric hemorrhage emergency management plans with checklists  (Maternal Health, 2019).  There are many components to this. Current evidence recommends that oxytocin be given as a third stage of active management (after delivery). This dosage has decreased the chance of PPH (OB Hemorrhage Toolkit, 2019).

It is important to know that signs of hypovolemia may not occur until there is large blood loss (OB Hemorrhage Toolkit, 2019).

*Pulse pressure is the difference between the systolic and diastolic blood pressure.

It is also important to remember that when the patient starts bleeding heavier than normal, atony is usually the cause. It is important to perform a thorough assessment, perform fundal massage, ensure her bladder is empty, and stay with the patient while help is called.

Some numerous checklists or algorithms follow the stages of hemorrhage. The checklists are similar, and each hospital should choose one to use. The ideal algorithm has all the stages on one page (OB Hemorrhage Toolkit, 2019). Some algorithms have a page for each stage of hemorrhage and treatment.

Table 3:

There may be some differences in definitions within each algorithm. Generally, stage 1 occurs when there is blood loss > 500mL in vaginal birth and >1000mL in a cesarean section, but under 1500mL blood loss. During stage 1, the RN (or designee) should establish IV access if not present, increase IV oxytocin rate, apply vigorous fundal massage, and start giving medication. Vital Signs, including O₂, sat & level of consciousness (LOC), should occur within 5 minutes. Administer oxygen to maintain O₂ sats at >95% as needed. The patient should have her bladder emptied with a straight catheter or foley and type and crossmatch for 2 units of red blood cells STAT. Providers and RN should be discussing the cause of PPH.

Stage 2 occurs when the bleeding continues but is <1500mL. The patient should have additional medications, a 2nd IV, and blood brought to the bed. Labs should be ordered. The reason for PPH still needs to be determined. The patient may need to go to the OR. A uterine tamponade balloon may be useful. All OB providers should be trained to use a uterine tamponade balloon. The RN may assist by filling the balloon as directed by the manufacturer.

Stage 3 occurs when blood loss is >1500mL; the patient has had 2 units of blood or is unstable. At this time, all emergency personnel, including anesthesia, should be present. The massive transfusion protocol should be activated. The patient will need blood and blood products. A body and fluid warmer should be used at this time. The patient may need central hemodynamic monitoring. The patient may also need a hysterectomy or uterine artery ligation. This woman is at risk of shock and cardiac arrest (OB Hemorrhage Toolkit, 2019). She may require close observation in the intensive care unit (ICU) once the crisis has passed.

All labor and delivery units should be prepared for hemorrhage. Every unit should have all medications available immediately. Each unit should also have a cart with hemorrhage supplies and checklists ready. A uterine tamponade balloon with instructions should also be included in the cart. Hospitals should also have a response team for this type of emergency, a massive transfusion protocol, and emergency blood release checklists  (Maternal Health, 2019). Labor and delivery units should also be conducting hemorrhage drills with L&D staff and providers. Drills allow the staff to improve communication and readiness and determine any barriers to appropriate treatment (Committee Opinion, 2011).

Postpartum hemorrhage is a traumatic experience for the woman, her family, and the caregivers. During a crisis, it is difficult to explain what is happening. Studies have shown that some women never receive an explanation of what happened. The woman needs to know what happened so she can process the event. During the crisis, it also may be beneficial to the woman and the family if the family can stay with the patient. It is important to provide a calm, healing environment after the crisis. Attention to the woman's emotional status is important. If needed, she must be assessed for acute trauma and referred to counseling services (OB Hemorrhage Toolkit, 2019). Caregivers may also experience acute trauma and should seek resources as needed. Most hospitals have an employee assistance program that can start the process., 2017).

Victoria is a 31-year-old G2P1 who underwent a cesarean at 11 pm for a prolonged second stage and arrest of descent after 24-hour labor with dysfunctional labor, augmentation, and a 3-hour second stage. The birth weight was 4800 grams. Pre-op hematocrit was 37%. During surgery, blood loss was reported to be 1000 mL, and an extension of the transverse uterine incision was sutured while extending in the left broad ligament. The patient is now in the recovery room at midnight and complaining of abdominal pain. BP 120/60, pulse 120. The patient passed a moderate amount of blood clots. Oxytocin running IV (125 cc/hr of D5RL with 20 U oxytocin). At 12:30 am, the patient passed more clots. BP 70/40, pulse 150, urine output less than 20cc since surgery. The abdomen seems distended.

Think about:

• Who should manage the patient?
• Is an exam or surgery required?
• What is the most likely cause?
• What supplies should be readily available?
• Who needs to be mobilized?

The patient is taken to surgery. Ten minutes before surgery, the patient is clearly in shock and oozing from IV sites and bleeding per vagina. The incision opened, revealing a large hematoma in the broad ligament extending retroperitoneally. Bleeding occurs from the left corner uterine incision. Massive transfusion protocol started.

Postpartum hemorrhage is a serious complication of childbirth that increases maternal morbidity and mortality. PPH can have long-lasting effects on the woman, her family, and her caregivers. All L&D units must always be prepared for a hemorrhage. Supplies, medications, drills, and debriefings are all necessary tools to improve a woman's care during a postpartum hemorrhage.

• Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol 2017; 130:e168. Reaffirmed 2019.
• Committee Opinion No. 487: Preparing for Clinical Emergencies in Obstetrics and Gynecology. Obstetrics & Gynecology. 2011;117(4):1032-1034. doi:10.1097/aog.0b013e31821922eb.
• Lockwood CJ. Regulation of plasminogen activator inhibitor 1 expression by the interaction of epidermal growth factor with progestin during decidualization of human endometrial stromal cells. Am J Obstet Gynecol 2001; 184:798.
• Massiah N, Athimulam S, Loo C, Okolo S, Yoong W. Obstetric care of Jehovah's Witnesses: a 14-year observational study. Arch Gynecol Obstet. 2007;276(4):339-343.
• Maternal Health | Council. Obstetric Hemorrhage ( AIM) -. Accessed November 27, 2019. Visit Source.
• Nationwide Sample of Deliveries. The Epidemiology of Postpartum Hemorrhage in a Large, (2010). Survey of Anesthesiology, 54(6), pp.282-283.
• Nyfløt, L., Sandven, I., Stray-Pedersen, B., Pettersen, S., Al-Zirqi, I., Rosenberg, M., Jacobsen, A. and Vangen, S. (2017). Risk factors for severe postpartum hemorrhage: a case-control study. BMC Pregnancy and Childbirth, 17(1).
• OB Hemorrhage Toolkit V 2.0. OB Hemorrhage Toolkit V 2.0 | California Maternal Quality Care Collaborative. Accessed November 26, 2019. Visit Source.
• Pphproject.org. (2019). The AWHONN Postpartum Hemorrhage Project |. Accessed November 27, 2019. Visit Source.
• Sheldon WR, Blum J, Vogel JP, et al. Postpartum hemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG 2014; 121 Suppl 1:5.
• Tirelli MA, Colpa-Lewis C. Nurse-Led Debriefing to Create a Culture of Safety Following Obstetric Emergencies. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2017;46(3). doi:10.1016/j.jogn.2017.04.115.
• Triton L&D — Gauss Surgical. Accessed November 27, 2019. Visit Source.