Subject: Postpartum Hemorrhage (PPH)

POLICY:  Obstetrical hemorrhage is defined as a blood loss of 500 cc or greater blood loss.  Note: Clinical estimation of blood loss may be often underestimated by 30-50%.

Possible Causes/ Risk Factors:

·         Uterine atony (caused by retained placental fragments or prolonged labor)

·         Over distended uterus

·         Distended bladder

·         PIH

·         Uterine infection

·         Multiple gestation

·         Polyhydramnios

·         Large baby

·         Precipitous labor and delivery, or prolonged 1st or 2nd stage

·         Grand multiparity

·         Cervical lacerations, extensive laceration of perineum and vagina

·         Uterine rupture, laceration of lower uterine segment

·         History of previous PPH

·         Pitocin induction of labor

·         Placental abnormalities- placental accreta, low lying placenta, partial separation of placenta

GUIDELINES: 1. Normal Care Following Delivery- Assessment of:

·         Uterine tone

·         Uterine position

·         Placental separation

·         Maternal vital signs

·         Completeness of the placenta

·         Estimated blood loss

2.  Measuring Estimated Blood Loss-

·         Visual inspection and estimation

·         Collecting blood in measuring cup

·         Weight of underpad and estimating (1cc of blood = apx. 1 gm)

·         Note: Blood collected with the placenta can include amniotic fluid, maternal urine, which can account for up to 10-20% of the total volume

 

PROCEDURE: 1. Facilitate 3rd Stage

·         Midwife and Birth Assistant will remain in the birth room with the mother for the entirety of the third stage until hemostasis.

·         Have client push with contraction

·         Apply gentle cord traction, while guarding the uterus

·         Initiate breastfeeding, or nipple stimulation

·         Assess bladder status, consider catheterization as necessary

·         Consider 10 IU pitocin IM, consider herbal tinctures if appropriate, consider administration of 400 mcg misoprostol PO or rectally

·         Change maternal position, ie: squat, stand

2.   Hemorrhage Before the Birth of the Placenta

·         Explain to client what is happening

·         Facilitate birth of the placenta (see procedure #1)

·         Assess blood loss, uterine atony

·         Assess uterine tone and position q 15 min and as needed.

·         Assess vitals, bladder status q 15 min and as needed.

·         Assess location of placenta if possible ie: still adhered, or detached from uterine wall, assess cord lengthening

Elicit uterine contraction, have mother push with gentle cord traction

·         Consider administering medications (10IU pitocin IM, 400 mcg misoprostol PO or rectally)

·         Consider applying oxygen, putting mother in shock position, keep mother warm and responsive

·         Consider catheterization

·         Consider IV hydration, consider 20 units pitocin in 1000cc LR fluid

·         In the case of immediate excessive hemorrhage before the placenta, consider manual removal of placenta

·         Consider transport to hospital, consider possibility of placental accreta

4.   Hemorrhage After the Birth of the Placenta

·         Explain to client what is happening

·         Assess blood loss: due to uterine atony, lacerations?

·         Assess uterine tone and position

·         Assess vitals, level of consciousness, avoid rough handling

·         Consider administration of medications (10IU pitocin, 400mcg misoprostol PO or rectally)

·         Assess full bladder, catheterize as needed

·         Assess completeness of placenta

·         Massage uterus to stimulate a contraction

·         Consider clots that need to be expelled

·         Consider external or internal bimanual compression

·         Consider applying oxygen, consider shock care, keep warm

·         Consider IV hydration, consider 20 units pitocin in 1000cc LR fluid and consider methergine 0.2mg IM or PO.

·         Consider the possibility of retained fragments, lobe

·         Consider transport

5.  If Significant PPH or Indications of Shock Present, Call EMS for Immediate Transport (SignificantPPH is >4-5 cups/~700cc-1000cc)

                        While waiting for EMS:

·         Inform client and family of what is happening

·         Continue to administer oxygen

·         Continue to treat client for s/s shock

·         If IV not in place, place IV fluids

·         Keep warm, avoid rough handling

·         Continue attempting to control bleeding by use of bimanual compression

·         Continue to attempt delivery of placenta if not delivered

·         Monitor vitals q 5 minutes until EMS arrives

·         Midwife to accompany client on transport

6.  Late PPH

·         Serious uterine hemorrhage occasionally develops 1-2 weeks postpartum, but could occur up to 6 wks pp

·         May be the result of abnormal uterine involution (subinvolution) of the placental site, due to retained portion of the placenta or placental fragment

·         May be caused by inappropriate physical activity of mother, “doing too much”

·         Infection may be a possible cause

·         Persistent anemia may be a factor in women continuing to bleed or experiencing late PPH

7.  Postpartum Care for Women With PPH

·         At 2 day pp visit, assess: bleeding, involution, Hct, any signs of infection, anemia

·         Advise iron supplementation

·         Assess for any signs of dizziness, heart palpitations, chest pain, shortness of breath, tachycardia, decreased blood pressure

·         If Hct less than 24.0/ hemoglobin of <8 mg/dL, refer to physician for consultation

·         Consider monitoring for s/s of: PPD, breastfeeding issues, milk productions concerns, poor bonding, increased fatigue

SIGNS AND SYMPTOMS OF SHOCK

·         Tachycardia: Pulse>120, or Bradycardia: Pulse <50

·         Respirations >30 or <10

·         Faintness, pallor

·         Decreased maternal temperature

·         Loss or change in consciousness

·         Persistent severe headache

·         Seizure

·         Chest pain, breathing difficulty

·         Maternal feeling of impending doom

·         Persistent fall in blood pressure , 80/50 (often a late symptom of shock)

MEDICATIONS USED IN TREATMENT OF PPH

·         Pitocin: 10 IU administered IM, maternal thigh, may be used up to two (2) injections

·         Misoprostol: 600mcg  administered PO or rectally

·         Methergine: 0.2mg ampule IM, may administer once only after delivery of the placenta and assessment of maternal blood pressure, as methergine can cause hypertension

·         Methergine: 0.2mg tablet may be given po q 4 hours x 6 doses to maintain uterine contracted state after the immediate PPH has been resolved

HERBS TO CONSIDER FOR USE IN NORMAL 3RD STAGE/PREVENT PPH

Herbs may be considered for use in the case of PPH prevention, however if the desired effect is not demonstrated quickly, the midwife will move on to use pharmacologic medications.

·         Cotton Root Bark: Powerful oxytocic properties, acts synergistically with and facilitates the action of oxytocin.  Effective in stimulating strong uterine contractions.  Has been used for years to control pp bleeding and to stimulate labor.  Can be used prior to the birth of the placenta and after. Dosage: 20-40 drops tincture under tongue, can be given every 2-5 minutes, up to 4 doses

·         Shepherd’s Purse: Promotes blood coagulation , vasoconstriction and uterine contraction.  Effects of shepherd’s purse usually noted within 30 seconds to 3 minutes. Do not use with women with severe varicosities or may be at risk of thrombophlebitis.  Dosage: Best to be used in combination with cotton root bark, ½ dropperful shepherd’s purse/ ½ dropperful cotton root bark.

·         Blue Cohosh: Excellent uterine tonic, used to stimulate uterine contractions, used well in combination with other oxytocic herbs, useful in promoting the birth of the placenta.  Dosage: ½ dropperful used in combination with ½ dropper of cotton root bark