21.3: Postpartum Hemorrhage

Learning Objectives

By the end of this section, you will be able to:

• Differentiate between immediate (early) postpartum hemorrhage and secondary (late) postpartum hemorrhage
• Analyze the risk factors and causes of postpartum hemorrhage
• Explain the management of a postpartum hemorrhage
• Develop a nursing diagnosis that would be appropriate for a person experiencing a postpartum hemorrhage

Postpartum hemorrhage (PPH) is one of the most common complications of birth, occurring after 1 percent to 5 percent of births. PPH is defined by the American College of Obstetricians and Gynecologists (ACOG; 2017) as 1,000 mL of blood loss within 24 hours of birth for both vaginal and cesarean births. However, if 500 mL of blood is lost after a vaginal birth, this indicates a need for intervention.

Detection of Postpartum Hemorrhage

Labor and postpartum nurses must be aware of risk factors, prevention, and treatment of PPH. Risk factors include large for gestational age (LGA) infant, multiple gestation, grand multiparity, prolonged labor, chorioamnionitis, prolonged or precipitous labor, and placenta previa or placental abruption. Facilities have instituted a PPH risk-assessment tool to be used in recognizing those at risk for PPH (Faysal et al., 2023). This tool allows the nurse to prepare and monitor for a potential PPH. Some providers practice active management of the third stage of labor, meaning the health-care provider may apply umbilical cord traction to deliver the placenta quickly, order oxytocin (Pitocin) to be administered after the birth of the placenta, and begin uterine massage after delivery of the placenta (ACOG, 2017). Estimating blood loss is difficult because blood is mixed with amniotic fluid. The nurse plays a role in early detection of PPH by performing quantitative blood loss (QBL), the process of weighing and measuring the amount of blood lost during the birth and immediately postpartum. Many birthing facilities have a rapid response or hemorrhage team the nurse can activate during PPH cases. A multidisciplinary team is vital in treating PPH and preventing maternal mortality.

Link to Learning

The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) provides guidelines for quantifying blood loss during childbirth. Accurate measurement of blood loss is crucial for identifying postpartum hemorrhage and ensuring timely interventions. This video describes how to accurately quantify blood loss during childbirth.

Morbidity and Mortality Specific to Postpartum Hemorrhage in the United States

Approximately 11 percent of maternal deaths in the United States are caused by PPH; unfortunately, 54 percent to 93 percent of those deaths may have been preventable (ACOG, 2019). ACOG notes that some preventable cases are due to health-care providers underestimating the amount of blood loss and delaying treatment of PPH. This led to ACOG (2019) recommending that quantitative blood loss be assessed at all births.

Cultural Context

Global Results of Postpartum Hemorrhage

Postpartum hemorrhage causes 25 percent of all maternal deaths globally and is the leading cause of maternal mortality in low-income countries (Yeshitila et al., 2021). In low-income countries such as Ethiopia, delay in receiving care for obstetric complications is a major risk factor for maternal mortality. Non-pneumatic anti-shock garments (NASGs) are used in low-resource areas to prevent shock and death from postpartum hemorrhage. NASGs are neoprene and Velcro devices applied to the legs, similar to a sequential compression device (Figure 21.3). The NASG is then applied to the pelvis and abdomen to compress those areas and increase blood flow to the heart, lungs, and brain. This device can prevent hypovolemic shock while transporting the postpartum person to a higher level of care. In Ethiopia, the NASG was introduced in 2011 and has reduced maternal deaths from postpartum hemorrhage by 79 percent (Yeshitila et al., 2021). In low-income areas, this device has made an overwhelming difference for birthing women.

Figure 21.3 Non-pneumatic Anti-shock Garments The non-pneumatic anti-shock garment is placed to increase blood to the heart, lungs, and brain after a postpartum hemorrhage. (credit: “Non-pneumatic Anti-Shock Garment” by Alison El Ayadi, Elizabeth Butrick, Jillian Geissler, and Suellen Miller/ResearchGate.net, CC BY 2.0).

Early (Primary) Postpartum Hemorrhage

Postpartum hemorrhage that occurs after the birth of the placenta up to 24 hours postpartum is considered early PPH or primary PPH. It is more common than secondary, or late, PPH. Common causes of PPH are the four T’s—tone, trauma, tissue, and thrombin—with uterine atony being the most common cause of early PPH (Salati et al., 2019). Because of the increased blood volume of the pregnant person, classic signs of hypovolemia may not occur until a significant hemorrhage has occurred. See Chapter 19 Complications of Labor and Birth for further discussion of early (primary) postpartum hemorrhage.

Late (Secondary) Postpartum Hemorrhage

Postpartum hemorrhage that occurs after the first 24 hours up to 12 weeks postpartum is considered late PPH or secondary PPH. The most common cause of late PPH is subinvolution, which is the inability of the uterus to return to its original size. At the 6-week follow-up, subinvolution is diagnosed when the patient’s uterus is larger than expected and the lochia has not progressed to lochia alba. Retained placenta or membranes can be another cause of late PPH and can also lead to infection and bleeding. Just as coagulation disorders can cause early PPH, these disorders can also cause late PPH. The nurse will give the patient anticipatory guidance and signs of when to call their health-care provider if late PPH were to occur.

Recognizing Postpartum Hemorrhage

Nurses caring for postpartum patients need to monitor for and recognize the signs and symptoms of postpartum hemorrhage before the patient is compromised. Two important nursing actions are monitoring blood loss and recognizing the signs and symptoms of hypovolemia. Both of these actions provide nurses with cues to diagnose fluid volume deficit.

Quantitative Blood Loss

Measuring quantitative blood loss (QBL) has been recommended for all births by ACOG (2019) because estimated blood loss is inaccurate. Research has shown that blood loss is underestimated with larger blood loss and overestimated with smaller blood loss (ACOG, 2019). To perform QBL, birthing facilities must provide scales for weighing sponges and drapes that allow quantification of blood loss. Research has also found that facilities using QBL have reduced rates of maternal morbidity, decreased time until escalation of care, and increased team awareness of the need for emergency intervention (AWHONN, 2021).

Clinical Safety and Procedures (QSEN)

Determining Quantitative Blood Loss

The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) recommends the following education and supplies be utilized for determining QBL:

1. using standardized items to calculate QBL
2. ensuring all labor and postpartum rooms and operative suites have access to scales and PPH carts
3. attaching a laminated list of the dry weight of sponges and pads to all scales for accurate measurement
4. ensuring electronic charting automatically deducts dry weights from wet weights
5. providing laminated staging algorithms in each room or on the PPH cart
6. practicing simulation drills for PPH with all members of the interprofessional team
7. debriefing after each PPH to identify areas of needed education

(AWHONN, 2021)

Signs and Symptoms of Hypovolemia

The blood loss from postpartum hemorrhage results in hypovolemia. Early symptoms and signs of hypovolemia include feeling weak, dizzy, and anxious; decreased blood pressure; and increased pulse and respiratory rates. Severe hypovolemia causes tachycardia, hypotension, decreased oxygen saturation, thirst, restlessness, low body temperature, and decreased urinary output (Figure 21.4). The postpartum person becomes pale and diaphoretic, confused, and loses consciousness as the hypovolemia becomes critical. The pregnant person has 50 percent more blood volume than the nonpregnant person (Agrawal et al., 2018). As a result, the postpartum person may not exhibit signs of hypovolemia until they have lost a significant amount of blood. Therefore, the nurse monitors blood loss closely for all postpartum patients, especially for those persons at higher risk for PPH.

Figure 21.4 Hypovolemic Shock These are symptoms and signs of hypovolemic shock. (CC BY 4.0; Rice University & OpenStax)

Causes of Postpartum Hemorrhage

As mentioned earlier, the causes of postpartum hemorrhage can be summarized using the four T’s of tone, trauma, tissue, and thrombin. See Chapter 19 Complications of Labor and Birth for further discussion of the four Ts.

Tone

Tone refers to the tone of the uterus. To stop bleeding from the placental site, the uterine muscles contract to strangulate the spiral arteries that are feeding blood to the placenta. If the uterine muscles are not contracted, the fundus is soft and boggy, and the spiral arteries are free to pump blood and cause rapid blood loss. Risk factors associated with PPH secondary to uterine atony include a large number of previous births, chorioamnionitis, prolonged labor with oxytocin (Pitocin) use, general anesthesia, macrosomic babies, multiple gestations, and polyhydramnios. A full bladder can also impede the uterus from contracting (Milton, 2024).

Trauma

Trauma refers to lacerations in the reproductive tract, uterine rupture, hematomas, and uterine inversion. All these circumstances can cause rapid blood loss. Hematomas might not be identified immediately, but the postpartum person will report increased pain, and vital signs will show a decrease in blood pressure and an increase in heart rate. Risk factors for PPH secondary to trauma include precipitous birth, delivery of an LGA infant, poor nutritional status, use of oxytocin during labor, uterine tachysystole, and the use of vacuum extractor or obstetric forceps. Risk factors leading to uterine inversion are excessive traction on the umbilical cord and fundal placenta implantation (Milton, 2024).

Tissue

Tissue refers to retained placental tissue. The retained tissue can be a large cotyledon or a small piece of membrane. This tissue interrupts the uterus from contracting and leads to PPH. Risk factors for retained placenta are early preterm birth (less than 32 weeks’ gestation), extra placental lobes, placenta accreta, and a history of uterine surgery. Retained tissue can also lead to postpartum infection (Shields et al., 2023).

Thrombin

Thrombin refers to coagulation disorders. Disorders in the activation or amount of thrombin include von Willebrand disease and thrombocytopenia. Other bleeding disorders include lack of required features of the clotting cascade (ACOG, 2017). Disseminated intravascular coagulation (DIC) can also lead to PPH because of the inability of the blood to clot. See Chapter 19 Complications of Labor and Birth for further discussion of DIC. Risk factors for coagulation issues are intrauterine fetal demise, placental abruption, sepsis, DIC, and genetic coagulation disease (ACOG, 2017).

Management of Postpartum Hemorrhage

Management of PPH differs for early and late PPH. Late PPH is managed in the office or perhaps in the emergency department and many times is treated with antibiotics or methylergonovine (Methergine). If retained placental products are suspected, dilation and curettage may be performed. Management of early PPH occurs in the birthing room and will depend on the cause of the hemorrhage. Because uterine atony is the most common cause of early PPH, interventions to induce uterine contractions are quickly performed.

Fundal Massage

Fundal massage is the technique of massaging the uterus to stimulate contractions to decrease postpartum bleeding. The nurse places one hand on the fundus and the other hand guards the uterus. The hand on the fundus massages until the uterus becomes firm. When the uterus contracts, it stops the blood from being pumped by the spiral arteries (Bilgin & Komurcu, 2020). This is almost always the first intervention for postpartum bleeding. Figure 21.5 demonstrates fundal massage.

Figure 21.5 Fundal Massage The nurse massages the fundus to induce uterine contractions to control postpartum bleeding. (CC BY 4.0; Rice University & OpenStax)

Oxytocin

Oxytocin (Pitocin) is the first-line medication to treat PPH. The usual dose is 10 to 40 units in 500 to 1,000 mL of intravenous (IV) fluid (ACOG, 2017). During PPH, oxytocin is infused as a bolus. It can also be administered intramuscularly (IM) with the usual dose of 10 units when IV access is not available. The goal is to stimulate contractions to treat uterine atony. The nurse explains to the postpartum person that strong uterine contractions will occur due to oxytocin administration but that the medication will treat or prevent PPH. See Chapter 19 Complications of Labor and Birth for further information regarding oxytocin.

Misoprostol

Misoprostol (Cytotec) is a prostaglandin used for cervical ripening or labor induction. It is also used to treat PPH because it induces uterine contractions. The usual dose for PPH is 600 to 1,000 mcg orally, rectally, or sublingually (ACOG, 2017). Even though it is a prostaglandin, misoprostol does not cause reactive airway constriction or an asthma flare. It can be given to persons with hypertension. Therefore, it is a safe prostaglandin to be administered to most postpartum persons. Misoprostol can, however, cause nausea, vomiting, diarrhea, chills, some rise in blood pressure, and fever. These symptoms are not severe and resolve over several hours.

Methylergonovine

Methylergonovine (Methergine) is also a uterotonic. It produces sustained uterine contractions to help treat PPH. It is the only uterotonic that causes sustained versus rhythmic contractions. The usual dose is 0.2 mg IM for early PPH (ACOG, 2017). It should not be given IV. It should also not be given to persons with hypertension or preeclampsia. Methylergonovine can be used for late PPH and subinvolution, but it is administered orally for several days. The side effects of methylergonovine include nausea, vomiting, and hypertension.

Carboprost

Carboprost (Hemabate) is a strong prostaglandin that induces uterine contractions. The usual dose is 250 mcg IM (ACOG, 2017). It can also be administered into the muscle of the uterus by the health-care provider in a severe case of PPH. Carboprost has serious side effects, and the nurse should inform the postpartum person that the following side effects may occur: nausea, vomiting, fever, diarrhea, chills, and bronchospasm. The nurse may medicate the person with an antipyretic and antidiarrheal, as prescribed, to possibly prevent these side effects. Carboprost should not be given to a person with asthma due to its bronchospasm side effect.

Tranexamic Acid

Tranexamic acid, or TXA (Cyklokapron), is an antifibrinolytic that can reduce mortality from PPH by reducing complications from the clotting cascade (ACOG, 2017). TXA blocks the breakdown of clots; prevents bleeding complications, such as DIC; and has very few side effects. The usual dose is 1 g in 100 mL of IV fluid administered over 10 minutes. It should be given within 3 hours of birth and is prescribed in conjunction with a uterotonic.

Intrauterine Tamponade

When PPH continues despite uterotonic administration and bimanual massage, compression of the uterus through bimanual compression or intrauterine tamponade may be the next intervention; the uterine tamponade system is inserted by the health-care provider (ACOG, 2017). Two systems of intrauterine tamponade are available in the United States, the Bakri Balloon and the Jada System. If neither is available, some health-care providers will pack the uterus with gauze. The Bakri Balloon is designed to be used as a tamponade during a PPH (Figure 21.6). The balloon is placed in the uterus and inflated by the health-care provider. Acting as a tamponade, the balloon compresses the inside of the uterus to stop the bleeding.

Figure 21.6 Bakri Balloon The Bakri Balloon is used as a tamponade in the uterus during a PPH. (CC BY 4.0; Rice University & OpenStax)

Link to Learning

This video from Cook Medical, the manufacturer of the Bakri balloon, explains how it is inserted.

The Jada System is a device that uses an intrauterine vacuum to contract the uterus around the device to stop the bleeding. It is also placed by a health-care provider. The system is then connected to a vacuum device or wall suction (Figure 21.7).

Link to Learning

This video from Jada explains how the system is inserted and how it works.

Figure 21.7 Jada System for Intrauterine Tamponade The Jada System is inserted by the health-care provider to treat PPH by causing the uterus to contract around the device to stop the uterus from bleeding. (CC BY 4.0; Rice University & OpenStax)

Hysterectomy

Hysterectomy is the last procedure if all other interventions to control a PPH have failed. The uterus is removed, and the blood vessels feeding the uterus are tied off and cauterized. Because the uterus is removed, a hysterectomy results in permanent sterilization (Kallianidis et al., 2021). The risk of surgical complications is increased, including infection, further blood loss, bladder and ureteral injuries, and damage to the bowel. The postpartum person will need a great amount of emotional support from the nurse after an unexpected hysterectomy. The nurse will provide postsurgical care and education, including encouragement of ambulation, teaching about signs of infection of the incision, pain control, and help with breast-feeding to avoid pain from the surgical site.

Nursing Assessment and Diagnosis

Nursing assessment for PPH begins by determining risk factors prior to birth. Several tools have been developed to measure a postpartum person’s risk for PPH (Lagrew et al., 2022). Assessment for PPH continues until discharge. The nurse will watch for bladder distention that could cause uterine atony and assist the patient in emptying the bladder in those cases. The nurse encourages the patient to void frequently (every 2 hours), performs QBL throughout the postpartum hospitalization, monitors vital signs for symptoms of hypovolemia, performs fundal assessment of the tone of the uterus and massages the fundus when needed, and assesses the perineum for signs of hematoma (Elsevier, 2024). When caring for a patient who had a cesarean birth, the nurse assesses the abdomen and incision for bleeding. Nursing diagnoses made according to these assessments include fluid volume deficit, impaired tissue perfusion, and risk for excessive bleeding.

Fluid Volume Deficit

Postpartum hemorrhage causes the postpartum person to have a deficiency in fluid volume. The nurse will assess for signs of dehydration (increased thirst, weakness, tachycardia, decreased urine output). The nurse will administer a rapid bolus of IV fluids or a blood transfusion to replace the lost fluid volume as prescribed by the health-care provider. When a blood transfusion is ordered, the nurse will also monitor for signs of a transfusion reaction and fluid overload. Urine output is monitored and should be at least 30 mL/hr. If the person does not have an indwelling urinary catheter, the nurse may insert one to monitor output more closely, when ordered.

Impaired Tissue Perfusion

The nurse will monitor capillary refill and oxygen saturation to assess for decreased tissue perfusion. During a PPH, the vessels of the extremities contract to shunt blood to the lungs, heart, and brain. Therefore, peripheral perfusion is decreased. A warm blanket is wrapped around the person to keep the body and extremities warm. The nurse positions the person with elevated legs and keeps the person on bed rest. Supplemental oxygen can be administered and titrated based on the oxygen saturation, as prescribed.

Risk for Excessive Bleeding

The nurse assesses for signs of excessive bleeding from the uterus, incision, and potential sites of hematomas. The nurse also assesses for cues that bleeding continues to be excessive. These cues include worsening vital signs, change in neurologic status, shortness of breath, pallor, and soaking a peripad in less than 1 hour. Lab results (CBC and clotting studies) are monitored often. Fundal assessment and massage are performed frequently to ensure the uterus continues to stay contracted (firm).

Unfolding Case Study

Labor and Delivery: Part 3

See Labor and Delivery: Part 2 for a review of the patient data.

After 20 hours of labor, Brianne had a vaginal delivery of a male infant with mild shoulder dystocia (shoulders delivered within 30 seconds). Infant birth weight is 3,995 g. Placenta delivered spontaneously and intact by inspection. A second-degree vaginal laceration was repaired. Quantitative blood loss is 450 mL. The postpartum admitting nurse received the past medical history during the SBAR (situation, background, assessment, and recommendation tool) from the labor and birth unit.

Past medical history	36 years old, G1 P1 Allergy to penicillin A negative, antibody screen negative Rubella nonimmune Negative tests for STIs at initial prenatal visit and 36 weeks’ gestation GBS positive and treated during labor Gestational diabetes diagnosed at 26 weeks Husband, Trey, present for labor and birth, very supportive
Nursing notes	Postpartum Admission Assessment
	Postpartum Data	Data Obtained at Admission to the Floor
	Maternal BP	128/84
	Maternal TPR	99.6°F, 88, 18
	Pain/location	2/perineal
	Breasts	Soft/nipples intact
	Location of fundus	Midline/2 finger breadths below umbilicus
	Consistency of fundus	Firm
	Color of lochia	Rubra
	Amount of lochia	Moderate
	Abnormal odor to lochia	Absent
	Labial edema	Present
	Laceration	Intact
	Perineum	Soft, no bruising
Flowchart	Vital Signs Admission to L&B Unit BP 128/74; Temp 98.2 (F), Pulse 84, Resp 18 10 hours after admission 120/64; 98.4°F, 76, 20 14 hours after admission 124/68; 99.8°F, 80, 20 1 hour after birth 118/68; 99.4°F, 84, 18
Provider’s orders	Transfer to mother/baby unit IV 1,000 mL LR with 20 units oxytocin (Pitocin) at 125 mL/hr May discontinue IV fluids when patient is tolerating regular diet and voiding without difficulty Regular diet Continue pad count to monitor cumulative QBL (quantitative blood loss) Ice pack to perineum for 24 hours Ibuprofen 600 mg po every 6 hours prn pain May get out of bed and shower with assistance when stable and has recovered from epidural RhoGAM workup if Rh negative Administer rubella vaccine before discharge if nonimmune

1.

The nurse assesses the patient 2 hours after admission to the mother/baby unit.

Postpartum Data	Current Data
Maternal BP	124/64
Maternal TPR	99.4 °F, 92, 20
Pain/location	4/uterine cramping
Breasts	Soft/nipples intact
Location of fundus	Deviated to right/2 finger breadths above umbilicus
Consistency of fundus	Boggy
Color of lochia	Rubra
Amount of lochia	Saturated peripad and passed two walnut-sized clots
Abnormal odor to lochia	absent
Labial edema	present
Laceration	intact
Perineum	soft, no bruising

What are the priority nursing actions at this time? Select three that apply.

1. Administer ibuprofen 600 mg po now.
2. Discuss the purpose of Rho(D) immune globulin.
3. Insert a Foley catheter to empty the bladder.
4. Educate the patient on signs and symptoms of preeclampsia.
5. Determine the patient’s QBL.
6. Educate the patient on the importance of ice to the perineum for the first 24 hours.
7. Massage the patient’s uterus.
8. Assist the patient to the bathroom to void.

2.

The nurse performs the priority nursing actions and obtains new patient data on Brianne. Identify if the new patient data demonstrate that nursing actions were effective, unchanged, or ineffective.

Patient Data	Data Obtained prior to Nursing Actions	New Patient Data after Nursing Actions	Effective, Ineffective, or Unchanged
Pain/location	5/uterine cramping	2/uterine cramping	effective ineffective unchanged
Location of fundus	Deviated to right/2 finger breaths above umbilicus	Midline/at the umbilicus	effective ineffective unchanged
Consistency of fundus	Boggy	Firm	effective ineffective unchanged
Color of lochia	Rubra	Rubra	effective ineffective unchanged
Amount of lochia	Saturated peripad and passed two walnut-sized clots	Saturated ¼ of the peripad	effective ineffective unchanged
Laceration	Intact	Intact	effective ineffective unchanged
Perineum	Soft, no bruising	Soft, no bruising	effective ineffective unchanged