Pathophysiology Paper: Post-partum hemorrhage

Jessi Crowden
For
Professor Sarah Holda
Nursing 176- Maternity Nursing
Jackson College Winter Semester
February 5, 2017
 Women who are coming in to give birth are not always thinking about their own health.

Being more concerned with the health of the baby, any complications that may occur, pain

associated with birth and maybe last on the list their own post-partum health. Post-partum

hemorrhage is huge factor in maternal death in the US and the world (McKinney). Wanting your

baby to be healthy and perfect is what is on most mothers’ minds, or how they are going to

take care of the baby once they go home. Their own health gets pushed to the back of their

mind especially once the baby is born. Educating mothers and caregivers to the signs and

symptoms of post-partum hemorrhage is a big deal and can possibly be a lifesaving maneuver.

Normal births are bloody and messy and there is an overabundance of fluid, but watching for

more than normal blood loss is an important assessment. Typical blood loss is 500mL for a

vaginal birth and 1000mL for a cesarean. If you lose more than that or if your hematocrit drops

10% you are automatically a candidate for a blood transfusion (McKinney).

Early

Early post-partum hemorrhage typically occurs within the first 24 hours after birth, and

this is why modern hospitals and medicine have decreased the maternal death rate in the US by

assessing patients, recognizing symptoms, and treatment of those symptoms. Some of these

interventions would not have been able to be done 100 years ago or in a home setting

(McKinney). After birth of the placenta your endometrial arteries are still bleeding and your

uterine contractions help stop the bleeding and shrink the size of the placenta site. Atony,

placenta accreta and trauma to the birth canal that causes hematomas are the most common

causes of early post-partum hemorrhage. The signs you need to be aware of are, a difficult to

find fundus, soft fundus, a uterus that is higher than expected when measuring, and excessive
lochia or clots (McKinney). The earlier the recognition of these symptoms the better off the

patient will be.

Late

After 24 hours and up until 6-12 weeks the most common cause of late post-partum

hemorrhaging is the delay of the uterus to shrink back down to its original size, called

subinvolution (McKinney). You can also get pieces of the placenta that stayed attached to your

myometrium and clots will form around them that can cause excessive bleeding for days after

delivery. This type is typically preventable by the doctor or midwife examining the placenta to

make sure all of it was intact after birth. If there were pieces missing they are then located in

the uterus and removed before they start any problems or infections (McKinney). Teaching

mothers what signs to look for and what is not normal is the best way to teach prevention of

this.

Therapeutic management

Just after birth, in early post-partum, while in the hospital it is a team effort to make

sure the mothers are being assessed for uterine atony and hemorrhaging. If the uterus is not

contracting the first thing to do is massage the fundus until it is firm and express the clots that

may have formed (McKinney). If the uterus is not staying contracted or is being displaced

sometimes urinating is the simple answer but there is also medicine that can help in the aid of

returning it to normal size. Pitocin is used to control the bleeding and help the uterus return to

original size. If these treatment are not successful then the doctor may perform bimanual

compression, use uterine packing, or even a laparotomy to identify the source of the bleed. If it
is a hemorrhage typically we are concerned with blood volume and will increase IV fluids or give

a transfusion depending on the extent of it (McKinney). Management of the late post-partum

hemorrhage is different because the patient has already left the hospital and is no longer under

the supervision of the doctor and nurse. Hopefully by educating the mother of the seriousness

of this they would contact the doctor right away and start treatment. This treatment typically

starts with Oxytocin, methylergonovine, and prostaglandins to flush out the left over placenta

with the increased bleeding. If that didn’t solve the problem a sonography is done to locate

placental fragments and antibiotics to prevent infections from the left over placenta

(McKinney).

Conclusion

With the treatment of post-partum hemorrhage, as in any health problem, the

education of the nursing staff and patients is the first step. The most common predisposing

factors are having an over distention of the uterus (ex: Mrs. Duggar, large infant, hydraminos),

multiparity, prolonged labor, extraction assistance device, caesarean, uterine inversion, clotting

disorders, fibroids, and the list goes on. Working with our patients to be knowledgeable and

understand the risks and signs of post-partum hemorrhage can help us find and intervene fast

and appropriately for each patient individually.

McKinney, E. S. (2013). Maternal-child nursing. St. Louis, MO: Elsevier/Saunders.