Nursing Care Management 109

Care for
Mother and
Child at Risk
Prepared by:

Sharmaine S. Pero, RN
Clinical Instructor
 Learning outcomes:

 Students will be able to identify the causes of post-

partum hemorrhage and dystocia;
 Identify nursing care management for both
complications;
 Design a nursing care plan.
What is post-partum
Hemorrhage?
Post-partum hemorrhage
remains a major cause of maternal mortality and
morbidity worldwide. Approximately, half a
million women die annually from causes related
to pregnancy and childbirth. PPH refers to any
amount of bleeding from or into the genital tract
following birth of the baby up to the end of
puerperium. It adversely affects the general
condition of the mother, evidenced by increase in
pulse rate and falling blood pressure.
PPH is generally defined as blood loss greater than or equal to
500ml within 24 hours after birth, while sever PPH is blood loss
greater than or equal to 1000ml within 24 hours.

Types of PPH
Primary post-partum hemorrhage- is the hemorrhage occurring
during the third stage of labor and within 24 hours of delivery

Secondary post-partum hemorrhage- is hemorrhage occurring

after 24 hours of delivery and within 6weeks of delivery. It is also
referred to as puerperal hemorrhage.
Causes:
Primary PPH

Atonic uterus
Trauma Mixed ( combination of both atonic and
trauma)
Retained product of conception
Uterine rupture
Uterine inversion
Blood coagulopathy
Secondary PPH

Retained bits of cotyledon or membranes

Infection
Cervico-vaginal laceration
Endometritis
Subinvolution of the placental site
Secondary hemorrhage from caesarean section
Other rare causes - chorion epithelioma, carcinoma
cervix, placental polyp, fibroid polyp and puerperal
inversion of
 Risk factors

Prolonged third stage of labor

Multiple delivery
Episiotomy Fetal macrosomia
History of postpartum hemorrhage
Grandmultiparity
Placenta previa
Placental abruption
Pregnancy induced hypertension
 symptoms

massive blood loss

passing large clots
dizziness
lightheadedness or fatigue
Decreased blood pressure
Increased heart rate
Swelling and pain in tissues in the vaginal and
perineal area
Etiology:
4Ts
TONE Uterine atony

TISSUE Retained placenta

TRAUMA Lacerations, uterine rupture

CLOTTING
Coagulopathy
Atony
Retained products of conception, most
often a retained placenta or retained
placental fragments, must be removed
to stop the bleeding.
Management:
Uterine massage
Medications (oxytocin,carboprost)
Gauze packing

Surgical:
Uterine Curettage
Uterine Artery Ligation
Hysterectomy
Retained Placenta
Retained products of conception, most
often a retained placenta or retained
placental fragments, must be removed
to stop the bleeding.

Management:
Oxytocin

Surgical:
D&C
Administration of prophylactic
antibiotics
Trauma
Trauma resulting from the birth
process can result in significant
blood loss. The source of trauma
must be quickly identified and
treated.
Vaginal bleeding is visible outside,
either as slow trickle or rarely a
copious flow. Rarely, the bleeding
is concealed either remaining
inside the uterovesical canal or in
the surrounding tissue space
resulting in hematoma.
Trauma
Management:

Emergency laparotomy
Resuscitation
Broad spectrum antibiotics
Observation for about two hours
after delivery to make sure that the
uterus is hard and well contracted
before sending women to ward.
Adequate post-operative care
Clotting
any derangement of hemostasis resulting in either excessive
bleeding or clotting, although most typically it is defined as
impaired clot formation.

Examples:

Abruptio placenta
Amniotic fluid embolism
Retained dead fetus
Inherited coagulopathy
Prevention of PPH
www.preventionofpph.com

Antenatal
Improvement of the health status.
High risk patients.
Blood group

Intranatal
Slow delivery of the baby.
Expert obstetric anesthetist needed.
Spontaneous separation and delivery of placenta
during caesarean section
www.preventionofpph.com

Active management of third stage of labor.

Examination of placenta.
Induced or accelerated labor by oxytocin.
Exploration of utero-vaginal canal.
To observe the patient for about two hours
after delivery.
Active treatment of
PPH
 www.activetreatmentofpph.com

Rub up the uterus to stimulate contraction and retraction.

Administer ergometrine(0.2mg) intramuscularly .
Syntometrine (1ml) intramuscularly may be given instead of
ergometrine.
Expel the placenta with the next uterine contraction by fundal
pressure or controlled cord traction.
Empty the urinary bladder by catheterization.
A second dose of syntometrine or ergometrine may be given
in ten minutes if bleeding is not controlled.
Treatment of true
PPH
 www.treatmentoftruepph.com

Uterine massage
If the uterus is soft, massage is performed by placing one
hand in the vagina and pushing against the body of the
uterus while the other hand compresses the fundus from
above through the abdominal wall. The posterior aspect of
the uterus is massaged with the abdominal hand and the
anterior aspect with the vaginal hand
 www.treatmentoftruepph.com

Uterotonic agents
Uterotonic agents include oxytocin, ergot alkaloids, and
prostaglandins.
Oxytocin - 10 international units (IU) should be injected
intramuscularly, or 20 IU in 1 L of saline may be infused at a
rate of 250 mL per hour. As much as 500 mL can be infused
over 10 minutes without complications.
Methylergonovine (Methergine) and ergometrine, a typical
dose of methylergo-novine, 0.2 mg administered
intramuscularly, may be repeated as required at intervals of
two to four hours.
 www.treatmentoftruepph.com

Prostaglandins
Carboprost can be administered intramyometrially or
intramuscularly in a dose of 0.25 mg; this dose can be repeated
every 15 minutes for a total dose of 2 mg.
Misoprostol is another prostaglandin; It can be administered
sublingually, orally, vaginally, and rectally. Doses range from
200 to 1,000 mcg; the dose recommended by FIGO is 1,000
mcg administered rectally.
 www.treatmentoftruepph.com

Lacerations and hematomas resulting from birth trauma

can cause significant blood loss that can be lessened by
hemostasis and timely repair.
Uterine Rupture - Symptomatic uterine rupture requires
surgical repair of the defect or hysterectomy.
Uterine inversion is rare
www.treatmentoftruepph.com

Hysterectomy

A surgical operation to remove all or part of the uterus

in case of life threatening condition of the women i.e.,
menorrhagia, post-menopausal period.
Dystocia
dystocia
defined as a long, difficult or abnormal labor, is a term
used to identify poor labor progression.
Dystocia may arise from any of the three major
components of the labor process—the powers (uterine
contractions), the passenger (fetus), or the passageway
(maternal pelvis).
Dystocia may be related to maternal positioning during
labor, as well as fetal malpresentation, anomalies,
macrosomia and multiple gestation. Also, maternal
psychological responses to the labor, based on past
experiences, cultural influences, and the woman’s
present level of support may play a role in the normal
progress of labor.
 Factors Associated with an Increased Risk for
Uterine Dystocia

Uterine abnormalities, such as congenital malformations and

overdistention (e.g., hydramnios, multiple gestation)
• Fetal malpresentation or malposition
• Cephalopelvic disproportion (CPD)
• Maternal body build (30 lbs. [13.6 kg] overweight, short
stature)
• Uterine overstimulation with oxytocin
• Inappropriate timing of administration of analgesic/anesthetic
agents
• Maternal fear, fatigue, dehydration, electrolyte imbalance
Pelvic dystocia
Pelvic dystocia occurs when contractures of the pelvic
diameters reduce the capacity of the bony pelvis, the
midpelvis, the outlet, or any combination of these
planes. Contractures of the maternal pelvis may result
from malnutrition, neoplasms, congenital
abnormalities, traumatic spinal injury, or spinal
disorders. In addition, immaturity of the pelvis may
predispose some adolescent mothers to pelvic
dystocia. During labor, contractures of the inlet,
midplane, or outlet can cause interference in
engagement and fetal descent, necessitating cesarean
birth.
Soft tissue dystocia
Soft tissue dystocia occurs when the birth passage is
obstructed by an anatomical abnormality other than
that involving the bony pelvis. The obstruction, which
prevents the fetus from entering the bony pelvis, may
be caused by placenta previa, uterine fibroid tumors
(leiomyomas), ovarian tumors, or a full bladder or
rectum. Bandl ring is a pathological retraction ring that
develops between the upper and lower uterine
segments. It is associated with protracted labor,
prolonged rupture of the membranes, and an increased
risk of uterine rupture
 Purposive Assignment
Situation:

Maria, a primigravid had just undergone a stat CS, her labor lasted for
36 hours and her OB decided to perform CS because of the non-
reassuring fetal heart rate and maternal exhaustion. After 2 hours, the
PACU nurse transferred the patient to her room and endorsed her to the
ward nurse. Upon rounds the ward nurse notices that Maria’s diaper
was soaked and her vitals are dropping. What is the nursing
intervention of the nurse?

Done by group
Thank You