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Postpartum Complication:PPHMargie Bridges, DNP, ARNP-BC, RNC-OBPerinatal Clinical Nurse SpecialistOverlake Hospital

PPH OBJECTIVES

NORMAL ADAPTATION

RECOGNITION

READINESS

RESPONSE

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Physiologic Adaptation of Pregnancy Provides Protection

Antepartum Volume Expansion

Uterine Contractility

Autotransfusion

Hypercoagulopathy

Normal Adaption

Uterus

Normal Involution Weight

Size

Fundal position

After pains

Breastfeeding

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Trends in Pregnancy Related Mortality in the U.S. (1987-2013)

CDC, 2017 https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

United States is ranked 47th

in the world for maternal mortality and the ONLY developed country that has a rising mortality rate

PPH is the leading cause of death

PPH incidence is approx.125,000 women a year; 2.9% of all births

PPH is the 4th leading cause of Maternal Death

CDC, 2017 https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

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Annual Rates of PPH caused by Atony, Mode of Del and Induction status

POSTPARTUM HEMORRHAGE

OB Hemorrhage Deaths are largely Preventable

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OverdistentionMultiple GestationPolyhydramniosMacrosomia

Uterine FatigueProlonged laborInduction/AugmentationPrior PPHChorioamnionitisProlonged ROMUterine AbnormalityFibroidsPlacenta Previa

MedicationBeta mimeticsMagnesium sulfateAnesthetic drugs

Tone

Preexisting Clotting AbnormalitiesHistory of Coagulopathy Liver Disease

Acquired in PregnancySepsis

DICFDIU

HELLPHemorrhage

Anticoagulation

LacerationPrecipitous deliveryMacrosomiaShoulder DystociaOperative DeliveryEpisiotomy

Uterine RupturePrior Uterine Surgery

Uterine InversionFundal PlacentaGrand MultiparityExcessive Traction on Umbilical Cord

Accreta/Increta/PercretaPrior Uterine SurgeryPlacenta PreviaMultiparity

Retained Placenta/MembranesManual Placental Removal                       

Tissue

Thrombin

Trauma

The “4 Ts”

Devine (2008)

AMTSL Active Management 3rd

stage of labor

Oxytocin IVPB or IM with delivery of anterior shoulder or prior to placenta infant or placenta

Cord clamping not delayed beyond 2 min

Controlled cord traction

Vigorous fundal massage (at least 15 sec) after placenta

Decreases blood loss

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Assessment Skills

• Uterus - firmness, tenderness, position (involution)

Lochia

• Color – rubra, serosa, alba

• Odor

• Amount – scant, light, moderate, large

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What to expect ?

Says who ?

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WHAT ?

HOW Vaginal Birth Part 1

1. Right after birthbefore the placenta check and document volume of fluid AKA “amniotic fluid” (it won’t be clear like in the picture).2. Re- Check & document fluid after delivery of placenta and repair 3. SUBTRACT amniotic fluid volume (before birth) from accumulated fluid after the birth = TOTAL FLUID QBL

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HOW Vaginal Birth Part 2

1. Weigh bloody material (raytecs etc.)

2. Calculate total dry weight

3. SUBTRACT dry weight from blood material weight = TOTAL MATERIAL QBL

WorkSheet

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Cesarean Birth Process

Recovery and Postpartum

Greater than 500 vaginal or1000 c/s requires increased is a Stage 1 Hemorrhage and requires management and close monitoringComplete at least a 1, 2 & 4 h QBL

All Births will require a 2 & 4h QBL

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EBL vs QBLMath not Magic

LET’S PRACTICE !!!

“The clinical symptoms of blood loss (low blood pressure, fast pulse, pallor and sweating, signs of hypovolemia and impeding shock) are often the primary indicators for intervention. However, relying on the onset of such symptoms may lead to delayed intervention, resulting in increased morbidity and mortality.”

B.S. Kodkany and R.J. Derman. Pitfalls in Assessing Blood Loss and Decision to Transfer

PPH Triggers

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Postural hypotension

Can Progress Rapidly Hypotension is a LATE sign

Many scales

↓cap refillSOB

O2 sat less reliable

PPH Triggers

Be vigilant in appreciating:HR > 110

Blood Loss > 500 ml, Vaginal delivery

Blood Loss > 1000 ml, C/S delivery

Blood Pressure ≤85/45 (>15% drop)

Oxygen Saturation <95%

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Be prepared with Triggers!

When triggers present:

Mobilize help Continue calculation of blood loss Confirm T & S done Confirm status of blood availability Confirm T & S done; Confirm blood availability Have uterotonics readily available PPH Cart

5 Major Causes

• Uterine Atony

• Lacerations

• Retained Placental Tissue/Fragments

• Hematoma

• Subinvolution

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Signs and Symptoms of Uterine Atony

• Marked hypotonia of the uterus• Leading cause of PPH – 80-90% of all cases

Signs and Symptoms:• Boggy, large uterus• Heavy, bright red vaginal flow• Expelled clots

Causes of Atony ?Marked hypotonia of the uterus

• Long Labor• Induction/augmentation of labor• Large Baby • Multiple Gestation• Uterine myomas or fibromas• High parity• MgSo4• Full bladder• Infection• Retained Placenta• HX PPH• Infection• History of PPH

Interventions???

Usual suspect…..

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MANAGEMENT OF ATONY

• Fundal Massage

• Uterotonics

• Empty bladder

• Bimanual compression

• Manual exploration of uterine cavity

• Surgical management – D&C, Balloon Placement or hysterectomy

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Bakari Baloon

B-Lynch

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Lacerations

Location: cervix, vagina and perineum

Signs and Symptoms:

• Bright red/heavy bleeding with a firmly contracted uterus

• Steady stream or trickle of unclotted blood or comes in spurts

Laceration Causes Large fetal head for size of

pelvis

Difficult second stage

Operative vaginal delivery

Scars from infections, surgery or injury

Precipitous delivery

Perineal or vaginal varicesInterventions?

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Causes of PPH- Retained Placental Fragments

• Manual removal of placenta

• Abnormal adherence of the placenta

• Over distension of uterus

• Prolonged labor with maternal exhaustion

• High parity

• Abruptio placenta

S & S of Retained Placental/Membrane Fragments

• Uterus remains large

• Heavy vaginal flow, usually beginning more than 24 hours after birth (around 7 days postpartum)

• Abnormal progression of lochia

INTERVENTIONS?

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Hematomas

Prolonged pressure of the fetal head on vaginal mucosa

Operative vaginal delivery

Nicking of blood vessel during episiotomy or laceration repair

A collection of blood in the connective tissue due to vessel wall damage: can be vulvar, vaginal, or retroperitoneal

Signs and Symptoms of Hematoma

• Complaints of severe perineal or pelvic pain

• Unilateral, tense bulging mass at opening of vagina or labia

• Unilateral bluish or reddish discoloration of the skin of the perineum or buttocks

• Hemodynamic instability

Interventions???

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Nursing Interventions for PPH

Fundal massage Record VS, O2 sat every 5 minutes Record cumulative blood loss, weigh pads Empty bladder: consider indwelling catheter IV access: at least 18 gauge: obtain labs with IV start Increase intravenous fluid Increase or start oxytocin Add other uterotonics as needed Determine and treat etiology – Confirm blood availability Order 2 units RBCs if ongoing bleeding; Consider ordering plasma

• I & O: hourly urine output• Maintain adequate ventilation: pulse oximeter and oxygen per mask as needed at 6-10

liters• Draw blood for type and crossmatch and hematocrit/hemoglobin• Give plasma expanders and packed RBC/blood products as ordered• Keep warm• At risk for Disseminated Intravascular Coagulation

GO TO OR

If uterotonics and bedside interventions do not control the bleeding Move to the OR

Consider D&C, intrauterine balloon, or other surgical intervention

Labs – CBC and coag studies repeat every 30 minutes with ongoing bleeding Order needs to be place in Epic

Repeat hemabate as often as every 15 minsDO NOT wait for labs to transfuse

Transfuse for clinical signs/symptoms

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OB MTP

Obstetrical Massive Hemorrhage Protocol OB Hemorrhage Phone Tree

Algorithm ( On OB Anesthesiologist Role Card)

STAFF ROLE CARDS

Lab Requisition Form

Bleeding Emergency Flow Sheet

Baseline Lab Tube packets ( blue and lavender tubes for DIC panel)

OB MTP JOB AID

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Blood Components Algorithm

Fibrinogen < (less than) 100mg/dl- Transfuse 2 cryo poolsPlatelets < (less than) 100,000- Transfuse one apheresis platelet unit (Preferred due to speed) or one 6 unit platelet poolINR> ( greater than) 1.5 and fibrinogen > 100mg/dl-Transfuse 4 units FFP

GoalPlatelets >100,000uLFibrinogen > 100mg/dLINR≤ 1.5Core Temp >35Ph> 7.4

OB Massive HemorrhageCryoprecipitate if DIC is suspected-one cryo pool will increase fibrinogen by 45mg/dLRBC’s : 1 RBC unit will increase HCT by approximately 3 % and HGB by 1g/dL in a stable (non-bleeding patient)FFP if INR > 1.5 AND fibrinogen is >200mg/dL. Start with two units and recheck INRKeep platelet count between 75 and 100,000/uL during acute bleeding episode-one apheresis platelet unit will increase count by at least 20,000/uL, often by 50,000/uL

DIC

Disseminated intravascular Coagulation:Thrombohemorrhagic disorder with concurrent activation of the coagulation and fibrinolytic pathways, resulting in simultaneous fibrin clot formation and lysis

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Long-term complications of PPH

Blood Component transfusion reactions/complications Temporary of permanent kidney failure Anemia Fluid overload ( pulmonary edema, Dilutional

coagulopapthy) Sepsis Asherman’s Syndrome (intrauterine scaring/adhesions) Infertility Death

Don’t miss the boat! Look early , look often, work fast……

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How can we help?The ability to give compassionate care will hold you up

• The unexpected will happen

Questions?