Postpartum Hemorrhage Management and Care

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Postpartum hemorrhage is the leading cause of maternal death, and the United States currently has a startling hemorrhage rate that’s responsible for 12% of maternal deaths (3). Along with accurate recognition and assessments, proper postpartum hemorrhage management, treatment, and education can actively work toward reducing the risk of maternal deaths from hemorrhages.  

Introduction to Postpartum Hemorrhage Management  

The processes of labor and birth receive a lot of discussions, including delivery and induction methods, birth plans, pain control, complications, and much more. With postpartum hemorrhages on the rise in the United States, there is an urgency to focus on postpartum hemorrhage management and treatment. Postpartum hemorrhage is a complication of birth, but is a preventable complication through early recognition, assessment, treatment, patient education, and follow-up. According to the CDC, 70% of postpartum hemorrhage-related deaths could be prevented in a hospital setting (9).  

Pathophysiology of Postpartum Hemorrhages

Hemorrhage occurring in the postpartum period can occur after a woman gives birth, and up to 12 weeks after. It is important to note that bleeding after a vaginal delivery or cesarean section is normal; however, the amount of bleeding and/or clinical symptoms is the determining factor for normal to abnormal hemorrhagic bleeding. After a vaginal delivery, normal blood loss is less than 500 mL and for a cesarean is 1000 mL (8). When the birth of a child occurs, the delivery of the placenta follows, and bleeding is typically controlled with two maternal mechanisms. Mechanical hemostasis is achieved with contraction of the myometrium, which also constricts the blood vessels to the uterus (2). The second mechanism that controls bleeding is local decidual hemostatic factors, including platelets, to cause clotting (2). Postpartum hemorrhage can become an obstetric emergency because of the large supply of blood volume to the uterus ranging from 500-700 mL/min, which equivalates to around 15% of the maternal cardiac output (2). There are many causative factors that can disrupt these mechanisms from functioning and why assessments can become an effective tool to prepare for potential postpartum hemorrhage management.  

Assessment 

There are a wide range of assessment tools in the U.S. currently being utilized, decrease the rates of hemorrhage-related maternal deaths. The key to assessment for postpartum hemorrhage management is starting early, before the delivery. Assessment tools should be initiated on admission, reassessed close to delivery, again within the hour after birth, and every 24 hours after birth while in the hospital. Patients should also be educated during their hospital stay and before discharge on signs, symptoms, and what to do if postpartum hemorrhage were to occur. Having an assessment tool that identifies potential risk factors and outlines preparatory interventions for when those risk factors are present. This will enable prompt postpartum hemorrhage management and treatment. 

Do you currently use any screening tools for risk factors on pregnant patients? 

Are they built into other assessments or stand-alone assessments? 

How often and when do you screen?  

Have you performed any nursing interventions based off of identified risk factors? 

Admission Assessment (1):  

When risk factors are identified on admission, ensure the entire care team for the maternal patient is notified, including the provider managing her care. Depending on your facility’s management for blood bank protocols, you could consider obtaining consent, type, and screen, or a type and cross. Ensuring you have an 18–20-gauge saline lock in place should also be considered.  

Past medical/Surgical history 

• Previous deliveries & complications, including previous postpartum hemorrhage 
• Cesareans, including how many and what type of incision (classical or transverse) 
• Number of vaginal deliveries 
• Bleeding disorders 
• Uterine fibroids 
• Any surgeries that have created weakened or scar tissue to the uterus 
• Obesity 
• Family History 
• Bleeding disorders 

Current pregnancy 

• Number of fetuses 
• Fetal Demise 
• Abruption 
• Macrosomia 
• Polyhydramnios 

Placenta abnormalities 

• Placenta Previa 
• Placenta accrete 
• Placenta percent 

Current blood counts 

• Hemoglobin 
• Hematocrit 
• Platelets 

Current medications 

• Induction/augmentation with oxytocin 
• Cervical ripening agents 

Think about each of these screening questions. Why would each of them be considered a risk factor for patients?

Before Birth Assessment (1): 

After performing a before-birth assessment and depending on the risk factors identified, consider updating the healthcare team of patient status and assessing the current IV in place. Initiate blood bank protocols for possible blood administration when necessary. If potential hemorrhagic criteria were identified on admission, begin reviewing the facility procedure on hemorrhage, ensure availably of hemorrhagic medications, in addition to checking all equipment and availability of supplies within the patient room as well as in hemorrhage cart.  

Medications 

• Magnesium sulfate administration 
• Oxytocin use for over 24 hours 

Placenta complications 

• Abruption 

Labor complications 

• The prolonged second stage of labor 
• Labor greater than 18 hours 

Infection 

• Temperature above 100.4 
• Chorioamnionitis  

Are there any other nursing interventions you would consider during this phase of the labor and delivery process to prepare for possible hemorrhage?

Post-Birth Assessment (1):

Type of delivery 

• Vaginal 
• Precipitous 
• Operative 
• Cesarean section 

Complications 

• Shoulder dystocia 

Lacerations 

• 3rd/4th degree 
• Cervical  
• Episiotomy 

Placenta delivery 

• Difficult extraction 
• Cord evulsion 
• Fragile placenta 

When risk factors are identified after the conduction of this assessment, activate blood bank facility protocols for potential blood administration and assess IV access. Update the healthcare team caring for this patient and bring the hemorrhage cart to the patient room. Increasing the frequency of postpartum assessments, including vitals, fundus, and vaginal bleeding should be considered to monitor the patient for postpartum hemorrhage. 

Identification 

Now that we have screened our patient for risk factors for hemorrhage potential, we need to recognize if our patient is within normal limits or having a postpartum hemorrhage. If a hemorrhage is identified, we will need to recognize the severity of the hemorrhage, based on collected data and defined criteria by your facility. Conducting postpartum hemorrhage management assessments through vital signs, fundus exams, and assessment of bleeding are the diagnostic criteria for determining hemorrhage. Postpartum assessments should occur every 15 minutes for 2 hours, then every 1 hour for three hours, then every 4 hours for 24 after delivery, and then every shift (8).  

What is your current practice for calculating blood loss? 

 When do you start? When do you stop calculating?  

What items are used to determine blood loss?  

Do you assess for color, clot formation, flow? 

When assessing for bleeding, using a quantified blood loss method versus estimated blood loss will provide you with a more accurate clinical picture. Quantified blood loss can be obtained through the use of calibrated scales, drapes, or canisters. Using calibrated scales to weigh any blood-soaked items with prior knowledge of dry weights to subtract from will help to determine patient blood loss, using the equivalent of 1gram=1mL.  

California Maternal Quality Care Collaborative (CMQCC) and the American College of Obstetrics and Gynecology (ACOG) have developed patient hemorrhage bundles that detail various definitive stages of hemorrhage. These stages of hemorrhage in the resources below include each stage with relation to signs and symptoms to define each stage and when to move to the next stage; guiding you to increase or decrease patient severity of hemorrhage.  

California Maternal Quality Care Collaborative Staging (5):

American College of Obstetrics and Gynecology (7):

Treatment 

Since we have assessed for risk factors, we have recognized the occurrence and the severity of hemorrhage, we need to treat it. Let’s begin by looking at possible causative factors for the occurring hemorrhage:   

Causative Factors-Consider 4 T’s (7): 

• Tone- uterine atony 
• Trauma- lacerations of the cervix, vaginal tissue, the blood vessel of the uterus 
• Tissue- Retained placenta 
• Thrombin- bleeding disorders 

Have you experienced any patients with tone, trauma, tissue, or thrombin occurrences?  

Did any of them hemorrhage or have increased bleeding?  

Were there any specific interventions utilized prior to delivery or after because of them?  

Having order sets and interventions that align with the severity will help guide healthcare teams in effective postpartum hemorrhage management and treatment.  

Treatment provided promptly is crucial because 90 % of maternal deaths related to postpartum hemorrhage occur within 4 hours of delivery (2). Treatment for postpartum hemorrhage can be achieved through a variety of pharmacological, surgical, or care team interventions. Pharmacological treatment options can include Pitocin, Methergine, Hemabate, and Cytotec, Transaschemic Acid, and blood products. Having up-to-date patient clinical assessment and medical history is critical because of the contraindications with some of these medications. Surgical interventions for treatment can include the repair of a laceration, D &C of the uterus, uterine artery ligation, B-Lynch suture, or hysterectomy. Care team interventions can include IV access, fundal massage, medication administration, emptying of the bladder, or insertion on a uterine tamponade balloon. Our goal to correct the hemorrhage is to stabilize the bleeding, correct the causative factor, restore blood volume, and prevent tissue ischemia or further coagulopathy. The CCQCC and ACOG scoring tools that helped us recognize the severity of hemorrhage; also have developed interventions within each stage to assist with guiding your treatment. While these interventions and treatments are outlined for each stage, please consider your scope of practice in your state. 

California Maternal Quality Care Collaborative Treatment Plan (5): 

ACOG’s Treatment Plan (7):

Recovery 

Once the patient is stabilized after the postpartum hemorrhage management and treatment protocols were followed, we must focus on recovery. The team should continue to provide heightened assessment surveillance on post-hemorrhage patients through lab work, vital signs, fundal assessments, lochia assessments, and patient symptoms according to your hospital policy.  Items including documentation, patient education, and staff mock or drills will allow continued success to reduce rising postpartum hemorrhage rates.  

Performing post-event debriefs is an extremely useful tool to assist with process improvements and to use for educational guidance. Debriefs should be completed once patients are cared for, but while events are still recent for the care team to remember.  

During the actual hemorrhagic events, documentation can become more complex with implementing appropriate and timely interventions and assessments. To provide efficient patient care, utilization of recorder and postpartum hemorrhage paper documentation, similar to code events, will provide focused attention on patients and establish a reference for noted events. Having documented assessments leading to implemented interventions, medication administrations, and blood bank activations, in addition to a reassessment of these items, will provide an event timeline of patient status. 

Patient education should be provided to all obstetric postpartum patients regardless of hemorrhage occurrence. All patients should be educated on when to call healthcare providers when to call 911, and normal versus abnormal bleeding. 

Education tips may include:  

• Instruct patients to expect to bleed and cramping over the next 4-6 weeks 
• Color of bleeding changing from red to pink to brown 
• Rising to a standing position from sitting or lying may create a gush due to the pooling of blood in the vaginal vault and gravity releasing it when standing 
• Bleeding that is soaking through a peri-pad in one hour or a blood clot the size of an egg or larger needs immediate attention (6) 

Staff education is a major piece to the puzzle in providing efficient and effective postpartum hemorrhage management. Knowledge of postpartum hemorrhage risk factors will facilitate planning and readiness for these occurrences. Ensuring staff are familiar with hospital policy and procedure for postpartum hemorrhage, contents and accessing of uterotonic medications, treatment supplies, and hemorrhage cart with included contents enable prompt response for patients. Creating outlined scoring methods to implement interventions based on severity allows for objective data utilization to maintain patient clinical wellbeing. Having quarterly education and drills for staff ensures competency, teamwork, and communication during these high-stress events.  

Conclusion 

When we can prevent a complication, we react with assessment, intervention, and education to ensure our nursing care is promoting the highest quality of patient care. Utilizing this method enables nurses to prepare for the possibility of complications whether they occur or not. Postpartum hemorrhage is the leading cause of maternal death (4). Ensuring resources, assessments, and educational opportunities provide us with the necessary tools to reduce the occurrence of life-altering events to this new mother & baby dyad. 

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