Postpartum hemorrhage is described as a life-threatening event that is characterized by a loss of more than 500 mL of blood after a vaginal birth and 1000 mL blood loss after a cesarean birth. Other conditions have been included in the definition, which are a 10% change in hematocrit between admission to labor and postpartum or the need for a blood transfusion. There are three major causes of postpartum hemorrhage: uterine atony, lacerations, and retained placental tissue.
Uterine atony occurs when the uterus becomes hypotonic. This is the most common cause of postpartum hemorrhage. When the uterus becomes flaccid and is unable to contract after birth, bleeding occurs. Normal coagulation is also impaired when the uterus fails to contract.
Lacerations during birth place the woman at a higher risk for hemorrhage. If the woman is noted to be bleeding despite having a firm and contracted uterus, it is possible that a retroperitoneal hematoma may be present resulting in hemorrhage.
After birth, it is important that all of the remains of the placenta are out of the uterus. Retention of the placenta can result in vaginal hemorrhage. This generally occurs due to poor separation of the placenta from the uterus.
The main sign of postpartum hemorrhage is bleeding from the vagina and perineum. If abnormal bleeding is noted, it is important to intervene as soon as possible.
As blood loss increases the patient may become hypotensive. Persistent blood loss progresses to hypovolemic shock.
Normally, the uterus should be firm and contracting, this aids in proper coagulation to prevent bleeding. When the uterus is boggy, the pregnant woman may start to hemorrhage because the uterus is not contracting and therefore not properly coagulating.
Oxytocin is used to increase uterine contractions. By increasing uterine contractions, the uterus can become more firm in order to decrease bleeding and hemorrhage.
When the uterus is boggy, the nurse should massage the fundus. This action helps stimulate contractions and aids in firming up the uterus to aid in coagulation.
If bleeding persists due to a continuously boggy uterus or placental retention, the doctor may consider surgical intervention to remove the retained placenta or if necessary, remove the uterus.
If the woman continues to lose blood, a blood transfusion may be necessary to prevent and/or treat hypovolemic shock.
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