Postpartum Hemorrhage
Introduction
Postpartum hemorrhage (PPH) is a significantly life-threatening complication that can occur after both vaginal and caesarean births (Ricci & Kyle, 2009). Simpson and Creehan (2008) define PPH as the amount of blood loss after vaginal birth, usually more than 500mL, or after a caesarean birth, normally more than 1000mL. However, the definition is arbitrary, attributed to the fact that loss of blood during birth is intuitive and widely inaccurate (Ricci & Kyle, 2009). In line with this, studies have suggested that health care providers consistently underestimate actual blood loss, thus, an objective definition of PPH would be any amount of bleeding that exposes a mother in hemodynamic jeopardy (Ricci & Kyle, 2009). Currently, PPH is the leading cause of maternal mortality worldwide, and it is estimated that, over 150, 000 women, die of the complication annually (Ricci & Kyle, 2009).
Causes of Postpartum Hemorrhage
Excessive bleeding can occur at any time between the separation of the placenta and its expulsion or removal, and in tandem to this, there are different facets that cause PPH (Simpson & Creehan, 2008). PPH can amount from uterine atony, failure of the uterus to contract and retract after birth (Ricci & Kyle, 2009). Uterine atony is the most common cause of PPH, accounting for 70% of cases (Sheiner, 2011), and it is usually delineated by a marked hypotonia of the uterus (Simpson & Creehan, 2008). In addition, uterine atony is likely to occur when the uterus is over distended, depicted through polyhydramnios, multiple gestations, and macrosomia (Simpson & Creehan, 2008). Other factors that induce uterine atony encompass; traumatic birth, halogenated anaesthesia, lengthened labour, induction or augmentation of labour, intraamniotic infection, tocolytics, and multiparity (Simpson & Creehan, 2008).
Sheiner (2011) also affirms that trauma is a significant cause of PPH, and it is typically associated with vaginal or birth canal lacerations and uterine rupture. Vaginal delivery can amount to varying asperity of vaginal, perineum-region between the genital organs and anus-, and cervix lacerations (Sheiner, 2011). Similarly, lacerations secondary to birth trauma may occur more frequently with operative vaginal birth, through the aid of forceps or vacuum (Simpson & Creehan, 2008). The lesions can lead to a concealed retroperitoneal or suprafascial hematomas, which inevitably leads to significant but unnoticed blood loss (Sheiner, 2011). On the other hand, uterine rapture is also a form of birth trauma that can effectively amount to life-threatening PPH, as well, it is a rare obstetrical complication, with incidence of approximately 0.6 -0.7 % in cases of a trial of vaginal birth after caesarean section (Sheiner, 2011). Uterine rupture can become symptomatic during the postpartum period manifesting as abdominal tenderness and maternal hemodynamic collapse (Sheiner, 2011).
Another cause of PPH is retained placenta, which is primarily associated with a mean duration of the third stage of labour (8-9 minutes), and Sheiner (2011) attests that longer intervals of the third stage of labour, poses as a great risk of PPH, with double the rate after ten minutes. Further, retained placental parts interpose and interfere with uterine contractions and may either cause early or late PPH (Sheiner, 2011). In conjunction to this, coagulation disorder is also a cause of PPH. It is a rare disorder that accounts only for one percent of cases (Sheiner, 2011). Other causes of PPH include; episiotomy, uterine inversion and hematomas of the vulva, which are also associated with muscle tones, tissues, stress and thrombosis (Ricci & Kyle, 2009).
Clinical Presentation and Risk Factors
PPH may be divided into two presentations; early PPH, which normally occurs before 24 hours, and late PPH, which usually takes place between 24 hours and six weeks (Ricci & Kyle, 2009). Moreover, symptoms of PPH vary according to the quantity and the rate of blood loss, as well as the general condition of the mother (Simpson & Creehan, 2008). The sign and symptoms of PPH include; the apparent excessive bleeding, hematocrit-reduction of the number of red blood cells, reduced blood pressure, development of symptoms of shock and anaemia, and severe pain and swelling of tissues and muscles of the vagina, vulva, pelvic and perineum (Simpson & Creehan, 2008). Besides, Ricci & Kyle (2009) avow that there are different factors that place a mother at risk for PPH, and they comprise; prolonged first, second or third stage of labour, previous history of PPH, foetal macrosomia, uterine infection, arrest of descent and multiple gestation. Other risk factors may include; mediolateral episiotomy, coagulation abnormalities, maternal hypertension, maternal exhaustion, malnutrition or anaemia, preeclampsia, precipitous birth, polyhydramnios and previous placenta previa (Ricci & Kyle, 2009).
Diagnosis and Assessment
The principal mode of diagnosis is a differential diagnosis, and it includes a plethora of facets; bleeding from implantation site, which may be due to uterine atony, with predisposing factors such as infections, and retained placenta or abnormal placentation (Sheiner, 2011). Coagulation disorders and trauma are also essential facets considered during diagnosis (Sheiner, 2011). Conventionally, there are different methods used for the estimation of blood loss during diagnosis, and they are majorly classified as clinical and quantitative methods (Ricci & Kyle, 2009). Clinical method remains the primary means to diagnose the magnitude of bleeding and to direct interventional therapy in obstetric practice (Ricci & Kyle, 2009). On the other hand, quantitative diagnosis entails visual assessment, which is relatively, cheap, straightforward and a standard method of observation used for measurement of blood loss (Simpson & Creehan, 2008). However, the method has a lot of inaccuracy and variation from one care-giver to another, and this is usually corrected through correlations of results obtained with clinical signs (Simpson & Creehan, 2008).
In light with this, assessment is also remarkably essential, and medical history available in the prenatal record can be assessed for previous bleeding disorders in order to assist the nurse in identification of risk factors for obstetrical precursors to hemorrhage (Simpson & Creehan, 2008). Further, assessment of the woman who is bleeding begins with careful evaluation of the quantity and colour of blood loss (Simpson & Creehan, 2008). Bright red vaginal bleeding suggests active bleeding, and dark brown blood may indicate past blood loss (Simpson & Creehan, 2008). Moreover, character of the uterine activity, presence of abdominal pain, stability of maternal signs, and foetal status, also constitute the critical processes of evaluation (Simpson & Creehan, 2008).
Treatment and Management
Simpson and Creehan (2008) attest that the key goals of treatment and management of PPH embraces the need for stopping hemorrhage, correction of hypovolemia and homeostasis, identification of risk factors, and eventually treatment of hemorrhage and the underlying causes. Recognition of PPH requires immediate action that combines diagnostic measures with established maternal resuscitation efforts (Sheiner, 2011). Effective and successful treatment also necessitates an interdisciplinary team approach that is indispensible for life saving (Sheiner, 2011). Therapeutic management is one of the central treatment methods used in offering remedy to PPH (Ricci & Kyle, 2009). It involves and focuses on the underlying causes of the hemorrhage (Ricci & Kyle, 2009). In cases where uterine atony is the causative factor, the first step of treatment of PPH involves the evaluation of the uterus to determine if it is firmly contracted (Simpson & Creehan, 2008), thereafter, there is the incorporate uterine massage, and the use of uterotonic drugs such as oxytocin, ergot alkaloids and prostaglandins (Sheiner, 2011; Simpson & Creehan, 2008).
When retained placental fragments are the cause, the fragments are separated and removed manually, and then a uterine stimulant is given to promote the uterus to expel fragments (Ricci & Kyle, 2009). Similarly, antibiotics are always administered to prevent infections and lacerations are sutured or repaired to prevent excessive bleeding (Ricci & Kyle, 2009). In addition, there is the use of desmopressin drug, a synthetic form of vasopressin (antidiuretic hormone) in reducing PPH (Ricci & Kyle, 2009). The drug stimulates the release of the stored factor VIII and von Willebrand factor from the lining of the blood vessels, which in turn increases platelet adhesiveness and shortens bleeding time (Ricci & Kyle, 2009). Other forms of medical management involve uterine packing, ligation of blood vessels-uterine, ovarian, and hypogastric arteries-, arterial embolization and bimanual compression (Simpson & Creehan, 2008).
Conclusion
Concisely, postpartum hemorrhage describes a mother or a woman who is experiencing or is on the verge of experiencing acute blood loss. As stated, the condition is the leading cause of maternal mortality worldwide attributed to its detrimental complication. Nevertheless, with the introduction of the various diagnoses, assessment, treatment and management methods, the condition can be corrected and loss of lives prevented. It is also advisable that individuals should be conversant with this condition, and visits to the clinics should be more frequent for pregnant women, so as to arrest and prevent such complications.
References
Ricci, S. S. & Kyle, T. (2009). Maternity and Pediatric Nursing. Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins.
Sheiner, K. E. (Ed.). (2011). Bleeding During Pregnancy: A Comprehensive Guide. New York, NY: Sringer Science + Business Media, LLC.
Simpson, R. K. & Creehan, A. P. (2008). Perinatal Nursing (3rd Ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
