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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

The processes of labor and birth receive a lot of discussion 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 management and treatment. Postpartum hemorrhage (PPH) is a complication of birth but is preventable through early recognition, assessment, treatment, patient education, and follow-up. PPH accounts for 11.4% of maternal mortality cases in the United States despite the ample resources available in this country. (4). To prevent additional maternal deaths, nurses need to remain educated on this fatal condition.   

Pathophysiology of Postpartum Hemorrhages

Hemorrhage occurring in the postpartum period can occur after a woman gives birth and up to 12 weeks afterward. It is important to note that bleeding after a vaginal delivery or cesarean section is normal; however, the amount of bleeding and clinical symptoms is the determining factor for normal to abnormal hemorrhagic bleeding.

In 2017, the American College of Obstetricians and Gynecologists (ACOG) revised its definition of PPH to include the following: A cumulative loss of blood greater than or equal to (≥) 1000 mL or bleeding associated with signs and symptoms of low blood volume (hypovolemia) within 24 hours of birth (3). 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 myometrium contraction, constricting the blood vessels to the uterus.

The second mechanism controlling bleeding is local decidual hemostatic factors, platelets, to cause clotting (3).PPH can become an obstetric emergency because of the ample supply of blood volume to the uterus ranging from 500-700 mL/min, which equates to around 15% of the maternal cardiac output  (3). Disrupting these mechanisms from functioning and using assessment tools early on can be for potential PPH management.  

Assessment 

The Joint Commission requires an evidence-based assessment tool to determine maternal PPH risk in admission and postpartum units (3). There is a wide range of assessment tools in the U.S. currently being utilized to decrease the rates of hemorrhage-related maternal deaths. The key to assessing PPH management is starting early, before delivery.

One such assessment tool, the Safe Motherhood Initiative, developed by ACOG, is used during the prenatal, antepartum, admission to L&D, and intrapartum (6). These assessments are provided in detail below, and each assessment discusses risk factors during those periods (prenatal, antepartum, L & D admission, and intrapartum) as well as intervention and management steps. (7)(8).

Patients should also be educated during their hospital stay and before discharge on signs and symptoms and what to do if PPH were to occur. Having an assessment tool that identifies potential risk factors and outlines preparatory interventions for when those risk factors are present is vital. This will enable prompt management and treatment.  

Prenatal & Antepartum Assessment (8) 

Prenatal

Risk Factors: 

• Pre-pregnancy BMI over 50 
• Suspected placenta percreta/previa/increta/accreta 
• Clinically significant bleeding disorder 
• Other significant surgical/medical risks (consider patients who refuse transfusion) 

Intervention:  

• Transfer to the appropriate level of care for delivery 

Antepartum

Risk Factors:  

• Placenta previa (Timing of delivery 36 0/7-37 6/7) 
• Placenta accreta (Timing of delivery 34 0/7-35 6/7) 
• Prior cesarean (classical) (Timing of delivery 36 0/7-37 6/7) 
• Prior myomectomy (Timing of delivery 37 0/7-38 6/7) 
• Prior myomectomy, if extensive (Timing of delivery 36-37) 

Placenta accreta management

• The placental location for one or more previous C-sections must be documented before delivery. Patients at higher risk of placenta accreta should;  
• Obtain proper imaging to assess risk before delivery 
• Be transferred to the appropriate level of care for delivery if accreta is suspected 

Labor and Delivery Admission and Intrapartum Assessment

Labor and Delivery Admission 

Risk Factors for Medium Risk:  

• Prior C-section, uterine surgery, or multiple laparotomies 
• Multiple gestation pregnancy 
• Greater than four births 
• Previous PPH 
• Large myomas 
• Estimated fetal weight > 4000 grams 
• BMI > 40 
• Hematocrit <30% and other risks 

Intervention:  

• Type and SCREEN, review protocol 

Risk Factors for High Risk:  

• Placenta previa/low-lying  
• Known coagulopathy 
• Active bleeding 
• Plateltet count <70,000 
• Suspected percreta/accreta 
• Two or more medium-risk factors 

Intervention:  

• Type and CROSS, review protocol  

Intrapartum

Risk Factors for Medium Risk:  

• Chorioamnionitis 
• Oxytocin longer than 24 hours 
• Prolonged 2nd stage 
• Magnesium sulfate  

Intervention:  

• Type and SCREEN, review protocol  

Risk Factors for High Risk:  

• New active bleeding 
• Two or more medium (admission and intrapartum) risk factors 

Intervention:  

• Type and CROSS, review protocol  

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 has PPH. If bleeding is identified, we will need to acknowledge the severity of the bleeding based on collected data and defined criteria by your facility. Postpartum maternal assessments are performed to prevent PPH and include vital signs, uterine fundal tone/location, lochia, and perineal and labial area evaluation (2). The vital signs, including temperature, pulse, blood pressure, and respirations, should be done every 15 minutes for the first 2 hours after birth. The uterine fundus and lochia should also be assessed with each vital sign assessment (2). Additional vital signs and fundal checks could also be done depending on facility protocol.  

• What is your current practice for calculating blood loss? 
• How often are your postpartum maternal assessments? 
• When do you start? When do you stop calculating?  
• What items are used to determine blood loss?  
• Do you assess for color, clot formation, and flow? 

When assessing for bleeding, using a quantified blood loss (QBL) method versus estimated blood loss (EBL) will provide you with a more accurate clinical picture. The use of EBL methods can delay the time-sensitive initiation of life-saving interventions and is commonly found among maternal morbidity and mortality cases. QBL describes a systematic use of weighing scales, volumetric containers, and computerized images to identify blood loss (3) accurately. Options to use in QBL include but are not limited to volumetry, gravimetry, colorimetry with artificial intelligence, and visual aids. It is important to note that the clinician should remember to account for fluids other than blood (urine, irrigation fluid, and amniotic fluid) that are collected or absorbed (3).  

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 bleeding. The resources below define bleeding stages, including signs and symptoms, and also include interventions necessary to advise clinicians when to increase or decrease the severity stage (1)(5).  

California Maternal Quality Care Collaborative Staging (5) 

American College of Obstetrics and Gynecology (1):

Treatment 

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

Causative Factors-Consider 4 T’s (3): 

• 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?  

Order sets and interventions aligning with the severity will help guide healthcare teams in effective PPH management and treatment.  

Treatment provided promptly is crucial because 90 % of maternal deaths related to PPH occur within 4 hours of delivery (2)(Belfort). PPH treatment encompasses a range of interventions, such as pharmacological, surgical, and interventional endovascular procedures, blood bank assistance, nonsurgical methods, and consultations (3). 

Pharmacological treatment options(3)

First line

• Oxytocin

Second line

• Ergots (Methylergonovine)
• Carboprost

Adjunctive agents

• Tranexamic acid
• Recombinant human factor VIIa
• Misoprostol

Surgical interventions(3):

• Laceration repair
• Curettage
• Uterus compression suture and uterine artery ligation
• Utero-ovarian artery cross clamp or ligation
• Pelvic packing
• Uterine tourniquet
• Focal myometrial excision
• Fibrin glues and patches to cover areas of oozing and to promote clotting
• Figure 8 Sutures or other hemostatic sutures in the placental bed
• Resuscitative endovascular balloon occlusion of the aorta (REBOA)
• Hypogastric artery ligation
• Aortic/iliac artery compression
• Total hysterectomy
• Supracervical hysterectomy

Interventional Endovascular procedures(3):

• Selective arterial embolization
• Intermittent aortic and common iliac artery balloon occlusion

Blood bank interventions (3):

• Platelets
• Packed red blood cells (PRBCs)
• Cryoprecipitate
• Fresh frozen plasma (FFP)

Nonsurgical interventions(3):

• Uterine massage
• IV fluids
• Intrauterine tamponade, including;
• Intrauterine balloon, Sengstaken-Blakemore tube, or bladder catheter bulb
• Intrauterine vacuum
• Uterine packing

Consultations(3);

• General surgery
• Anesthesia team
• Interventional Radiology (IR)
• Urology
• Gynecology Oncology
• Trauma surgery

The overall goals of treating PPH are to eliminate the underlying obstetric cause, avoid or reverse coagulopathy, restore or preserve adequate tissue oxygenation, and restore adequate circulatory volume (3).

The CCQCC and ACOG scoring tools helped us recognize the severity of bleeding; we also developed interventions within each stage to guide 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): 

American College of Obstetrics and Gynecology (1):

Recovery 

Once the patient is stabilized after the PPH management and treatment protocols are followed, we must focus on recovery. According to your hospital policy, 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. Measures including documentation, patient education, and staff mock-ups or drills will allow continued success in reducing rising PPH rates.  

Performing post-event debriefs is a handy tool for assisting with process improvements and providing educational guidance. Debriefs should be completed once patients are cared for, but events are still recent for the care team to remember.  

During the actual hemorrhagic event, documentation can become more complex with implementing appropriate and timely interventions and assessments. An events recorder and paper documentation will focus on patients and establish a reference for noted events to provide efficient patient care. Having documented assessments leading to implemented interventions, medication administrations, and blood bank activations will give 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 cramp over the next 4-6 weeks. Give detailed instructions on how much bleeding to expect and how much is abnormal.  
• The color of the bleed changes from red to pink to brown 
• Rising to a standing position from sitting or lying may create a gush “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 (9) 

Staff education is vital in facilitating efficient and effective PPH management. Knowledge of PPH risk factors will facilitate planning and readiness for these occurrences. Ensuring staff are familiar with hospital policy and procedure for PPH and uterotonic medications, treatment supplies, and hemorrhage carts with included contents enables prompt patient response. Creating outlined scoring methods to implement interventions based on severity allows for objective data utilization to maintain patient clinical well-being. 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 promotes the highest quality patient care. Utilizing this method enables nurses to prepare for the possibility of complications, whether they occur or not. PPH is the leading cause of maternal death(4), and ensuring that resources, assessments, and educational opportunities are available will provide us with the necessary tools to reduce the occurrence of life-altering events in the new mother, baby, and family.

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