Postpartum Hemorrhage
Key Points
- postpartum-hemorrhage occurs in about 1 to 5 percent of births and can progress rapidly to hypovolemic shock.
- ACOG defines postpartum hemorrhage as 1,000 mL blood loss within 24 hours after birth, while 500 mL after vaginal birth still requires intervention.
- Early hemorrhage (birth to 24 hours) is most often due to uterine atony; late hemorrhage (after 24 hours to 12 weeks) is often linked to subinvolution or retained products.
- Quantitative blood loss (QBL) and rapid escalation are central to preventing preventable maternal mortality.
Pathophysiology
Postpartum hemostasis depends on strong uterine contraction and intact coagulation. When uterine tone is poor, tissue is retained, trauma is present, or clotting is impaired, blood loss can accelerate and exceed compensatory reserve. Because pregnancy increases blood volume, clinical hypovolemia signs may appear late, so objective blood-loss measurement is essential.
Hemorrhage causes decreasing circulating volume, peripheral vasoconstriction, and shunting to vital organs. Without timely correction, maternal status can progress from weakness and dizziness to tachycardia, hypotension, hypoxia, oliguria, altered mental status, and loss of consciousness.
Classification
- Early (primary) PPH: Birth to 24 hours postpartum; commonly linked to the four Ts.
- Late (secondary) PPH: After 24 hours through 12 weeks postpartum; often associated with subinvolution, retained tissue, or coagulation abnormalities.
- Etiologic framework (four Ts): Tone (atony), Trauma (laceration, hematoma, inversion/rupture), Tissue (retained placenta), Thrombin (coagulation disorder).
Nursing Assessment
NCLEX Focus
Priority questions emphasize early recognition: increasing blood loss, boggy/deviated fundus, and evolving hypovolemia cues require immediate action.
- Perform QBL for all births and trend cumulative blood loss rather than relying on visual estimation.
- Assess fundal tone, position, and bladder distention; a full bladder can worsen uterine atony.
- Monitor vital signs, oxygen saturation, mental status, skin perfusion, and urine output (target at least 30 mL/hr).
- Assess perineum/incision and symptoms of concealed bleeding such as hematoma pain and worsening instability.
- Track CBC and clotting studies in ongoing or severe hemorrhage pathways.
Nursing Interventions
- Initiate immediate fundal massage with uterine support and assist bladder emptying when atony is suspected.
- Activate hemorrhage response pathway and coordinate multidisciplinary support early.
- Administer prescribed uterotonics and adjunct agents rapidly while reassessing response in real time.
- Support intravascular volume restoration with IV fluids and blood products as ordered; monitor for transfusion reactions.
- Prepare escalation to mechanical tamponade or surgical management when bleeding persists despite first-line therapy.
Delayed Treatment Increases Mortality
Underestimation of blood loss and delayed escalation are major contributors to preventable maternal deaths from hemorrhage.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| uterotonics | Oxytocin, methylergonovine, misoprostol, carboprost | Oxytocin is first line; choose alternatives based on hypertension/asthma contraindications and side-effect profile. |
| antifibrinolytics | Tranexamic acid (TXA) | Give with uterotonic support in active hemorrhage; recommended early, ideally within 3 hours of birth. |
| intravenous-fluids | Isotonic crystalloid resuscitation context | Stabilizes perfusion while cause-targeted hemorrhage control proceeds. |
Clinical Judgment Application
Clinical Scenario
Two hours postpartum, a patient has a boggy fundus deviated to the right, saturates a peripad, passes clots, and develops rising pulse with lightheadedness.
Recognize Cues: Ongoing blood loss, uterine atony pattern, and early hypovolemia signs. Analyze Cues: Bladder distention and poor uterine contraction are likely driving hemorrhage. Prioritize Hypotheses: Immediate priority is restoring uterine tone and preventing progression to shock. Generate Solutions: Massage fundus, assist voiding/catheterization, quantify loss, give ordered uterotonics, and call hemorrhage team. Take Action: Implement hemorrhage protocol and prepare additional interventions if bleeding persists. Evaluate Outcomes: Fundus becomes firm/midline, blood loss slows, and perfusion parameters stabilize.
Related Concepts
- complications-in-the-third-stage-of-labor - Third-stage placental and tone problems are major antecedents of early PPH.
- monitoring-during-labor-for-emerging-complications - Ongoing surveillance supports rapid recognition of maternal deterioration.
- postpartum-infections - Retained tissue and invasive management may overlap infection and hemorrhage pathways.
- maternal-sepsis - Severe blood loss and invasive treatment can coexist with sepsis risk in complex postpartum cases.
- nursing-care-during-the-postpartum-period - Discharge teaching must include late-PPH warning signs and escalation instructions.
Self-Check
- How does early postpartum hemorrhage differ from late postpartum hemorrhage in timing and common causes?
- Why is quantitative blood loss superior to visual estimation during postpartum surveillance?
- Which contraindications influence selection of methylergonovine or carboprost during PPH treatment?