Moving on to the next complication, a
secondary postpartum hemorrhage.
Secondary being different than an immediate
postpartum hemorrhage, the secondary
postpartum hemorrhage actually occurs 24
hours to 12 weeks
after delivery. The clinical features
include heavy bleeding,
we can also notice passing of very large
In previous lectures where we describe normal
postpartum bleeding, we describe maybe the
size of a golf ball as being a possibility
If we get into some other sport like
baseball or softball, those are too big.
That's too much blood.
We monitor labs postpartum and often, with a
secondary postpartum hemorrhage, we'll
notice that the hematocrit and hemoglobin
drop more than expected.
And that may be our sign of a postpartum
Risk factors include uterine atony, that is
going to be your number one
thing you need to remember, any time there's
bleeding postpartum, the number one
cause is usually uterine atony.
Uterine atony refers to the tone of the
So instead of being firm like a tennis ball,
it's boggy and soggy.
There can also be retained placental
You can't contract when there's something
inside the uterus.
So I've got to get everything out if we have
attachments. So normally the uterus and the
placenta part ways after
birth, right during third stage, the
If the placenta has invaded too much into
the uterine wall, they may not be able to
divorce so easily.
And when that happens, then we can have
retained placenta and that will increase
So sometimes, especially if we've had a
forcep delivery or a very
difficult second stage where we've done a
lot of pushing and have a lot of friable
tissue, then the patient can experience
vaginal lacerations that continue to bleed.
And if we don't find them during the
inspection, then they may continue to bleed
and lead to a hemorrhage.
Having a coagulation disorder.
So if your blood doesn't clot, then having a
hemorrhage is certainly possible.
And finally, an infection.
So, again, any time the uterus is infected,
it doesn't contract.
Well, how do we measure a postpartum
We use a procedure called a QBL or
quantitative blood loss.
We used to use something called an EBL, an
estimated blood loss.
And that looks something like, I'm the
I look at the bleeding and I say, I think
it's about 300
mL. That doesn't sound very accurate and it's
accurate. And they've done studies to prove
So now we actually weigh it.
And when we weigh it, we know exactly the
So QBL is the correct procedure to determine
the level of a hemorrhage.
Also following the labs.
Remember, we're collecting that usually on
day one postpartum and day two postpartum and
we can see an actual decline in that
hematocrit and hemoglobin.
So what does the nurse do during a
The first thing, because we know the number
one cause is uterine atony, is we
massage the fundus.
So uterine atony, massage the fundus.
So, uterine atony, massage the fundus, they
We want to make sure that we locate the
source of the bleeding.
So remember, I talked about lacerations
potentially being the risk for postpartum
hemorrhage. If we're massaging the fundus
and it's firm and the client is still
bleeding, we might need to suspect that
there are lacerations either on the cervix or
in the vaginal vault somewhere that we did
not find earlier.
We want to notify the provider because
ultimately they are likely to have to come in
and give some orders or do some inspection
in order to fix what's happening.
So the sooner you call, the better.
Making sure the bladder is empty.
An empty bladder creates space for a uterus
We can give a uterotonic, so a uterotonic is
going to cause uterine
contractions. So there's several options for
And that includes oxytocin.
We can give misoprostol, carboprost; and
we'll go through a cascade.
And we talk about this more in our lecture
We want to monitor vital signs and look for
signs of shock and draw labs as
ordered, specifically the
hemoglobin-hematocrit, and possibly the white
blood cell count. We also want to prepare in
case the provider needs to
remove retained placental fragments.
So setting the client up for that procedure
may be required.
And finally, if we have a severe postpartum
hemorrhage, we may need to offer some
oxygenation in order to increase the support
for the mother.