Secondary Postpartum Hemorrhage (Nursing)

00:01 Moving on to the next complication, a secondary postpartum hemorrhage.

00:06 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 clots.

00:25 In previous lectures where we describe normal postpartum bleeding, we describe maybe the size of a golf ball as being a possibility of normal.

00:33 If we get into some other sport like baseball or softball, those are too big.

00:38 That's too much blood.

00:41 We monitor labs postpartum and often, with a secondary postpartum hemorrhage, we'll notice that the hematocrit and hemoglobin drop more than expected.

00:49 And that may be our sign of a postpartum hemorrhage.

00:53 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.

01:06 Uterine atony refers to the tone of the uterus.

01:09 So instead of being firm like a tennis ball, it's boggy and soggy.

01:15 There can also be retained placental fragments.

01:18 You can't contract when there's something inside the uterus.

01:20 So I've got to get everything out if we have abnormal placental attachments. So normally the uterus and the placenta part ways after birth, right during third stage, the placenta detaches.

01:33 If the placenta has invaded too much into the uterine wall, they may not be able to divorce so easily.

01:40 And when that happens, then we can have retained placenta and that will increase bleeding.

01:46 Also, lacerations.

01:47 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.

02:01 And if we don't find them during the inspection, then they may continue to bleed and lead to a hemorrhage.

02:08 Having a coagulation disorder.

02:10 So if your blood doesn't clot, then having a hemorrhage is certainly possible.

02:14 And finally, an infection.

02:16 So, again, any time the uterus is infected, it doesn't contract.

02:20 Well, how do we measure a postpartum hemorrhage? We use a procedure called a QBL or quantitative blood loss.

02:28 We used to use something called an EBL, an estimated blood loss.

02:32 And that looks something like, I'm the provider.

02:35 I look at the bleeding and I say, I think it's about 300 mL. That doesn't sound very accurate and it's not very accurate. And they've done studies to prove such.

02:47 So now we actually weigh it.

02:49 And when we weigh it, we know exactly the right amount.

02:52 So QBL is the correct procedure to determine the level of a hemorrhage.

02:57 Also following the labs.

02:58 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.

03:09 So what does the nurse do during a postpartum hemorrhage? The first thing, because we know the number one cause is uterine atony, is we massage the fundus.

03:17 So uterine atony, massage the fundus.

03:23 So, uterine atony, massage the fundus, they go together.

03:25 We want to make sure that we locate the source of the bleeding.

03:29 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.

03:46 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.

03:54 So the sooner you call, the better.

03:57 Making sure the bladder is empty.

03:59 An empty bladder creates space for a uterus to contract.

04:03 We can give a uterotonic, so a uterotonic is going to cause uterine contractions. So there's several options for that.

04:10 And that includes oxytocin.

04:12 We can give misoprostol, carboprost; and we'll go through a cascade.

04:17 And we talk about this more in our lecture on hemorrhage.

04:21 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.

04:37 So setting the client up for that procedure may be required.

04:41 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.