What Is Postpartum Hemorrhage?
ACOG (reVITALize) defines PPH as cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of hypovolemia, within 24 hours of birth regardless of delivery route. The older, route-specific definition (over 500 mL after a vaginal birth or over 1,000 mL after a cesarean) is still widely taught, but the single 1,000 mL threshold standardizes the diagnosis across vaginal and cesarean deliveries (ACOG Practice Bulletin No. 183).
Pathophysiology
The main causes bleed through different mechanisms. In uterine atony, the uterus stops contracting and the open placental sites keep bleeding. Lacerations bleed directly. Retained placental fragments keep the uterus from clamping down and can cause massive bleeding.
Risk Factors
Watch for these in any postpartum woman:
- Anything that overdistends the uterus: multiple gestation, hydramnios, a large baby, uterine myomas.
- Anything that sets up cervical or uterine lacerations: operative birth or rapid birth.
- Abnormal placental attachment: placenta previa, abruptio placentae.
- A uterus that will not contract: deep anesthesia during cesarean delivery, advanced maternal age, high parity.
- Inadequate coagulation: disseminated intravascular coagulation.
Signs and Symptoms
- Heavy vaginal bleeding: over 500 mL in a vaginal delivery or over 1,000 mL in a cesarean delivery.
- Tense, rigid uterus, which can point to concealed bleeding on top of what you see.
Medical Interventions
- Pitocin to restore and maintain uterine tone when the uterus will not contract.
- Carboprost tromethamine, a prostaglandin derivative, for sustained uterine contractions.
- Blood transfusion after type and crossmatch to replace the loss.
- Oxygen at 4 L/min via face mask if the woman is in respiratory distress.
Surgical Management
- Suturing to control bleeding from severe uterine atony.
- Hysterectomy as a last resort to save the mother's life.
Nursing Management
Assessment
- Quantify the bleeding.
- Get baseline maternal vital signs.
- Watch for signs of shock.
- Assess uterine tone and position.
Nursing Diagnosis
- Deficient fluid volume related to excessive bleeding after birth.
Interventions
- Save and weigh all perineal pads to quantify blood loss.
- Position the woman side lying so blood does not pool unseen beneath her.
- Assess lochia frequently against normal limits.
- Monitor vital signs, especially blood pressure.
Evaluation
- Blood pressure stays above 100/60 mmHg.
- Pulse rate stays within 60-100 beats per minute.
- Lochia flow is less than one saturated pad per hour.
Frequently Asked Questions
How is postpartum hemorrhage defined? ACOG defines PPH as cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of hypovolemia, within 24 hours of birth regardless of route. The traditional definition (over 500 mL vaginal, over 1,000 mL cesarean) is still commonly taught (ACOG Practice Bulletin No. 183).
What is the most common cause of PPH? Uterine atony, where the uterus fails to contract after delivery and the open placental sites keep bleeding. Other causes include genital tract lacerations, retained placental fragments, and coagulation problems.
How serious is PPH worldwide? It is the leading cause of maternal death, affecting an estimated 14 million women a year and causing about 70,000 deaths, most in low and middle-income countries (WHO).
What are the early warning signs? Heavy vaginal bleeding and a tense, rigid uterus that can signal concealed bleeding, along with rising pulse, falling blood pressure, and other signs of developing shock.
What is the first-line drug for uterine atony? Oxytocin (Pitocin) to restore and maintain uterine tone. Carboprost tromethamine, a prostaglandin derivative, is used for sustained contractions when bleeding continues.
How do nurses quantify blood loss? Save and weigh all perineal pads, assess lochia against normal limits, and position the woman side lying so blood does not pool unseen beneath her, while monitoring vital signs closely.