Nancy J. MacMullen, PhD, APN/cCNS, Laura A. Dulski, MSN, APN/cCNS, and Barbara Meagher, MSN, RN, CNM, PNNP, RDMS

ABSTRACT The purpose of this article is to help nurses understand how to quickly and effectively manage the nursing care of patients with perinatal hemorrhage. The etiology, symptoms, medical management, and nursing care of the patient experiencing a perinatal hemorrhage are discussed. Hemorrhage during the antepartum, intrapartum, or postpartum period is a life-threatening emergency for the mother and/or fetus. Early antepartum hemorrhage (before 20 weeks gestation) can be related to abortion/miscarriage, ectopic pregnancy, or gestational trophoblastic disease; late antepartum hemorrhage (after 20 weeks gestation) may result from placental abruption and placenta previa. Intrapartum hemorrhage is most commonly due to placental abruption, or to uterine rupture, uterine inversion, invasive conditions of the placenta, or complications of Cesarean birth. Postpartum hemorrhage is defined as blood loss greater than 500 ml in a vaginal delivery or 1000 ml in a Cesarean birth; early postpartum hemorrhage occurs during the first 24 hours after delivery; late postpartum hemorrhage occurs after the first 24 hours after delivery. The most common cause of postpartum hemorrhage is uterine atony; however, lacerations, hematomas, and subinvolution of the uterus can also cause postpartum hemorrhage. Nurses who understand how to assess, plan, intervene, and evaluate outcomes for perinatal hemorrhage are in the position to prevent the major tragedies that can accompany hemorrhage in pregnancy and shortly afterward. Key Words: Hemorrhage; Labor complications; Pregnancy complications; Puerperal disorders. 46

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t is 7:25 A.M. on a busy mother/baby unit. You have just finished collecting the report about Mrs. Davis, a 25-year-old gravida 6, para 5015, who delivered at 2:34 A.M. The night nurse’s report indicates an uneventful postpartum course thus far. You are about to begin your rounds when the emergency light in Mrs. Davis’ room goes on. As you walk in the door, she screams, “I’m bleeding!” You see her gown, chux , and bedding saturated with blood. Responding quickly to situations such as this is a necessary skill for the perinatal nurse. Management of hemorrhage during the antepartum, intrapartum, and postpartum periods is a complex process involving keen assessment and timely intervention. This article presents a brief summary of the etiology, symptoms, and medical and nursing management of perinatal hemorrhage (Table 1).

Antepartum Hemorrhage Hemorrhage in the antepartum period can occur early (first 20 weeks) or late (after 20 weeks) in gestation. Etiology of hemorrhage during the first 20 weeks of pregnancy includes elective, induced, or spontaneous abortion (threatened, incomplete, complete), ectopic pregnancy, and Gestational Trophoblastic Disease (GTD), cervical polyps, cervicitis, or cervical cancer (Claydon & Pernoll, 2003; Gilbert & Harmon, 2003). Early Pregnancy

In early pregnancy, in the case of threatened abortion, expectant management of hemorrhage is employed if fetal January/February 2005

cardiac activity is detected; evacuation of the uterus will be performed for incomplete abortions (Yashar, 1998). If hemorrhage is caused by an ectopic pregnancy, surgical or pharmaceutical management (Methotrexate, IM) is employed, depending on the patient’s desires and the location of the ectopic (Genovese, 2004). Patients with GTD must have the trophoblastic tissue evacuated and have Beta hCG levels measured frequently to assure that there is no occurrence of choriocarcinoma (Dyne, 2004; Nimrod & Oppenheimer, 1999). Cervical polyps, cervicitis, or cervical cancer treatment is specific to the type of lesion identified (Claydon & Pernoll, 2003).

vasa previa. Vasa previa is the velamentous insertion of umbilical vessels that cross in front of the fetal presenting part (Heppard & Garite, 2002). Management of hemorrhage after 20 weeks of gestation depends upon several factors: the etiology, the severity of the bleeding, fetal gestational age, and whether the patient is in labor. Patients with significant blood loss are prepared for emergency Cesarean birth regardless of gestational age. Minor bleeding episodes can be managed with bed rest in a side-lying position and fetal surveillance (Heppard & Garite, 2002).

Late Pregnancy

Hemorrhage during labor is most commonly caused by placental abruption (Cunningham et al., 2001); however, other complications such as undiagnosed placenta previa, uterine rupture, uterine inversion, invasive placentas (acreta, increta, percreta), and hemorrhage during operative delivery can cause bleeding (Gilbert & Harmon, 2003). Patients experiencing these intrapartum complications are prepared for emergency surgery (Cesarean birth or hysterectomy), while being stabilized with volume resuscitation, medication, and oxygen, if necessary. Once the uterus is empty, uterotonic drugs are given, if indicated (Kramer & Weiner, 2000) (Table 2). While Cesarean births occur frequently, and are at times even encouraged as elective primary modes of giving birth

In late pregnancy bleeding is generally caused by either placental abruption or placenta previa. Placental abruption is the premature separation of a normally implanted placenta (Heppard & Garite, 2002), and is classified as mild (Grade 1, 10% detached), moderate (Grade 2, 20-50% detached), or severe (Grade 3,
50% detached). The amount of blood loss is proportional to the grade of abruption, as is the severity of the abdominal pain (Genovese, 2004). Placenta previa, abnormal implantation of the placenta either completely or partially covering the cervical os, is classified as low lying, marginal, partial, or total, depending upon how much of the internal os is covered (Miller, 2002). A rare cause of painless late-antepartum hemorrhage is January/February 2005

Intrapartum Hemorrhage

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TABLE 1. Types of Perinatal Hemorrhage Type of Hemorrhage Antepartum (Early) Abortion

Dark spotting to frank, bright red bleeding; cramping, cervical dilatation Vague pain/cramping; dark red discharge Brownish vaginal bleeding; uterus small for dates; bright red when molar tissue starts separating from uterus

Ectopic GTD (Late) Abruption Previa Intrapartum Uterine rupture Uterine inversion Invasive placentas Operative delivery Postpartum (Early) Atony Retained placenta Lacerations Hematoma (Late) Atony Retained placenta Subinvolution Infection

(Minkoff & Chervenak, 2003), it is essential that nurses remember that hemorrhage can occur at the time of Cesarean birth. If uterine atony occurs, bimanual pressure and uterotonic drugs are given via the appropriate routes (Dickinson, 1999). If these methods fail to arrest the hemorrhage, uterine artery ligation/embolization and hypogastric artery balloon occlusion may be employed (Oei et al., 2001).

Postpartum Hemorrhage Experienced perinatal nurses know that even with an uncomplicated vaginal or Cesarean birth, hemorrhage can still occur after delivery. A postpartum blood loss of
500 ml in a vaginal delivery or 1,000 ml in a Cesarean is designated as a hemorrhage. Early postpartum hemorrhage is that which occurs within the first 24 hours after delivery, and late postpartum hemorrhage occurs after the first 24 hours postpartum (Cohen, 2000; Dildy, 2002). The most common cause of early postpartum hemorrhage is uterine atony, but other etiologies including placental anomalies, uterine inversion, retained placental tissue, obstetric lacerations, and coagulation defects are also implicated (Cohen, 2000; Tropper, 2002). Causes of late postpartum hemorrhage are atony, infection, subinvolution (incomplete return of the uterus to its 48

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Dark vaginal bleeding; abdominal pain Painless bright red bleeding Bright Bright Bright Bright

red red red red

vaginal bleeding; sharp abdominal pain vaginal bleeding; atony vaginal bleeding bleeding from uterus or operative site

Bright red vaginal bleeding; clots; boggy (soft) uterus Bright red vaginal bleeding; clots; boggy uterus tissue Bright red vaginal bleeding; oozing; uterine fundus firm Exquisite pain at site of hematoma Bright red bleeding, boggy uterus Bright red bleeding, tissue, clots Irregular/prolonged/excessive bleeding; uterus larger than normal Pinkish brown vaginal drainage, foul smelling

prepregnant size and shape), and retained placenta (James, 2001). Uterine atony is treated by fundal massage, expressing clots, and administering medications to achieve uterine contractility (Table 2). When these means of containing atony are unsuccessful, bimanual compression or surgical intervention may be necessary (uterine/hypogastric artery ligation/embolization, hysterectomy) (Cunningham et al.,2001). Suture techniques such as the B-Lynch procedure also may prove effective (and may potentially preserve fertility) if other efforts at reversing uterine atony fail (Dildy, 2002; Roman & Rebarber, 2003). If retained placental fragments are causing the bleeding, they must be removed, perhaps necessitating dilation and curettage (Gorrie, McKinney & Murray, 1998). If uterine atony is not present, other causes of hemorrhage must be explored. Careful inspection of the cervical, vaginal, and perineal area should be performed; lacerations or hematomas should be repaired and coagulopathies managed appropriately (Bowes & Thorpe, 2004). Medical interventions for late postpartum hemorrhage caused by subinvolution of the uterus depend upon the cause. If the cause is retained placental fragments, they are removed. If infection is the cause, it is treated with IV antibiotics (Chamberlin, 1999). January/February 2005

TABLE 2. Examples of Medications Used for Uterine Atony Medication

Dosage

Route

Frequency

Contraindications Nursing Actions

Oxytocin

10-40 in 1 L of normal saline or lactated Ringer’s solution

IV

Infusion (continuous)

None for postpartum hemorrhage

Methylergonovine

0.2 mg

IM

Every 2-4 hr. up Maternal to 5 doses hypertension/ toxemia; known drug sensitivity

Monitor uterine bleeding

15-90 min Hypertension, intervals not to cardiac, pulmonary exceed 8 doses renal; hepatic (active) symptoms

Monitor VS, uterine tone/bleeding, renal, cardiac, pulmonary symptoms

(IV not recommended)

15-mPGF2alpha

0.25 mg

IM, IMM*

Monitor fluids to avoid water intoxication; monitor uterine bleeding

*IMM, intramyometrially by physician.

TABLE 3. Assessment of Vaginal Bleeding Color

Debris

Amount*

Flow*

Bright red

Clots (red lumps, no tissue)

Scant—-less than 1-inch stain

Scant

Dark red

Tissue (shiny gray material; Light—-less than 4-inch stain may be interspersed with clots

Trickle

Brown

Heavy-saturated within 1 hour Excessive-1 pad saturated within 1 hour

*Sources: Cashion (2004); Jacobsen (1985); James (2001).

Nursing Care for Perinatal Hemorrhage Clinical reasoning leading to diagnostic, ethical, and therapeutic judgments by nurses in providing care for patients with perinatal hemorrhage can be achieved through the nursing process: assessment, planning, intervention, and evaluation (Sherwin, Scolovino, & Weingarten, 1999). Assessment

The first step in assessment is to review the patient’s history for data that may indicate the risk for perinatal hemorrhage; particular attention should be paid to a history of previous obstetrical hemorrhages and their causative or precipitating factors (Harkreader & Hogan, 2004). Assessment includes monitoring vital signs, bleeding, intake and output, pain experience, and emotional status. Continuous fetal monitoring should be instituted if there is a viable fetus, in order to detect ominous patterns. Vital signs are taken until bleeding is controlled and vital signs remain or return to normal; they are taken more frequently (1-5 minutes) if the patient’s condition is unstable (Burke-Sosa, 2001). The site, color, odor, and the amount of bleeding are observed. January/February 2005

Perineal pads are counted and any tissue or clots are noted and saved for the physician to examine. The presence or absence of tissue indicates the type of perinatal hemorrhage, as does the color of the blood (Sherwin et al., 1999) (Table 3). Intake and output with specific gravity should be measured every hour; urinary output should not fall below 30 ml/hr; for 30 ml of urine/hr indicates decreased perfusion and the need for volume replacement (Heppard & Garity, 2002). Current and previous lab data (including blood type) should be reviewed, and a Kleinhauer-Betke or APT test done for women who are Rh negative to determine if the blood is of fetal origin and to calculate RhoGam dosage (Schnell, VanLeeuen, & Kranpitz, 2003). The site, frequency, duration, and quality of pain need to be observed. Intensity, duration, and frequency of contractions are also monitored to establish that the patient is in labor, which will affect medical and nursing management. The patient’s emotional state also must be assessed to evaluate the emotional response to the hemorrhage. Coping strategies and available support mechanisms are assessed for the purpose of assisting the patient and family to decrease anxiety and to realistically plan for future events (Doenges & Moorhouse, 1998). MCN

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Even with an uncomplicated vaginal or Cesarean birth, hemorrhage can occur after delivery. Nursing Diagnoses Nursing diagnoses related to perinatal hemorrhage (NANDA, 2003) are: • deficient fluid volume; • maternal/fetal injury, risk for; • ineffective tissue perfusion, maternal/fetal; • excess fluid volume; • risk for infection; • acute pain; • ineffective individual/family coping; and • deficient knowledge of hemorrhagic condition. Expected Outcomes Expected outcomes for the client experiencing perinatal hemorrhage are: • resolve hemorrhage; • prevent shock, infection and DIC , and other complications; • avoid fetal injury/loss if fetus is viable; and • provide psycohological/spiritual support. Planning

Planning includes being prepared to initiate nursing interventions to manage any instance of hemorrhage. In an emergency situation such as perinatal hemorrhage, the ability to rapidly revise the care plan as the patient’s condition changes is essential. Current knowledge of appropriate nursing strategies enables the nurse to collaborate and consult with other members of the perinatal team. Nurses working in perinatal units must continually update their knowledge by joining specialty organizations, attending continuing education programs, subscribing to and reading appropriate nursing journals, and accessing informative Web sites. Interventions

Timely, prioritized nursing interventions are necessary to contain hemorrhage and prevent complications. Nursing actions common to all types of hemorrhage include the following: 1. Starting two large bore IVs and administering fluids, blood/blood products, and drugs. Larger IV catheters allow for rapid flow rates. 2. Using an intravenous crystalloid solution (normal saline 50

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or Ringer’s Lactate) to restore circulation, because its fluid and electrolytes are similar to plasma (Burke-Sosa, 2001; Phillips, 2001). 3. Auscultating breath sounds before and after fluids are given to determine if fluid overload has occurred. 4. Initiating foley catheter insertion, pulse oximetry, EKG, and blood gases to monitor circulatory perfusion. 5. Preparing for the possible use of a CVP or Swan-Ganz device to monitor circulatory volume. 6. Teaching and counseling the patient throughout the experience. 7. Documenting all care in the medical record clearly and concisely. 8. Notifying the neonatal team that a maternal hemorrhage is anticipated and there is a viable fetus. Interventions Specific for the Early Antepartum Hemorrhage Nursing management of early antepartum hemorrhage is dependent upon several factors: severity of bleeding, gestational age of the fetus, and underlying cause of the hemorrhage. Nursing interventions specific to managing early antepartum hemorrhage are (Melson et al., 1999): • instruct the patient about bed rest/supportive care; • prepare for surgery and recovery, if indicated; • administer RhoGam and medications specific to type of hemorrhage; • provide information on the products of conception; and • administer pain medications cautiously (because of potential for fetal effects). Interventions Specific for Late Antepartum Hemorrhage • Provide fetal surveillance (continuous fetal monitoring, ultrasound, and biophysical profile) • Administer tocolytics, RhoGam, fetal steroids as indicated • Instruct on bed rest (lateral position) with or without bathroom privileges • Monitor contractions/pain • Prepare for emergency operative vaginal birth or cesarean birth • Summon neonatal team/perform neonatal resuscitation Intrapartum Hemorrhage Interventions Interventions specific for intrapartum hemorrhage are (Doenges & Moorhouse, 1999): • monitor fetus continuously; intervene with positioning, O2, IV bolus, if pattern nonreassuring; • assess contractions; • provide pain management and assess quality of relief; • prepare for emergency procedures; and • alert and assist neonatal team. Postpartum Hemorrhage Interventions Interventions specific for postpartum hemorrhage are (Melson et al., 1999): • assess fundus and gently massage uterus until firm, after patient’s bladder is emptied (a full bladder can displace the uterus and prevent its contraction) (Lowdermilk, 2004); January/February 2005

• express clots (clots also can interfere with uterine contraction); • provide uterotonic drugs and drugs for pain management; and • prepare for surgery if uterine atony is not resolved. Evaluation

Evaluation assesses the quality of nursing care and links positive patient outcomes to quality care. It includes examining reasons why interventions were effective or ineffective. After evaluating the impact of nursing interventions, the nurse decides if the plan is to be continued or revised. Revision of the plan is necessary if outcomes were not reached (Harkreader & Hogan, 2004).

Conclusion Because hemorrhage can unexpectedly occur during any stage of the perinatal period, planning for care of the perinatal patient must include the potential of hemorrhage. The well-prepared perinatal nurse is knowledgeable about the etiology, symptoms, and medical and nursing management of all types of perinatal hemorrhage. The nurse competent to initiate and implement an effective plan of care for any perinatal emergency would respond to Mrs. Davis’ hemorrhage by rapidly assessing and intervening with appropriate nursing actions. ✜ Nancy J. MacMullen is a University Professor, Governors State University, University Park, IL. She can be reached via e-mail at [email protected]. Laura A. Dulski is a Nursing Instructor, West Suburban College of Nursing, Oak Park, IL. Barbara Meagher is a Midwife/Nurse Practitioner, The University of Chicago Hospitals, IL. References

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March of Dimes www.marchofdimes.com AWHONN (nursing standards and care links to other sources) www.awhonn.org Medscape (research and clinical nursing and medical articles) www.medscape.com ACOG (Standards of care, technical bulletins, press releases) www.acog.org

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