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Copy of Postpartum Hemorrhage

for CDH nurses

Heather Kleis

on 29 July 2013

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Transcript of Copy of Postpartum Hemorrhage


A Closer Look at Prevalance, Causes, Prevention & Management Styles

Presentation by Heather Kleis
Introduction & Background
World Health Organization defined PPH as <500ml
Every 4 minutes a woman dies of PPH
Leading cause of maternal death worldwide, 25%
Leading cause of maternal death in USA, 17%
3rd stage of labor most hazardous because of PPH risk
2 main management styles: Active vs. Expectant
What can be done?
PICOT Question
During hospitalization of laboring women, does the use of active management versus expectant management in the third stage of labor result in less blood loss and thus lower postpartum hemorrhage incidences?
The population laboring pregnant women in the hospital.
- Population - The population is laboring/postpratum women.
- Intervention - Active management of postpartum women in the third stage of labor
- Comparison - Comparison is expectant management of the third stage of labor
- Outcome - Expected outcome is to have lower average postpartum blood loss and thus lower incidences of postpartum hemorrhages.
- Third stage of labor
Active vs. Expectant Management
What is the common mangement style in the US?

Literature Review Findings
Lower blood loss in actively managed women
Lower incidences of postpartum hemorrhages in actively managed
Shorter duration of the third stage of labor
Risk factors predictive of postpartum hemorrhage
Major differences found in management style chosen by physicians vs. midwives
WHO supports active management, estimated use 20%
Clinical Implications
Goal: Implement active management protocol as a standard practice for the third stage of labor
Risk Factors
Barriers & Ethical Considerations
Reluctance of RNs, Doctors, midwives
Financial constraints:
Algorithm tool
Additional staffing
Additional training
Al-Zirqi, I., Vangen, S., Forsen, L., & Stray-Pedersen, B. (2008). Prevalence and risk factors of severe obstetric haemorrhage. BJOG: An International Journal of Obstetrics & Gynaecology, 115(10), 1265-1272.
Audrureau, E., Deneux-Tharaux, C., Lefevre, P., Brucato, S., Morello, R., Dreyfus, M., & Bouvier-Colle, M. (2009). Practices for prevention, diagnosis and management of postpartum haemorrhage: impact of a regional multifaceted intervention. BJOG: An International Journal of Obstetrics & Gynaecology, 116(8), 1325-1333.
Burke, C. (2010). Active versus expectant management of the third stage of labor and implementation of a protocol. Journal of Perinatal & Neonatal Nursing, 24(3), 215-228. doi:10.1097/JPN.0b013e3181e8ce90.
Eskild, A., & Vatten, L. (2011). Placental weight and excess postpartum haemorrhage: a population study of 308 717 pregnancies. BJOG: An International Journal Of Obstetrics & Gynaecology, 118(9), 1120-1125. doi:10.1111/j.1471-0528.2011.02954.x
Jangsten, E., Mattsson, L., Lyckestam, I., Hellström, A., & Berg, M. (2010). A comparison of active management and expectant management of the third stage of labour: a Swedish randomised controlled trial. BJOG: An International Journal Of Obstetrics & Gynaecology, 118(3), 362-369. doi:10.1111/j.1471-0528.2010.02800.x.
Jangsten, E., Bergh, I., Mattsson, L., Hellström, A., & Berg, M. (2011). Afterpains: a comparison between active and expectant management of the third stage of labor. Birth (Berkeley, Calif.), 38(4), 294-301. doi:10.1111/j.1523-536X.2011.00487.x
Malabarey, O., Almog, B., Brown, R., Abenhaim, H., & Shrim, A. (2011). Postpartum hemorrhage in low risk population. Journal Of Perinatal Medicine, 39(5), 495-498. doi:10.1515/JPM.2011.059.
Magann, E., Doherty, D., Briery, C., Niederhauser, A., Chauhan, S., & Morrison, J. (2008). Obstetric characteristics for a prolonged third stage of labor and risk for postpartum hemorrhage. Gynecologic And Obstetric Investigation, 65(3), 201-205.
Tan, W., Klein, M., Saxell, L., Shirkoohy, S., & Asrat, G. (2008). How do physicians and midwives manage the third stage of labor?. Birth: Issues In Perinatal Care, 35(3), 220-229.
Causes of Postpartum Hemorrhage
70% of cases
Postpartum Hemorrhage
>500mL blood loss
Lack of
, known as uterine atony, can be caused from a variety of things inlcluding:
Prolonged labor
Large baby
Multple babies

Remember - the uterus is a muscle - so anything that overstretches or overexerts the muscle can cause a
lack of tone!
20% of cases
to the soft tissue during birthing process
Lacerations to uterus, vaginal walls or tearing of peritoneum
Damage to the blood vessels themselves

So if the uterus is firm...but excessive bleeding is occurring, this could be an indication of
10% of cases
issues to consider: abnormal placentation and retained placenta

<1% of cases
Coagulation Disorders: Acquired or inherent
Abnormal Placentation:
placenta previa
placenta accreta
plcenta increta
placenta percreta
Retained Placenta:
Fragments impede spiral artery constriction
Amniotic fluid embolism
Intrauterine fetal demise
HELLP syndrome
thrombocytopenic purpura
von Willebrand's disease
History of PPH
Placenta previa
Placental abruption
Multigravida mother
Multiple baby pregnancy
Coagulation disorders
Advanced maternal age
Prolonged labor
Artificial induction of labor
Prolonged third stage of labor
Risk factors can be identified antenatally or during labor
Risk factors can contribute to the
of PPH...
Active (think proactive!)
Early umbilical cord clamping
Administration of uterotonic drug
Controlled cord traction
Uterine massage
Expectant (think reactive)
Clamping upon pulsation cessation
Early skin-to-skin
Push placenta out
Develop education on pathophysiology of PPH and how active management is beneficial
Forums for discussion of questions and concerns (nurses, doctors, midwives...)
Implement a clinical tool to evaluate a patient's risk for PPH
Implement more accurate measuring of blood loss
Audit system for implenting new protocol
Potential Barriers
Ethical Considerations
Patient autonomy?
Full transcript