SOAP. – Secondary Postpartum Hemorrhage

Susan Drummond

Definition

A.Secondary postpartum hemorrhage is defined as blood loss of 500 mL or more after the first 24 hours of delivery and within 6 to 12 weeks of delivery.

Incidence

A.Incidence is approximately 0.5% to 2% of women in developed countries.

Pathogenesis

A.Hemorrhage may result from retained placental fragments, subinvolution of the uterus, intrauterine infection, or inherited coagulation defects.

Predisposing Factors

A.Abnormally adherent placenta.

B.Prolonged rupture of membranes leading to infection.

C.Overdistended uterus from multiple gestation, and polyhydramnios.

D.Hematoma.

Common Complaints

A.Heavy red bleeding or slow reddish-brown oozing.

B.Abdominal pain.

C.Loss of appetite.

D.Fatigue; cannot get enough rest and is unable to complete self-care and infant care activities.

Other Signs and Symptoms

A.Lochia rubra is bright-red discharge immediately after delivery (1–3 days) and may contain a few small clots. A continuous trickle of bright-red blood suggests a laceration of the cervix or vagina. Saturation of one peri-pad in less than 15 minutes (two pads in 30 minutes, or rapid pooling of blood under the buttocks) is considered excessive bleeding and requires immediate attention.

B.Foul odor: Lochia should not be malodorous. Lochia usually has a fleshy odor.

C.Boggy uterus: Check the consistency of the uterus, whether it is firm or boggy. If atony is present, support the lower uterine segment, and massage the uterus or do bimanual compression.

D.Faintness.

E.Tachycardia.

F.Hypotension.

Subjective Data

A.Elicit onset, duration, and course of symptoms.

B.Elicit the amount and color of lochia, including size of blood clot(s).

C.Review symptoms of infection including fever and malodorous lochia.

D.Review labor and delivery events, including the date of delivery, use of forceps or vacuum, weight of baby, manual removal of placenta, complications, and postpartum course.

E.Review pregnancy for predisposing factors such as multiple gestation and polyhydramnios (as previously noted).

Physical Examination

A.Check temperature, blood pressure (BP), pulse, and respirations.

B.Inspect:

1.Note color and amount of vaginal bleeding. Lochia may appear heavier when the woman first stands up because the lochia pools in the vagina while she is recumbent. Once the pooled blood is discharged, lochial flow should return to normal.

2.Inspect episiotomy or abdominal incision.

C.Palpate:

1.Check for consistency of uterus, massaging uterus if boggy.

2.Express clots, if applicable.

3.By 2 weeks postpartum, the uterus should have involuted and once again be a pelvic organ.

4.Check abdominal tension.

D.Pelvic exam:

1.Speculum exam: Assess cervical lacerations.

2.Bimanual exam: Rule out retroperitoneal hemorrhage.

Diagnostic Tests

A.Complete blood count (CBC) with differential.

B.If bleeding is not under control, type and cross match blood.

C.Coagulation test, if disseminated intravascular coagulation (DIC) is suspected.

D.Blood cultures to rule out infection.

E.Possible evaluation for a coagulation disorder such as von Willebrand’s disease.

Differential Diagnoses

A.Late postpartum bleeding.

B.Normal postpartum bleeding.

C.Postpartum infection.

Plan

A.General interventions:

1.Perform uterine massage: Support the lower uterine segment during massage to prevent uterine prolapse.

2.Give IV hydration for hypovolemic shock: hypotension, tachycardia, and faintness.

3.Hospitalization is usually required for postpartum hemorrhage.

4.Encourage breastfeeding (if applicable) to increase uterine contraction.

5.Advise the patient to rest and increase oral fluids.

B.Pharmaceutical therapy:

1.Drug of choice: Methylergonovine maleate (Methergine) 0.2 mg orally every 4 hours for six doses.

Do not give if the patient is hypertensive.

2.For severe hemorrhage:

a.Oxytocin (Pitocin) 10 to 20 units in 250 mL to 1,000 mL IV fluids.

b.Methylergonovine maleate (Methergine) 0.2 mg by IM injection, if the patient has no history of hypertension. Advise the patient to take full course of oral Methergine even if bleeding stops.

c.Hemabate: 250 mcg, may repeat every 15 to 90 minutes as needed.

d.Misoprostol (Cytotec, PGE1): 800 to 1,000 mcg, prolonged release (PR).

e.Continue bimanual compression, and notify a physician.

3.If infection is suspected or confirmed, antibiotics are prescribed.

Follow-Up

A.Reevaluate the patient 1 week from the date of discharge from the hospital.

B.Repeat Hct/CBC at postpartum visit.

C.The patient may need iron replacement therapy, if not already prescribed. If stable at 1-week follow-up visit, have the patient return in 4 to 6 weeks postpartum for routine postpartum exam.