Apostpartum Hemorrhage

Apostpartum hemorrhage (PPH) is often defined as blood loss exceeding 500 ml after childbirth or blood loss exceeding 1000 mL after cesarean section. Given that many women are at least 500 ml of blood during childbirth, and no symptoms, a more accurate way to detect PPH lost 1% body weight after the birth of the baby (1 ml of blood weighs 1 gram) are. For example, a patient weighing 175 pounds or 80 kg to 800 ml of blood loss is classified as PPH. More than 10% decrease in hematocrit prenatal otherwise used, suggesting that PPH occurred, this value should be used cautiously, because the hematocrit is influenced by factors other than blood loss and dehydration. It is estimated that 2% to 4% of all births in the PPH, which is an important contribution to maternal morbidity and mortality.

PPH classified as early bleeding (during the first 24 hours after birth) or late bleeding (occurs more than 24 hours after birth). The current trend in obstetric practice to send patients home after the birth for 48 hours or less after birth, it is important to PPH, especially late bleeding is profound. Casto severity of bleeding depends on the speed with which it is diagnosed and treated, if the patient is bleeding at home, their risk increases.

There are several causes of PPH, particularly uterine atony, trauma, and retained placental fragments. Several predisposing factors associated with these causes can be found in Section 2, the number one reason for the start of PPH is uterine atony, a condition where the uterus does not contract enough to increase blood loss from the placental implantation site. If the placenta is delivered, the uterus shrink, separating the hip. If the uterus is infected, the placenta is smaller, resulting in less bleeding.

Tears in the perineum, vagina and cervix can occur during vaginal childbirth. Damage to the cervix occur in rapid expansion pressure on the full expansion. During the second stage of labor, vaginal, perineal and periurethral tears happen. Failure to properly repair these breaks can cause a slow, steady trickle of blood.

The most common reason for termination of PPH are retained placenta fragments. As part of the placenta remains in the uterus after childbirth, small blood clots form around the protected areas and closed the bleeding. After a while, Marsh clots and heavy bleeding. Subinvolution (slow involution) can also be a causal factor at the end of PPH.

Care Plan assessment and physical examination
Since the PPH can be repeated in subsequent pregnancies, always ask whether multiparameter previous PPH. Request for family history of bleeding disorders or excessive bleeding during menstruation or surgery. Whether the patient has perineal pain. Although some problems are to be expected after a vaginal delivery, severe pain or pressure is uncommon and often refers to a hematoma.

Getting the size and characteristics of blood loss, sometimes a pool of blood and the passage of large clots. Usually saturated with water from the perineal route in 15 minutes or saturation of two or more pads per hour indicates bleed. And you can see two hands shows the enlargement of the uterus or the presence of the pelvic hematoma can be established. Palpate the fundus, consider whether the company or is wet, the middle or deviate laterally, and when it's above or below the navel. Usually after the birth of the fundus is firm, department and level of the navel. Fundus of the navel and turned sideways in full-blown show. Wet uterus is a sign of uterine atony, and if not corrected, lead to PPH. If the fundus is firm, department, and at or below the navel, and if a stable, is bright red bleeding further evaluation is needed for trauma. Look carefully all dams unrepaired lacerations or bleeding from the episiotomy repair another. If the hematoma is suspected, the patient lithotomiepositie and placed in the vagina and the perineum is thoroughly investigated. Bump and discoloration of the skin called the hematoma is present. Assessment of vital signs. Temperature greater than 100.4 ° F may indicate uterine infection, which reduces the ability of myometrium to contract and makes the patient more susceptible to PPH. Note that a foul vaginal odor, accompanied by fever infection. Rapid pulse, delayed capillary refill, low blood pressure, respiration and a higher speed can be recorded when a PPH. Evaluation of skin color and temperature of the patient's pallor and cool, clammy skin indicate hypovolemic shock.

PPH is a traumatic experience because of health complications for those who expect a happy time at the same time. The assessment of fear of the patient, the patient went into hypovolemic shock is very nervous and then lost consciousness. Another important experience high levels of anxiety, and have great support.

Nursing plan, primary nursing diagnoses: Fluid volume deficit related to blood loss.

Care plan interventions and treatment
The goal of treatment is to determine the cause and replace lost fluids. Patients should have nothing by mouth to a hemostasis. Proper diagnosis and treatment of cases, the chance of a blood transfusion reduction. Treatment of uterine fundus include regular massage, hand massage two times (physicians only) and pharmacological therapy. Fluid saline Ringer's lactate, expanders or whole blood may be necessary. Multiple venous access points, 100% oxygen, and the Foley catheter is often necessary. If not corrected quickly uterine atony, hysterectomy life.

Look hematocrit and hemoglobin and patient tracking fluid intake and output stage. If the infection is the cause of atonia, the doctor may prescribe antibiotics. PPH caused by a trauma that aseptic conditions require surgical correction. Hematomas can be alone, but when large incisions, the evacuation of clots and ligation of the bleeding vessel is required. The management of perineal pain analgesics. If the retained fragments were suspected at the time of delivery, the uterine cavity under investigation. If manual removal of blood clots or expression / placenta fragments were unsuccessful, cervical dilation and curettage indicated fragments retain removed.

Be aware of PPH in all patients after delivery, especially those of some predisposing factors. It is often the nurse who discovered the bleeding. For the first 24 hours after birth, which regularly fundus inspection. If the fundus is wet, massage, until it feels firm, but to feel that big, hard grapefruit. When massaging the fundus, holding a hand over the pubic support for the lower uterine segment, while gently but firmly rub the fundus, which can lose their tone and the body was suspended. Explain that cramping or a feeling that "work is restart is expected that the liberal use of oxytocin is used to control bleeding. Monitor for hypertension compared with oxytocics and prostaglandins are used. Encourage the patient to a full bladder is empty and prevents normal involution uterine contraction. If the patient is able to urinate only a right catheterization is needed.

Monitor Lochia usually dark red vaginal bleeding and should be filled more than perineal every 2 to 3 hours. Ask the doctor if the bleeding is bright red and stable in the presence of normal fundus company, it usually means tearing. Leda and the bath can help perineal discomfort. The patient usually complete bed rest. Living in a baby can be difficult to safely care for a child's room, while her mother. The patient and significant others as possible newborn care quality time between mother and her newborn baby with ease. To help the patient walk in the first few out of bed, loss of consciousness are common for large blood loss. Get plenty of rest.

Nursing guidelines for discharge planning and home care
Discover how the patient to see and do fundus fundus massage, it is particularly important in patients at risk at the beginning of the hospital. Preparing the physician to the patient to contact the following: Wet uterus is firm with massage, super-bright red or dark red bleeding, large clots, fever above 100.4 ° C, persistent or severe pain, injury or pressure. If iron supplements are learning the patients to the medication with orange juice to take and expect some constipation and dark stools. If oxytocics, with emphasis on the importance of them, like clockwork, as required. If antibiotics are ordered, the patient learned the recipe to the end, although the symptoms may be terminated.

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