Early Post-Partum Haemorrhage - Case Study Example

EARLY POST-PARTUM HAEMORRHAGE Vermice Newton, a 30 year-old patient, is well on her 39th week of pregnancy but still shows nosigns of labor. The whole term of her pregnancy went well except for the edema that went from bad to worse in the last two weeks. Feeling restless, she then requested that she be induced to labor. Several hours later, she was back on her room with her baby sleeping quietly. Upon checking on her, the nurse finds her quite pale. When she got her vital signs, her pulse was at 98 beats per minute and her blood pressure at 90/50. When her sheets were checked, blood was pooling on her back and her deep slumber prevented her from knowing it. She was having one of the most serious complications of pregnancy known as post-partum hemorrhage(PPH). According to the Centers for Disease Control and Prevention (2006), hemorrhage, blood clot, high blood pressure, infection, stroke, amniotic fluid in the bloodstream and heart muscle disease are the leading causes of pregnancy-related deaths which sums up to 2-3 pregnancy-related deaths each day. Although deaths due to pregnancy complications have dramatically declined during the period of 1900-1982, the number of cases has ceased to show any decrease since then, which raises so much concern for the women of child bearing age. Furthermore, there seem to be a link between a woman’s race, ethnicity, country of birth, and age and her risk of dying of pregnancy complications. For example, African American women are four times as prone to pregnancy-related deaths as white women, and that, women aged 35-39 are three times at greater risk than women aged 20-24 years old. The risk goes up to five times for a woman aged 40 and above. Post-partum hemorrhage accounts for a high 17% of mortality in women, and a case such as this would require a nurse/midwife with the proper knowledge and skills to address the situation and save the mother from an otherwise life-threatening situation. This paper is aimed at exploring the guidelines in the management of early post-partum hemorrhage and the treatments available for such condition. A woman in labor undergoes three different stages. The first stage is dilatation. It begins with the period of true labor contractions and ends with when the cervix is fully dilated. The first stage is further divided into three phases: the latent, the active and the transition phases. A regularly perceived uterine contraction marks the beginning of the latent phase. It ends when the rapid dilation of the cervix begins. In the active phase of labor, the cervix dilates more rapidly from 4cm to 7cm with stronger contractions in 3 to 5-minute intervals. Contractions reach their peak in the transition phase where the cervix is fully dilated from 8 to 10cm and complete cervical effacement has occurred. The second stage of labor is the period from full dilatation and effacement to the birth of the infant. The last and final stage of labor is the placental stage which begins upon the delivery of the infant and ends with the delivery of the placenta and result to a normal blood loss of 300-500ml (Pillitteri, 2003). Post-partum hemorrhage is traditionally defined as a blood loss of greater than 500ml in vaginal delivery and greater than 1000ml in caesarian delivery. However, it was later found out in studies that a blood loss of 500ml in an uncomplicated delivery may not compromise the mother’s condition. Thus, PPH was, according to Wainscott (2006) redefined as any bleeding that results in signs and symptoms of hemodynamic instability, or bleeding that could result in hemodynamic instability, if untreated. It may also be a case of a blood loss of more than 1000mL with a vaginal delivery or a decrease in postpartum hematocrit level greater than 10% of the prenatal value. ETIOLOGY The causes of post-partum hemorrhage can easily be remembered by the 4 Ts which stand for Tone, Trauma, Tissue and Thrombin. Uterine atony (Tone), which refers to the failure of the uterus to constrict properly, is identified as the most frequent cause of PPH. The risk factors for this condition are overdistended uterus (due to multiple gestation, fetal macrosomia or hydramnios), fatigued uterus (due to prolonged labor and amnionitis), and obstructed uterus which could be due to retained placenta or fetal fragments and placenta accreta. Trauma to the uterus, cervix, and/or vagina is the second leading cause of PPH. Risk factors for this condition includes delivery of a large infant, instrumentation or intrauterine manipulation, vaginal birth after caesarean section (VBAC), and episiotomy. Excessive bleeding may also be caused by thrombocytopenia (Thrombin) which could be preexisting or occurring during the second and third stage of labor. Finally, PPH can be due to placental tissue that was retained in the uterus (Wainscott, 2006). Other risk factors include preeclampsia or pregnancy-related hypertension, a history of PPH, Asian or Hispanic ethnicity, and nullity or multiparity. MANAGEMENT OF EARLY POST-PARTUM HEMORRHAGE Post-partum hemorrhage can be of two kinds. It can be early PPH, occurring within the first 24 hours of after delivery, or late PPH, occurring from 24 hours to 6 weeks after giving birth. Though the causes and the associated risk factors have been identified, one would wonder why PPH is still one of the major causes of mortality and morbidity among women. This may be due to the fact that most cases do not present with the classic causes and risk factors for PPH. It is therefore important that the emergency procedure for the management of PPH be known by heart by any member of the medical team in the delivery room. Clinical management of post-partum hemorrhage starts with the preventive measures that should be exercised during the third stage of labor. Management of PPH can either be expectant or active. According to Maughan, Heim and Galazka (2006), expectant management is also called a physiologic method and can better be termed as the “hands off” approach. In this type of management, the umbilical cord is not clamped or cut until it stops pulsating, and the placenta is delivered unaided and spontaneously. In the active management of PPH, the physician takes part in the delivery procedure by facilitating the separation and delivery of the placenta and aids in facilitating effective contraction of the uterus to shorten the length of the third stage of labor, thereby preventing post-partum hemorrhage. A Cochrane systematic review of five randomized controlled trials comparing active and expectant management in 6400 subjects revealed that active management resulted to a shorter third stage of labor, reduced risk of PPH and anemia, a decreased need for blood transfusion and decreased need for additional uterotonic medication. ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR According to the International Confederation of Midwives and the International Federation of Obstetricians and Gynecologists (2006), active management of the third stage of labor involves the administration of uterotonic agents, controlled cord traction and uterine massage after the delivery of the placenta. Uterotonic agents are medications that aid in the uterine contraction. It is administered within one minute of delivery of the baby, after palpation of the abdomen has been done to rule out the presence of another baby. Oxytocin is the preferred choice (10 units of oxytocin IM) because of its fast effect (within 2-3 minutes after injection), its minimal side effects and that it can be used in all women. Controlled cord traction is done by first clamping the cord close to the perineum once pulsation stops and holding it with one hand. The other hand is then placed just above the woman’s pubic bone and the uterus is stabilized by applying counter-pressure during controlled traction, keeping slight tension on the cord and waiting for a strong uterine contraction for about 2-3 minutes. With the strong uterine contraction, the mother is then encouraged to push and the cord is very gently pulled downward to deliver the placenta, while continuously applying counter-pressure to the uterus. If the placenta does not descend within 30-40 seconds from controlled cord traction, do not continue pulling on the cord. Just wait for another contraction and do the controlled cord traction with counter-pressure on the uterus. As the placenta delivers, hold the placenta with two hands and gently turn it until the membranes are twisted, and slowly pull to complete delivery. Examine the placenta and make sure it is intact. If a portion of the maternal side is missing, take appropriate action. The placenta has two sides, the fetal side and the maternal side. One can tell one side from the other by its appearance. The fetal side is shiny, while the maternal side looks dirty. Uterine massage is done by massaging the fundus of the uterus until it is contracted. It is then palpated every 15 minutes and massaging is repeated as needed for up to 2 hours, making sure that the uterus remains contracted even when the massage has stopped. The Society of Obstetricians and Gynecologists in Canada published their guidelines in the prevention and management of post-partum hemorrhage (Schuumans, 2000). Their recommendations are as follows: 1. Clinicians should assess each woman’s risk for PPH and make appropriate arrangements for her care; 2. Routine prophylactic oxytocin after the delivery of the shoulder reduces the risk of PPH; 3. Third stage care should also include early cord clamping, controlled cord traction with uterine palpation and the inspection of both the placenta and the lower genital tract; 4. Initial treatment of PPH includes early recognition followed by the prompt attention to the resuscitation and the simultaneous search for the cause of bleeding. Baseline laboratory tests should be ordered; 5. The second step in the management of PPH involves attention to the specific cause, proceed with massage and medications for atony, evacuation of the uterus for retained blood clots or products of conception, physical repair of any trauma and reversal of coagulation defects; 6. For the small proportion of women not responding to the initial management steps, a multi-disciplinary team should be assembled including a second obstetrician or surgeon, anesthesiologist, and the associated staff from the operating room, blood bank and intensive care unit. If invasive radiology services are available consideration may be given to angiographic embolization. While such arrangements are being made, blood loss should be minimized by compression, packing and/or vasopressin. Fluid and blood component therapy must be continued to maintain hemodynamic and coagulation status; 7. The approach to intractable PPH will be individualized depending on the clinical situation and the skills and technology available. Continued monitoring and fluid blood component replacement and use of all available expertise are essential; 8. Uterine vessel ligation may be effective in controlling PPH; 9. Internal iliac artery ligation has been reported for use in PPH, however its effectiveness is not yet proven. This procedure requires more extensive surgical skills and the situation may deteriorate if the iliac veins are injured; 10. Peripartum hysterectomy can be life-saving in PPH. A clamp, cut and drop technique should be used to gain control of bleeding as rapidly as possible; 11. Diffuse post hysterectomy bleeding may be controlled by abdominal packing to allow time for the normalization of the woman’s hemodynamic and coagulation status. Specific vessels with hemorrhage persistently may be controlled by embolization procedures; 12. Patients who cannot be given blood require careful pre-labor assessment and transfer to the center most equipped to deal with PPH should it occur. While respecting the woman’s desire for no blood products to be given, the clinician must employ all other treatment options for PPH to the fullest. In cases where the patient is suspected or obvious to have PPH, like in the case of Vermice Newton, emergency procedures are as follows (Wainscott, 2006): Resuscitative measures include the following: (1) administration of 100% oxygen; (2) placement of several intravenous lines with large-bore catheters and infusion of crystalloid solutions (isotonic sodium chloride or lactated Ringer solution warmed, if possible); and (3) cardiac, blood pressure, pulse, pulse oximetry monitoring. Obtain samples for laboratory tests, with special instructions to the laboratory personnel regarding determination of the cause of bleeding. Type and cross match packed red blood cells for transfusion. If the patient is in critical condition, type-specific blood may be needed. Transfuse these with blood warmers; in patients in unstable condition, warmers permitting rapid infusion are preferred. Platelets and FFP may also be necessary. Assess the uterus with bimanual examination. A soft, boggy uterus signifies atony, and uterine massage will stimulate uterine contractions and frequently stops uterine hemorrhage. Exercise caution not to use excessive pressure on the fundus of the uterus; this may increase the risk of uterine inversion. Massaging a hard, contracted uterus can actually impede detachment of the uterus and may increase bleeding. A contracted uterus should initiate a prompt search for lacerations, retained parts, or both. If uterine inversion occurs or has already occurred, gently push the uterus back into position. Fortunately, when this inversion occurs on an emergency basis, the cervix generally does not have time to contract firmly around the inverted uterus. Oxytocin as 20 units in 1L LR at 600 mL/h should be initiated to stimulate and maintain uterine contraction and control hemorrhage. The next drug would be 15-methyl-prostaglandin as 0.25 mg IM. Caution is advised when these agents are considered for the treatment of patients with hypertension. Check the placenta for evidence of missing placental tissue, which still may be attached to the wall of the uterus, causing excessive bleeding. Removal of retained tissue can be difficult and painful. Depending on the skill of the ED physician, it may be wise to let the obstetrician manage removal of retained tissue with use of the hand or an instrument. If bleeding is severe, the ED physician may wrap gauze around one hand, then gently insert it into the uterus and gently sweep the inner wall of the uterus to remove retained placenta tissue. The cervix and vagina must be thoroughly inspected for any trauma (laceration or hematoma). Direct pressure over lacerations in the perineum, cervix, vagina, or uterus may help control bleeding. Perineal, vaginal, and cervical lacerations should be repaired. Most authors do not recommend packing the uterus with gauze, although a few still advocate this in extreme circumstances. A case report of successful hemorrhage control with uterine packing with gauze soaked in thrombin exists. If the patient has coagulopathy, consider the transfusion of fresh frozen plasma. If the patient is thrombocytopenic, consider platelet transfusion. In cases of uterine inversion or manual extraction of placenta or fetal parts, prophylactic antibiotics should be given to prevent amnionitis. In cases of uterine rupture, emergent laparotomy is required. Ergotamines (eg, ergonovine, methylergonovine) are less frequently used due to occasional dramatic hypertension and no proven benefit over oxytocin alone. HOMEBIRTHS While giving birth in a hospital offers a lot of security for the mother and the baby, still some mothers opt to deliver their babies in the comforts of their own homes despite their apprehensions. In a study conducted by Janssen, et al (2002) entitled “Outcomes of planned homebirths versus planned hospital births after regulation of midwifery in British Colombia,” outcomes of 862 planned home births attended by midwives were compared with those of planned hospital births attended by either midwives (n = 571) or physicians (n = 743). Comparison subjects who were similar in their obstetric risk status were selected from hospitals in which the midwives who were conducting the home births had hospital privileges. Results show that women who gave birth at home attended by a midwife had fewer procedures during labor compared with women who gave birth in hospital attended by a physician, and that women in the homebirth group were less likely to have epidural analgesia, be induced and have their labors augmented with oxytocins or prostaglandins, or have an episiotomy. There was also no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. This just goes to show that while post-partum hemorrhage may pose a great risk for the mother, it should not hinder the mother from having a homebirth, should she want to do so. It is quite important, though, that the attending regulated midwife is someone that the mother can trust and that the midwife should be well informed of emergency procedures should the occasion call for it. COMPLICATIONS AND TREATMENTS FOR PPH Advances in the field of Obstetrics and Gynecology have reduced of incidence of post-partum hemorrhage quite significantly. With the aid of drugs and advanced technology, women who are at high risk of developing PPH now have better chances of survival. While the danger of PPH’s complications still loom, prevention from these complications are still possible with early intervention. These complications are the ones associated with blood transfusion, consumptive coagulopathy, disseminated intravascular coagulation (DIC), other bleeding disorders, multiple organ failure associated with circulatory collapse and decreased organ perfusion, need for hysterectomy and loss of child-bearing potential, and need for emergent surgical intervention and potential complications (Wainscott, 2006). A step-wise approach to the management of PPH includes (Schuurmans, et al, 2000): Step 1) Initial Assessment and Treatment which includes resuscitation, assessment of etiology and laboratory tests; Step 2) Directed therapy after the cause of PPH has been identified as either Tone, Tissue, Trauma or Thrombin; Step 3) Intractable PPH which involves getting help from a multi-disciplinary team, administering local control through manual compression, and BP and blood products should the patient require transfusion; Step 4) Surgery to repair lacerations, ligate vessels and perform hysterectomy if necessary; and Step 5) Post Hysterectomy Bleeding which needs abdominal packing and angiographic embolization. Through this step-wise approach, a health practitioner will have a clearly directed path in treating post-partum hemorrhage. CONCLUSION Early post-partum hemorrhage may be one of the most life-threatening complications of pregnancy, but with early intervention through active management of the third stage of labor, it can successfully be prevented. Though there may be cases where bleeding persists despite active management of labor, the midwife’s knowledge of the emergency procedures would prove crucial in augmenting the life of the expectant mother. 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