Postpartum Haemorrhage: The Case of Mrs H - Essay Example

? Postpartum Haemorrhage: The case study of Mrs H MODULE Complicated Childbirth MODULE MW50015W/Z NUMBER 21155785 Postpartum Haemorrhage: The case study of Mrs H This essay is based on the case study of Mrs. H. (see appendix) who suffered from postpartum haemorrhage after the birth of her second child. A pseudonym Mrs. H has been used to comply with Nursing and Midwifery Council (NMC), (2008) rules of confidentiality. It examines pathophysiology of postpartum haemorrhage; a major cause of maternal death in developing and developed countries (Lombard and Pattinson, 2009). This essay will also explore the effects of postpartum haemorrhage in relationship to the case study of Mrs. H, focusing on the physical range of interventions that were undertaken to prevent fatal consequences by using oxytocic drugs and fluid replacement as per trust guidelines; care given by the Midwife and also the psychosocial care that is needed to prevent women from suffering from post-traumatic stress disorder. Mrs H was found to have ruptured her uterus affecting the involution of the uterus and therefore causing the haemorrhage. A postpartum haemorrhage is traditionally defined as bleeding from the genital tract of five hundred millilitres or more following delivery (Hofmeyr, 2001). This can result in death from hypovolemic shock. Sometimes these effects occur long after the event of the haemorrhage, which can cause women to experience psychological impact from effects such as post-traumatic stress disorder. This essay focuses on two effects that can come as a result of postpartum haemorrhage: hypovolemic shock and post-traumatic stress disorder. The basic definition of haemorrhage is the abnormal loss of blood (Varney, Kriebs, & Gegor 2004, p. 925). Intrapartum haemorrhage (IPH, occurring during delivery) and bleeding that is considered primary postpartum haemorrhage (PPH, occurring immediately after delivery) is the experience of excessive blood loss during the course of delivery or within the 24 hour period after labour and for which the source of the blood is the genital tract (Crafter 2011, p. 149). Women in labour suffer from substantial fluid loss; so they need to be kept well hydrated to ensure enough circulating volumes to enable them to cope with any excessive blood loss (Hofmeyr and Mohlala 2001, p. 646). After childbirth there is the risk of haemorrhage that can come from a variety of locations. Immediate haemorrhage is more commonly associated with mortality and can come from different factors surrounding the birth. In as much as 90% of the cases of immediate post-birth haemorrhage the cause is uterine atony which has a number of causes, including incomplete delivery of the placenta. When there are cotyledons, or retained placental fragments, there is both the risk of immediate haemorrhage and of delayed haemorrhage (Varney, Kriebs, & Gegor 2004, p. 925). The amount of bleeding can be any amount that compromises the health of the mother but is generally considered to be 500mls or more. In healthy pregnancy, women have a plasma volume increase of at least 1250mls and the red cell mass also increases, as a result women are able to tolerate up to a litre of blood loss with no adverse effects (Hofmeyr, 2001) In cases of women who suffer from severe anaemia, they may be unable to tolerate blood loss that healthy women can (Crafter, 2011). The speed of the blood flow through the intervillous space can be estimated to be about 600ml per minute (Hofmeyr et al, 2008). There are 4 most common known causes of PPH; traditionally known as the 4T: tone, trauma, tissue, and thrombin (Mukherjee and Arulkukarin 2009, p. 4). Tone refers to poor contraction of the uterus, which is also called uterine atony. The tearing of tissue and vessels known as trauma is the cause that is seen in the case of Mrs. H. The contributing factors to her ending up with a PPH were instrumental delivery, episiotomy, uterine rupture as well as genital tract lacerations. Tissue refers to when the placenta or membranes are not totally expulsed and thrombin is when a woman suffers from clotting problems (Alfirevic, 2008). The issues of tone, trauma, tissue, and thrombin can all be addressed through uterine massage which helps in keeping the uterus well contracted. Uterine massage is known to decrease the bleeding and consequently reduce PPH incidents (Je?kkab 2008). During labour it is important that uterine massage take place so that the Midwife can keep the uterus contracted and identify any cause of bleeding. This occurs through palpating the uterus to make sure that it is well contracted and checking to see that there are no genital tract lacerations which would need suturing to avoid them from bleeding out. The uterus must be firm upon touching and should remain below the umbilicus region (White et al, 2006). The use of active management in the final stages of labour lowers the chances of PPH (Van der Walt, 2005). In the case of Mrs. H there was a rupture of her uterus. Stafford, I., Belfort, M. A., and Dildy, G. (2010) write that rupture of a scarred uterus is more common than rupture of an unscarred uterus. As Mrs. H had previously experienced a caesarean section for her first pregnancy, she was at higher risk for uterus rupture. NICE (2007) documents that a plan of care should be tailored to suit individual women, taking into considerations their physical, social and psychological needs. It is fundamental for midwives to be able to prevent, identify and manage PPH in relationship to the history that a woman has that can affect the potential for haemorrhage. In the case of Mrs. H, a severe haemorrhage with the loss of 2000 ml of blood meant that the obstetrician was needed to provide additional intervention. Mrs H was treated with oxytocin infusion intravenously; Ergometrine was also given intravenous and intramuscularly following Trust protocols. The midwife took the blood for a full blood count and also for cross match and clotting studies (INR, APTR and Fibrinogen). Misoprostol was administered and haemabate of stated dose was given within 15 minutes intervals in order to improve uterine contraction. In this instance the Trust protocol for treating PPH was followed. Had these measures not been as successful in replenishing volume, hypovolemic shock may have occurred. The midwife and the obstetrician followed Trust protocol for Mrs H in managing the postpartum haemorrhage and fluid resuscitation to avoid her going into shock. Plasmalyte, a water, calorie, and electrolyte pharmaceutical and gelafusin, a plasma replacement product, were given as per local Trust guidelines. Two units of O negative blood were transfused and blood was cross matched and 6 units were ordered (see Appendix). The Midwife was constantly assessing Mrs. H by monitoring vital signs like blood pressure, pulse, saturation, respiratory every fifteen minutes and temperature every hour. In a case like this, fluid balance charts must be maintained and a record of urine output and fluid intake should be written in the chart. An hourly urine catheter should be used in order have an accurate measure of the output (Ebbeson and Kollman 2010, p. 580). Hypovolemic shock refers to a medical condition in which haemorrhage and consequent inadequate perfusion leads to multiple organ failure. This occurs when there is a loss in plasma. The problem advances into shock when blood volume is no longer sufficient to fill the intravascular space. Circulation becomes insufficient and this leads to tissue perfusion (Hardin and Kaplow 2006, p. 246). It presents in three stages which can be described as mild, moderate, and severe. This is dependent upon the amount of volume that has been lost. The rate of progression through these stages is dependent upon the loss of volume, which at the mild stage would be between 0% and 10%, which is about 500 ml. There is a decrease in venous return and in the CO level. At this point, the autonomic nervous system will be activated and this is intended to compensate for the losses in volume. Because of this compensation, the levels of vasoconstriction and the contractions at the myocardial level increase which maintains arterial pressure and the level of CO. This is called the compensatory stage as well as the mild stage (Hardin and Kaplow 2006, p. 246). At the moderate stage arterial pressure will fall rapidly and significantly as blood volume is lowered by 15% to 20%. At this stage the arteriolar vasoconstriction is intense, causing less blood flow to the pancreas, liver, gastrointestinal tract,and the kidneys (Hardin and Kaplow, 2006, p. 246). It is critical to continue monitoring urine output as this will indicate the kidney function, which will ultimately contribute to observing organ failure should the kidneys stop functioning properly. The severe stage shows volume decreases over 25% and there are major decreases in pressure, CO and in tissue perfusion. All of the compensatory mechanisms are working to capacity, with the brain and the myocardium vulnerable to perfusion. This will be observed through confusion and anxiety that may be accompanied with agitation and eventually a comatose state (Hardin and Kaplow 2006, p. 246). Symptoms include a rise in the pulse rate and a subsequent drop in blood pressure. Sweating, poor capillary refill and cold extremities can accompany these symptoms. The woman can also show signs of thirst, dizziness and nausea (Alfirevic, 2008). Fluid resuscitation is the main method of reducing morbidity and mortality in the management of postpartum haemorrhage (Clarke and Butt, 2005). An hourly catheter must be used in order to monitor output accurately. Depending on the amount of blood lost, crystalloids can be used as well as colloids. Fluid is drawn out of the cells to compensate the fluids that have been lost from the intravascular space. The aim is to replace what is lost from cells and as well as blood vessels. Shamir et al (2011) have shown that during phlebotomy, mean urine output decreases from 5.7+8mL/min to 1.07+2.5mL/min. This is indicative of systolic blood pressure and haemoglobin decreases. They concluded in their study that while other test were time consuming and would delay knowledge of hypovolemic shock, taking intervals of urine and measuring output could lessen the delay in getting treatment. Post-traumatic stress disorder (PTSD) follows after a trauma has created an intense sense of helplessness and fear. Although it can manifest much later than the time of the event, the disorder is induce by stressors that create psychopathological reactions. There are a whole range of symptoms that can be experienced, including hyper vigilance which means that the individual is overly cautious and afraid that death is the consequence of what might otherwise seem harmless to others. However, it can also manifest as a persistent state of negativity or distortions about how blame can be assigned (Stein, D. J., Friedman, M. J., and Blanco 2011, p. 15). Beck (2004)writes that “Mothers with post-traumatic stress disorder attributable to childbirth struggle to survive each day while battling terrifying nightmares and flashbacks of the birth, anger, anxiety, depression, and painful isolation from the world of motherhood” (p. 217). Having PTSD means that there is a struggle to move on from the past, perpetually stuck in the emotions that resulted from the trauma. Midwives have a critical role to play in ensuring that psychosocial care is delivered after the traumatic experience (Hofmeyr et al, 2008). Post-traumatic stress disorder after child birth causes mothers to feel increasingly isolated and detached (WHO, 2007). Mothers suffering from PTSD experience flashbacks and nightmares from the traumatic event (Chandraharan and Arulkumaran, 2012). The flashbacks and nightmares affect their relationships with both the family as a whole (Butterfield, Becker, and Marx 2002). Midwives can use routine assessment of infant-mother interactions at the postpartum stage to identify cases of PTSD and offer psychosocial care. The best intervention may include debriefing sessions to minimise the effects of trauma. Responses should be closely monitored (Alfirevic, 2008). The psychosocial care should include deliberate and consistent follow-ups by midwives as well as exposure to other mothers who share the same experiences to reduce the feeling of isolation. Women who have suffered from a significant postpartum haemorrhage need to receive one-to-one care to ensure that their mental health is monitored as well as their physical health (Hazra et al 2004, p. 519). Care provided by Midwives must include psychological well-being and the integration of the family unit, who may be unfamiliar with the effects experienced by the mothers in the postpartum period (Simpson, 2005). Baum et al (2013) points out that services should be based on taking into consideration the life circumstances that the patient brings, which are provided when different disciplines come together to form a team approach. Social barriers mean that advocacy is essential for patients and that, according to Baum et al (2013), “health care workers are required to transverse “diplomatic space” in their work” in order to get the patient the services that they need on a more holistic and comprehensive approach. To conclude, the case of Mrs. H. included the potential of manifesting into hypovolemic shock. Had measures not been taken hypovolemic shock might have set in from loss of blood volume, leading to the possibility of organ failure and death. The trauma of this experience might lead to PTSD, which is a disorder in which traumatic events are sustained as traumatic and peaceful existence is interrupted by a pervasive feeling that something bad is happening or will happen. Trauma counselling and support by the Midwives is central to the delivery of psychosocial care after the traumatic process. Midwives are expected to have the skills to identify women at risk of developing PTSD and refer to appropriate health practitioners. Bibliography Alfirevic, Z. (2008) Postpartum Haemorrhage. Kidlington. Oxford: Elsevier. Ayers, S. Eagle, A. and Waring, H. (2006). The effects of childbirth-related post- traumatic stress disorder on women and their relationships: A qualitative study. Psychology Health and Medicine, 8,1, p. 5-12. Baum, F. E., Legge, D. G., Freeman, T., Lawless, A., Labonte, R., & Jolley, G. M. (2013). The potential for multi-disciplinary primary health care services to take action on the social determinants of health: actions and constraints. BMC public health, 13(1), 460. Beck, C. T. (2004). Post-traumatic stress disorder due to childbirth: the aftermath. Nursing Research, 53,4, p. 216-224. Butterfield, M. I., Becker, M., and Marx, C. E. (2002). Post-traumatic stress disorder in women: Current concepts and treatments. Current Psychiatry Reports, 2,2, p. 6-8. Byrom, S., Edwards, G., & Bick, D. (2010). Essential midwifery practice. Chichester, West Sussex: Wiley-Blackwell. Chandraharan, E., and Arulkumaran, S. (2012). Obstetric and intrapartum emergencies: A practical guide to management. Cambridge, UK: Cambridge University Press. Crafter, H (2011) Intrapartum and primary postpartum haemorrhage. (p. 149-167) In Boyle, M (ed) Emergencies around childbirth. 2nd edition. Oxon: Radcliffe. Ebbeson, R. L., and Kollman, T. R. (2010). Systemic Capillary Leak Syndrome Should be Considered in the Differential Diagnosis of Multi-Organ Failure and Hypovolemic Shock. The Pediatric Infectious Disease Journal, 39, 6, p. 580. Hardin, S. R., and Kaplow, R. (2006). Critical care nursing: Synergy for optimal outcomes. Sudbury, Mass: Jones and Bartlett. Hazra S, Chilaka VN, Rajendran S, and Konje JC.(2004). Massive postpartum haemorrhage as a cause of maternal morbidity in a large tertiary hospital. J Obstet Gynaecol 24, p. 519–520. Hofmeyr G.J,and Mohlala B.K.F. (2001) Hypovolaemic shock. Best Practice Res Clinic Obstet Gynaecol 15, 645–662. Hofmeyr J. Neilson J., Alfirevic, Z., Crowther, C., Duley, L. Gulmezoglu, A. M. Hodnett, E. (2008). Pregnancy and childbirth. London: Wiley-Blackwell Je?kkab, A. (2008). A comprehensive textbook of midwifery. New Delhi: Jaypee Brothers Medical Publishers. Lombard, H., and Pattinson, R. C. (2009). Common errors and remedies in managing postpartum haemorrhage. Best Practice and Research in Clinical Obstetrics and Gynaecology, 9, 2, p. 4-7. Mukherjee, S. and Arulkumaran, S. (2009). Post-partum haemorrhage. Obstetrics, Gynaecology and reproductive Medicine. 19, 5, p. 1214-1216. NICE (2007) [Online] Available at: http://pathways.nice.org.uk/pathways/antenatacare (Accessed 18 June 2013). NMC (2012) Midwives rules and standards [Online] Available at http://www .nmcuk.org/Documents/NMC-Publications/NMC-Midwives-rules- andstandards.pdf. (Accessed 18 June 2013). Shamir, M. Y., Kaplan, L., Marans, R. S., Willner, D., & Klein, Y. (2011). Urine flow is a novel hemodynamic monitoring tool for the detection of hypovolemia. Anesthesia & Analgesia, 112, 3, p. 593-596. Simpson KR. (2005). Failure to rescue: implications for evaluating quality of care during labour and birth. J Perinat Neonat Nursing 19, p. 24–34. Stafford, I., Belfort, M. A., and Dildy, G. (2010). Etiology and management of haemorrhage. In G. R. Saade, M. Foley, J. Phelan, M. Belfort, and G. Dildy (eds). Critical care obstetrics. Oxford: John Wiley and Sons, Inc. Stein, D. J., Friedman, M. J., and Blanco, C. (2011). Post-traumatic stress disorder. Chichester, West Sussex, UK: John Wiley & Sons. Van der Walt, P. (2005). A comparison between four Midwife obstretic units in the Pretoria region. University of Pretoria. Varney, H., Kriebs, J. M., and Gegor, C. L. (2004). Varney's midwifery. London: Jones and Bartlett Pub. White, T., Matthey, S., Boyd, K., and Barnett, B. (2006). Postnatal depression and post? traumatic stress after childbirth: Prevalence, course and co?occurrence. Journal of Reproductive and Infant Psychology, 5,2, p.10-14. WHO (2007). Midwifery education modules: Education for safe motherhood. Department of Making Pregnancy Safer, Geneva: World Health Organization. Wryobeck, J. M., and Rubenfire, M. (2012). Pulmonary Arterial Hypertension: psychosocial implications and treatment. Psychiatry and Heart Disease: the Mind, Brain, and Heart. Wiley-Blackwell, John Wiley & Sons, Ltd., West Sussex, UK, p. 88-98. APPENDIX SBAR HANDOVER FROM DELIVERY SUITE TO POSTNATAL WARD SITUATION G2 P2 Consultant care for VBAC Rh. Pos Was for IOL for post-dates but went into spontaneous labour Forceps Delivery @ 23:42 PPH of 2500mls, Rusch balloon Last Hb 9.6 BACKGROUND Previous EM-LSCS for fetal distress Last Hb. Antenatal 10.9 Uncomplicated pregnancy MRSA Neg (date given) Scan @34/40 for LFD Depression taking 20mg Fluoxetine ASSESSMENT Uterus now well contracted Known Hypotensive Syntometrine 1amp Syntocinon infusion 30iu in 500mls saline, Hemabate x2, misoprostal x5 of 200mcg, IV fluids 1000mls plasmalyte and 1000mls gelafusion RECOMMENDATION IVABx due @ 1535hrs 1000mg of IV ferinject as charted Continue with IV Fluids over 6hrs 167mls/hr Hourly obs and urine output Monitor lochia and uterus Encourage skin to skin and feeding baby For review by Reg on ward round For Cystogram in 10 days Obstetric History Gravida 2 Para 1 Previous EM-LSCS for fetal distress Consultant care in this pregnancy Family History NAD Medical History History of Depression and is taking 20mg of fluoxetine Social History NAD Booking History Booked @10/40 with husband BP 98/58 known to be hypotensive Booking bloods taken Nuchal + Anomally scan discussed and accepted Discussed concerns re: previous birth experience Mrs H. keen to go for Vaginal Birth after Caesarean Section, information leaflet on VBAC given Antenatal History Booking bloods – NAD Rubella- Immune Scans @ Nuchal - 12/40 Anomally - 21/40 Extra scan requested @ 34/40 for LFD Uncomplicated pregnancy throughout Hb. 12.5 @ 10/40, 11.7 @28/40 and 10.7 @34/40 Ferrous Sulphate prescribed for iron as Hb. keeps dropping Booked for Induction of Labour on her EDD if she gets to 41/40 Admission 17:40 Assessed in the Day Assessment Unit presenting signs of early @ 40+6 Decision was made not to VE as she hadn’t been contracting for long 18:00 transferred to observation room until in established labour for transfer to DS Still measuring LFD 18:05 Obs normal, CTG commenced as she is for VBAC Urinalysis showing haematuria ++ and ketones ++, Contracting 2:10 18:45 Paracetamol 2x500mg and codeine 2x30mg given as she not coping with pain Transfer to Delivery Suite 19:30 Mrs H now contracting 4 in 10. Complaining of severe back pain and lower abdo pain. On palpation, No scar tenderness but firm abdo 19:45 Cannulated by anaesthetist, Full Blood Count and Group and Save taken 20:00 Spontaneous Rupture of Membranes, Mrs H asking for epidural, anaesthetist unavailable as in theatre with another patient. 20:10 Diamorphine offered and accepted, 10mg given with 50mg Cyclizine. Ranitidine and TEDS given, heavy show with blood+++ 21:20 Mrs H feeling more pressure and urge to push, still complaining of severe abdo pain, still no scar tenderness but firm abdo 21:30 Vaginal Examination to check progress. Mrs H is fully dilated; head still high -2 to the spines, Caput, moulding, allowing 1 hour for descend 21:45 Reassessing risks Vaginal Birth after Caesarean Section 21:50 Reg in to review, charted IV Fluids. Ranitidine 22:00 IV fluids going, Renatidine 150mg as charted 22:15 Mrs H feeling more urge to push so started pushing 22:45 Mrs H pushing for about 30 minutes and nothing visible 23:00 Reviewed by Senior Obstetrician as labour now spurious and slow progress. Maternal Tachycardia - 110-120bpm Considering trial in theatre 23:15 For trial in theatre but can carry on pushing; constant pain but not on scar CTG reassuring 2nd stage approaching 1 hour and refusing to push 23:40 In theatre, blades on forceps, Episiotomy with consent 23:42 Head out on 2nd pull, baby out and in good condition 23:43 1ml Syntometrine given IM 23:44 Raised PV loss, placenta removed manually, suspected uterine rupture and damage to bladder 23:45 Blood cross matched, 2nd cannula sited, estimated blood loss so far 1500ml, 500mcg ergometrine given (250mcg IM and 250mcg IV). Misoprostol given 1000mcg per rectum (5x200mcg). Syntocinon infusion charted and running 100mls/hr. (30iu of syntocinon in 500mls of normal saline) clots taken out of vagina and by cervix, Placenta and membranes appears complete 23:48 Catheter inserted, 5 Litres facial Oxygen, Major Obstetric Haemorrhage 2000mls 23:55 Tear to Uterus repaired; Tear to bladder repaired, Episiotomy and vaginal tear sutured, Rusch balloon in situ with 600mls of water. 00:00 1st dose 250mcg Haemobate given 00:20 M O H 2500mls, Drain cited, Plasmalyte 1000mls, Fluid balance chart, HDU chart commenced and FBC and clotting done. Hb 7.6, blood transfusion of 2 Units of O Neg given, Pain relief given as charted. 00:30 2nd dose of 250mcg haemobate given, Transfer back to Delivery Suite, Catheter changed to Foley catheter to measure hourly urine output. First Obs taken BP – 60/40, Pulse – 90bpm, Resps – 18 and Temp 37.0C. MOWS 1 for hypotension. Plan to continue Obs every 15 minutes due to Mrs H being hypotensive. All other vital signs satisfactory 01:15 Reg in to review, Cath for 10 days, Rusch for 12 hours, Hb 9.6 for ferrinject, Synto to continue post theatre for 4 hours then review again for hypotension but on discussion Mrs H points out that she has always been hypotensive. For warding Day 1 on pn ward Mrs H FBC was taken and her Hb was found to be 9.6. So Ferrinject was administered as charted, Analgesia given as charted. Mrs H. very oedematous. Obstetrician and Anaesthetist in to speak to Mrs H to find out if she understands her birth experience and to see if she had any questions. Obstetrician team in to see Mrs H as well on the ward round and reviewed her. Recommended to stay in postnatal ward and for a review every day to determine discharge date. Peer Review- A handover and presentation of case study.   1. Was the handover communicated in a clear and logical manner?         5- Excellent. Very clear and concise Really good handover Very good use of SBAR. 2. Did the handover contain all the pertinent information required?    5- Excellent. Relevant Information produced Good Information provided. 3. Were the key aspects of the case covered in the presentation of the case study? 4 - Good. Clear information 4. What aspect of care (physical or psychosocial) was discussed?       Post-Traumatic Stress Disorder 5. Were the relevant aspects of midwifery care included? 5-Excellent Explained role of midwife clear and concise. 6. Were key references provided? 5-Excellent   7. Any suggestions for improvements that may help in preparation for your essay. Your case study can benefit from bullet point system, you have all the information and it just needs to be collated more accurately. You could lead the reader by putting times and not dates and names of wards for confidentiality purposes. Read More