Nursing Assignment Sample
Q1:
Answer :Introduction
Postpartum hemorrhage (PPH) is one of the main causes of maternal morbidity and mortality globally. It is blood loss of ≥500 mL following vaginal delivery or ≥1000 mL following cesarean section. PPH is a potentially life-threatening obstetric emergency necessitating prompt treatment. Midwives are central to the early identification, prevention, and treatment of PPH and thus a major priority in midwifery education and practice.
This essay investigates the pathophysiology, risk factors, clinical presentation, emergency management, drug treatments, and long-term implications of PPH, emphasizing evidence-based midwifery to maximize maternal outcome.
Pathophysiology of Postpartum Hemorrhage
PPH is caused by the failure of the physiological hemostatic processes post-delivery. The main mechanisms involved are:
1. Uterine Atony (Most Frequent Cause – 70-80%)
The uterus contracts following delivery to compress the spiral arteries and prevent bleeding.
In uterine atony, the uterus does not contract properly, and hemorrhage continues.
2. Trauma (20%)
Laceration of the vagina, cervix, or perineum may lead to excessive blood loss.
Rupture of the uterus or inverted uterus may also be responsible.
3. Retained Placental Tissue (10%)
Incomplete expulsion of the placenta results in ongoing bleeding because placental tissue interferes with uterine contraction.
4. Coagulopathies (1-2%)
Disseminated intravascular coagulation (DIC), placental abruption, or HELLP syndrome compromises clotting mechanisms.
Risk Factors for PPH
The risk factors for PPH must be identified by midwives to initiate preventive interventions. These are:
History of PPH
Multiple gestation pregnancy (overdistension)
Protracted or rapid labor
Administration of uterotonic drugs (e.g., oxytocin induction)
Macrosomia (fetal weight >4 kg)
Preeclampsia or gestational hypertension
Instrumental delivery (forceps, vacuum)
Placental pathology (placenta previa, accreta, increta, percreta)
Maternal coagulopathy (e.g., thrombocytopenia, von Willebrand disease)
Early Recognition and Assessment of PPH
Early recognition of postpartum hemorrhage is crucial. Midwifery evaluation includes:
Vital Signs Monitoring:
Tachycardia (>100 bpm) – Early sign of hemorrhagic shock
Hypotension (SBP <90 mmHg) – Late sign of decompensation
Altered mental status, dizziness, syncope
Quantification of Blood Loss (QBL):
Visual estimation with traditional method is unreliable.
Improved accuracy is done using weighed drapes and calibrated collection bags.
Uterine Tone Assessment:
Boggy, non-contracted uterus implies uterine atony.
Vaginal and Perineal Examination
Examine for hematomas, cervical lacerations, or tears as a cause of bleeding.
Laboratory Tests:
Complete blood count (CBC) – Hemoglobin, hematocrit levels.
Coagulation profile – PT, INR, fibrinogen levels (to evaluate risk of DIC).
Emergency Midwifery Interventions for PPH
The initial objective in the management of PPH is quick control of bleeding and the restoration of hemodynamic stability. The intervention adheres to the "Four Ts" mnemonic:
1. Tone (Uterine Atony – 70-80%)
Immediate Fundal Massage:
Two-handed technique to trigger contraction.
Bimanual Compression:
One hand in the vagina, one on the abdomen to compress the uterus.
Pharmacological Uterotonics (First-Line):
Oxytocin (IV/IM, 10-40 units) – First-line drug.
Ergometrine (IM, 0.2 mg) – Contraindicated in hypertension.
Carboprost (Hemabate, IM, 250 mcg) – Contraindicated in asthma.
Misoprostol (Sublingual, 600-800 mcg) – Alternative in resource-poor environments.
Surgical Repair:
Suturing vaginal/cervical lacerations.
Uterine Inversion Management:
Immediate manual replacement followed by tocolytics (e.g., terbutaline).
3. Tissue (Retained Placenta, Clots)
Manual Removal of Placenta:
Under sterile conditions with proper analgesia.
Curettage (D&C):
In case fragments are left within the uterus.
4. Thrombin (Management of Coagulopathy)
Transfusion of Blood Products:
Packed RBCs, fresh frozen plasma, platelets as required.
Antifibrinolytics:
Tranexamic Acid (TXA, 1g IV in 3 hrs) – Decreases mortality.
Monitor for DIC:
If so, give cryoprecipitate, fibrinogen concentrate.
Non-Pharmacological and Surgical Measures
If medical management is unsuccessful, advanced procedures might be necessary:
Uterine Balloon Tamponade (Bakri Balloon):
Intrauterine balloon exerts pressure to arrest bleeding.
B-Lynch Suture (Uterine Compression Sutures):
Used in cases of severe atony during cesarean section.
Uterine Artery Embolization:
Radiological intervention to occlude bleeding vessels.
Hysterectomy (Resort of Last Resort):
Done in life-threatening hemorrhage not responsive to all interventions.
Long-Term Considerations and Maternal Outcomes
Hypovolemic Shock and Multi-Organ Failure:
Excessive hemorrhage may result in renal failure, liver failure, DIC.
Postpartum Anemia:
Needs iron supplementation or blood transfusion.
Emotional and Psychological Impact:
PPH can result in postpartum depression (PPD), anxiety, PTSD.
Future Pregnancy Considerations:
Risk of placenta accreta, uterine rupture, recurrence of PPH is increased.
Conclusion
Postpartum hemorrhage is a significant obstetric emergency that requires prompt recognition and treatment to avoid maternal death. Midwives play a leading role in PPH prevention, early detection, and emergency care. Evidence-based guidelines, active management of the third stage of labor (AMTSL), and prompt administration of uterotonics have dramatically enhanced maternal outcomes. Yet more research and training are needed to maximize PPH care in low-resource environments to provide safer childbirth worldwide.