Postpartum hemorrhage is one of the leading causes of maternal mortality worldwide. It is defined as blood loss of 500ml or more within 24 hours after birth. Early postpartum hemorrhage occurs within the first 24 hours after delivery. Preventing excessive blood loss in the early postpartum period is crucial to avoiding the potentially life-threatening complications of postpartum hemorrhage. As nurses play a vital role in caring for women throughout labor, delivery and the postpartum period, it is essential that they are knowledgeable about interventions to prevent early postpartum hemorrhage. This article will examine the most important nursing interventions to prevent early postpartum hemorrhage.
Active management of the third stage of labor
Active management of the third stage of labor is considered the single most important intervention for preventing postpartum hemorrhage. The third stage begins after the baby is born and ends with the delivery of the placenta. Active management involves three components:
1. Administration of a uterotonic drug after delivery of the baby, but prior to delivery of the placenta. Oxytocin is the preferred uterotonic drug. It causes contractions of the uterus to reduce bleeding from the placental attachment site.
2. Early cord clamping and cutting. This should be performed 1-3 minutes after birth.
3. Controlled cord traction to deliver the placenta.
Research has consistently shown that active management reduces the risk of severe postpartum hemorrhage by up to 60% compared to expectant management. Expectant management involves allowing the placenta to deliver spontaneously without the use of uterotonic medications.
As nurses caring for women during labor and delivery, it is essential to be knowledgeable about active management and ensure that all three components are implemented for every woman as standard protocol. This includes having oxytocin prepared and ready for immediate administration following birth.
Oxytocin administration
The use of uterotonic medications is the cornerstone of active management of the third stage of labor. Oxytocin is the uterotonic of choice due to its rapid onset, minimal side effects, and low cost. When administered promptly following birth, oxytocin promotes uterine contractions to reduce bleeding from the placental detachment site.
Key nursing responsibilities regarding oxytocin administration include:
– Preparing an infusion of 10 units of oxytocin diluted in 1000mL of saline following delivery.
– Administering the oxytocin infusion within 1 minute after birth. The dose is typically 10-40 units IV given as a bolus over 1-2 minutes.
– Monitoring for signs of excess dosage such as hypotension and arrhythmias.
– Massaging the uterus every 15 minutes for the first 2 hours after birth to encourage continued contractions.
– Monitoring vaginal bleeding and uterine tone.
– Promptly notifying the provider if bleeding is excessive or the uterus feels boggy or soft, as additional interventions may be needed.
Adhering to proper oxytocin dosing, timing of administration, and ongoing monitoring of the uterus and bleeding is essential to preventing hemorrhage in the early postpartum period.
Controlled cord traction
The third component of active management of the third stage of labor is controlled cord traction to assist with placental delivery. Controlled cord traction should only be performed once the uterus is contracted. This involves gently pulling the umbilical cord using counter traction on the uterus to create gentle downward tension.
Key nursing responsibilities regarding controlled cord traction include:
– Waiting until the uterus is firmly contracted before applying any tension on the cord
– Applying gentle steady downward traction on the cord
– Continuing uterine massage with the other hand
– Having emergency supplies available including uterotonics, IV fluids, and emergency medications
– Monitoring for signs of placental separation such as a small gush of blood, lengthening of the cord, and uprising of the uterus in the abdomen
– Asking the mother to give a small push as the placenta delivers
– Continuing firm uterine massage after placental delivery to encourage contractions
– Inspecting the placenta to ensure it is intact
Following controlled cord traction, ongoing uterine massage and monitoring are essential to prevent delayed postpartum hemorrhage.
Timing of cord clamping
The optimal timing of umbilical cord clamping has been a topic of debate in recent years. Immediate cord clamping was previously routine; however, research now supports delayed cord clamping of at least 1-3 minutes to allow blood flow between the placenta and newborn.
Delayed cord clamping has several benefits including increased hemoglobin levels, iron stores, and reduced risk of anemia for the newborn. It has also been associated with reduced risk of postpartum hemorrhage. Allowing blood flow to continue for a few minutes after birth promotes uterine contractions and expulsion of the placenta due to the presence of oxytocin and other bioactive substances in the cord blood.
Nursing responsibilities related to cord clamping include:
– Delaying clamping for at least 1-3 minutes in vigorous infants
– Clamping sooner if there are concerns about maternal bleeding or the need for resuscitation
– Holding the infant at the level of the introitus or below during delayed clamping to allow optimal blood flow
– Clamping and cutting the cord once it is no longer pulsating
Establishing standard policies around delayed cord clamping of 1-3 minutes for all vigorous newborns is an important nursing role to ensure adequate placental transfusion. This contributes to reducing maternal hemorrhage risk.
Vigilant observation and monitoring
Diligent monitoring of blood loss and uterine tone is crucial during the postpartum period to identify hemorrhage promptly. Nursing responsibilities include:
Monitoring of vital signs
– Assessing vital signs (blood pressure, pulse, respirations) at a minimum every 15 minutes for the first hour after birth, then every 30 minutes for the next 1-2 hours. An increasing heart rate or falling blood pressure may indicate bleeding.
Quantifying blood loss
– Performing ongoing visual estimates of blood loss, including pads, under buttocks, linens
– Weighing pads and other materials to obtain a quantitative measure
– Documenting cumulative blood loss at regular intervals
Uterine massage
– Massaging the uterus every 15 minutes for the first 2 hours to stimulate contractions
– Assessing uterine tone by palpating the fundus to ensure the uterus stays firm and contracted
Monitoring urine output
– Placing a voiding hat or catheter to accurately measure urine output hourly
– Oliguria may signify hypovolemia from excessive bleeding
Emotional support
– Providing reassurance and emotional support throughout the monitoring process
Thorough observation and use of standardized procedures around quantitative blood loss and vital sign monitoring are key nursing responsibilities to identify hemorrhage in a timely manner. This maximizes the opportunity for early intervention.
Early recognition of risk factors
Certain conditions place women at increased risk of postpartum hemorrhage. It is important for nurses to be aware of these risk factors and have a higher index of suspicion for potential bleeding in these cases.
Risk factors for hemorrhage include:
– Prolonged third stage of labor (>30 minutes)
– History of postpartum hemorrhage
– Multiple gestation pregnancy
– Polyhydramnios or large fetus
– Precipitous labor (Prevention of uterine inversion
Uterine inversion is a rare but serious complication that can occur if excessive cord traction is applied before the placenta has fully separated from the uterine wall. It occurs when the uterus turns inside out and descends into the vagina or even protrudes outside the vagina. This results in severe hemorrhage from the exposed uterine vessels.
Key nursing responsibilities to prevent inversion include:
– Avoiding traction on the cord until uterine contraction is well established
– Applying slow, gentle traction on the cord to deliver the placenta once contraction has occurred
– Stopping traction if resistance is felt and awaiting another contraction
– Massaging the uterus while delivering the placenta to ensure it remains contracted
– Examining the placenta for completeness
– Closely inspecting the vagina and cervix for signs of inversion
– Promptly reporting any concerns about possible inversion to the provider
Prevention of inversion relies on controlled cord traction only after uterine contraction, careful examination to confirm placental separation, and meticulous monitoring to identify inversion early if it occurs.
Genital tract laceration repair
Perineal or vaginal tearing during childbirth can lead to substantial blood loss. Repair of genital tract lacerations by a skilled provider is an important intervention to reduce hemorrhage risk. Nursing responsibilities related to laceration repair include:
– Applying pressure to lacerations to reduce bleeding until repair can occur
– Administering local anesthetic for pain control during the repair
– Assisting the provider by irrigating the laceration and providing instruments
– Supporting the patient during the repair process
Prompt laceration assessment and skillful repair results in excellent hemostasis from the lacerated tissues. This prevents ongoing oozing that can contribute to maternal hemorrhage. Competent nursing assistance facilitates the repair process.
Fundal massage
Uterine massage is a simple but highly effective nursing intervention to prevent postpartum hemorrhage. Massaging the fundus stimulates uterine contractions which compresses uterine blood vessels to reduce bleeding. Key aspects include:
– Massaging the fundus in a circular motion every 15 minutes for the first 2 hours after birth
– Applying firm pressure against the posterior surface of the uterus
– Assessing for uterine relaxation between massages by palpating uterus
– Educating the patient and family to immediately notify nurses about uterine softening
– Continuing fundal massages for women at high risk of hemorrhage
– Documenting characteristics of the uterus including firmness, position, and any abnormalities
Regular fundal massage is a safe, low-cost intervention that can prevent atony and encourage sustained uterine contractions after delivery. Thorough patient teaching about the importance of fundal massage is also key.
Early breastfeeding
Initiating breastfeeding soon after delivery further promotes uterine contractions to reduce blood loss. The infant suckling triggers release of oxytocin which decreases uterine blood flow. Nurses should encourage mothers to begin breastfeeding within the first hour after birth. Nursing responsibilities related to breastfeeding include:
– Assisting the mother into a comfortable position to breastfeed
– Helping the mother initiate latch if needed
– Providing reassurance and supportive instruction about breastfeeding
– Avoiding unnecessary interruptions during initial breastfeeding
– Documenting time of breastfeeding initiation
– Continuing fundal massage during breastfeeding
Early breastfeeding works synergistically with endogenous oxytocin release to maintain uterine tone and prevent atony. It is a simple, natural intervention nurses can easily integrate into postpartum care.
Team communication
Clear communication between nurses and providers is essential for prompt identification and treatment of early postpartum hemorrhage. Key aspects of communication include:
– Consistent use of protocols and tools to quantify blood loss
– Briefing all team members at the start of each shift about patients at higher risk
– Calling out key observations such as decreasing blood pressure
– Using clear language to declare emergency (“we have a hemorrhage”)
– Pre-briefing prior to procedures about plans for difficult scenarios
– Debriefing after an event to identify successes and areas for improvement
Ongoing collaboration, a shared mental model between team members, and assertive communication optimizes rapid recognition and response to obstetrical hemorrhage.
| Nursing Interventions to Prevent Postpartum Hemorrhage | Key Aspects |
|---|---|
| Active management of third stage of labor | Oxytocin after delivery, early cord clamping, controlled cord traction |
| Oxytocin administration | IV bolus within 1 minute of birth. Monitor bleeding and uterine tone. |
| Controlled cord traction | Gentle traction on cord only when uterus contracted. Support uterus. |
| Delayed cord clamping | Clamp 1-3 minutes after birth in vigorous infants. Allows placental transfusion. |
| Monitoring and quantification of blood loss | Ongoing visual estimates, weighing pads, vital signs. |
| Early recognition of risk factors | Prepare additional supplies for high risk women. Shortened monitoring intervals. |
| Prevention of uterine inversion | Avoid premature cord traction. Careful examination of placenta. |
| Genital laceration repair | Apply pressure. Assist provider with repair. |
| Fundal massage | Firm massage every 15 minutes for 2 hours. Assess uterine tone. |
| Early breastfeeding | Initiate within first hour after birth. |
| Team communication | Brief team on risk factors. Clearly declare emergency. |
Conclusion
Postpartum hemorrhage remains one of the most significant causes of preventable maternal mortality worldwide. A multifaceted approach is needed to prevent excessive blood loss after birth. The most impactful nursing interventions include active management of the third stage of labor, vigilant monitoring and quantification of blood loss, uterotonic administration, fundal massage, early breastfeeding initiation, and prompt laceration repair. Awareness of risk factors along with assertive team communication optimizes rapid recognition and treatment of early postpartum hemorrhage. By consistently implementing best practices for the prevention and management of postpartum hemorrhage, nurses play a pivotal role in promoting patient safety and reducing mortality.