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Hemorrhage and Shock

NCLEX Review Guide: Postpartum Hemorrhage and Shock

Postpartum Hemorrhage Overview

Definition and Classifications

Primary PPH: Blood loss >500 mL vaginal delivery or >1000 mL cesarean within 24 hours postpartum
Secondary PPH: Excessive bleeding occurring 24 hours to 12 weeks postpartum
Early recognition is critical as maternal mortality increases significantly with delayed intervention

Key Points

Visual estimation of blood loss is often inaccurate - quantitative assessment preferred
Signs of shock may not appear until 30-40% blood volume lost

The Four T's of PPH Causes

Memory Aid: "The Four T's"

Tone - Uterine atony (90% of cases)
Trauma - Lacerations, hematomas
Tissue - Retained placenta/membranes
Thrombin - Coagulation disorders

Uterine Atony (Most Common)

Risk factors: Overdistended uterus (twins, polyhydramnios), prolonged labor, grand multiparity, magnesium sulfate use
Assessment findings include boggy, soft uterus that doesn't contract with massage

Trauma-Related Hemorrhage

Cervical, vaginal, or perineal lacerations causing bright red bleeding with firm fundus
Hematomas present as severe pain, pressure sensation, and possible visible swelling

Assessment and Clinical Manifestations

Early Warning Signs

Tachycardia (>100 bpm) - often first sign before hypotension develops
Increased respiratory rate, restlessness, and anxiety indicating compensatory mechanisms
Decreased urine output (<30 mL/hr) suggesting reduced perfusion

Stages of Hemorrhagic Shock

Stage	Blood Loss	Signs/Symptoms
Stage 1	15% (750mL)	Minimal symptoms, slight tachycardia
Stage 2	15-30% (750-1500mL)	Tachycardia, decreased pulse pressure
Stage 3	30-40% (1500-2000mL)	Hypotension, altered mental status
Stage 4	>40% (>2000mL)	Severe hypotension, unconsciousness

Nursing Interventions and Management

Immediate Actions for PPH

Call for help immediately - activate rapid response team
Assess fundal height and perform bimanual uterine massage
Establish two large-bore IV access (18-gauge or larger) for fluid resuscitation
Administer oxygen 8-10 L/min via face mask to improve tissue oxygenation
Empty bladder via catheter as full bladder prevents uterine contraction

Clinical Scenario

A postpartum client delivered 2 hours ago. VS: BP 90/50, HR 120, RR 24. Fundus is boggy at umbilicus, heavy bleeding noted. Priority action: Massage fundus while calling for physician - uterine atony is most likely cause.

Pharmacological Interventions

Oxytocin (Pitocin): First-line drug, 10-40 units in 1000mL IV or 10 units IM
Methylergonovine (Methergine): 0.2mg IM q2-4h - contraindicated in hypertension
Carboprost (Hemabate): 250mcg IM q15-90min - contraindicated in asthma
Misoprostol: 600-1000mcg rectally, sublingual, or buccal administration

Commonly Confused Points

PPH vs Normal Postpartum Bleeding

Assessment	Normal Lochia	Hemorrhage
Amount	Moderate, decreasing	Heavy, soaking pad/hour
Fundus	Firm, midline	Boggy or displaced
Clots	Small, few	Large (>golf ball)
Vital Signs	Stable	Tachycardia, hypotension

Memory Aid: "HEMORRHAGE"

Help - call for assistance
Establish IV access
Massage fundus
Oxygen administration
Replace fluids/blood
Remove clots from uterus
Hemoglobin monitoring
Assess for shock
Give medications
Empty bladder

Study Tips and Quick Checks

Common Pitfalls

Don't wait for hypotension - tachycardia is the earliest sign of hemorrhage
Remember that firm fundus with bright red bleeding = trauma, not atony
Never give Methergine to hypertensive clients - can cause stroke

Quick Check Questions

Can you identify the four T's of PPH?
Do you know contraindications for uterotonic drugs?
Can you differentiate stages of hemorrhagic shock?
Do you understand priority nursing actions for PPH?

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