HISTORY. Because PPH can be repeated in subsequent pregnancies, always ask a multipara if she had a previous PPH. Inquire about a family history of coagulation disorders or excessive bleeding with surgical procedures or menses. Ask if the patient has perineal pain. Although some discomfort is expected after a vaginal delivery, severe pain or pressure is uncommon and often indicates a hematoma.

PHYSICAL EXAMINATION. Observe the amount and characteristics of blood loss; sometimes there is a pooling of blood and the passage of large clots. Usually, complete saturation of one perineal pad within 15 minutes or saturation of two or more pads in 1 hour suggests hemorrhage. A bimanual exam may be done to determine tone, uterine enlargement, or presence of pelvic hematomas. Palpate the fundus, noting if it is firm or boggy, if it is midline or deviated laterally, and if it is above or below the umbilicus. Normally, after delivery, the fundus is firm, midline, and at the level of the umbilicus. A fundus above the umbilicus and deviated laterally may indicate a full bladder. A boggy uterus is indicative of uterine atony and, if it is not corrected, results in a PPH. If the fundus is firm, midline, and at or below the umbilicus and if there is steady, bright red bleeding, further assessment for trauma is necessary. Inspect the perineum carefully to discern any unrepaired lacerations or bleeding from a repaired episiotomy. If a hematoma is suspected, the patient is placed in lithotomy position, and the vagina and perineal

756 Postpartum Hemorrhage area are carefully inspected. A bulging and discoloration of the skin is noted if a hematoma is present. Assess the patient's vital signs. A temperature above 100.4°F may indicate uterine infection, which decreases the myometrium's ability to contract and makes the patient more susceptible to PPH. Note any foul vaginal odor that may accompany the fever with infection. Elevated heart rate, delayed capillary refill, decreased blood pressure, and increased respiratory rate may be noted if PPH is occurring. Assess the patient's color and skin temperature; pallor and cool, clammy skin also indicate hypovolemic shock.

PSYCHOSOCIAL. PPH is a traumatic experience because medical complications are unexpected during what is anticipated as a happy time. Assess the anxiety level of the patient; the patient going into hypovolemic shock is highly anxious and then may lose consciousness. The significant others experience a high level of anxiety as well and need a great deal of support.

Diagnostic Highlights

General Comments: Diagnosis of PPH Is usually based on the estimated blood loss, which eventually Is reflected In serum laboratory tests. Coagulation studies may also be done if bleeding remains excessive.


Normal Result

Abnormality with Condition


Red blood cell (RBC) count

4-5.4 million/pL

Decreases several hours after significant blood loss has occurred

Active bleeding causes decrease

Hemoglobin (Hgb)

12-16 g/dL

Decreases several hours after significant blood loss has occurred

Active bleeding causes decrease

Hematocrit (Hct)


Decreases several hours after significant blood loss has occurred

Active bleeding causes decrease

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