The document discusses normal physiological changes during the postpartum period, including uterine involution and lochia. It describes how the uterus decreases in size from 1000g immediately after birth to 50g by 6 weeks postpartum. Lochia is described as changing from red to pink/brown to white over the first 3 weeks. Guidelines for evaluating lochia include amount, consistency, pattern, odor, and absence. Risk factors for postpartum hemorrhage include uterine atony, issues with uterine tissue like fibroids, trauma during birth, and retained placental fragments. Uterine atony is identified as the most common cause due to the uterus' inability to contract after delivery.

1. Postpartum
Hemorrhage
BY: JERARD LLOYD B. DOMINGO
BSN 2A
#MCNCompilations

2. Normal Physiological
Changes
of
Postpartum Period
Reference: Maternal & Child Health Nursing:
Care of the Childbearing & Childrearing Family
By: Adelle Pillitteri (Edition 6).
Retrogressive physiologic
changes that occur during the
postpartal period include
those related specifically to
the reproductive system as
well as other systemic changes

3. Reproductive System Changes
Involution is the process whereby the reproductive organs return to
their non pregnant state. A woman is in danger of hemorrhage from
the denuded surface of the uterus until involution is complete (Poggi,
2007).
1. The Uterus
- Involution of the uterus involves two main processes.
1. The area where the placenta was implanted is sealed off to
prevent bleeding.
2. The organ is reduced to its approximate pre-gestational size.
The sealing of the placenta site is accomplished by rapid contraction of the uterus
immediately after delivery of the placenta. This contraction pinches the blood
vessels entering the 7-cm-wide area left denuded by the placenta and stops
bleeding.

4. 1. The Uterus
• Although the uterus will never completely return to its
prepregnancy state, its reduction in size is dramatic.
• Immediately after birth, the uterus weighs about 1000 g.
At the end of the first week, it weighs 500 g. By the time
involution is complete (6 weeks), it weighs
approximately 50 g, similar to its pre-pregnancy weight.
Time Weight (g)
After Birth 1000 g
After 1st Week 500 g
After 6 weeks 50 g

5. - From then on, it decreases one fingerbreadth
(1cm) per day—on the first postpartal day, it will
be palpable 1cm below the umbilicus; on the
second day, 2 cm below the umbilicus; and so
on. In the average woman, by the ninth or tenth
day, the uterus will have contracted so much
that it is withdrawn into the pelvis and can no
longer be detected by abdominal palpation.
Because uterine contraction begins immediately
after placental delivery, the fundus of the uterus may
be palpated through the abdominal wall, halfway
between the umbilicus and the symphysis pubis,
within a few minutes after birth.
One hour later, it will have risen to the level of the
umbilicus, where it remains for approximately the
next 24 hours.

6. • The fundus is normally in the midline of the
abdomen.
*Occasionally, it is found slightly to the
right, because the bulk of the sigmoid
colon forces it to that side during
pregnancy and it tends to remain in that
position.
*Assess fundal height shortly after a
woman has emptied her bladder for most
accurate results, because a full bladder or
distended bladder can keep the uterus
from contracting, pushing it upward and
possibly deviating it from the midline,
because of the laxness of the uterine
ligaments.

7. Note: Uterine involution may be delayed by a
condition such as the birth of multiple fetuses,
hydramnios, exhaustion from prolonged labor or a
difficult birth, grand multiparity, or physiologic effects
of excessive analgesia. Contraction may be difficult
if there is retained placenta or membranes.
Involution will occur most dependably in a woman
who is well nourished and who ambulates early after
birth (gravity may play a role).

8. Physiology of muscle contraction

9. Lochia
• The postpartum uterine flow, consisting of blood, fragments of
decidua, white blood cells, mucus, and some bacteria, is known
as lochia. It is because of the layer adjacent to the uterine cavity
that becomes necrotic and is cast off as a uterine discharge similar
to a menstrual flow.
- For the first 3 days after birth, a lochia discharge consists
almost entirely of blood, with only small particles of
decidua and mucus. Because of its mainly red color, it is
termed lochia rubra.
- As the amount of blood involved in the cast-off tissue
decreases (about the fourth day) and leukocytes
begin to invade the area, as they do with any healing
surface, the flow becomes pink or brownish (lochia
serosa).
- On about the 10th day, the amount of the flow
decreases and becomes colorless or white (lochia
alba). Lochia alba is present in most women until the
third week after birth, although it is not unusual for a
lochia flow to last the entire 6 weeks of the
puerperium

10. Guidelines for evaluating lochia flow 
1. Evaluate the AMOUNT!
Lochia amount will vary from woman to woman. Mothers who breastfeed tend to
have less lochial discharge than those who do not, because the natural release of
the hormone oxytocin during breastfeeding strengthens uterine contractions.
Conservation of fluid for lactation also may be a factor. Lochial flow increases on
exertion, especially the first few times a woman is out of bed, but decreases again
with rest. The increase in amount that occurs with ambulation is the result of vaginal
discharge of pooled lochia, not a true increase in amount. However, lochia amount
truly does increase with strenuous exercise, such as lifting a heavy weight or walking
up stairs. Saturating a perineal pad in less than 1 hour is considered an abnormally
heavy flow and should be reported.
2. Check the CONSISTENCY!
Lochia should contain no large clots. Clots may indicate that a portion
of the placenta has been retained and is preventing closure of the
maternal uterine blood sinuses. In any event, large clots denote poor
uterine contraction, which needs to be corrected.

11. Guidelines for evaluating lochia flow 
3. Observe the PATTERN!
Lochia is red for the first 1 to 3 days (lochia rubra), pinkish-brown from
days 4 to 10 (lochia serosa), and then white (lochia alba) for as long as
6 weeks after birth. The pattern of lochia (rubra to serosa to alba)
should not reverse. A red flow after a pink or white flow may indicate
that placental fragments have been retained or that uterine
contraction is decreasing and new bleeding is beginning.
4. Assess the ODOR!
Lochia should not have an offensive odor. Lochia has the same odor
as menstrual blood. An offensive odor usually indicates that the uterus
has become infected. Immediate intervention is needed to halt
postpartal infection.

12. Guidelines for evaluating lochia flow 
5. Watch for ABSENCE!
Lochia should never be absent during the first 1 to 3 weeks. Absence
of lochia, like presence of an offensive odor, may indicate postpartal
infection. Lochia may be scant in amount after cesarean birth, but it
is never altogether absent.
ACPOA
1.Evaluate the AMOUNT!
2.Check the CONSISTENCY!
3.Observe the PATTERN!
4.Assess the ODOR!
5.Watch for ABSENCE!

13. Postpartum
Hemorrhage
BY: JERARD LLOYD B. DOMINGO
BSN 2A
#MCNCompilations

14. Definition
 Any blood loss of >500 mL within a 24 hour period (Pavone, Purinton,
& Petersen, 2007).
 Significant amount of blood loss that results in signs and symptoms of
low blood volume (low BP, pallor, rapid pulse, low urine output, low
temperature). -khanacademy
 Significant loss of blood after giving birth. It is the #1 reason for
maternal morbidity and mortality.
 Losing >500 ml of blood after a normal spontaneous vaginal delivery,
and losing >1000 ml after a C-section delivery.
Classification
Primary PPH Secondary/ Late PPH
- Significant bleeding
within 24 hours.
-significant bleeding
after 24 hours.

15. Risk Factors
T – Tone
T – Tissue
T – Thrombin
T – Trauma

16. Uterine atony
ATONY – LACK/ ABSENCE OF TONE.
UTERINE ATONY - INABILITY OF THE UTERUS TO CONTRACT.
UTERINE ATONY, OR RELAXATION OF THE UTERUS, IS THE MOST
FREQUENT CAUSE OF POSTPARTAL HEMORRHAGE (Poggi,
2007). THE UTERUS MUST REMAIN IN A CONTRACTED STATE
AFTER BIRTH TO KEEP THE OPEN VESSELS AT THE PLACENTAL SITE
FROM BLEEDING.

17. RISK FACTORS
1. Grand Multiparity
2. Overdistention of the uterus
3. Uterine fibroids
4. Retroversion that resulted into incarceration of the uterus
5. Endometritis and Chorioamnionitis
6. Uterine Prolapse/ Rupture
7. RPOC
8. Maternal Sepsis
9. Anesthetics
10. Prolonged Use of Magnesium Sulfate
11. Precipitous Labor & Prolonged Labor with oxytocin stimulation
12. Cesarean Section

18. 1. Grand Multiparity
- Grand multiparity is a term used in reference to a women who have given birth several
times specifically who has had >5 births (live or stillborn) at greater than or exactly 20 weeks
aog.
- “Great grand multiparity” – defined as >10 births in > or = 20 weeks gestation
(uptodate.com).
- Those mother who is grand multipara has a very thin uterine lining due sto subsequent
menstruation, and pregnancy.
- Repetitive pregnancy, decreases mechanical attributes of the uterus.
- REPETITIVE MECHANICAL STRETCHING CAUSES WEAKENED MYOMETRIAL CELLS.
How? (PM is the key, char).
- According to American Professors or Gynecology and Obstetrics (APGO), repeated
exposure to endogenous and exogenous oxytocin, causes uterine receptors to become
“desensitized” or less sensitive to oxytocin, that results in a loss in capacity to respond to
oxytocin, that resulted into lack of UC, and inability of the uterus to return to it’s prepregnant
state (involution).

19. 1. Grand Multiparity
- Grand multiparity is a term used in reference to a women who have given birth several
times specifically who has had >5 births (live or stillborn) at greater than or exactly 20 weeks
aog.
- “Great grand multiparity” – defined as >10 births in > or = 20 weeks gestation
(uptodate.com).
- Those mother who is grand multipara has a very thin uterine lining due sto subsequent
menstruation, and pregnancy.
- Repetitive pregnancy, decreases mechanical attributes of the uterus.
- REPETITIVE MECHANICAL STRETCHING CAUSES WEAKENED MYOMETRIAL CELLS.
How? (PM is the key, char).
- According to American Professors or Gynecology and Obstetrics (APGO), repeated
exposure to endogenous and exogenous oxytocin, causes uterine receptors to become
“desensitized” or less sensitive to oxytocin, that results in a loss in capacity to respond to
oxytocin, that resulted into lack of UC, and inability of the uterus to return to it’s prepregnant
state (involution).

20. 2. Overdistention of the uterus
Conditions like fetal macrosomia, hydramnios, multiple
pregnancy, and uterine fibroids.
- The overdistension of uterine muscles has it limits when it
comes to pressure, force and strength uterine contractions.
- Overdistension pulls apart the actin and myosin
mechanism, so they cannot overlap to connect and bind
which limits the contraction/contractile ability of smooth
muscles.

21. 3. Uterine Fibroids
- UF’s may also cause enlargement of the uterus (submucosal,
intramural, subserosal, intracavitary).
*Enlarging UF’s may outgrow their blood supply and detach from it
causing the necrosis of fibroids. Necrosis causes inflammation and
swelling to uterus. After the delivery of the baby, and fibroids are still
present (cause normally, due to the dramatic decline of steroid
hormones, fibroids shrink and degenerate).
- It is hypothesized that any form of inflammation/infection may
interfere with effective uterine contractility because the inflammatory
process consumes myometrial cells energy via the cytokine induced
nitric oxide production that inhibits mitochondrial energy production
and impairs contractile functions of myocytes.

22. 4. Retroversion that resulted in incarceration of the uterus.
 Retroversion of the uterus – a uterus that curves in a backward
position at the cervix, instead of a forward or anterversion.
 Retroversion is also known as “tilted uterus”
 Cause: Can be congenital or acquired.
 Pathology: Associated with pelvic scarring or adhesions. Scar
tissue or adhesions can cause the uterus to stick in a
backward position, like gluing it in place.
 INCARCERATED UTERUS – occurs when a retroverted uterus
does not resolve beyond mid-gestation, and the uterine
corpus becomes confined in the hollow of the sacrum, that
causes the cervix to become displaced above against the
pubic symphysis.

23. 4. Retroversion that resulted in incarceration of the uterus.
INCARCERATED UTERUS – or also known as “trapped utrerus”
describes an extremely rare situation, where a retroverted or
retroflexed uterus fails to ascend in the abdominal cavity
because it is wedged progressively firmly into the hollow of
sacrum.
HOW DOES IT CAUSE UTERINE ATONY?
- SINCE THE UPPER PORTION OF UTERUS IS CONFINED AND
WEDGED IN THE HOLLOW OF THE SACRUM AND SIGNIFICANT
DISTORTION ALSO CAUSES ENTRAPMENT OF A PORTION OF THE
UTERUS THAT CAUSES AN INEFFECTIVE UTERINE CONTRACTION
AND LATER PROGRESSES IN SUBINVOLUTION.

24. 5. Endometritis and chorioamnionitis
Endometritis: inflammation of the endometrium caused by infected
cesarean incision and also prolonged rupture of membranes (PROM).
Chorioamnionitis: infection of the membranes and amniotic fluid.
- It is hypothesized that any form of inflammation/infection may
interfere with effective uterine contractility because the inflammatory
process consumes myometrial cells energy via the cytokine induced
nitric oxide production that inhibits mitochondrial energy production
and impairs contractile functions of myocytes.
- Inflammatory pathways consumes energy that with otherwise be
readily available for uterine smooth muscle contraction.

25. 6. Uterine Prolapse
Uterine Prolapse: occurs when pelvic floor muscles and ligaments
overstretch and weaken and no longer provide enough support to
the uterus.
 Caused by high parity, macrosomia, and other conditions that
causes overdistention and excessive weight and pressure to the
uterus. Obesity, severe coughing or straining on the toilet, and
hormonal changes after menopause, that can damage the pelvic
organ support structures.
 When the uterus collapse, it descends, and protrude outside the
vagina. Normal involution can be impaired because there is a high
possibility of a total prolapse. The uterus will not contract anymore
because it is not attached to its supporting ligaments, and
vascularity.

26. 7. RPOC after delivery
- in cases with deep adherence of the placenta to the uterine wall. Placenta accreta ( an
abnormally adhered placenta to the superficial uterine wall, but does not penetrate the
uterine muscle (myometrium). Deep attachment causes RPOC, and attempts to remove it
manually may lead to severe hemorrhage. More severe forms of abnormal placental
adhesions are increta, and percreta.
 RPOC refers to intrauterine tissue that develops after conception and persists after
medical and surgical pregnancy terminations, miscarriage, and vaginal or C-section
delivery.
 Placental fragments retained within the uterus (the tissue becomes necrotic and serves as
an excellent bed for bacterial growth).
 Most important condition highly associated with RPOC is Placenta accreta.
*RPOC is one of the most common cause of PP bleeding, but in the clinical presentation can
be also characterized by pain or fever.
- After delivery, due to RPOC, the necrosis and sloughing of the decidua is impaired
because the RPOC alters normal uterinecontractions. This causes to ineffective shrinkage
and subinvolution especially the placental site as a whole. As a consequence, excessive
bleeding occurs because constriction/clumping of spiral arteries is impaired.

27. 8. Puerperal sepsis
- Puerperal sepsis was defined as the
infection of the genital tract occurring at
any time between the onset of ROM &
labor.
- Theoretically, the uterus is sterile during
pregnancy and until the membranes
rupture. After rupture, pathogens can
invade. The risk of infection is even greater
if tissue edema and trauma are present.
*If infection occurs, the prognosis for
complete recovery depends on the
virulence of the invading organism, and
the woman’s general health.

28. 8. Puerperal sepsis
It is hypothesized that any form of
inflammation/infection may interfere with
effective uterine contractility because the
inflammatory process consumes myometrial
cells energy via the cytokine induced nitric
oxide production that inhibits mitochondrial
energy production and impairs contractile
functions of myocytes.
- Inflammatory pathways consumes energy
that with otherwise be readily available for
uterine smooth muscle contraction. (American
Professors of Gynecology and Obstetrics).

29. 9. Anesthetics and analgesics
- Effects of analgesics and anesthetics can lead to
hypotension that causes a decrease in circulating oxytocin,
that causes diminished uterine contractions.
Pharmacologic management of pain during labor and
birth includes analgesia, which reduces or decreases
awareness of pain, and anesthesia, which causes partial or
compete loss of sensation. Other effects on the mother;
respiratory depression, and most important hypotension.

31. 10. Prolonged use of magnesium sulfate
MgS04 (Magnesium sulfate): Indicated to prevent seizures associated with
pre-eclampsia, and for control of seizures with eclampsia. Used as a
tocolytic to stop preterm labor. Magnesium sulfate is a central nervous
system depressant that acts to block neuromuscular transmission of
acetylcholine to halt convulsions. It also halts premature labor, as it relaxes
smooth muscle (Karch, 2009).
*Continuous long term use (longer than 5-7 days) causes
HYPERMAGNESEMIA.
 How does it cause Uterine atony?
- Prolonged use of MgSO4, causes high levels of magnesium in the blood.
Magnesium competes and blocks the calcium channels through which
the calcium enters the intracellular cytoplasm. Without an influx or
intracellular calcium to activate myosin light chain kinase, the mechanism
of smooth muscle contraction is inhibited specifically on the uterus.

32. 11. Precipitous Labor and Prolonged labor
Precipitate labor and birth occurs when uterine contractions are so strong that a woman gives
birth with only a few, rapidly occurring contractions. It is often defined as a labor that is
completed in fewer than 3 hours. Contractions can be so forceful that they lead to premature
separation of the placenta, placing the woman at risk for hemorrhage. Rapid labor also poses a
risk to the fetus, because subdural hemorrhage may result from the rapid release of pressure on
the head. A woman may sustain lacerations of the birth canal from the forceful birth. She also
can feel overwhelmed by the speed of labor.
Prolonged Labor - may also be referred to as "failure to progress."
- Prolonged labor can be determined by labor stage and whether the cervix has thinned and
opened appropriately during labor. If your baby is not born after approximately 20 hours of
regular contractions, you are likely to be in prolonged labor. Some health experts may say it
occurs after 18 to 24 hours. If you are carrying twins or more, prolonged labor is labor that lasts
more than 16 hours.
Prolonged and precipitous labor caused by strong and intense UC, causes fatigue to the
myometrial cells, causes its contractile ability to lessen or become inefficient. This may cause
uterine atony and later causes hemorrhage and subinvolution.

33. 12. Cesarean Section
Complications of a C-section includes post cesarean wound
infection, uterine adhesions or scarring, lacerations may also occur if
the baby is too large and cannot pass the incision. This may cause
lacerations o the incision site that causes tearing if the uterine tissue.
Another complication is when large clots form in the mother’s legs or
pelvic area due to excessive bleeding, that may cause embolism
and thrombophlebitis.
C- section may cause incision infection, that may
predispose into the hypothesis that inflammation process
decreases uterine capability to contract. Scarring and
trauma also decreases myosin and actin filaments that also
contributes to uterine atony and uterine subinvolution.

34. Conditions That Lead to Inadequate Blood Coagulation
Fetal death
Disseminated intravascular coagulation
Di pa tapos wait lang aralin ko muna DIC

35. Signs & Symptoms

36. Signs and symptoms: BLIP-FI
1. Boggy Uterus - a flaccid, relaxed, soft uterus, atonic uterus. Because the its ability
to contract effectively is impaired.
-normally the fundus must be located on the midline of the umbilicus, if fundus is
palpated on the left or right of umbilicus. Instruct the patient to void (distended
bladder affects normal UC).
2. Larger than normal uterus – normally after delivery, the length of the uterus (fundal
height) is 20 cm and can be felt at the level of the umbilicus. After one week it is
midway between umbilicus and symphysis pubis. After 2 weeks, can be palpated at
the level of symphysis. By the end of the 6th week, it is 7.5 cm long.
3. Irregular/ excessive bleeding - because the uterus cannot effectively to clump
and constrict spiral arteries, it causes irregular or excessive bleeding.
4. Prolonged lochial discharge
Normally, lochia which is composed of blood, uterine tissue, mucus, and WBC lasts
for about 4-6 weeks postpartum. It is because of the shedding and restoration of the
uterine lining.
 Persistence of a red lochia indicates subinvolution.

37. Signs and symptoms: BLIP-FI
5. Fever – if RPOC is present and cause of infection. The necrosis of RPOC, which are
prone to infection by the vaginal and cervical flora. It may spread further into the
parametrium (endomet, myomet, and perimet) and peritoneal cavity. The infection
may then progress to bacteremia and sepsis. Fever is a result of immune system
mechanism, because elevated body temperature is optimal for WBC to fight
infections.
6. Irregular cramp like pains – because of RPOC, uterine contracts more strongly to
compensate and limit blood loss. During contractions, blood vessels constrict,
reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle
fibers. This anoxia can cause pain in the same way that blockage of the cardiac
arteries causes the pain of a heart attack. As contractions become longer and
harder, the ischemia to cells increases, the anoxia increases, and the pain
intensifies.

38. Diagnosis

39. Diagnosis: T-FALL
1. Fundal height measurement
2. Lochia Monitoring – assess for pattern
3. Assessment of Vital signs
a. Temperature – elevated BT indicates puerperal sepsis, low BT
may indicate excessive blood loss.
b. Pulse Rate – tachycardia may indicate hypovolemic shock.
c. Blood pressure – hypotension may also indicate hypovolemic
shock.
d. Respiratory rate – tachypnea also indicates for hypovolemic
shock.
4. Consistent frequent assessment of uterine tone
5. Lab assessments - such as Hematocrit and Hemoglobin count.

40. Management

41. Management: BUBU
1. Uterine Massage – helps to evacuate the uterus of any clots as well as
re-approximate myofilaments to provide contractions.
2. Uterine Artery Ligation – decreases pulse pressure, and slows bleeding
from the spiral arterioles. It decreases blood and clot collection in the
uterus and placental bed.
3. B – Lynch Stitch – causes manual compression of the uterus that can
also aid in approximating smooth muscle fibers. It is done by using
sutures.
4. Bakri Balloon – placement of a balloon to distend the uterine cavity.
The main role of the balloon is to provide counter pressure at the
placental site. It effectively allows for compressing the spiral arteries
and arterioles to decrease bleeding and achieve hemostasis. It can
be done while waiting for the effects of uterotonics (uterine
stimulants).

42. Management: BrItUcomm
5. Blood Replacement – blood typing, crossmatching were done before
administration of blood products.
6. Iron Therapy – for good hemoglobin formation.
7. Uterotonics - to stimulate uterine contractions.
a. Oxytocin (Pitocin)
b. Methylergonovine (methergine)
c. Carboprost tromethamine (hemabate)
d. Misoprostol (cytotec)

43. Uterine Subinvolution – is incomplete return of the
uterus to it’s pre-pregnant size and shape.
Uterine Atony – is a multifactorial uterine condition,
were the uterus losses its contractile ability, or
ineffective uterine contractions that later causes
postpartum hemorrhage.
Postpartum hemorrhage - any significant blood
loss of more than 500 ml of blood in normal vaginal
spontaneous delivery, and more than 1000 ml or 1L
blood in cesarean section delivery.