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PROVIDING AND MANAGING AN UTERINE ATONY AFTER DELIVERY Uterine Atony - one of the causes of postpartal hemorrhage.

Relaxation of the uterus.

Factors to uterine atony: 1. Grand multiparity. 2. Advanced maternal age 3. Overdistension of the uterus - The uterus can become 'over stretched or over-distended' in a sense, leading to an increased chance of it being less able to contract adequately enough to control the bleeding after the baby is born. Includes the following: Multiple pregnancy Polyhydramnios: greater than 1,500 ml Diabetic mellitus complicating pregnancy: large babies or macrosomia 4. Dysfunctional labor: Precipitate (rapid) - Occasionally a fast labour and birth can be followed by a primary postpartum haemorrhage. It is as if the uterus has worked very hard for a short period of time then decided to 'stop work', not contracting adequately after the birth Dystocia (prolonged) labor - If the labour is unusually prolonged the uterus can 'tire' and not contract efficiently after the birth. 5. Oxytocin stimulation or augmentation during labor 6. General inhalation anesthesia which produces uterine relaxation 7. Placental complications: Placenta previa - . With a placenta previa the thin, lower segment of the uterus (where the placenta is attached) is less efficient at contracting, compared with the thick, upper segment of the uterus, increasing the chances of a postpartum haemorrhage. Abruption placenta - can cause bleeding into the uterine muscles, decreasing the muscles ability to contract efficiently after the baby is born, in some cases leading to a PPH. 8. Mismanagement of the third stage of labor 9. Use of tocolytic that relax uterine muscles 10. Previous postpartal hemorrhage - If the woman has experienced a primary postpartum haemorrhage with a previous birth, then she has an increased chance of experiencing one with a subsequent birth (but it does not necessarily mean that she will definitely haemorrhage again). 11. Unknown cause Signs and Symptoms: 1. Uterine fundus is soft, boggy or non- palpable 2. Vaginal bleeding 3. Pallor 1

4. Tachycardia 5. Absence of any laceration 6. Complete placenta Managing Uterine Atony: A. Call a doctor/ refer Uterine Atony is a serious complication after delivery, a nurse, a midwife, or traditional birth attendant should refer clients with complications of labor and delivery. B. Stay Do not leave a mother with soft fundus. She can hemorrhage to death. C. Rub up a contraction by massaging fundus express any clots. D. Oxytocics (Pitocin, methergine or ergotrate) and IV fluids may be given. E. Dont pack the uterus packing the uterus dilates it, thus concealing further bleeding. F. Employ bimanual compression and massage consist of a gloved abdominal hand to massage the fundus of the uterus or posterior aspect of the uterus with the other (the gloved and fisted) hand inserted through the vagina to pressed against the uterus and massage the anterior aspect of the uterus with the hands knuckles in contact with the uterine wall. G. Keep all pads and linens to assess the volume of blood loss. H. Remain calm and continue to support the mother until she regains feeling of confidence and security. I. If the condition happens in the home, transport the client to the nearest hospital. Position the woman flat with legs elevated in modified trendelenburg position Keep warm with blanket Reassure the client to keep her calm Monitor blood loss, pulse and respiration The most important endeavor to keep uterus firm and contracted: Additional measures: A. Offer a bedpan or assist the ambulating woman to the bathroom at least every 4 hours to keep bladder empty. A full bladder pushes an uncontracted uterus into an even more uncontrated state. To reduce bladder pressure, insertion of a urinary catheter may be ordered. Encourage the mother to stimulate her nipple to enhance oxytocin release by posterior pituitary gland Place an ice cap over the fundus.

B. If the woman is experiencing respiratory distress from decreasing blood volume, administer oxygen by face mask at a rate of 4L/min Position her supine to allow adequate blood flow to the brain and kidneys.

C. Obtain vital signs frequently and make sure to interpret them accurately, looking for trends. Ex. Continuously rising pulse rate is an ominous pattern.

If a woman is losing enough blood to affect her systematic circulation, she will develop signs of shock: Increased, thread and weak pulse 2

Decreased blood pressure Increased and shallow respirations Pale Clammy skin Increasing anxiety References: http://www.birth.com.au/Postpartum-haemorrhage-(PPH)/Causes-of-a-PPH.aspx?view=full Rosalinda Parado Salustiano, RN, RM, MAN, PhD.,Dr. RPS Essential Procedures for Safe Maternity Care., Second Edition. Page 311-314 Adele Pillitteri.,Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family.,Vol. 1, 5th Edition. Page 656-659