Q: While researching, I read that women with PPH sometimes present no identifiable risk factors, so I wanted to ask, do risk factors for postpartum hemorrhage show, and if so what are they?
    A: They definitely show. Some risk factors are long labors, inductions, the use of a lot of Pitocin during the delivery and before… For risk factors too, it’s really interesting, light, fair-skinned, red-headed people also have a higher incidence for postpartum hemorrhage [1], multiple births, so twins, triplets… every child that you have can increase the risk because the uterus is all worked out… anytime there’s been any cysts on the uterus... But like the patient I had, she had no risk factors.

Q: Do you think a big problem in this field is a lack of education towards risks for complications during delivery?
     A: I definitely think it’s a problem. For me, I lost a lot of blood when I had Lotus (*Destinee's third child). I was scared, and even I knew what was going on. They actually had to give me Cytotec and Pitocin after the delivery and then they massaged the uterus to really get it contracting again, and that’s something I would do at work… So when a patient’s delivered, two hours after labor and delivery, they would go over to postpartum. So when you’re assessing your patients, that’s what you always do: you feel the uterus and you make sure it’s nice and firm. If not, you can rub it, and usually it tightens up. That’s the big part of the assessment: just making sure the uterus is nice and tight and where it should be. 
But going back to me knowing what was going on, some women don’t know about that risk of hemorrhaging. There’s so many support groups for these mothers both before and after the birth of their children, but education and being informed about these things and what to expect is so important, especially prior to delivery. A lot of women, when something like this happens after being discharged, don’t know what to do because they don’t know if it’s normal, like the blood clots, for example: anything passed bigger than a quarter is abnormal. In our hospital, we always say discharge isn’t when a patient is leaving. We plan for discharge as soon as you get that patient. So as soon as you get that patient, you are teaching them: what to do and expect when they get home, teaching them how to take care of themselves, answering any questions they have. Education is especially important, especially with new moms. 

Q: You’ve been mentioning pitocin, what exactly is pitocin?
    A: Pitocin (*oxytocin injection) [2] is what actually makes the uterus contract. Mostly all the time, unless you have a completely natural birth, when you go into the hospital, they give you Pitocin. That’s kind of what starts labor. Say you go in for your delivery, after being induced, the doctors get you in there, you’re not actually in labor yet, they just usually hook you up with Pitocin beforehand to make the uterus contract. But what happens over time, when there’s too much Pitocin used and the labor is too long, and the uterus basically tires out. And at that time, that’s when the hemorrhaging could start, because the uterus won’t contract anymore.
    And also with Pitocin, the uterus is a hollow muscle that tires out just like your bicep does after doing bicep curls, for example. Your body produces oxytocin which gets the uterus contracting during labor, and along with Pitocin given at the hospital which makes the contractions stronger, so you’re making the uterus work even harder, with induction. So they try to avoid giving that Pitocin too much. 

Q: So, with all that being said, besides giving units of blood and Pitocin, what is the standard treatment for postpartum hemorrhage?
    A: So depending on how much blood a patient lost or how the whole process is going, the after-delivery treatment, like for the patient I had, would be running IV fluid and Pitocin, and then there’s a medication called Cytotec, which also helps clamp all the muscles, and sometimes an injection of Methergine (*used after childbirth to help prevent and control postpartum hemorrhage) [3]. So those three medications work together to control the bleeding and to really tighten up the uterus.

Q: Do you recall how much blood the patient you had lost/know how much blood you can lose from PPH?
      A: During those situations we weigh everything, but she probably lost and you can lose up to 800 cc’s of blood… and that’s in addition to what she lost during the delivery. Normal delivery blood loss is 300-500 cc’s of blood [4]. 

Q: If you’re doing a C-section, are you losing more blood and more likely to hemorrhage?
    A: Yes, with C-sections, you could normally lose up to 1000 cc’s [5], so you could be more likely to hemorrhage. So since you are in the hospital for 2-3 days after delivery, you could hemorrhage after 3 days. It’s not as common but it can happen.

Q: Have you ever treated women who have hemorrhaged during delivery specifically?
    A: So, the one patient I was telling you, is probably the one that stands out the most. She was already brought back over from labor and delivery, so it was probably like 6 hours after her delivery before she hemorrhaged. I’ve only really had experience working with other nurses that have had to deal with that: a patient that has passed away from PPH right after delivery. She started hemorrhaging and the mom died but the baby lived.

Q: What are the other signs of postpartum hemorrhage?
    A: Because you’re losing all that blood and fluid, your pulse increases, blood pressure drops, and that’s if it’s going on for an extended period of time, and also blood clots [6]. That’s a sign that we watch for because moms afterwards can pass a lot of blood clots. Also during delivery, the uterus gets really soft, so we look for that. But it’s mainly the blood loss for signs though. 

Q: When we discussed the topic for this capstone (the obstetric crash cart), prior to our interview, you said you believe your unit at Spring Valley had something similar to an emergency kit, what can you tell us about its contents, how it worked, anything like that?
    A: It had your standard bags of Pitocin, Cytotec, they had sutures, packing, and they had like a balloon for a Bakri Balloon procedure, that they’d blow up, fill it up with fluid to hold the soft uterus open and constrict all the vessels then deflate it after. The balloon would stay there from 12-24 hours before deflating.

Q: While researching about PPH and these carts, I read about the contents that would potentially be in the crash carts, such as sponge forceps, retractors, gauze etc. so all those materials aren’t nearby or readily available?
    A: Most of these things would be in the OR, so if it happens outside of the OR or even in the postpartum unit, going over to the labor and delivery unit, which was pretty far away from the postpartum unit, would mean losing a lot of time. Medication is also a big one too. We need this medication right away, so we need someone to run to the medication room, put their fingerprint in, grab the medication, and run back, so that’s taking up more time. So having all these medication on hand would help, along with having sutures nearby because a lot of the time, hemorrhaging can be due to lacerations. 

Q: While researching, I also read about the surgical techniques that sometimes need to be performed, such as uterine compression sutures, major vessel ligation, and a hysterectomy, what can you tell us about the hysterectomy or any of those other procedures?
    A: A hysterectomy is like a last resort, and they basically take the uterus out. And like I said, it’s the last measure you’d take because after that, there’s no chance of having another kid. And for a vessel ligation, when a blood vessel is bleeding, a ligation is burning the vessel and cloterizing it to stop the bleeding. 

Q: Knowing that 100 per 100,000 women die of PPH and that every 10 minutes a woman almost dies of pregnancy-related complications (with PPH as the leading cause of these complications), why do you think these carts are not established already and what impact do you think such a cart would do if it was implemented in every hospital?
    A: I think the process for approval and the money are the biggest reasons why these aren’t established. And I think the biggest thing for the impact is the time resource. You could have everything right in front of you within reach. No one has to run to grab something. The time would definitely cut down with something like this.