post partum hemorrhage nursing care plan

Postpartum hemorrhage (PPH) is the most significant cause of maternal deaths during or after childbirth, as it can lead to severe blood loss that can be life-threatening. It occurs at more than 10% of births and has a fatality rate of 1%. It is also estimated to account for 19.7% of all deaths related to pregnancy globally and it causes 25% of all maternal deaths. Due to the unpredictability of the problem and its rapid progression, reducing the incidence of PPH and improving maternal health outcomes becomes a challenge.

PPH

Traditionally, postpartum hemorrhage is defined as blood loss of 500 ml or more following a vaginal birth; this occurs in as many as 5% to 15% of postpartum women. With a cesarean birth, hemorrhage is present when there is a 1,000-ml blood loss or a 10% decrease in the hematocrit level. Although hemorrhage may occur either early (within the first 24 hours following birth) or late (from 24 hours to 6 weeks after birth), the greatest danger is in the first 24 hours because of the grossly denuded and unprotected uterine area left after detachment of the placenta.

The body initially responds to a reduction in blood volume with increased heart and respiratory rates. These reactions increase the oxygen content of each erythrocyte and cause faster circulation of the remaining blood. Tachycardia is usually the first sign of inadequate blood volume. Blood flow to nonessential organs gradually stops, to make more blood available for vital organs.

The four main reasons for postpartum hemorrhage are uterine atony, trauma, retained placental fragments, and the development of disseminated intravascular coagulation (DIC). These causes are generally referred to as the four T’s of PPH: tone, trauma, tissue, and thrombin. Conditions that increase the client’s risk for postpartum hemorrhage include the following:

  • Conditions that distend the uterus beyond the average capacity
  • Conditions that could cause cervical or uterine lacerations
  • Conditions with varied placental site or attachment
  • Conditions that leave the uterus unable to contract readily
  • Conditions that lead to inadequate blood coagulation

When planning care for a client diagnosed with postpartum hemorrhage, provide measures that will restore the client most quickly to health and promote contact among her, her child, and her primary support persons. The following are nursing diagnoses associated with the management of postpartum hemorrhage:

  • Deficient Fluid Volume
  • Ineffective Tissue Perfusion
  • Risk for Infection

Postpartum Hemorrhage Nursing Care Plan 

Below are sample nursing care plans for the problems identified above.

Deficient Fluid Volume

As a consequence of increased circulating blood volume during pregnancy, vital signs of hypovolemic shock become relatively insensitive in pregnancy. Tachycardia does not usually develop until blood loss exceeds 1,000 ml, and blood pressure is usually maintained in the normal range. A blood loss of up to 1,500 ml will begin to manifest clinical signs, such as a rise in pulse and respiratory rate, and a slight recordable fall in systolic blood pressure. Hypovolemic clients who begin to decompensate, as evidenced by hypotension, will deteriorate extremely rapidly.

Nursing Diagnosis

  • Deficient Fluid Volume

Related Factors

  • Excessive blood loss after birth

Evidenced by

  • Hypotension
  • Narrow pulse pressure
  • Tachycardia
  • Tachypnea
  • Decreased urine output
  • Mental status changes

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

  • Maintain a blood pressure level within the normal range.
  • Maintain a pulse rate within the normal limits.
  • Demonstrate a balanced intake and output.
  • Exhibit lochia flow less than one saturated perineal pad per hour

Nursing Interventions

Assessment Rationale
Assess the character, amount, and site of bleeding and document. Routine frequent assessment of lochia in the fourth stage of labor helps identify early postpartum hemorrhage. when the amount and character of the lochia are normal and the uterus is firm, but signs of hypovolemia are still evident, the cause may be a large hematoma. Excessive bright red bleeding despite a firm fundus may indicate cervical or vaginal laceration.
Assess the characteristics of lochia. Lochia rubra should be dark red. The amount of lochia during the first few hours should be no more than one saturated perineal pad per hour. a few small clots may appear in the drainage, but large clots are not normal.
Monitor the client’s vital signs. A rising pulse rate is often the first sign of inadequate blood volume. A rising pulse rate and falling blood pressure also occur. Routine postpartum care involves assessing the vital signs every 15 minutes until stable. the nurse should suspect hypovolemic shock if the pulse rate is greater than 100 beats/min. Decreased blood pressure may be a late sign of hypovolemic shock.
Assess the location of the uterine fundus and its degree of contractility. The best safeguard against uterine atony is to palpate the client’s fundus’ at frequent intervals to be assured her uterus is remaining contracted. Under usual circumstances, a well-contracted uterus feels firm and is easily recognized because it feels like no other abdominal organ. If unsure whether you have located the fundus’ location on palpation, it means the uterus is probably in a state of relaxation.
Assess for the presence of hematomas. If the client reports severe pain in the perineal area or a feeling of pressure between her legs, inspect to see if a hematoma could be causing this. It appears as an area of purplish discoloration with obvious swelling. It could be as small as 2 cm or as large as 8 cm in diameter. at first, it may feel fluctuant, but as seepage into the area continues and tissue is drawn taut, it palpates as a firm globe and feels tender.
Measure the client’s intake and output. Intake and output should be recorded and IV therapy monitored. As the blood flow to the kidneys decreases, they respond by conserving fluid. Urine output decreases and eventually stops.
Count and weigh perineal pads. By counting the number of perineal pads saturated in given lengths of time, a rough estimate of the amount of blood loss can be formed. Weighing perineal pads before and after use and then subtracting the difference is an accurate technique to measure vaginal discharge: 1 g of weight is comparable to 1 ml of blood volume, so if a pad weighs 50 g more after use, the client has lost 50 ml of blood.
Independent
Massage the client’s boggy uterus to encourage contractions. In the event of uterine atony, the first step in controlling hemorrhage is to attempt fundal massage to encourage contractions. Ask the client to void first to prevent displacement of the uterus and ensure accurate assessment of uterine tone.
Elevate the client’s lower extremities. Elevate the client’s lower extremities while lying supine to improve circulation to essential organs. During hypovolemic shock, blood flow to non-essential organs gradually stops, to make more blood available for vital organs, specifically the heart and brain.
Offer a bedpan or assist the client to the bathroom to void. Offer a bedpan to the client or assist the client to the bathroom at least every 4 hours to be certain that her bladder is emptying because a full bladder predisposes the client to uterine atony.
Apply an ice pack to areas with hematomas. Applying an ice pack covered with a towel to prevent thermal injury to the skin may prevent further bleeding.
Keep the client in nothing per orem (NPO). The client who develops a hemorrhagic complication should be kept on NPO status until the healthcare provider evaluates her condition, because she may need general anesthesia for correction of the problem.
Educate the client and significant others regarding the identification of warning signs of bleeding. Because hemorrhage from retained placental fragments may be delayed until after the client is at home, be certain that the client and her significant others know to continue to observe the color of lochia and to report any tendency for the discharge to change from lochia serosa or alba back to rubra.
Educate the client regarding the importance of breastfeeding. The infant suckling the breast stimulates the client’s posterior pituitary gland to secrete oxytocin, which causes uterine contraction.
Review the client’s blood typing and crossmatching results for possible blood replacement. In most agencies, blood typing and cross-matching are done when the client is admitted to the labor service so blood can be rapidly cross-matched.
Dependent
Administer IV fluids using an 18-gauge catheter. Resuscitation with crystalloids and colloids is effective in optimizing tissue oxygenation preoperatively. IV fluid resuscitation reduces the viscosity of blood and improves cardiac output.
Administer fresh whole blood or other blood products as indicated. Fresh frozen plasma should be considered in massive ongoing PPH when there is a clinical suspicion of coagulopathy and laboratory tests are not normal. Platelets should be transfused when the count is 75×10⁹/L, aiming to maintain a level >50×10⁹/L during ongoing PPH.
Administer medications as ordered. When oxytocin is given intravenously, its action on the uterus is immediate. If oxytocin is not effective at maintaining tone, carboprost tromethamine, a prostaglandin F2a derivative, or methylergonovine maleate, an ergot compound, both given intramuscularly, are second possibilities.
Assist in surgical intervention as indicated. Rarely, a hysterectomy is needed to remove the bleeding uterus that does not respond to any measures. Removal of the retained placental fragment is necessary to stop the bleeding and can usually be accomplished by a dilatation and curettage (D&C). If a hematoma is large or continues to increase in size, the client may have to be returned to the birthing room to have the site incised and the bleeding vessel ligated under local anesthesia.
Administer oxygen by face mask. Administer oxygen by face mask at a rate of about 10 to 12 L/min if the client is experiencing respiratory distress from decreasing blood volume. Position her supine to allow adequate blood flow to her brain and kidneys.
Insert an indwelling Foley catheter as indicated. Bladder distention is an easily corrected cause of uterine atony. The nurse should catheterize the client if she cannot urinate on the toilet or bedpan. Most healthcare providers include an order for catheterization to prevent delaying this corrective measure.

 

Ineffective Tissue Perfusion

The body initially responds to a reduction in blood volume with increased heart and respiratory rate. These reactions increase the oxygen content of each erythrocyte and cause faster circulation of the remaining blood. Blood flow to non-essential organs gradually stops, to make more blood available for vital organs specifically the heart and brain. This change causes the client’s skin and mucous membranes to become pale, cold, and clammy. As blood loss continues, flow to the brain decreases, resulting in mental changes. As blood flow to the kidneys decreases, they respond by conserving fluid.

Nursing Diagnosis

  • Ineffective Tissue Perfusion

Related Factors

  • Decreased volume of circulating blood in the body

Evidenced by

  • Hypotension
  • Tachycardia
  • Diminished arterial pulses
  • Decreased capillary refill
  • Altered mental status
  • Decreased urine output

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

  • Demonstrate vital signs within the normal range.
  • Exhibit laboratory results within normal limits.
  • Maintain a normal amount of intake and output

Nursing Interventions

Assessment Rationale
Assess the client’s vital signs closely. Tachycardia does not usually develop until blood loss exceeds 1,000 ml and blood pressure is usually maintained in the normal range. A blood loss of up to 1,500 ml will begin to manifest clinical signs, such as a rise in pulse and respiratory rate, and a slight fall in systolic blood pressure. Systolic blood pressure below 80 mm Hg usually indicates a blood loss in excess of 1,500 ml clinically associated with worsening tachycardia, tachypnea, and alteration in mental status.
Monitor the client’s oxygen saturation levels. The major risk of hemorrhage is hypovolemic shock, which interrupts blood flow to body cells. This prevents normal oxygenation, nutrient delivery, and waste removal at the cellular level. Oxygen saturation levels are monitored in early postpartum hemorrhage.
Monitor the client’s arterial blood gases (ABG) and pH levels. Due to sympathetic nervous system activation, blood is diverted away from noncritical organs and tissues to preserve blood supply to vital organs such as the heart and brain. While prolonging heart and brain function, this also leads to other tissues being further deprived of oxygen causing more lactic acid production and worsening acidosis.
Assess the client’s mental status. Blood flow to non-essential organs gradually stops, to make blood available for vital organs. As blood loss continues, flow to the brain decreases, resulting in mental changes, such as anxiety, confusion, restlessness, and lethargy.
Observe for cool and pale skin, nail beds, and oral mucosa, and assess for a delayed capillary refill. The body compensates for volume loss by increasing heart rate and contractility, followed by baroreceptor activation resulting in sympathetic nervous system activation and peripheral vasoconstriction. Cool extremities and delayed capillary refill are signs of peripheral vasoconstriction.
Independent
Elevate the side rails on the client’s bed as appropriate. A client with mental health changes may be restless and at risk for falls. Elevating the side rails may reduce the risk for injury
Lower the head of the bed and elevate the client’s legs when lying supine or sitting. Lowering the head of the bed increases venous return. Raising the legs improves venous return and is consistent with the positioning used to diagnose and treat the underlying causes of bleeding.
Educate the client on how to perform breast self-examination (BSE). Sheehan’s syndrome has been usually described to affect pregnant women after moderate to profound hypovolemic shock throughout delivery. However, it is usually diagnosed months to years after the hemorrhagic event. Learning how to perform BSE may help determine symptoms such as a decrease in breast tissue.
Dependent
Administer IV fluids as prescribed. Restrictive crystalloid resuscitation (1-2 ml of crystalloid for every 1 ml of blood loss) as initial resuscitation is recommended according to the clinical condition and the estimated blood loss.
Administer supplemental oxygen, as indicated. Administer oxygen by face mask at a rate of 10 to 12 L/min if the client is experiencing respiratory distress from decreasing blood volume.
Administer blood and blood products. Blood transfusion to replace blood loss with postpartum hemorrhage is often necessary. If bleeding continues after administration of 4 RBC units, fresh, frozen plasma transfusion (FFP) of at least 1:2 FFP: RBC ration is recommended.

Risk for Infection

Placental fragments are more likely to be retained if the placenta does not separate cleanly from its implantation site after birth or if there is disruption of the placental scab. Clots form around these retained fragments and slough several days later, sometimes carrying the retained fragments with them. Blockage of the lochial flow because of the retained placenta or clots increases susceptibility to infection.

Nursing Diagnosis

  • Risk for Infection

Risk Factors

  • Stasis of body fluids or lochia
  • Retained placental fragments
  • Invasive procedures
  • Traumatized tissues

Evidenced by

  • Not applicable on risk diagnosis; the presence of signs and symptoms establishes an actual diagnosis

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

  • Demonstrate vital signs within the normal range.
  • Maintain laboratory results with normal limits.
  • Display a normal amount of lochia which is free from a foul odor.

Nursing Interventions

Assessment Rationale
Assess the character and amount of lochia. The nurse should be able to interpret the normal color, quantity, and odor of lochia discharge and the size, consistency, and tenderness of a normal postpartum uterus to recognize if an infection is present. Lochia is usually dark brown and has a foul odor when there is an infection.
Assess the client’s vital signs. Slight temperature elevations with no other signs of infection often occur during the first 24 hours because of dehydration. The nurse should look for other signs of infection if the client’s temperature is elevated, regardless of the time since delivery. A pulse rate that is higher than expected and an elevated temperature often occur when the client has an infection.
Assess the client’s episiotomy wound or incision from a cesarean birth. If the client has a suture line on her perineum from an episiotomy or a laceration repair, a ready portal of entry exists for bacterial invasion. Inspection of the suture line may reveal inflammation. One or two stitches may have sloughed away, so an area of the suture line is open with purulent drainage present.
Assess the client’s fundal height. Subinvolution of the uterus is a slower than expected return of the uterus to its nonpregnant state. Infection and retained fragments of the placenta are the most common causes. Normally, the uterus descends at the rate of 1 cm (1 finger’s width) per day and is no longer palpable by 12 days postpartum.
Independent
Enforce the importance of hand hygiene among the client and her significant others. The client should be taught to wash their hands before and after performing self-care that may involve contact with secretions. Client hand hygiene may be as important as healthcare worker hand hygiene in preventing the transmission of microorganisms.
Educate the client about proper perineal care. Instruct the client to wipe front to back after urinating or a bowel movement to prevent bringing contamination forward from the rectum onto the healing area. When the nurse gives perineal care, they must make sure that they perform hand hygiene and wear gloves. Each postpartum client should have their own perineal supplies and should not share them to prevent the transfer of pathogens from one client to another.
Encourage the client to consume vitamin-C-rich foods and foods rich in protein and iron. The client’s own body must overcome infection and heal any wound. Nutrition is an essential component of her body’s defenses. The nurse should teach her about foods that are high in protein (meats, cheese, milk, legumes) and vitamin C (citrus fruits and juices, strawberries, cantaloupe) because these nutrients are especially important for healing. Foods high in iron, to correct anemia, include meats, enriched cereals and bread, and dark green, leafy vegetables.
Use the aseptic technique in performing procedures for the client. To help prevent infection, any articles such as gloves or instruments that are introduced into the birth canal during labor, birth, and the postpartum period should be sterile. In addition, adherence to standard infection precautions is essential.
Educate the client about warning signs of infection and when to report them. Teach the client about signs of infection that should be reported after discharge. The client may be at home when signs of infection occur, therefore, the nurse should be certain that the client is taught about the signs and symptoms of infection before she is discharged.
Educate the client about perineal pad changes. Remind the client to change perineal pads frequently. Because they are contaminated by drainage, if left in place too long, they might cause vaginal contamination or reinfection.
Caution the client about the effects of antibiotics on the infant if breastfeeding. Be certain that the client who is breastfeeding is not prescribed antibiotics incompatible with breastfeeding. alert them to observe for problems in their infant, such as white plaques or thrush in their infant’s mouth that can occur when a portion of maternal antibiotic passes into the breast milk and causes an overgrowth of fungal organisms.
Dependent
Administer antibiotics as prescribed. Intravenous antibiotics are usually prescribed for a postpartum infection. Frequently used antibiotics include ampicillin, gentamicin, and third-generation cephalosporins such as cefixime. If the client will be continuing drug therapy at home, stress that she must take the full course to prevent the infection from recurring.
Administer oxytocic agenst as indicated. Treatment for retained placental fragments consists of the administration of drugs such as oxytocin, methylergonovine, or prostaglandins to contract the uterus.
Obtain a vaginal culture specimen if indicated. When taking culture to identify the offending organism, be certain to obtain fluid from the vagina using a sterile swab rather than from a perineal pad to ensure you are culturing the endometrial infectious organism and not an unrelated one from the pad.

Post Partum Hemorrhage Nursing Care Plan Sample

Nursing Diagnosis: Fluid Volume Deficit

Nursing Diagnosis: Fluid
Volume Deficit
Goals/ objectives:Nursing InterventionsRationaleEvaluation
Possible Etiologies:
(Related to)

• Uterine Atony
• Lacerations
• Retained placental
fragments
• Disseminated
intravascular
coagulation
• Subinvolution of uterus

Defining characteristics:
(Evidenced by)

• Blood loss more
than 500 ml
• Heavy lochia flow
• Increased
temperature due to
uterine infection
predisposing to
uterine atony
• Elevation of pulse
rate indicating
hypovolemia
• Sudden drop in
blood pressure
implying
hemorrhage
• Pain in the perineal
sutures
• Decreased uterine contractility
• Drop in the
haemoglobin and
hematocrit
laboratory results
• Decreased urine
output
• Pallor, easy
fatigability, anxiety


Short term goal:

Client will
maintain fluid
volume at a functional level as evidenced by individually adequate haemoglobin, hematocrit laboratory results, stable vital signs, adequate urine output, good uterine contractility, good skin turgor and capillary refill after one week.

Long term goal:
Client will demonstrate
behaviours

Nursing Actions

1.) Assess uterine contraction and lochia flow every 2 hours.
2.) Assess vital signs and
note for peripheral pulses.
3.) Note client’s physiologic response to blood loss.
4.) Keep accurate record of subtotals of solutions/ blood
products during replacement therapy.
5.) Maintain bed rest and schedule activities to
provide undisturbed rest periods.
6.) Keep fluids within reach of client.
7.) Teach client perineal self- care.
8.) Encourage client to do Kegel’s exercises
every 4 hours.
9.) Administer fluids/ volume expanders as
indicated.
10.) Replace blood products as ordered by the physician.
11.) Administer methylergonovine as prescribed by the
physician.
12.) Monitor laboratory studies (haemoglobin
and hematocrit, creatinine/ BUN)
13.) Assist in the preparation for surgery specifically
hysterectomy.


1.) That is to note how
much blood loss the
client is experiencing and to prompt for
immediate intervention.
2.) Changes in BP and
pulse may be used
for rough estimate
of blood loss.
Postural hypotension reflects a decrease in
circulating volume.
3.) Symptomatology
may be useful in
gauging severity of
bleeding episode.
4.) Potential exists for
over transfusion of
fluids, especially
when volume
expanders are given
prior to blood
transfusion.
5.) Activity may
predispose to further
bleeding.
6.) To encourage fluid
intake
7.) To prevent
development of
perineal infections.
That is to note how
much blood loss the
client is experiencing and to prompt for immediate intervention.
8.) Changes in BP and
pulse may be used
for rough estimate
of blood loss.
Postural
hypotension reflects
a decrease in
circulating volume.
9.) Symptomatology
may be useful in
gauging severity of
bleeding episode.
10.) Potential exists for
over transfusion of
fluids, especially
when volume
expanders are given
prior to blood
transfusion.
11.) Activity may
predispose to further
bleeding.
12.) To encourage fluid
intake
13.) To prevent
development of
perineal infections.

Outcome Criteria:

• Client’s pulse is
between 80 to 100
beats per min and
blood pressure is
110/60 mmHg,
lochia slows to
moderate amount of
flow with no large
clots, uterus is firm
and haemoglobin
level is above
11g/L.

• Client verbalizes
understanding of the
causative factors
and purpose of
interventions and
medication;
participates in
procedures without
hesitations;
attentive and
monitors own vital
signs upon
assessment; and
follows restrictions
applied.

References

  1. Adewumi, R. (2021). American College of Obstetricians and Gynecologists Postpartum Hemorrhage Protocol. Walden University Dissertations.
  2. Gonzalez, J. G. G., Almaguer, O. D. B., Montenegro, A. S., Guajardo, R. R., Plazas, A. E., Luna, R. M.-O., & Gutierrez, R. R. (2018, February 26). Sheehan’s Syndrome Revisited: Underlying Autoimmunity or Hypoperfusion? International Journal of Endocrinology, 2018. https://doi.org/10.1155/2018/8415860
  3. Hooper, N., & Armstrong, T. J. (2021, July 13). Hemorrhagic Shock – StatPearls. NCBI. Retrieved March 23, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK470382/
  4. Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
  5. Muñoz, M., Stensballe, J., Bouthors, A.-S. D., Bonnet, M.-P., De Robertis, E., Fornet, I., Goffinet, F., Hofer, S., Holzgreve, W., Manrique, S., Nizard, J., Christory, F., Samama, C.-M., & Hardy, J.-F. (2019). Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement. Blood Transfusion, 17, 112-136. 10.2450/2019.0245-18
  6. Rath, W. H. (2011). Postpartum hemorrhage – update on problems of definitions and diagnosis. ACTA Obstetricia et Gynecologica, 90, 421-428. 10.1111/j.1600-0412.2011.01107.x
  7. Sharma, A. (2019). Labour Room Emergencies. Springer Singapore.
  8. Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
  9. Srigley, J.A., Furness, C.D., & Gardam, M. (2016, September). Interventions to improve patient hand hygiene: a systematic review. Journal of Hospital Infection, 94(1), 23-29. https://doi.org/10.1016/j.jhin.2016.04.018
  10. Usoro, N. I., Emechebe, C. I., Okonkwo, C. U., Inaku, K., Enabulele, J. O., Inyama, M. A., & Asuquo, E. E.J. (2021, February). Bloodless Management of Severe Obstetric Hemorrhage With Very Severe Anemia: A Case Report. A & A Practice. 10.1213/XAA.0000000000001396
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