Postpartum Hemorrhage

Postpartum Hemorrhage Nursing Care Plans Diagnosis and Interventions

Postpartum Hemorrhage NCLEX Review Care Plans

Nursing Study Guide on Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a medical emergency that involves the abnormal or excessive vaginal bleeding of the mother after the birth of her baby.

It is important to note that vaginal bleeding called lochia is normally heavy from just after delivery until the next few hours and may not stop until the next few days.  

Nursing Stat Facts 1

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Nursing Stat Facts 1

The color of blood will usually change from bright red to brown over a couple of weeks. The full stoppage of lochia normally occurs no more than 12 weeks after delivery.

However, in postpartum hemorrhage there is either a heavy vaginal bleeding of at least 500 mL in the first 24 hours of delivery or between 23 hours and 12 weeks of delivery.

Types of Lochia

Postpartum hemorrhage may involve excessive bleeding and abnormality of lochia or postpartum vaginal discharge. It is especially important to take note of the duration of lochia rubra to help in the diagnosis of PPH. The following are the normal characteristics of the types or stages of lochia:

  1. Lochia rubra – refers to the first vaginal discharge; rubra means red in color; usually happens from Day 1 to Day 5 after birth
  2. Lochia serosa – the vaginal discharge appears either brownish or pinkish; typically occurs until Day 10 after birth
  3. Lochia alba – the vaginal discharge appears whitish or yellowish; typically happens from the 2nd week to the 6th week after birth, but may also extend to 12 weeks postpartum

Types of Postpartum Hemorrhage

  • Primary PPH – occurs when the mother loses at least 500 mL or more of blood within the first 24 hours of delivering the baby.
  • Major Primary PPH – losing 500 mL to 1000 mL of blood
  • Minor Primary PPH – losing more than 1000 mL of blood
  • Secondary PPH – occurs when the mother has heavy or abnormal vaginal bleeding between 24 hours and 12 weeks of delivering the baby.

Signs and Symptoms of Postpartum Hemorrhage

  • Uncontrolled bleeding
  • Hypotension – decreased blood pressure
  • Tachycardia – increased heart rate
  • Anemia – decrease in the red blood cell count or hemoglobin level
  • Edema or hematoma – swelling and pain in or around the vaginal area
  • Fatigue – extreme tiredness

The patient should also be educated on the following warning signs that would indicate the need to inform their healthcare provider either during hospital stay or after discharge:

  • Excessive or increased vaginal bleeding – if the patient needs a new sanitary pad after an hour, or if she passes large blood clots
  • Blurry vision or other visual disturbances
  • Light-headedness or dizziness
  • New or worsening stomach pain
  • Fatigue  
  • Tachycardia

Causes and Risk Factors of Postpartum Hemorrhage

The 4 T’s is a mnemonic that can be used to remember the 4 common causes of postpartum hemorrhage:

  1. Tone – uterine atony is the most common cause of PPH; overstretched uterus may cause a soft and boggy tone
    • Trauma – rupture, inversion, hematoma, and/or laceration
    • Tissue – retained or invasive placenta
    • Thrombin – coagulopathy; bleeding disorders or blood clotting problems

The following are risk factors of postpartum hemorrhage:

A. Before Delivery

  • Placenta previa – a condition wherein the placenta is situated low near the neck of the uterus
  • Abruptio placentae – a condition wherein the placenta separates from the uterus earlier than expected
  • Multiple pregnancies – carrying twins or more
  • History of postpartum hemorrhage
  • Pre-eclampsia – high blood pressure
  • Obesity or having a BMI of greater than 35
  • Anemia
  • Thrombocytopenia or other blood clotting problems
  • On anticoagulant therapy
  • Fibroids

B. After Delivery

  • Delivery by Cesarean section
  • Forceps delivery
  • Induction of labor
  • Delayed delivery of placenta or retained placenta – not passing the placenta within the hour after birth of the baby
  • Tear in the perineum (lacerations) or episiotomy
  • Fetal macrosomia – having a baby that weighs more than 9 lbs or 4 kg
  • Hyperthermia during labor
  • Having had a long labor – more than 12 hours
  • Age of the mother – having the first baby at age 40 years or above
  • Use of general anesthetic during delivery

Complications of Postpartum Hemorrhage

  1. Hypovolemic shock
  2. Failure of major organs, such as the lungs and kidneys
  3. Anemia
  4. Postpartum fatigue

Diagnosis of Postpartum Hemorrhage

  • Measurement of blood loss – PPH is defined as blood loss of more than 500 mL in the first 24 hours post delivery
  • Blood tests – include full blood count (particularly hemoglobin and hematocrit), clotting factors, and factor essays
  • Pelvic exam – pregnant women who are at risk for PPH will undergo pelvic exam which checks the vagina, uterus, and cervix
  • Imaging – ultrasound is the first imaging choice to visualize the baby and the pelvic organs

Prevention of Postpartum Hemorrhage

The following measures can be undertaken to prevent the likelihood of postpartum hemorrhage:

  1. Active management of the third stage of labor. This includes the administration of oxytocin no earlier than the delivery of the anterior shoulder. It also involves controlled traction, as well as uterine massage after the delivery of the placenta.
    • Early recognition of the risk for PPH. Stopping or reducing anticoagulants, oral iron supplementation, coagulation tests, and regular antenatal check-ups are helpful in preventing PPH.

Treatment for Postpartum Hemorrhage

  1. Medications. Several medications may be prescribed to treat PPH:
  2. Uterotonic agents – utilized to prevent or control PPH. Oxytocin is the first-line prevention and treatment for PPH. It is used to decrease the blood flow through the uterus after the delivery of the baby.
  3. Adjuvant therapies – anti-bleeding drugs can be administered within the first 3 hours of the start of PPH
  4. Antibiotics – may be required if a bacterial infection has caused or contributed to PPH based on the culture results of the lochia
  5. Intravenous fluid replacement
  6. Uterine massage
  7. Transfusion – low hemoglobin /hematocrit level and excessive blood loss may require transfusion of blood and plasma products.
  8. Application of pressure on labial or perineal lacerations
  9. Episiotomy Repair – timely repair of lacerations and episiotomy is important in controlling PPH
  10. Reduction of uterine inversion – the Johnson method is a manual procedure wherein the protruding uterus is returned in the normal position by pushing it inside toward the direction of the umbilicus
  11. Manual removal of retained placental tissues
  12. Surgery- hysterectomy (removal of the uterus) or laparatomy may be needed if the other treatments are not effective in stopping PPH

Nursing Care Plans for Postpartum Hemorrhage

Nursing Care Plan 1

Nursing Diagnosis: Fluid Volume Deficit related to blood volume loss secondary to postpartum hemorrhage as evidenced by lochia rubia of 500 mL in the first 24 hours post-delivery, decrease in red blood cell count/ hemoglobin/ hematocrit levels, skin pallor, heart rate of 120 bpm, blood pressure level of 85/50, and lightheadedness

Desired Outcome: The patient will have a lochia flow of less than one saturated pad per hour, a hemoglobin (HB) level of over 100, blood pressure and heart rate levels within normal range, full level of consciousness, and normal skin color

InterventionsRationales
Assess vital signs, particularly blood pressure level.Hypovolemia due to PPH may lower blood pressure levels and put the patient at risk for hypotensive episodes that may lead to shock.
Administer uterotonic agents and other medications as prescribed.Uterotonic agents are utilized to prevent or control PPH. Oxytocin is the first-line prevention and treatment for PPH. It is used to decrease the blood flow through the uterus after the delivery of the baby
Assist the physician in performing the appropriate procedure to treat the underlying cause of PPH.PPH should be managed depending on the underlying cause. The team may be required to perform one or more of the following:
Uterine massage
Transfusion of blood and/or blood products
Application of pressure on labial or perineal lacerations
Episiotomy Repair
Reduction of uterine inversion using the Johnson method
Manual removal of retained placental tissues
Surgery such as hysterectomy (removal of the uterus) or laparatomy  
Insert an indwelling Foley catheter as indicated.To accurately monitor the patient’s urine output which can clearly reflect renal perfusion.
Commence a fluid balance chart, monitoring the input and output of the patient. Output monitoring should include the amount of blood-soaked pads within 24 hours.To monitor patient’s fluid balance accurately and to see the progression of PPH.
Start intravenous therapy as prescribed. Electrolytes may need to be replaced intravenously.To replenish the fluids and electrolytes lost from blood volume loss, and to promote better blood circulation around the body.
Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside.To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. 
Administer blood transfusion as prescribed.To increase the hemoglobin level and treat anemia and hypovolemia related to PPH.
Maintain the patient on bed rest with a leg elevation of 20 to 30 degrees.To promote recovery and reduce fatigue, bed rest is strongly recommended in patients with PPH. Leg elevation is important to obtain good venous return for improved blood flow to the brain and other vital organs. This can also help prevent edema.
Advise the patient to report any vaginal fullness or persistent perineal pain.PPH may result to hematoma formation due to the laceration/s in the birth canal.

Nursing Care Plan 2

Nursing Diagnosis: Risk for Bleeding related to C-section delivery of the baby

      Desired Outcome: To prevent any bleeding episode after C-section delivery of the baby.

InterventionsRationales
Assess the patient’s vital signs and perform a focused physical assessment, looking for any signs of bleeding.Delivery via C-section can put the patient at risk for bleeding. Low blood pressure, increased heart rate, low temperature, and altered mentation may result from excessive bleeding.
Before the operation, obtain blood samples to check platelet counts as well as coagulation levels (INR, PT, and PTT).To measure the risk of bleeding by knowing the platelet counts and coagulation levels of the patient.
Advise the patient to stop the use of non-steroidal anti-inflammatory drugs (NSAIDs), anticoagulants, and certain herbal remedies prior to surgery, as indicated by the physician.NSAIDs and anticoagulants can increase the risk for bleeding. Some herbal remedies can affect clotting factors, such as ginseng and gingko biloba.
Obtain Group and Save blood samples from the patient. Anticipate the need for the patient to have whole blood replacements.To prepare for any need to perform blood transfusion as prescribed. If the blood loss is too much and immediate correction is warranted, whole blood transfusion is administered.
Perform the blood transfusion if indicated.Blood transfusion may be required if there is too much blood loss.
Post-surgery, assess and monitor the patient’s surgical wound site for any signs of unexpected bleeding.To treat any unexpected bleeding as early as possible.
Post C-section, monitor the patient’s lochia or vaginal discharge.To treat postpartum hemorrhage as early as possible.

Other possible nursing diagnoses:

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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