Postpartum Hemorrhage Nursing Diagnosis and Nursing Care Plan

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Postpartum Hemorrhage Nursing Care Plans Diagnosis and Interventions

Postpartum Hemorrhage NCLEX Review and Nursing Care Plans

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.  

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
  2. Trauma – rupture, inversion, hematoma, and/or laceration
  3. Tissue – retained or invasive placenta
  4. 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 Diagnosis for Postpartum Hemorrhage

Nursing Care Plan for Postpartum Hemorrhage 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

 Postpartum Hemorrhage Nursing 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 for Postpartum Hemorrhage 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.

 Postpartum Hemorrhage Nursing 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.

Nursing Care Plan for Postpartum Hemorrhage 3

Ineffective Tissue Perfusion

Diagnosis: Ineffective Tissue Perfusion related to hypovolemia secondary to postpartum hemorrhage as demonstrated by reduced arterial pulsations, cold and pale color skin at the extremities, increased perspiration, lesser capillary refill, reduced milk production, changes in vital signs, and altered neurologic status.

Desired Outcomes:

  • The patient will exhibit vital signs within the normal range.
  • The patient laboratory result of arterial blood gases, hematocrit, and hemoglobin levels are acceptable findings.
  • The patient will show signs of desired hormonal changes such as a sufficient supply of breastmilk for lactation, and resumption of normal menstruation cycle.
 Postpartum Hemorrhage Nursing InterventionsRationale
Monitor and record the patient’s vital signs closely.                            Risk of extreme blood risk might happen immediately after birth up to the first-hour postpartum. The patient may manifest symptoms of hypovolemic shock including a drop in blood pressure; an increase in pulse rate or weak,  small fine pulse; rapid and shallow breathing; pale color and clammy skin, and increasing anxiety.
Check the patient’s oxygen saturation levels.  Monitoring blood pressure and oxygen saturation level can help in identifying if the patient is developing serious complications such as hemorrhage and hypovolemic shock. Pulse oximetry is a device used in monitoring tissue perfusion and oxygen saturation.
Observe the patient’s temperature; the color of the nail beds, gums, tongue, and buccal mucosa.  In case of volume loss, the body will compensate by activating baroreceptors. This will result in activation of the sympathetic nervous system and peripheral vasoconstriction. These 2 mechanisms will lead to vasoconstriction or narrowing of blood vessels and shunting of blood to vital organs. Diminished circulation in the peripheral blood vessels will follow, resulting in bluish discoloration of the skin and cold temperature of the skin.
Assess the neurologic status and monitor for any changes in the behavior.  One of the early signs of hypoxia is changes in mental activities. Heavy blood loss may result in decreased circulation to the brain, resulting in changes in mentation such as anxiety, confusion, and lethargy.
Obtain arterial blood gases (ABGs) and pH levels as ordered.  Monitor the degree of tissue hypoxia or acidosis by testing the arterial blood gases and pH levels. It will indicate if there’s a build-up of lactic acid resulting in anaerobic metabolism. To achieve to preserve the blood supply to vital organs, blood is diverted away from noncritical organs and tissues. Bringing about an increase in lactic acid production and worsening acidosis.
Instruct the client on performing breast self-examination at least once a day; Examine for changes in breast size and the presence or absence of lactation.   Postpartum hypopituitarism or Sheehan’s syndrome is a condition wherein the level of prolactin is reduced caused by pituitary gland necrosis from hemorrhagic shock during pregnancy. Resulting in absence of lactation or agalactorrhea and a decrease in breast tissue.
Elevate the patient’s legs and lower the head of the bed when lying down or sitting as indicated  by Trendelenburg’s position or lowering the head of the bed promotes venous return. Elevating the legs promotes blood flow back to the heart. Raising the lower extremities lessens tissue swelling and quickly empties superficial and tibial veins, enhancing venous return. Improving blood circulation ensures that other nonvital organs and tissues can be reached by blood flow.
Ensure safety by raising the side rails on the patient’s bed, if not contraindicated.  Due to reduced blood return to the brain, the patient may have altered mental status. Provide safety by raising the side rails to prevent the occurrence of falls and injury in a confused or lethargic patient.
Obtain intravenous access and start IV fluids as ordered.  The principal objective is to bring back circulating volume and perfusion to vital organs actively.
Provide oxygen supplementation as indicated.  To keep oxygen saturation more than 95%, oxygen administration is started. In non-breathing patients, assisted ventilation may be required. Oxygen supplementation should be continuously provided even if the patient’s breathing is already normal. Continuous monitoring of saturation should also be rendered.
  Facilitate blood transfusion as ordered.  In case of too much bleeding, blood transfusion is necessary to replace blood lo

Nursing Care Plan for Postpartum Hemorrhage 4

Risk for Infection

Nursing Diagnosis: Risk for Infection related to the stasis of body fluids and traumatized tissues secondary to postpartum hemorrhage.

Desired Outcomes:

  • The patient will express an understanding of the causative, and risk factors.
  • The patient’s vital signs will be maintained within normal ranges.
  • The patient’s will exhibit lochia free from foul smelling odor.
  • The patient’s laborataory values will improve and within normal levels.
 Postpartum Hemorrhage Nursing InterventionsRationale
Measure the patient’s fundal height to monitor the rate of uterine involution.    Subinvolution of the uterus occurs when the return of the uterus to its nonpregnant condition is slower than expected. The most common causes are infection and retained pieces of the placenta. One distinctive sign of subinvolution is a fundal measurement that is greater than expected for the amount of time since birth.
Evaluate the quality of lochial discharges.  One sign of abnormal uterine involution secondary to infection is persistent lochia bleeding or slow progress in its 3 stages. Retained placenta or blood clots can block the lochial flow making it more susceptible to infection. A darkly browned color lochia with a foul smell can indicate the presence of infection. Due to poor uterine involution, the blood amount may increase. However, if there is a presence of high fever, bleeding may be scanty or absent.  
Check the patient’s vital signs closely, especially the temperature.  Increased temperature is a defense mechanism of the body to fight off harmful infections. One indication of an existing infectious process is having more than 38 degrees temperature after the first 24 hours of birth, and two consecutive 24-hour periods. Elevated pulse rate also occurs when there is a present infection.
Assess the patient’s episiotomy site or C-section wound.  Assess the patient’s wound using the REEDA criteria. It stands for redness, edema, ecchymosis, discharge, and approximation. The assessment should be done and recorded promptly. These are the characteristics of wound infection: redness, edema, heat, pain, separation of the suture line, and presence of pus in the drainage.
Ask the patient for any plans on breastfeeding the infant upon discharge.  When the patient was diagnosed with a postpartum infection, make sure that they are not prescribed incompatible antibiotics with breastfeeding. Remind them of what problems should be observed in their infant, such as white plaques or thrush in the infant’s mouth which occurs when an amount of the maternal antibiotic passes into the breast milk. Also, it can be an indication of oral candidiasis.
Discuss with the patient and family members the proper handwashing and self-care techniques. Educate them about the appropriate handling and disposal of infectious waste like used dressings, pads, and linens.By proper hand washing the spread of infectious microorganisms can be prevented.  Hand washing before and after self-care should also be taught. Wearing gloves when in contact with any blood, bodily fluids, and other potentially infectious materials.
Discuss with the patient the proper way how to do perineal care.  Proper perineal care should also be instructed, example is the proper way of wiping the perineum. To prevent the contamination of E.coli organisms from the rectum, wiping should be from front to back. Washing hands and wearing gloves when giving perineal care is advisable. Advise the patient to not share their perineal supplies, each patient should have their own to avoid the transfer of pathogens from one patient to another.
Educate the patient on signs of infection and when to report it to the healthcare provider.  The onset of symptoms varies, some patients develop infection days after discharge. By providing enough information on what they should monitor at home, for example taking of temperature, and when to report it to their doctors. Signs and symptoms depend on the severity of the infection, some patients may experience chills, loss of appetite, and body pain. The patient may also have painful to touch uterus, foul-smelling and dark brown colored lochia. The attending doctor should be informed promptly if these signs are present to avoid the progression of infection to septicemia.
Providing sterile techniques in wound care and invasive procedures.  Many factors may contribute to increasing the risk of infection. A contaminated environment, unsterile personnel contacts in the sterile field, and failure to comply with infection precautions are some of the causes. To control the spread of infection, using of sterile techniques at all times when introduced into the birth canal upon labor, birth, and after delivery. Also, maintaining the application of the standard infection protocols is important.

Nursing Care Plan for Postpartum Hemorrhage 5

Risk for Impaired Attachment

Nursing Diagnosis: Risk for Impaired Attachment related to anxiety associated with the parent role secondary to postpartum hemorrhage.

Desired Outcomes:

  • The patient will verbalize a feeling of happiness with the role as a parent.
  • The patient will take the duty for the physical and emotional well-being of the infant.
  • The patient will show proper behavior related to positive attachment to the infant.
  •  The patient will participate in mutually satisfying contact with the child.
 Postpartum Hemorrhage Nursing InterventionsRationale
1. Discuss with the patient her understanding of the situation and if they have any concerns.  The physical distance of the infant from the parents because of the critical circumstances of either the parent or the infant affect the anticipated parental role that will happen, and the incapability of the parents to protect the infant hold a vital role in the occurrence of the parent’s feeling of distress, lacking, guilt and insolvency.
2. Assess the attachment process, connecting behaviors, and parenting capacity of the patient once she assumes the care of her infant.  An assessment gives information on the mother’s physical, psychological, and physiological abilities. Having communication with the mothers and providing them with important details could boost their self-confidence among mothers.
3. Talk about the mother’s perception of infant care duties and parenting tasks.  To give details on how the patient looks these role changes that will help recognize areas of learning needs. Emotional and psychological support from the healthcare team is an influential factor to increase parents’ inner strength in connecting with their newborns.
4. Discuss the factors that accompany the separation of mother and infant caused by the postpartum hemorrhage.  Giving accurate information helps reduce anxiety levels and feelings of helplessness connected to the mother’s incapability to perform the responsibilities expected of her. Studies have shown that the main source of a mother’s stress during an infant’s hospital confinement is related to the interruption in the trend of attachment and feeling of insolvency in how to take care of the newborn and accomplish parental roles effectively.
5. Make available useful information about the use of community resources and follow-up health care recommendations including well-baby clinics and classes for good parenting.  Delivering instructive details to the parents lessens stress and supports positive information previously provided by the health team. It also encourages self-reliance and personality development. Giving support to the mothers to achieve and empower their self-confidence forms an opportunity to help them out in providing care to the infants and have interactions with them.
6. Encourage parents to get in touch with the infant, by showing photos or getting information from others who have seen the baby until the mother can see and take care of the infant.    This is to reassure the mother of the baby’s health condition and the rightful way how to take care of the infant. Giving emotional and informative support after the baby’s birth can help to destress the parents and enhance their capacity to take care of their infant and take the role of the parents wholeheartedly.
7. Encourage the mother to breastfeed her baby.  Oxytocin plays a major role in the mother after giving birth. It binds oxytocin receptors in the uterus to stimulate contractions and expel pregnancy products from it. Oxytocin also closes the spiral blood vessels in the placenta to stop bleeding. Oxytocin is also related to breastfeeding after giving birth. Another importance of oxytocin is its psychophysiological effects on the mother. It includes a sense of calm and linkage between the mother and baby during breastfeeding. Oxytocin also lowers anxiety levels, lower blood pressure, and has an antidepressant effect.
8. Include the parents in activities with the infant that they can complete.  Accomplishing infant care improves the parent’s self-concept and increases eagerness to involve themselves in the future infant’s care. Looking at their capacity to provide successful infant care intensifies their confidence in parenting abilities.

More Postpartum Hemorrhage Nursing Diagnosis

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. (2022). 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. (2020). 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.

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Nursing Stat Facts

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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