Postpartum Hemorrhage

Overview

Definition:
Postpartum Hemorrhage (PPH) is a serious complication that occurs after

childbirth, defined as a blood loss of over 1,000 mL accompanied by signs

of hypovolemia. It can occur in two phases:

• Primary PPH: Within the first 24 hours after delivery.
• Secondary PPH: From 24 hours to 12 weeks postpartum.

Causes:
The most common cause is uterine atony, where the uterus fails to contract effectively after the placenta is delivered. If not treated promptly, PPH can lead to shock or death, accounting for 25% of maternal deaths worldwide.

Key Components

Nursing Assessment

1. Review of Health History:

• Physical Assessment:
  • Vital Signs: Monitor for tachycardia and hypotension.
  • Genital Examination: Check for lacerations or hematomas.
  • Retained Placenta: Inspect for completeness within 30 minutes of delivery.
  • Uterine Tone: Assess for firmness; a soft uterus indicates atony.
• DIC Assessment: Watch for signs like widespread bleeding, bruising, hypotension, and confusion.
• Lochia Monitoring: Normal bleeding should be heavy but manageable; excessive bleeding requires intervention.

Nursing Interventions:

• Acute Pain Management: Address discomfort related to PPH.
• Anxiety Reduction: Provide emotional support and information to alleviate concerns.
• Fluid Volume Management: Monitor and replace fluids as needed to prevent hypovolemia.
• Patient Education: Teach about PPH signs, recovery monitoring, and follow-up care.
• Nutritional Support: Address any imbalances in nutrition due to PPH.

Diagnostic Procedures

1. Laboratory Tests:

• Complete Blood Count (CBC): Monitor hemoglobin, hematocrit, and platelets.
• Blood Typing and Screening: Prepare for potential blood transfusion.

1. Coagulation Studies:

• Initial tests may appear normal, but abnormalities can indicate conditions such as:
  • Abruptio placenta
  • HELLP syndrome
  • Fatty liver of pregnancy
  • Intrauterine fetal death
  • Embolic events
  • Septicemia
  • Disseminated Intravascular Coagulation (DIC)

1. Investigate Elevated INR and aPTT:

• If these values are high, consider testing:
  • Fibrinogen levels
  • Thrombin time
  • D-dimer
  • Blood film analysis

1. Ultrasound:

• Conduct a bedside ultrasound to detect clots or retained placental tissue.

Nursing Interventions

Nursing Care Plans

Nursing care plans help prioritize assessments and interventions to address both short-term and long-term goals in managing postpartum hemorrhage.

    Nursing Diagnosis 1:

  Related to:

• Tissue damage
• Hematoma
• Surgical interventions
• Uterine atony

   Expected Outcomes:

• Patient will identify and demonstrate appropriate interventions for pain relief.
• Patient will report relief from pain or discomfort.

Assessment:

1. Comprehensive Pain Assessment: Identify pain level, characteristics, location, and duration.
2. Perineal Trauma Assessment: Check for lacerations or hematomas that may cause discomfort.
3. Fundal Height Assessment: Monitor for signs of subinvolution, which may indicate delayed recovery.

Interventions:

1. Encourage Relaxation Techniques: Use deep breathing, meditation, or

distractions to reduce discomfort.

2. Administer Pain Medications: Provide pain relief for acute pain due to

 trauma or surgical interventions.

3. Use Cold Compress or Sitz Bath: Apply cold compresses to reduce hematoma formation; warm sitz baths can relieve episiotomy pain.
4. Prepare for Surgical Intervention: Be ready for necessary surgical procedures if pain indicates complications.

Nursing Diagnosis 2:

Related to:

• Traumatic delivery
• Threat of death

Expected Outcomes:

• Patient will report decreased anxiety and a feeling of control.
• Patient will implement two strategies to decrease anxiety.

Assessment:

1. Differentiate Symptoms: Identify physiological symptoms of anxiety versus those of PPH.
2. Assess Thoughts and Feelings: Encourage expression of thoughts to dispel misconceptions

and prevent panic.

Interventions:

1. Maintain Clear Communication: Provide reassurance and communicate interventions and

their outcomes.                                                                                          

2. Involve Support System: Include family and partners in care and education to support the patient.
3. Keep Mother and Baby Together: Facilitate bonding and reduce stress by keeping them together when possible.
4. Provide Therapy Resources: Offer information about counseling to cope with anxiety and prevent postpartum depression.

Nursing Diagnosis 3:
Related to:

• Blood loss after birth (hemorrhage)

  As Evidenced By:

• Changes in mental status
• Hypotension
• Tachycardia
• Decreased urine output
• Decreased hemoglobin levels

 Expected Outcomes:

• Patient will maintain blood pressure above 90/60 mm Hg.
• Patient will not exceed 1000 mL of blood loss following vaginal birth.
• Patient will maintain hemoglobin levels within normal limits.

Assessment:

1. Monitor Vital Signs and LOC: Observe for hypotension, tachycardia, confusion, and weakness.
2. Assess the Uterus: Check for a soft or “boggy” uterus indicating uterine atony.
3. Obtain Lab Work: Look for low hemoglobin and potential abnormalities in coagulation studies.
4. Monitor Lochia: Assess the amount and characteristics of vaginal bleeding.

 Interventions:

1. Massage Uterus: Encourage contractions to prevent further hemorrhage.
2. Administer Oxytocin: Given routinely to prevent or treat PPH.
3. Maintain Bed Rest: Promote safety and reduce the risk of dizziness and

falling; elevate legs to improve venous return.

1. Administer IV Fluids: Use normal saline to increase intravascular volume.
2. Administer Blood Products: Provide packed red blood cells and/or plasma as needed.
3. Prepare for Surgery: Be ready for surgical intervention if bleeding is due to lacerations or retained tissue.

Nursing Diagnosis 4:

  Related to:

• Lack of information provided
• Unfamiliarity with the situation

 Expected Outcomes:

• Patient will verbalize an understanding of the situation and treatments.
• Patient will recognize signs and symptoms of PPH that require follow-up.
• Patient will actively participate in their care plan.

Assessment:

1. Identify Risk Factors: Note risk factors for PPH such as placenta previa or prolonged labor.
2. Assess Patient’s Understanding: Review complications and signs to watch for at discharge.

Interventions:

1. Provide Discharge Education: Educate on what is normal postpartum and when

to seek help.

1. Encourage Immediate Breastfeeding: Promote early breastfeeding to stimulate

oxytocin and reduce bleeding.

1. Review Follow-Up Care: Discuss the importance of lab tests and monitoring

iron levels.

Nursing Diagnosis 5:

 Related to:

•  Blood loss
• Inadequate food intake
• Pain and nausea

Expected Outcomes:

• Patient will identify foods high in iron.
• Patient will demonstrate normal RBC count, hemoglobin, and iron levels.

Assessment:

1.  

   Postpartum Hemorrhage

   Overview

   Definition:
   Postpartum Hemorrhage (PPH) is a serious complication that occurs after

   childbirth, defined as a blood loss of over 1,000 mL accompanied by signs

   of hypovolemia. It can occur in two phases:

   • Primary PPH: Within the first 24 hours after delivery.
   • Secondary PPH: From 24 hours to 12 weeks postpartum.

   Causes:
   The most common cause is uterine atony, where the uterus fails to contract effectively after the placenta is delivered. If not treated promptly, PPH can lead to shock or death, accounting for 25% of maternal deaths worldwide.

   Key Components

   Section	Description
   Nursing Process	Nurses must recognize signs of PPH, educate patients on risks, and provide post-delivery care.
   Nursing Assessment	Gather physical, psychosocial, emotional, and diagnostic data regarding the patient’s condition.
   Health History	Assess for bleeding symptoms and review medical and obstetric history for risk factors.
   Physical Assessment	Monitor vital signs, examine the genitalia, check for retained placenta, assess uterine tone, and evaluate for DIC.
   Nursing Interventions	Implement strategies to manage pain, anxiety, fluid volume, knowledge deficits, and nutrition.

   Nursing Assessment

   1. Review of Health History:

   o   Symptoms of Acute Bleeding: §  Weakness §  Dizziness §  Cold feeling §  Restlessness §  Tachycardia §  Hypotension and §  Decreased urine output o   Medication Review: §  Look for anticoagulants, NSAIDs, and certain antidepressants that may increase bleeding risk.

   o   Risk Factors: §  Medical history: High blood pressure, preeclampsia, blood clotting disorders, obesity, etc. §  Obstetric history: Placental issues, multiple pregnancies, excessive amniotic fluid.

    

    

    

    

    

    

    

    

   
   
   • Physical Assessment:
     • Vital Signs: Monitor for tachycardia and hypotension.
     • Genital Examination: Check for lacerations or hematomas.
     • Retained Placenta: Inspect for completeness within 30 minutes of delivery.
     • Uterine Tone: Assess for firmness; a soft uterus indicates atony.
   • DIC Assessment: Watch for signs like widespread bleeding, bruising, hypotension, and confusion.
   • Lochia Monitoring: Normal bleeding should be heavy but manageable; excessive bleeding requires intervention.

    

   Nursing Interventions:

   • Acute Pain Management: Address discomfort related to PPH.
   • Anxiety Reduction: Provide emotional support and information to alleviate concerns.
   • Fluid Volume Management: Monitor and replace fluids as needed to prevent hypovolemia.
   • Patient Education: Teach about PPH signs, recovery monitoring, and follow-up care.
   • Nutritional Support: Address any imbalances in nutrition due to PPH.

   Diagnostic Procedures

    

   1. Laboratory Tests:
   • Complete Blood Count (CBC): Monitor hemoglobin, hematocrit, and platelets.
   • Blood Typing and Screening: Prepare for potential blood transfusion.
   1. Coagulation Studies:
   • Initial tests may appear normal, but abnormalities can indicate conditions such as:
     • Abruptio placenta
     • HELLP syndrome
     • Fatty liver of pregnancy
     • Intrauterine fetal death
     • Embolic events
     • Septicemia
     • Disseminated Intravascular Coagulation (DIC)
   1. Investigate Elevated INR and aPTT:
   • If these values are high, consider testing:
     • Fibrinogen levels
     • Thrombin time
     • D-dimer
     • Blood film analysis
   1. Ultrasound:
   • Conduct a bedside ultrasound to detect clots or retained placental tissue.

   Nursing Interventions

   Intervention	Description
   Manage the Bleeding
   Treat Causative Factors	Address the underlying cause of PPH while resuscitating the patient.
   Ensure Continuous Organ Perfusion	Maintain hemodynamic stability; ensure IV access and elevate legs for better venous return.
   Begin IV Fluids	Infuse large volumes of crystalloid solutions (e.g., normal saline, Lactated Ringer's).
   Initiate Blood Transfusions	Prioritize blood product administration, monitoring cumulative blood loss.
   Monitor Vital Signs and Urine Output	Keep track of blood pressure, pulse, oxygen saturation, and urine output for treatment response.
   Repair Trauma	Perform necessary surgical interventions like uterine exploration and laceration repair.
   Treat Uterine Atony	Options include bimanual massage, uterotonics (oxytocin, carboprost), and surgical management.
   Remove Retained Tissue	Manual removal or dilation and curettage may be needed for retained placental tissue.
   Prepare for Surgical Procedures	If recurrent bleeding occurs, consider arterial ligation or more invasive procedures if necessary.
   Prevent Further Bleeding
   Identify Bleeding Risk	Assess high-risk patients pre-delivery to inform delivery method decisions.
   Administer Iron Supplements	Provide iron for anemic patients, especially with hematocrit < 30%.
   Erythropoietin-Stimulating Agents	Offer as prescribed to high-risk patients who refuse transfusions.
   Collaborate with Healthcare Provider	Work together to make informed decisions during labor and delivery based on risk factors.
   Encourage Immediate Breastfeeding	Promote breastfeeding to stimulate oxytocin release, aiding uterine contraction and reducing bleeding.
   Educate on Signs of Secondary PPH	Inform patients to monitor for bleeding changes and symptoms like fever or dizziness post-delivery.

    

    

   Nursing Care Plans

   Nursing care plans help prioritize assessments and interventions to address both short-term and long-term goals in managing postpartum hemorrhage.

   Acute Pain

   As Evidenced By: ·        Reports of pain intensity ·        Diaphoresis ·        Guarding or protective behavior ·        Positioning to ease pain ·        Abdominal cramping or pelvic pain

       Nursing Diagnosis 1:
   
   

     Related to:

   • Tissue damage
   • Hematoma
   • Surgical interventions
   • Uterine atony

                                                                      

      Expected Outcomes:

   • Patient will identify and demonstrate appropriate interventions for pain relief.
   • Patient will report relief from pain or discomfort.

    

   Assessment:

   1. Comprehensive Pain Assessment: Identify pain level, characteristics, location, and duration.
   2. Perineal Trauma Assessment: Check for lacerations or hematomas that may cause discomfort.
   3. Fundal Height Assessment: Monitor for signs of subinvolution, which may indicate delayed recovery.

    

   Interventions:

   1. Encourage Relaxation Techniques: Use deep breathing, meditation, or

   distractions to reduce discomfort.

   2. Administer Pain Medications: Provide pain relief for acute pain due to

    trauma or surgical interventions.

   3. Use Cold Compress or Sitz Bath: Apply cold compresses to reduce hematoma formation; warm sitz baths can relieve episiotomy pain.
   4. Prepare for Surgical Intervention: Be ready for necessary surgical procedures if pain indicates complications.

   Anxiety

   As Evidenced By: Expressions of fear or impending doom Awareness of physiological symptoms (e.g., tachypnea, tachycardia) Feelings of helplessness Restlessness and distress

   Nursing Diagnosis 2:
   
   

   Related to:

   • Traumatic delivery
   • Threat of death

    

    

   Expected Outcomes:

   • Patient will report decreased anxiety and a feeling of control.
   • Patient will implement two strategies to decrease anxiety.

    

   Assessment:

   1. Differentiate Symptoms: Identify physiological symptoms of anxiety versus those of PPH.
   2. Assess Thoughts and Feelings: Encourage expression of thoughts to dispel misconceptions

   and prevent panic.

    

   Interventions:

   1. Maintain Clear Communication: Provide reassurance and communicate interventions and

   their outcomes.                                                                                          

   2. Involve Support System: Include family and partners in care and education to support the patient.
   3. Keep Mother and Baby Together: Facilitate bonding and reduce stress by keeping them together when possible.
   4. Provide Therapy Resources: Offer information about counseling to cope with anxiety and prevent postpartum depression.

    

   Deficient Fluid Volume

   Nursing Diagnosis 3:
   Related to:

   • Blood loss after birth (hemorrhage)

     As Evidenced By:

   • Changes in mental status
   • Hypotension
   • Tachycardia
   • Decreased urine output
   • Decreased hemoglobin levels

    Expected Outcomes:

   • Patient will maintain blood pressure above 90/60 mm Hg.
   • Patient will not exceed 1000 mL of blood loss following vaginal birth.
   • Patient will maintain hemoglobin levels within normal limits.

    

   Assessment:

   1. Monitor Vital Signs and LOC: Observe for hypotension, tachycardia, confusion, and weakness.
   2. Assess the Uterus: Check for a soft or “boggy” uterus indicating uterine atony.
   3. Obtain Lab Work: Look for low hemoglobin and potential abnormalities in coagulation studies.
   4. Monitor Lochia: Assess the amount and characteristics of vaginal bleeding.

    

    Interventions:

   1. Massage Uterus: Encourage contractions to prevent further hemorrhage.
   2. Administer Oxytocin: Given routinely to prevent or treat PPH.
   3. Maintain Bed Rest: Promote safety and reduce the risk of dizziness and

   falling; elevate legs to improve venous return.

   1. Administer IV Fluids: Use normal saline to increase intravascular volume.
   2. Administer Blood Products: Provide packed red blood cells and/or plasma as needed.
   3. Prepare for Surgery: Be ready for surgical intervention if bleeding is due to lacerations or retained tissue.

    

   Deficient Knowledge

   As Evidenced By: Exaggerated behaviors Information-seeking Statements reflecting misinformation Development of PPH

   Nursing Diagnosis 4:
   
   

     Related to:

   • Lack of information provided
   • Unfamiliarity with the situation

    

    

   
   

    Expected Outcomes:

   • Patient will verbalize an understanding of the situation and treatments.
   • Patient will recognize signs and symptoms of PPH that require follow-up.
   • Patient will actively participate in their care plan.

    

   Assessment:

   1. Identify Risk Factors: Note risk factors for PPH such as placenta previa or prolonged labor.
   2. Assess Patient’s Understanding: Review complications and signs to watch for at discharge.

    

    

   Interventions:

   1. Provide Discharge Education: Educate on what is normal postpartum and when

   to seek help.

   1. Encourage Immediate Breastfeeding: Promote early breastfeeding to stimulate

   oxytocin and reduce bleeding.

   1. Review Follow-Up Care: Discuss the importance of lab tests and monitoring

   iron levels.

    

    

    

   As Evidenced By: Hypoglycemia Delayed wound healing Fatigue Altered lab values

   Imbalanced Nutrition: Less Than Body Requirements

   Nursing Diagnosis 5:
   
   

    Related to:

   •  Blood loss
   • Inadequate food intake
   • Pain and nausea

    

    

   Expected Outcomes:

   • Patient will identify foods high in iron.
   • Patient will demonstrate normal RBC count, hemoglobin, and iron levels.

    

   Assessment:

   1. Assess Laboratory Values: Check CBC for signs of anemia and iron loss.
   2. Assess Fluid Status: Monitor for dehydration and fluid balance.
   3. Assess for Signs of Anemia: Identify symptoms like fatigue and pallor.
   4. Assess Appetite: Note any barriers to adequate food intake.

    

    

   Interventions:

   1. Encourage Adequate Fluid Intake: Promote hydration to restore fluid balance.
   2. Instruct on Sources of Iron in Food: Educate on foods rich in iron, such as lean

   meats and beans.

   1. Educate on Iron Supplements: Provide guidelines for optimal use and absorption.
   2. Refer to a Dietitian: Collaborate with a dietitian for tailored nutritional planning.
   Assess Laboratory Values: Check CBC for signs of anemia and iron loss.
2. Assess Fluid Status: Monitor for dehydration and fluid balance.
3. Assess for Signs of Anemia: Identify symptoms like fatigue and pallor.
4. Assess Appetite: Note any barriers to adequate food intake.

Interventions:

1. Encourage Adequate Fluid Intake: Promote hydration to restore fluid balance.
2. Instruct on Sources of Iron in Food: Educate on foods rich in iron, such as lean

meats and beans.

1. Educate on Iron Supplements: Provide guidelines for optimal use and absorption.
2. Refer to a Dietitian: Collaborate with a dietitian for tailored nutritional planning.