Postpartum Hemorrhage Nursing Diagnosis and Nursing Care Plan

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

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 2 nd week to the 6 th 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:

• 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

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.

Nursing Care Plan for Postpartum Hemorrhage 3

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.

• 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.

Nursing Care Plan for Postpartum Hemorrhage 4

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

• 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.

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.

• 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.

More Postpartum Hemorrhage Nursing Diagnosis

• Risk for Shock (Hypovolemic)
• Fatigue
• Risk for Injury
• Anxiety
• Ineffective Coping

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.

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.

Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.