9 Bleeding in Pregnancy (Prenatal Hemorrhage) Nursing Care Plans

Risk for Bleeding

Within the circulatory system, blood must flow normally and yet if vessels are damaged it must form a clot quickly to restrict excessive bleeding. Due to the competing demands of flow and hemostasis, the coagulation system is necessarily complex. Pregnancy results in increased levels of fibrinogen and bleeding factors. An altered fibrinolytic state is part of a normal physiological response to pregnancy due to increased fibrinolytic inhibitors and tissue plasminogen activators (Lefkou & Hunt, 2018).

Nursing Diagnosis

• Risk for Bleeding

May be related to

• Incomplete abortion
• Ectopic pregnancy
• Premature cervical dilatation

Possibly evidenced by

• Changes in fetal heart rate/activity
• Vaginal spotting
• Uterine cramping

Desired Outcomes

• The client will display normal vital signs and stable fetal heart rates.
• The client will have reduced or absence of vaginal spotting or bleeding.
• The client will exhibit self-precaution to avoid the recurrence of bleeding.

Nursing Assessment and Rationales

1. Assess the client’s reproductive history.
A review of the menstrual history and prior ultrasonography if applicable can help establish gestational dating and determine whether the pregnancy location is known (Hendricks et al., 2019).

2. Assess maternal vital signs.
Assess the client’s pulse, respiration, and blood pressure every 15 minutes and apply a pulse oximeter and automatic blood pressure cuff as necessary. This provides baseline data on maternal response to blood loss. With significant blood loss, the pulse rate and respiratory rate will start to increase as the heart attempts to compensate for the decreased circulatory volume and the respiratory system increases gas exchange to better oxygenate the RBCs.

3. Auscultate and report FHR; note bradycardia or tachycardia. Note change in hypoactivity or hyperactivity.
The initial response of a fetus to decreased oxygenation is tachycardia and increased movements. A further deficit will result in bradycardia and decreased activity. In placenta previa, the fetus or neonate may have anemia or hypovolemic shock because some of the blood loss may be fetal blood. Fetal hypoxia may occur if a large disruption of the placental surface reduces the transfer of oxygen and nutrients.

4. Note expected date of birth (EDB) and fundal height.
This provides an estimate for identifying fetal viability. When a threatened abortion occurs, efforts are made to keep the fetus in utero until the age of viability. Termination of pregnancy after 20 weeks of gestation (age of viability) is called preterm labor. Abortion is the spontaneous or intentional termination of pregnancy before the age of viability.

5. Monitor and record maternal blood loss and uterine contractions.
Excess maternal blood loss compromises placental perfusion. If uterine contractions are accompanied by cervical dilatation, bed rest and medications may not be effective in maintaining the pregnancy. The nurse documents the amount and character of bleeding and saves anything that looks like clots or tissue for evaluation by a pathologist. A pad count and an estimate of how saturated each is documented blood loss most accurately.

6. Assess for signs of hypovolemia.
The client should be assessed for signs and symptoms of hypovolemia. The increased blood volume of pregnancy allows more than normal blood loss before hypovolemic shock processes begin. Because “normal” blood pressure varies from client to client, it is important to know the baseline blood pressure of a pregnant woman when evaluating for hypovolemic shock. Signs and symptoms include tachycardia, tachypnea, hypotension, cold clammy skin, decreased urine output, dizziness, and decreased central venous pressure.

Nursing Intervention and Rationales

1. Place the client in a lateral position.
The lateral position relieves pressure on the inferior vena cava and enhances placental circulation and oxygen exchange. Urge the client to rest in a left side-lying position to help prevent vena cava compression. If this is not possible, position her on her back, with a wedge under one hip to minimize uterine pressure on the vena cava and prevent blood from being trapped in the lower extremities (supine hypotension syndrome).

2. Schedule the client’s periods of rest and activities.
The client may avoid strenuous activities for 24 to 48 hours to prevent a threatened abortion, assuming the threatened miscarriage involves a live fetus and presumed placental bleeding. Complete bed rest is usually not necessary as this may appear to stop the vaginal bleeding but only because blood pools vaginally. When the client does ambulate again, the vaginal blood collection will drain and bleeding will reappear.

3. Avoid vaginal examinations.
Omitting vaginal examinations prevent tearing of the placenta if placenta previa is the cause of the bleeding.

4. Obtain vaginal specimen for alkali denaturation test (APT test), or use Kleihauer-Betke test to determine maternal serum, vaginal blood, or products of gastric lavage.
When vaginal bleeding is present these tests differentiate maternal from fetal blood in amniotic fluid, provide a rough quantitative estimate of fetal blood loss, and indicate implications for fetal oxygen-carrying capacity, and maternal need for Rh immunoglobulin G (RhIgG) injections, once delivery occurs. The Kleihauer-Betke test is more sensitive and quantitatively accurate than the APT test, but is time-consuming and may be impractical if the specimen is sent to an outside laboratory (Fung, 2021).

5. Carry out/repeat NST, as indicated.
Electronically evaluating the FHR response to fetal movements is useful in determining fetal well-being (reactive test) versus hypoxia (nonreactive). Additionally, this assesses whether labor and fetal status are still present. An external system avoids additional cervical trauma.

6. Assist with ultrasonography and amniocentesis. Explain procedures.
Ultrasound is used to determine if the fetus is living and supplies information about placental and fetal well-being. Using an amniocentesis technique, an analysis of the lecithin/sphingomyelin (L/S) ratio in surfactant is a primary test of fetal maturity.

7. Prepare client for appropriate procedures as indicated.
Cerclage, or suturing an incompetent cervix that opens when the growing fetus presses against it, is successful in most cases of threatened abortion.