Vaginal bleeding during pregnancy is always a deviation from the normal, is always potentially serious, may occur at any point during pregnancy, and is always frightening. Approximately 25% of pregnant women experience bleeding before 12 weeks’ gestation (Hendricks et al., 2019). Several bleeding disorders can complicate early pregnancy, including spontaneous abortion, ectopic pregnancy, and hydatidiform mole. Maternal blood loss decreases the oxygen-carrying capacity of the blood, resulting in fetal hypoxia, and places the fetus at risk.
A client with any degree of bleeding needs to be evaluated for the possibility that she is experiencing a significant blood loss or is developing hypovolemic shock. Because the uterus is a non-essential body organ, danger to the fetal blood supply occurs when the client’s body begins to decrease blood flow to peripheral organs. Signs of hypovolemic shock occur when 10% of blood volume, approximately 2 units of blood, have been lost; fetal distress occurs when 25% of blood volume is lost.
The primary causes of bleeding during the first and second trimester of pregnancy include threatened spontaneous miscarriage, imminent miscarriage, missed miscarriage, incomplete spontaneous miscarriage, complete spontaneous miscarriage, ectopic pregnancy, hydatidiform mole, and premature cervical dilatation. Causes of bleeding during the third trimester of pregnancy include placenta previa, abruptio placentae, and preterm labor.
Bleeding during pregnancy happens due to certain physiological problems in the early or late stages of pregnancy, each with its own signs and symptoms, which aids in determining a differential diagnosis and in formulating a care plan. This nursing care plan focuses on managing hemorrhages during the pregnancy period. Specific interventions are identified to address each physiological problem as indicated.
Nurse care planning for a client with pregnancy includes assessing maternal/fetal condition, maintaining circulatory fluid volume, assisting with efforts to nurture the pregnancy, if possible, avoiding complications, providing emotional support to the client/couple, and providing knowledge on short- and long-term complications of the hemorrhage.
Here are 9 nursing care plans and nursing diagnoses for bleeding during pregnancy (prenatal hemorrhage):
- Risk for Bleeding
- Acute Pain
- Deficient Fluid Volume
- Deficient Knowledge
- Risk for Imbalanced Fluid Volume
- Risk of Injury
- Anticipatory Grieving
- Risk for Ineffective Tissue Perfusion
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).
May be related to
- Incomplete abortion
- Ectopic pregnancy
- Premature cervical dilatation
Possibly evidenced by
- 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.
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans related to the care of the pregnant mother and her baby:
- Abortion (Termination of Pregnancy) | 8 Care Plans
- Cervical Insufficiency (Premature Dilation of the Cervix) | 4 Care Plans
- Cesarean Birth | 11 Care Plans
- Cleft Palate and Cleft Lip | 7 Care Plans
- Gestational Diabetes Mellitus | 8 Care Plans
- Hyperbilirubinemia (Jaundice) | 4 Care Plans
- Labor Stages, Induced, Augmented, Dysfunctional, Precipitous Labor | 45 Care Plans
- Neonatal Sepsis | 8 Care Plans
- Perinatal Loss (Miscarriage, Stillbirth) | 6 Care Plans
- Placental Abruption | 4 Care Plans
- Placenta Previa | 4 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 5 Care Plans
- Prenatal Hemorrhage (Bleeding in Pregnancy) | 9 Care Plans
- Preeclampsia and Gestational Hypertension | 6 Care Plans
- Prenatal Infection | 5 Care Plans
- Preterm Labor | 7 Care Plans
- Puerperal & Postpartum Infections | 5 Care Plans
- Substance Abuse in Pregnancy | 9 Care Plans
References and Sources
Recommended journals, books, and other interesting materials to help you learn more about bleeding in pregnancy nursing care plans and nursing diagnosis:
- Baird, S., Gagnon, M. D., deFiebre, G., Briglia, E., Crowder, R., & Prine, L. (2018, June). Women’s experiences with early pregnancy loss in the emergency room: A qualitative study. Sexual & Reproductive Healthcare, 16, 113-117.
- Belousov, A. (2018). Hematocrit, As Part of an Integrated Condition Assessment System of the Body. ARC Journal of Anesthesiology, 3(1), 15-17.
- Bosboom, J. J., Klanderman, R. B., Zijp, M., Hollman, M. W., Veelo, D. P., Binnekade, J. M., Geerts, B. F., & Vlaar, A. P.J. (2017, December 13). Incidence, risk factors, and outcome of transfusion-associated circulatory overload in a mixed intensive care unit population: a nested case-control study. Transfusion, 58(2), 498-506.
- Cassaday, T. M. (2018, September 1). Impact of Pregnancy Loss on Psychological Functioning and Grief Outcomes. Obstetrics & Gynecological Clinics, 45(3), 525-533.
- Colucci, W. S. (2022, January 3). Treatment of acute decompensated heart failure: Specific therapies. UpToDate.
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
- Edelman, A., & Kapp, N. (2018). Dilatation & Evacuation (D&E) Reference Guide: Induced abortion and postabortion care at or after 13 weeks gestation (‘second trimester’).
- Fung, F. K. (2021, August 11). Kleihauer Betke Test – StatPearls. NCBI. Retrieved April 19, 2022.
- Hendricks, E., MacNaughton, H., & Mackenzie, M. C. (2019, February 1). First Trimester Bleeding: Evaluation and Management. American Family Physician, 99(3), 166-174.
- Jose, M., Amir, S., & Desai, R. (2019, December 4). Chronic Sheehan’s Syndrome – A Differential to be Considered in Clinical Practice in Women with a History of Postpartum Hemorrhage. Cureus, 11(12).
- Knez, J., Day, A., & Jurkovic, D. (2014, July). Ultrasound imaging in the management of bleeding and pain in early pregnancy. Best Practice & Research Clinical Obstetrics and Gynaecology, 28(5), 621-636.
- Lefkou, E., & Hunt, B. J. (2018, July). Bleeding disorders in pregnancy. Obstetrics, Gynaecology and Reproductive Medicine, 28(7), 189-195.
- Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
- Lothian, J. A. (2004, Summer). Do Not Disturb: The Importance of Privacy in Labor. The Journal of Perinatal Education, 13(3).
- Nehring, S. M., Tadi, P., & Tenny, S. (2021, September 29). Cerebral Edema – StatPearls. NCBI. Retrieved April 27, 2022.
- Pillitteri, A., & Silbert-Flagg, J. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
- Santoso, J. T., Saunders, B. A., & Grosshart, K. (2005, December). Massive Blood Loss and Transfusion in Obstetrics and Gynecology. Obstetrics & Gynecological Survey, 60(12), 827-837.
- Sarode, R. (2022, February). Complications of Transfusion – Hematology and Oncology – MSD Manual Professional Edition. MSD Manuals. Retrieved April 27, 2022.
- Sperling, R. (Ed.). (2020). Obstetrics and Gynecology. John Wiley & Sons, Incorporated.
- Tanaka, M., Matsuzaki, S., Endo, M., Kakigano, A., Mimura, K., Takiuchi, T., Miyake, T., Tomimatsu, T., Ueda, Y., & Kimura, T. (2018, June 29). Obstetric outcomes and acceptance of alternative therapies to blood transfusion by Jehovah’s Witnesses in Japan: a single-center study. International Journal of Hematology, 108, 432-437.
- Tobian, A. (2022, January 7). Transfusion-Associated circulatory Overload (TACO). UpToDate. Retrieved April 27, 2022.
Reviewed and updated by M. Belleza, R.N.