Postpartum hemorrhage is defined as any blood loss from the uterus of more than 500ml during or after delivery. It may occur either early (within the first 24 hours after delivery), or late (anytime after the 24 hours during the remaining days of the six-week puerperium).
Nursing Care Plans
The primary role of the nurses is to assess and intervene early or during a hemorrhage to help the patient regain her strength and to prevent complications. Data such as the amount of bleeding, the condition of the uterus, checking of the maternal vital signs and observing for signs of shock would play a vital role in the care of the patient with hemorrhage.
- Deficient Fluid Volume
- Risk for Excess Fluid Volume
- Ineffective Tissue Perfusion
- Risk For Infection
- Risk For Pain
- Risk for Altered Parent-Infant Attachment
- Deficient Knowledge
Deficient Fluid Volume (isotonic)
Deficient Fluid Volume: It is defined as decreased intravascular, interstitial, and intracellular fluid.
May be related to
- Excessive blood loss after birth.
Possibly evidenced by
- Changes in the mental status.
- Concentrated urine.
- Delayed capillary refill.
- Decrease in the red blood cell count (hematocrit).
- Decrease blood pressure (hypotension).
- Dry skin/mucous membrane.
- Increase heart rate (tachycardia).
- Patient will maintain a blood pressure of at least 100/60 mm Hg.
- Patient will maintain a pulse rate between 70-90 beats per minute.
- Patient will have a balanced 24-hour intake and output.
- Patient will have a cognitive status within expected range.
- Patient will have a lochia flow of less than one saturated perineal pad per hour.
- Patient will demonstrate improvement in the fluid balance as evidenced by a good capillary refill, adequate urine output, and skin turgor.
|Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and if possible save blood clots to be evaluated by the physician.||The amount of blood loss and the presence of blood clots will help to determine the appropriate replacement need of the patient.|
|Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis.||The degree of the contractility of the uterus will measure the status of the blood loss. Placing one hand just above the symphysis pubis will prevent possible uterine inversion during a massage.|
|Review the records and note certain conditions such as retained placental fragments, any laceration, abruptio placenta, etc.||This will help in determining the management of the situation thus preventing further complications.|
|Monitor vital signs including systolic and diastolic blood pressure, pulse and heart rate. Check for the capillary refill and observe nail beds and mucous membranes.||Increased heart rate, low blood pressure, cyanosis, delayed capillary refill indicates hypovolemia and impending shock. Decrease fluid volume of 30-50% will reflect changes in the blood pressure.|
|Note for the presence of vulvar hematoma and apply an ice pack if indicated.||Small hematoma can be managed by an ice pack and rest.|
|Measure a 24-hour intake and output. Observe for signs of voiding difficulty.||This will help in determining the fluid loss.A urine output of 30-50 ml/hr or more indicates an adequate circulating volume. Voiding difficulty may happen with hematomas in the upper portion of the vagina causing pressure in the urethra.|
|Observe for reports of persistent perineal pain or feeling of vaginal fullness. Apply counterpressure on labial or perineal lacerations.||Hematomas often result from continued bleeding from laceration of the birth canal.|
|Use caution when performing vaginal and rectal examinations.||May increase hemorrhage if cervical, vaginal, or perineal lacerations or hematomas are present. Note: Careful examination may be required to monitor status of the hematoma.|
|Monitor clients with placenta accreta (condition that occurs when blood vessels and other parts of the placenta grow too deeply into the uterine wall.), PIH or abruptio placenta for signs of Disseminated intravascular coagulation (DIC).||Thromboplastin released during attempts at manual removal of the placenta may result in coagulopathy as manifested by continued vaginal bleeding; epistaxis; oozing from incisions, mucous membranes, gums, IV site.|
|Measure hemodynamic parameters include central venous pressure (CVP) or pulmonary artery wedge pressure (PAWP) if available.||This will provide direct measurement of circulating volume, replacement needs, and response to therapy in case of a life-threatening situations.|
|Maintain a nothing-by-mouth status (NPO) while assessing client status.||This will prevent aspiration of gastric contents in case that the mental status is impaired and also if a surgical management is required.|
|Maintain a bed rest with an elevation of the legs by 20-30° and trunk horizontal.||The position increases venous return, making sure a greater availability of blood to the brain and other vital organs. Bleeding may be decreased with the bed rest.|
|Start 1 or 2 IV infusion(s) of isotonic or electrolyte fluids with an 18-gauge catheter or via a central venous line. Administer fresh whole blood or other blood products (e.g., platelet concentrate, plasma, cryoprecipitate) as indicated||This is important for rapid or multiple infusions of fluids or blood products to increase circulating volume and enhance clotting. Note: Each unit of whole blood increases the hematocrit level by three percentage points.|
|Administer medications as ordered:|
|Increases contractility of the boggy uterus and myometrium, closes off exposed venous sinuses, and stops hemorrhage in the presence of atony.|
|Antibiotics act as prophylaxis to prevent infection or may be needed for an infection that caused or contributed to uterine subinvolution or hemorrhage.|
|Insertion of indwelling Foley catheter (IFC).||This will provide an accurate measurement of the renal status and perfusion with regards to fluid volume. Note: Pressure on the urethra may obstruct urine flow/cause bladder distention if vaginal packs are inserted.|
|Insertion of a large indwelling catheter into the cervical canal.||Insertion of an indwelling catheter into the cervical canal and injecting the balloon with 60 ml of a saline solution that acts as a tamponade have some reports of success in limiting the hemorrhage caused by implantation of the placenta into a noncontractile cervical segment.|
|Monitor laboratory values as indicated such as:|
|Measures severity of Disseminated intravascular coagulation (DIC); determines replacement needs and effects of therapy.|
|Prepare for surgical intervention if indicated; e.g., evacuation of hematoma and ligation of a bleeding point, laceration or episiotomy extension, D & C, abdominal hysterectomy or bilateral ligation of hypogastric artery.||Surgical repair of lacerations/episiotomy, evacuation of hematoma and removal of retained tissues will stop the bleeding;|
Immediate abdominal hysterectomy is indicated for the abnormally adherent placenta.
Note: D & C may not be indicated if there is a concern that the procedure may traumatize the implantation site and increase bleeding.
|Assist with procedures as indicated such as manual separation and removal of placenta.||Hemorrhage stops once placental fragments are removed and uterus contracts, closing venous sinuses.|
|Uterine replacement or packing if inversion seems about to recur.||Replacement of the uterus allows it to contract, closing venous sinuses and controlling the bleeding.|
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Maternal and Newborn Care Plans
Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:
- Abruptio Placenta| 3 Care Plan
- Cesarean Birth | 10 Care Plans
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Elective Termination | 6 Care Plans
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperbilirubinemia | 4 Care Plans
- Labor Stages, Induced and Augmented Labor | 36 Care Plans
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 4 Care Plans
- Prenatal Hemorrhage | 7 Care Plans
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Pregnancy Induced Hypertension | 6 Care Plans
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 6 Care Plans
- Puerperal Infection | 4 Care Plans
Recommended books and resources:
- Nursing Care Plans: Diagnoses, Interventions, and Outcomes
- Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
- Nursing Diagnoses 2015-17: Definitions and Classification
- Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
- Manual of Psychiatric Nursing Care Planning
- Maternal Newborn Nursing Care Plans
- Delmar's Maternal-Infant Nursing Care Plans, 2nd Edition
- Maternal Newborn Nursing Care Plans