Nursing Diagnosis Care Plan Postpartum Hemorrhage: Comprehensive Guide for Nurses

Postpartum Hemorrhage (PPH) stands as a critical obstetric emergency, affecting 1-5% of mothers globally. Defined by the American College of Obstetricians and Gynecologists (ACOG) as blood loss exceeding 1,000 mL accompanied by hypovolemic signs, PPH poses a significant threat in the postpartum period. Primary PPH occurs within the first 24 hours following delivery, while secondary PPH can manifest from 24 hours up to 12 weeks postpartum.

Uterine atony, the failure of the uterus to contract adequately after placental delivery, is the leading cause of PPH, resulting in excessive blood loss. Without prompt recognition and intervention, PPH can rapidly escalate to maternal shock and even death. Globally, PPH is responsible for approximately 25% of all maternal deaths, underscoring the urgency and importance of effective nursing care.

In this article, we will delve into a comprehensive nursing approach to postpartum hemorrhage, focusing on nursing assessment, interventions, and crucially, the Nursing Diagnosis Care Plan Postpartum Hemorrhage. This guide aims to equip nurses with the knowledge and strategies to effectively manage and mitigate the risks associated with PPH.

Nursing Process in Postpartum Hemorrhage

Nurses in labor and delivery and postpartum units are at the forefront of identifying and responding to postpartum hemorrhage. Their expertise in recognizing the signs and symptoms, coupled with swift action, is vital. Furthermore, educating patients about their individual risk factors and empowering them with self-monitoring techniques for home recovery and follow-up care is a cornerstone of preventative nursing practice.

Nursing Assessment for Postpartum Hemorrhage

The nursing assessment is the initial and crucial phase of care. It involves a systematic gathering of physical, psychosocial, emotional, and diagnostic data. This section outlines both subjective and objective data pertinent to postpartum hemorrhage.

Review of Health History

1. Identify Acute Postpartum Bleeding Symptoms: Recognizing the early signs of PPH is paramount. Symptoms may include:

• General: Generalized weakness, lightheadedness upon standing, chills, and restlessness.
• Central Nervous System (CNS): Dizziness and potential loss of consciousness.
• Cardiovascular: Palpitations, tachycardia (rapid heart rate), and hypotension (low blood pressure).
• Respiratory: Tachypnea (rapid breathing).
• Integumentary: Diaphoresis (excessive sweating) and pallor (pale skin).
• Genitourinary: Decreased or absent urine output, reflecting reduced organ perfusion.

2. Detailed Medical History Review: A thorough review of the patient’s medical history is essential to identify pre-existing risk factors for PPH. These include:

• Pre-existing hypertension.
• Preeclampsia and eclampsia.
• Presence of infection.
• Blood clotting disorders such as Disseminated Intravascular Coagulation (DIC).
• General bleeding disorders.
• Anemia.
• Obesity.
• Advanced maternal age.

3. Obstetric History Assessment: Specific conditions in the obstetric history can significantly elevate PPH risk:

• Placental anomalies:
  • Placenta accreta (placenta abnormally attached to the uterine wall).
  • Placenta previa (placenta covering the cervix).
  • Placental abruption (premature separation of the placenta).
• Retained placental tissue.
• Multiparity (five or more pregnancies).
• Multiple gestations (twins, triplets, etc.).
• Fetal macrosomia (infant weighing over 9 pounds).
• Polyhydramnios (excessive amniotic fluid).

4. Medication Review: Certain medications can increase the risk of bleeding. A careful review of the patient’s medication list should include:

• Anticoagulants: heparin and aspirin.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): diclofenac and ibuprofen.
• Oral corticosteroids: dexamethasone and prednisone.
• Selective serotonin reuptake inhibitors (SSRIs): citalopram and fluoxetine.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs): desvenlafaxine and duloxetine.

Physical Assessment

1. Monitor Vital Signs and Vaginal Blood Loss: Close monitoring of maternal vital signs is crucial. Tachycardia and hypotension are key indicators of significant blood loss in postpartum women. Trends in heart rate and blood pressure are more telling than single measurements, especially in response to blood volume loss exceeding 25%.

2. Genitalia Examination: A thorough examination of the genitalia is necessary to identify potential sources of bleeding such as lacerations, hematomas, or uterine rupture. For vaginal deliveries, inspect and palpate the cervix and vagina meticulously.

3. Placental Tissue Assessment: Ensure complete expulsion of the placenta, typically within 30 minutes of delivery. Inspect the placenta for intactness and missing fragments. Retained placental tissue can lead to infection, foul-smelling discharge, bleeding, and pain.

4. Uterine Tone and Size Palpation: Assess uterine tone by palpation. Uterine atony, characterized by a soft, “boggy,” or non-contracted uterus, is the most frequent cause of PPH. Atony prevents the uterus from effectively clamping down blood vessels at the placental site.

5. Disseminated Intravascular Coagulation (DIC) Assessment: Be alert to signs of DIC, a severe complication involving widespread clotting factor disruption leading to bleeding from multiple sites (nose, gums, IV sites), bruising, hypotension, dyspnea (shortness of breath), and confusion.

6. Lochia Observation: Postpartum vaginal bleeding (lochia) is expected. Initially, lochia rubra is red and may resemble a heavy menstrual flow. Saturation of more than one pad per hour or the passage of large clots requires immediate intervention.

Diagnostic Procedures

1. Laboratory Tests: Essential laboratory tests include:

• Complete Blood Count (CBC): To monitor hemoglobin, hematocrit, and platelet levels, providing insights into blood loss severity.
• Blood Typing and Screening: Preparedness for potential blood transfusion is crucial.

2. Coagulation Studies: Initial coagulation tests may be normal, but abnormalities can arise in conditions associated with PPH risk, such as:

• Placental abruption.
• HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count).
• Acute fatty liver of pregnancy.
• Intrauterine fetal death.
• Embolic events.
• Septicemia.
• DIC.

3. Elevated INR and aPTT Investigation: If International Normalized Ratio (INR) and activated Partial Thromboplastin Time (aPTT) are elevated, further investigations are warranted:

• Fibrinogen levels.
• Thrombin time measurement.
• D-dimer levels.
• Blood film analysis.

4. Ultrasound Assistance: Bedside ultrasound can be invaluable in identifying retained clots or placental tissue within the uterus.

Nursing Interventions for Postpartum Hemorrhage

Nursing interventions are critical in managing postpartum hemorrhage and facilitating patient recovery. The following section details essential nursing interventions.

Managing Active Bleeding

1. Address Causative Factors: The primary goal of PPH management is to resuscitate the patient while simultaneously identifying and treating the underlying cause.

2. Maintain Organ Perfusion: Hemodynamic stability is paramount to ensure continuous perfusion of vital organs. Establish and maintain patent large-bore intravenous (IV) access. Elevate the patient’s legs to enhance venous return. Administer supplemental oxygen as indicated.

3. Initiate IV Fluid Resuscitation: Infuse large volumes of crystalloid solutions such as normal saline or Lactated Ringer’s to restore intravascular volume.

4. Blood Transfusion Initiation: Early administration of blood products is critical and should be prioritized, alongside meticulous monitoring of cumulative blood loss. Fresh frozen plasma or platelet transfusions may be necessary to correct coagulation abnormalities.

5. Vital Signs and Urine Output Monitoring: Continuously monitor blood pressure, pulse, oxygen saturation, and urine output to assess perfusion status and treatment response.

6. Trauma Repair Assistance: Immediate surgical interventions may include:

• Uterine exploration for rupture.
• Laceration repair.
• Correction of uterine inversion.

7. Uterine Atony Treatment: Treatment strategies for PPH due to uterine atony range from bimanual massage and uterotonic medications (oxytocin, intramuscular carboprost) to uterine tamponade, pelvic artery embolization, and surgical management.

8. Retained Tissue Removal: Manual removal or dilation and curettage (D&C) may be necessary to remove retained placental tissue.

9. Surgical Procedure Preparation: In cases of persistent bleeding in a stable patient, ligation of bleeding arteries may be required. Fluoroscopy can guide the location and sealing of bleeding vessels. Uterine rupture may necessitate laparotomy or hysterectomy if repair is not feasible.

Preventing Recurrent Bleeding

1. Bleeding Risk Identification: Proactive identification of high-risk patients before delivery is crucial for preventing PPH-related morbidity and mortality. Ultrasound evaluation prior to delivery aids in determining the most appropriate delivery method.

2. Iron Supplementation: Anemic patients should receive iron supplements, either oral or parenteral, particularly if hematocrit is below 30%.

3. Erythropoietin-Stimulating Agents: For high-risk patients, especially those declining blood transfusions, erythropoietin-stimulating agents may be administered following hematological consultation.

4. Healthcare Provider Collaboration: Collaborative decision-making with healthcare providers during labor and delivery is essential. Factors that increase bleeding risk, such as:

• Cesarean section delivery.
• General anesthesia.
• Prolonged labor.
• Intrapartum infection.
• History of PPH in prior deliveries.

5. Early Breastfeeding Promotion: Encourage immediate breastfeeding post-delivery. Breastfeeding triggers natural oxytocin release, promoting uterine contraction and bleeding control.

6. Secondary PPH Education: Educate patients about the possibility of secondary PPH, which can occur up to six weeks postpartum. Instruct them to monitor for and immediately report signs such as changes in lochia, severe abdominal cramping, fever, or dizziness. Treatment principles remain similar to primary PPH.

Nursing Care Plans for Postpartum Hemorrhage

Once nursing diagnoses are identified for postpartum hemorrhage, nursing care plans become instrumental in prioritizing assessments and interventions, guiding both short-term and long-term care goals. Here are examples of nursing diagnosis care plan postpartum hemorrhage.

Acute Pain Nursing Care Plan

Acute pain is a common concern in PPH, particularly if associated with perineal trauma or lacerations.

Nursing Diagnosis: Acute Pain

Related to:

• Tissue damage
• Hematoma formation
• Surgical interventions
• Uterine atony

As evidenced by:

• Patient reports of pain intensity.
• Diaphoresis.
• Expressive pain behaviors.
• Guarding or protective behaviors.
• Positioning to alleviate pain.
• Abdominal cramping.
• Pelvic pain and heaviness.

Expected Outcomes:

• Patient will identify and utilize appropriate pain relief interventions.
• Patient will report a reduction in pain or discomfort to a manageable level.

Assessments:

1. Comprehensive Pain Assessment: Determine pain level, characteristics, location, and duration to guide treatment. Uterine atony may manifest as lower back pain. Internal bleeding can cause abdominal pain or tenderness.
2. Perineal Trauma Extent: Assess for perineal and vaginal lacerations, a source of pain in 20% of PPH cases. Increased pressure and discomfort without visible trauma may indicate hematoma development.
3. Fundal Height Postpartum: Assess fundal height; acute pain with bleeding may signal subinvolution, a rare cause of PPH involving delayed uterine involution.

Interventions:

1. Relaxation and Diversion: Encourage relaxation techniques (deep breathing, meditation, back rubs) and diversional activities to refocus attention and reduce discomfort.
2. Pain Medication Administration: Administer prescribed pain medications to alleviate pain from perineal trauma or surgical interventions.
3. Cold/Warm Therapy: Recommend cold compresses to reduce hematoma formation and pain in the perineum and vulva. Warm sitz baths can relieve episiotomy pain and promote relaxation.
4. Surgical Intervention Preparation: Prepare for potential surgical interventions indicated by persistent pain, such as laceration repair, laparotomy for uterine repair, artery ligation, or hematoma drainage.

Anxiety Nursing Care Plan

Traumatic childbirth experiences, such as PPH, can induce significant anxiety and even post-traumatic stress.

Nursing Diagnosis: Anxiety

Related to:

• Traumatic delivery experience.
• Perceived threat to life.

As evidenced by:

• Expressed feelings of fear and impending doom.
• Awareness of physiological anxiety symptoms.
• Expressions of helplessness.
• Restlessness and distress.

Expected Outcomes:

• Patient will report reduced anxiety and an increased sense of control.
• Patient will implement at least two strategies to manage anxiety.

Assessments:

1. Physiologic vs. Psychologic Symptoms: Differentiate between anxiety symptoms (restlessness, tachypnea, tachycardia) and PPH symptoms, as they overlap.
2. Patient’s Thoughts and Feelings: Encourage expression of thoughts and perceptions to address misconceptions and prevent panic.

Interventions:

1. Clear Communication: Maintain clear and consistent communication about interventions and outcomes. Provide empathetic reassurance to reduce anxiety.
2. Support System Involvement: Involve the patient’s support system (partner, family) in education and care. They can provide emotional support and reinforce the treatment plan.
3. Mother-Baby Dyad Support: Keep mother and baby together whenever possible to promote bonding and reduce maternal stress, unless medically contraindicated.
4. Therapy Resources: Offer resources for counseling and therapy to address potential long-term stress, anxiety, and postpartum depression following a traumatic event like PPH.

Deficient Fluid Volume Nursing Care Plan

Reduced circulating blood volume in PPH compromises perfusion to vital organs.

Nursing Diagnosis: Deficient Fluid Volume

Related to:

• Blood loss secondary to postpartum hemorrhage.

As evidenced by:

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

Expected Outcomes:

• Patient will maintain a blood pressure above 90/60 mm Hg to ensure vital organ perfusion.
• Patient will not experience more than 1000 mL of blood loss post-vaginal delivery (if applicable and measurable).
• Patient will maintain hemoglobin levels within acceptable limits.

Assessments:

1. Vital Signs and LOC: Monitor vital signs closely for hypotension, tachycardia, confusion, faintness, and weakness, indicative of hypovolemia and impending shock.
2. Uterine Assessment: Identify the bleeding source. A soft or boggy uterus suggests atony. Assess for uterine inversion or lacerations if atony is not the primary cause.
3. Laboratory Data: Review lab work for low hemoglobin and potentially abnormal platelet counts or coagulation studies.
4. Lochia Monitoring: Assess lochia amount, color, and presence of clots. Expect lochia to decrease over time without large clots.

Interventions:

1. Uterine Massage: Perform uterine massage to stimulate contractions and control bleeding.
2. Oxytocin Administration: Administer oxytocin as per protocol to prevent or treat PPH.
3. Bed Rest and Positioning: Maintain bed rest with legs elevated to prevent orthostatic hypotension and promote venous return, reducing the risk of falls and further bleeding.
4. IV Fluid Administration: Administer IV crystalloids (normal saline) to expand intravascular volume.
5. Blood Product Administration: Prepare for and administer blood products (packed red blood cells, plasma) as ordered to replace blood loss.
6. Surgical Preparation: Prepare the patient for potential surgical interventions for lacerations, hematomas, trauma, or retained placental tissue.

Deficient Knowledge Nursing Care Plan

Educating mothers about postpartum expectations and potential complications empowers them and their support systems.

Nursing Diagnosis: Deficient Knowledge

Related to:

• Insufficient information provided regarding postpartum hemorrhage.
• Unfamiliarity with the condition and its management.

As evidenced by:

• Exaggerated responses or behaviors due to lack of understanding.
• Active information seeking.
• Statements reflecting misinformation about PPH.
• Development of PPH complications due to delayed recognition.

Expected Outcomes:

• Patient will verbalize understanding of PPH, its causes, and treatments.
• Patient will verbalize signs and symptoms of PPH requiring follow-up care.
• Patient will actively participate in the care plan to minimize PPH complications.

Assessments:

1. Risk Factor Identification: Identify individual risk factors for PPH (placenta previa, abruption, multiparity, preeclampsia, etc.).
2. Understanding Assessment: Evaluate the patient’s understanding of PPH risks, signs, and symptoms requiring medical attention post-discharge.

Interventions:

1. Discharge Education: Provide comprehensive discharge education on normal postpartum changes versus PPH warning signs (increased bleeding, large clots, dizziness, fatigue, abdominal pain). Emphasize the need to seek immediate medical advice.
2. Breastfeeding Education: Educate on the benefits of immediate breastfeeding in stimulating uterine contractions and reducing bleeding. Encourage breastfeeding if desired.
3. Follow-Up Care Review: Review necessary follow-up care, including potential lab tests to monitor blood counts and iron levels, and recommendations for iron supplementation or dietary adjustments.

Imbalanced Nutrition: Less Than Body Requirements Nursing Care Plan

PPH complications can lead to anemia and iron deficiency, impacting nutritional status.

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

Related to:

• Blood loss and iron depletion.
• Potential inadequate oral intake due to pain, nausea, or fatigue.
• Insufficient knowledge of postpartum nutritional needs.

As evidenced by:

• Potential hypoglycemia.
• Delayed wound healing.
• Fatigue and weakness.
• Altered laboratory values (low hemoglobin, iron).
• Lightheadedness.

Expected Outcomes:

• Patient will verbalize knowledge of iron-rich foods to include in their diet.
• Patient will demonstrate improvement in red blood cell count, hemoglobin, and iron levels towards normal ranges.

Assessments:

1. Laboratory Values: Assess CBC for RBC count, hemoglobin, iron, and ferritin levels to evaluate anemia and iron deficiency.
2. Fluid Status: Assess for dehydration signs and monitor fluid intake/output and electrolyte balance, as PPH can disrupt fluid and electrolyte homeostasis.
3. Anemia Signs: Monitor for fatigue, pallor, and weakness, common anemia symptoms.
4. Appetite and Intake Barriers: Assess for factors affecting appetite (pain, nausea, depression) that may impede adequate nutritional intake.

Interventions:

1. Fluid Intake Promotion: Encourage adequate oral or IV fluid intake to restore fluid balance, support organ function, and nutrient delivery. Hydration improves appetite and overall well-being.
2. Iron-Rich Food Education: Educate on dietary sources of heme iron (lean meats, seafood) and non-heme iron (beans, lentils, fortified grains).
3. Iron Supplement Education: Educate on iron supplement use, including:
   • Taking supplements with vitamin C for enhanced absorption.
   • Avoiding concurrent intake with calcium or antacids.
   • Optimal timing of iron supplementation.
   • Avoiding tea or coffee close to iron supplement intake.
4. Dietitian Referral: Consider referral to a dietitian for personalized meal planning and nutritional guidance tailored to postpartum needs.