Nursing Diagnosis for Postpartum Hemorrhage: A Comprehensive Guide

Postpartum Hemorrhage (PPH) remains a significant obstetric emergency, affecting 1-5% of mothers following childbirth. Defined by the American College of Obstetricians and Gynecologists (ACOG) as blood loss exceeding 1,000 mL accompanied by signs of hypovolemia, PPH is categorized as primary if it occurs within 24 hours of delivery and secondary if it arises between 24 hours and up to 12 weeks postpartum.

Uterine atony, the failure of the uterus to contract after placental delivery, is the leading cause of PPH, resulting in excessive blood loss. Prompt recognition and intervention are critical to prevent maternal shock and death. Globally, PPH contributes to approximately 25% of all maternal deaths, underscoring the urgency and importance of effective nursing care and diagnosis.

Nurses in labor and delivery and postpartum care settings play a vital role in identifying, managing, and educating patients about postpartum hemorrhage. Understanding the nuances of Nursing Diagnosis For Hemorrhage is paramount for timely intervention and improved patient outcomes. This guide will explore the essential aspects of nursing assessment, interventions, and nursing diagnoses related to postpartum hemorrhage, ensuring comprehensive care for at-risk mothers.

Nursing Assessment for Postpartum Hemorrhage

The cornerstone of effective nursing care begins with a thorough nursing assessment. This process involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic – to accurately identify and address potential issues. In the context of postpartum hemorrhage, a meticulous assessment is crucial for early detection and intervention.

Review of Health History: Identifying Risk Factors for Hemorrhage

1. Assess for Acute Postpartum Bleeding Symptoms: Recognizing the signs and symptoms of acute postpartum bleeding is the first step in identifying hemorrhage. These symptoms may include:

• General: Weakness, feeling faint upon standing, cold sensations, restlessness.
• Central Nervous System (CNS): Dizziness, loss of consciousness.
• Cardiovascular: Palpitations, tachycardia, decreased blood pressure.
• Respiratory: Tachypnea.
• Integumentary: Diaphoresis, pallor.
• Genitourinary: Decreased or absent urine output.

2. Obtain a Detailed Medical History: A thorough review of the patient’s medical records is essential to identify pre-existing conditions that elevate the risk of PPH. These conditions include:

• Hypertension
• Preeclampsia
• Eclampsia
• Infection
• Blood clotting disorders (Disseminated Intravascular Coagulation – DIC)
• Bleeding disorders
• Anemia
• Obesity
• Advanced maternal age

3. Review Obstetric History: A detailed obstetric history helps pinpoint factors during pregnancy and delivery that increase hemorrhage risk. Key factors include:

• Placental problems:
  • Placenta accreta
  • Placenta previa
  • Placental abruption
• Retained placenta
• Multiple pregnancies (more than 5)
• Multiple births (twins, triplets, or more)
• Fetal macrosomia (baby over 9 pounds)
• Excessive amniotic fluid (polyhydramnios)

4. Review Medication List: Certain medications can predispose patients to bleeding. It’s crucial to review the patient’s medication list for:

• Anticoagulants: Heparin and aspirin
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Diclofenac and ibuprofen
• Oral steroids: Dexamethasone and prednisone
• Selective Serotonin Reuptake Inhibitors (SSRIs): Citalopram and fluoxetine
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): Desvenlafaxine and duloxetine

Physical Assessment: Recognizing Signs of Hemorrhage

1. Closely Monitor Vital Signs and Vaginal Blood Loss: Tachycardia and hypotension are critical indicators of blood loss in postpartum women. Monitor vital signs frequently, noting changes in heart rate and blood pressure that suggest significant blood volume loss (more than 25% of total blood volume).

2. Examine the Genitalia: Inspect the genitalia for lacerations, hematomas, or uterine rupture. After vaginal deliveries, carefully inspect and palpate the cervix and vagina to identify potential bleeding sources.

3. Assist in Checking for Retained Placental Tissue: Ensure the placenta is fully expelled within 30 minutes after delivery. Inspect the placenta for intactness, noting any missing fragments. Retained placental tissue can lead to infection, foul-smelling discharge, bleeding, and pain.

4. Palpate Uterine Tone and Size: Uterine atony, characterized by a soft, “boggy,” or non-contracted uterus, is the most prevalent cause of PPH. A uterus that fails to contract cannot effectively stop bleeding from the placental site.

5. Assess for Disseminated Intravascular Coagulation (DIC): DIC is a severe complication involving the disruption of clotting factors, resulting in widespread bleeding from various sites (nose, gums, IV sites). Observe for bruising, hypotension, dyspnea, and confusion, which may indicate DIC.

6. Observe Lochia: Vaginal bleeding (lochia) is expected postpartum. In the initial days, lochia is red and similar to a heavy menstrual flow. Saturating more than one pad per hour or passing large clots requires immediate intervention.

Diagnostic Procedures: Confirming Hemorrhage and Underlying Issues

1. Obtain Samples for Lab Tests: Laboratory tests are essential to assess the extent of blood loss and identify potential complications. Key tests include:

• Complete Blood Count (CBC): To monitor hemoglobin, hematocrit, and platelet levels.
• Blood typing and screening: In preparation for potential blood transfusion.

2. Perform Coagulation Studies: Initial coagulation tests may be within normal ranges but can become abnormal in conditions associated with PPH, such as:

• Abruptio placenta
• HELLP syndrome
• Fatty liver of pregnancy
• Intrauterine fetal death
• Embolic events
• Septicemia
• DIC

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

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

4. Assist with Ultrasound: A bedside ultrasound can be invaluable in locating clots or retained placental tissue within the uterus.

Nursing Interventions for Postpartum Hemorrhage

Effective nursing interventions are critical for managing postpartum hemorrhage and ensuring patient recovery. These interventions are aimed at controlling bleeding, restoring hemodynamic stability, and addressing the underlying cause of the hemorrhage.

Manage the Bleeding: Immediate Actions

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

2. Ensure Continuous Organ Perfusion: Maintaining hemodynamic stability is paramount to ensure adequate perfusion of vital organs. Establish patent large-bore intravenous (IV) access. Elevate the patient’s legs to promote venous return. Administer supplemental oxygen as needed.

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

4. Initiate Blood Transfusions: Early administration of blood products is crucial, along with meticulous monitoring of cumulative blood loss. Fresh frozen plasma or platelet transfusions may be necessary to address coagulation abnormalities.

5. Closely Monitor Vital Signs and Urine Output: Continuous monitoring of blood pressure, pulse, oxygen saturation, and urine output is essential to assess perfusion status and response to treatment.

6. Repair Trauma: Immediate surgical procedures may be required to address trauma:

• Exploration of the uterus for rupture
• Repair of lacerations (cervical, vaginal, perineal)
• Correction of uterine inversion

7. Treat Uterine Atony: Management of uterine atony, the most common cause of PPH, includes:

• Bimanual uterine massage
• Uterotonic medications (oxytocin, misoprostol, methylergonovine, carboprost)
• Uterine tamponade (balloon tamponade)
• Pelvic artery embolization (in cases of persistent bleeding)
• Surgical management (uterine compression sutures, hysterectomy as a last resort)

8. Assist in Removing Retained Tissue: Manual removal of retained placental fragments or dilation and curettage (D&C) may be necessary to eliminate sources of continued bleeding.

9. Prepare for Surgical Procedures: In cases of recurrent bleeding in a stable patient, ligation of bleeding arteries may be required. Fluoroscopy can be used to locate and seal off bleeding vessels. Uterine rupture may necessitate laparotomy or hysterectomy if repair is not feasible.

Prevent Further Bleeding: Proactive Strategies

1. Identify Bleeding Risk: Identifying high-risk patients before delivery is crucial for preventing PPH-related morbidity and mortality. Ultrasound evaluation antepartum can help in determining the safest delivery method and anticipating potential complications.

2. Give Iron Supplements as Recommended: Anemic patients should receive oral or parenteral iron supplements, particularly if their hematocrit is below 30%.

3. Administer Erythropoietin-Stimulating Agents as Prescribed: In high-risk patients, especially those who decline blood transfusions, erythropoietin-stimulating agents may be administered following hematological consultation.

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

• Cesarean delivery
• General anesthesia
• Prolonged labor
• Infection during labor and delivery
• History of PPH in previous deliveries

should be carefully considered in the management plan.

5. Encourage Immediate Breastfeeding: Promote breastfeeding immediately after delivery. Breastfeeding stimulates the natural release of oxytocin, promoting uterine contraction and reducing bleeding.

6. Educate on Signs of Secondary PPH: Educate patients about the possibility of secondary PPH, which can occur up to 12 weeks postpartum. Instruct them to monitor for signs such as changes in lochia, severe abdominal cramping, fever, or dizziness and to seek immediate medical attention if these symptoms arise. Treatment for secondary PPH mirrors that of primary PPH.

Nursing Care Plans and Nursing Diagnoses for Hemorrhage

Once a nurse identifies the potential for postpartum hemorrhage, formulating appropriate nursing diagnoses is crucial. Nursing care plans, guided by these diagnoses, prioritize assessments and interventions to achieve both short-term and long-term care goals. Several nursing diagnoses are pertinent in the context of postpartum hemorrhage.

Acute Pain related to Postpartum Hemorrhage

Acute pain is a common concern in patients experiencing postpartum hemorrhage, often associated with perineal trauma, lacerations, or interventions to manage bleeding.

Nursing Diagnosis: Acute Pain

Related to:

• Tissue damage (perineal lacerations, surgical incisions)
• Hematoma formation
• Surgical interventions (episiotomy repair, Cesarean section)
• Uterine atony and cramping

As evidenced by:

• Patient reports of pain intensity (using pain scales)
• Diaphoresis
• Expressive pain behaviors (grimacing, guarding)
• Protective behaviors
• Positioning to alleviate pain
• Abdominal cramping or pelvic pain

Expected Outcomes:

• Patient will verbalize a reduction in pain intensity.
• Patient will demonstrate effective pain relief strategies.
• Patient will report improved comfort levels.

Assessment:

1. Conduct a comprehensive pain assessment: Evaluate pain location, quality, intensity, duration, and aggravating/relieving factors. Differentiate pain sources (perineal, uterine).
2. Assess perineal trauma: Evaluate the extent of lacerations or episiotomy and signs of hematoma formation.
3. Assess fundal height and uterine tenderness: Persistent pain or tenderness might indicate subinvolution or infection.

Interventions:

1. Encourage relaxation techniques: Deep breathing, guided imagery, and massage can reduce pain perception.
2. Administer pain medications: Provide analgesics as prescribed, considering pain severity and patient history.
3. Promote comfort measures: Cold compresses for perineal pain, warm sitz baths to promote healing and comfort.
4. Prepare for surgical intervention: If pain persists or worsens, surgical exploration or repair may be necessary.

Anxiety related to Postpartum Hemorrhage

The experience of postpartum hemorrhage can be traumatic and life-threatening, leading to significant anxiety for the patient.

Nursing Diagnosis: Anxiety

Related to:

• Traumatic birthing experience
• Perceived threat to life
• Fear of complications or death

As evidenced by:

• Expressed feelings of fear, worry, or impending doom
• Awareness of physiological symptoms of anxiety (tachycardia, tachypnea)
• Expressions of helplessness or loss of control
• Restlessness and agitation

Expected Outcomes:

• Patient will report a decrease in anxiety levels.
• Patient will verbalize feeling more in control of the situation.
• Patient will utilize coping strategies to manage anxiety.

Assessment:

1. Differentiate physiological vs. psychological symptoms: Distinguish anxiety symptoms from hemorrhage symptoms (e.g., tachycardia can be due to both).
2. Assess patient’s thoughts and feelings: Encourage verbalization of fears and concerns. Provide a safe space for emotional expression.

Interventions:

1. Maintain clear and calm communication: Explain procedures and treatments in a reassuring manner.
2. Involve support system: Include partner/family in communication and support efforts.
3. Keep mother and baby together: Promote bonding and reduce maternal anxiety by keeping the newborn nearby when possible.
4. Provide resources for therapy: Offer information on postpartum support groups or mental health professionals for ongoing support.

Deficient Fluid Volume related to Postpartum Hemorrhage

Blood loss in postpartum hemorrhage directly leads to a decrease in circulating fluid volume, posing a significant threat to organ perfusion.

Nursing Diagnosis: Deficient Fluid Volume

Related to:

• Excessive blood loss secondary to postpartum hemorrhage

As evidenced by:

• Changes in mental status (confusion, lethargy)
• Hypotension
• Tachycardia
• Decreased urine output
• Decreased hemoglobin and hematocrit levels

Expected Outcomes:

• Patient will maintain stable vital signs, including blood pressure within acceptable limits for perfusion.
• Patient will exhibit adequate urine output, indicating renal perfusion.
• Patient will maintain hemoglobin levels within acceptable range.

Assessment:

1. Monitor vital signs and level of consciousness (LOC): Frequent monitoring is crucial to detect hypovolemia and shock.
2. Assess uterine tone and position: Evaluate for uterine atony or inversion as the source of bleeding.
3. Review laboratory results: Monitor hemoglobin, hematocrit, and coagulation studies.
4. Monitor lochia amount and characteristics: Assess for excessive bleeding and clots.

Interventions:

1. Uterine massage: Perform fundal massage to promote uterine contraction and reduce bleeding.
2. Administer uterotonic medications: Follow protocols for oxytocin and other uterotonics.
3. Maintain bed rest with leg elevation: Promote venous return and prevent orthostatic hypotension.
4. Administer IV fluids: Replace fluid volume with crystalloids and blood products as ordered.
5. Prepare for potential surgical interventions: Be ready for procedures to control bleeding if conservative measures fail.

Deficient Knowledge related to Postpartum Hemorrhage

Lack of understanding about postpartum hemorrhage and its potential risks can hinder early recognition and timely seeking of care.

Nursing Diagnosis: Deficient Knowledge

Related to:

• Lack of prior information about postpartum hemorrhage
• Unfamiliarity with postpartum complications

As evidenced by:

• Expressed misinformation or misunderstandings about PPH
• Failure to recognize warning signs of PPH
• Development of PPH complications due to delayed recognition

Expected Outcomes:

• Patient will verbalize understanding of postpartum hemorrhage, risk factors, and warning signs.
• Patient will describe appropriate actions to take if PPH symptoms occur after discharge.
• Patient will actively participate in the plan of care to minimize PPH risks.

Assessment:

1. Identify risk factors specific to the patient: Assess for predisposing conditions from medical and obstetric history.
2. Assess patient’s current understanding: Evaluate knowledge about postpartum recovery and potential complications.

Interventions:

1. Provide pre-discharge education: Explain normal postpartum changes versus signs of PPH (increased bleeding, clots, dizziness, fatigue, pain).
2. Emphasize warning signs: Instruct to seek immediate medical attention for heavy bleeding, large clots, dizziness, or new abdominal pain.
3. Review follow-up care: Explain the importance of postpartum check-ups and potential need for further bloodwork or iron supplementation.
4. Educate on breastfeeding benefits: Explain how breastfeeding can help contract the uterus and reduce bleeding.

Imbalanced Nutrition: Less Than Body Requirements related to Postpartum Hemorrhage

Blood loss during postpartum hemorrhage can lead to anemia and iron deficiency, necessitating nutritional support to replenish losses.

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

Related to:

• Iron loss due to postpartum hemorrhage
• Potential for inadequate dietary intake postpartum
• Fatigue and decreased appetite post-delivery

As evidenced by:

• Laboratory values indicating anemia (low hemoglobin, hematocrit, ferritin)
• Reports of fatigue, weakness, or lightheadedness
• Pallor
• Potential for delayed wound healing

Expected Outcomes:

• Patient will verbalize understanding of iron-rich food sources.
• Patient will demonstrate improved iron levels and red blood cell indices over time.
• Patient will report increased energy levels and reduced fatigue.

Assessment:

1. Assess laboratory values: Monitor CBC, iron studies, and ferritin levels to evaluate for anemia.
2. Assess fluid status: Evaluate for dehydration, which can exacerbate fatigue and nutritional deficits.
3. Assess for signs of anemia: Note pallor, fatigue, and weakness.
4. Assess appetite and dietary intake: Evaluate for factors affecting nutritional intake (nausea, pain, fatigue).

Interventions:

1. Encourage adequate fluid intake: Promote oral hydration and administer IV fluids as needed.
2. Educate on iron-rich foods: Provide dietary guidance on incorporating lean meats, seafood, beans, lentils, and iron-fortified foods.
3. Educate on iron supplementation: Instruct on proper administration of iron supplements (with Vitamin C, avoiding calcium and caffeine concurrently).
4. Refer to a dietitian: Consider referral for personalized meal planning and nutritional counseling, especially for patients with significant anemia or dietary restrictions.

By understanding these nursing diagnoses for hemorrhage and implementing targeted assessments and interventions, nurses can significantly improve the care and outcomes for women experiencing postpartum hemorrhage, ensuring their safety and well-being during the critical postpartum period.