Postpartum Hemorrhage (PPH) remains 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 hypovolemia signs, PPH is categorized into primary, occurring within 24 hours of delivery, and secondary, from 24 hours to 12 weeks postpartum. Uterine atony, the failure of the uterus to contract post-placenta delivery, is the leading cause, resulting in excessive blood loss and potential maternal shock or death if not promptly addressed. Alarmingly, PPH contributes to 25% of maternal deaths worldwide.
Nurses in labor and delivery and postpartum care settings are pivotal in recognizing and immediately responding to PPH. Their expertise extends to educating patients about PPH risk factors, home recovery monitoring, and the importance of follow-up care. This guide delves into the nursing process for PPH, emphasizing accurate nursing assessment and effective interventions, and highlighting key nursing diagnoses for postpartum haemorrhage.
Nursing Process
The nursing process is fundamental in managing postpartum hemorrhage. It begins with a thorough nursing assessment to gather comprehensive patient data, followed by the formulation of nursing diagnoses, planning and implementation of interventions, and evaluation of outcomes. For PPH, this systematic approach is crucial for timely and effective care.
Nursing Assessment
The initial nursing assessment is crucial for identifying postpartum hemorrhage. It involves collecting physical, psychosocial, emotional, and diagnostic data. Both subjective and objective data are vital in recognizing PPH early and initiating prompt interventions.
Review of Health History
1. Assess for Acute Postpartum Bleeding Symptoms. Recognizing the symptoms of acute postpartum bleeding is the first step in assessment. These can be subtle or overt and require careful evaluation:
- General: Generalized weakness, feeling faint upon standing (orthostatic lightheadedness), sensations of coldness, and restlessness can be early indicators of blood loss.
- CNS: Dizziness and loss of consciousness (syncope) are neurological signs reflecting reduced cerebral perfusion due to hypovolemia.
- Cardiovascular: Palpitations (awareness of rapid heartbeats), tachycardia (elevated heart rate), and decreased blood pressure (hypotension) are direct consequences of blood volume depletion.
- Respiratory: Tachypnea (rapid breathing) is a compensatory mechanism to improve oxygen delivery in response to decreased blood volume.
- Integumentary: Diaphoresis (excessive sweating) and pallor (pale skin) are signs of the body’s stress response and reduced blood flow to the skin.
- Genitourinary: Decreased or absent urine output (oliguria or anuria) indicates reduced kidney perfusion, a critical sign of hypovolemia and potential organ compromise.
2. Obtain a Detailed Medical History. A thorough review of the patient’s medical records is essential to identify pre-existing conditions that elevate PPH risk. These include:
- Hypertension (High blood pressure): Chronic hypertension can impair uterine blood vessels and increase bleeding risk.
- Preeclampsia: This pregnancy-specific condition involves hypertension and proteinuria and is strongly linked to PPH.
- Eclampsia: Seizures in the context of preeclampsia further elevate PPH risk due to systemic effects and potential coagulopathies.
- Infection: Infections, particularly chorioamnionitis, can lead to uterine atony and increased bleeding.
- Blood clotting disorders (DIC – Disseminated Intravascular Coagulation): Pre-existing or pregnancy-induced coagulopathies significantly increase the risk of uncontrolled bleeding.
- Bleeding disorders: Conditions like von Willebrand disease or hemophilia predispose patients to PPH.
- Anemia: Pre-existing anemia reduces the patient’s tolerance to blood loss, making PPH more dangerous.
- Obesity: Obesity is associated with an increased risk of uterine atony and cesarean delivery, both PPH risk factors.
- Advanced maternal age: Older mothers have a higher incidence of conditions like uterine fibroids and are at increased risk for uterine atony.
3. Review Obstetric History. Past obstetric events can significantly predict PPH risk in the current pregnancy. Key factors include:
- Placental problems:
- Placenta accreta: Abnormal placental attachment increases the risk of hemorrhage during attempted removal.
- Placenta previa: Placenta previa, where the placenta overlies the cervix, increases bleeding risk before and during delivery.
- Placental abruption: Premature placental separation is a major cause of antepartum and postpartum hemorrhage.
- Retained placenta: Failure to expel the entire placenta can lead to uterine atony and secondary PPH.
- Multiple pregnancies (> 5): High parity is linked to uterine atony due to uterine muscle fatigue.
- Multiple births (twins, triplets, or more): Uterine overdistension in multiple gestations increases atony risk.
- Fetal macrosomia (baby over 9 pounds): Large babies can lead to uterine overdistension and delivery complications increasing PPH risk.
- Excessive amniotic fluid (polyhydramnios): Similar to multiple births, polyhydramnios can overstretch the uterus, predisposing to atony.
4. Review the Patient’s Medication List. Certain medications can predispose patients to bleeding or interfere with clotting mechanisms, increasing PPH risk:
- Anticoagulants: Heparin and aspirin, commonly used for thromboembolic conditions, directly increase bleeding risk.
- NSAIDs: Diclofenac and ibuprofen, while common pain relievers, can inhibit platelet function and increase bleeding, especially with prolonged use.
- Oral steroids: Dexamethasone and prednisone, particularly with long-term use, can affect blood vessel fragility and clotting.
- Selective serotonin reuptake inhibitors (SSRIs): Citalopram and fluoxetine, used for depression, can interfere with platelet aggregation in some individuals.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs): Desvenlafaxine and duloxetine, similar to SSRIs, may also have effects on platelet function.
Alt text: Nurse attentively monitors postpartum patient’s blood pressure, a crucial step in postpartum hemorrhage assessment.
Physical Assessment
1. Closely Observe Maternal Vital Signs and Vaginal Blood Loss. Vital signs are critical indicators of hemodynamic status. Tachycardia and hypotension are hallmark symptoms of significant blood loss in postpartum women. It is important to note trends and changes in heart rate and blood pressure, especially in response to estimated blood loss exceeding 25% of total blood volume.
2. Examine the Genitalia of the Patient. A physical examination of the genitalia is necessary to identify potential sources of bleeding. Inspect for lacerations of the perineum, vagina, and cervix, and assess for hematomas, which can develop rapidly and cause significant blood loss. In cases of cesarean delivery, assess the surgical site for signs of bleeding or hematoma formation. Uterine rupture, though rare, should also be considered in severe cases of PPH, especially in women with previous uterine surgeries.
3. Assist in Checking for Retained Placental Tissue. The placenta should be delivered intact within 30 minutes of the baby’s birth. Nursing assessment includes inspecting the placenta to ensure it is whole and complete, with no missing cotyledons (lobes). Retained placental fragments are a common cause of secondary PPH. Signs of retained tissue may include persistent bleeding, fever, foul-smelling vaginal discharge, and pelvic pain.
4. Palpate the Uterine Tone and Size. Assessing uterine tone is paramount. Uterine atony, characterized by a soft, “boggy,” or non-contracted uterus, is the most frequent cause of PPH. Palpate the fundus (top of the uterus) to assess its firmness. A well-contracted uterus should feel firm and midline, typically at or below the umbilicus after delivery. A uterus that is not firm needs immediate intervention to promote contraction and control bleeding.
5. Assess for DIC. Disseminated intravascular coagulation (DIC) is a severe complication of PPH, representing a breakdown in the body’s clotting system. Assess for signs of widespread bleeding from multiple sites, such as nosebleeds (epistaxis), gum bleeding, bleeding from IV sites, and unusual bruising. Other signs include hypotension, dyspnea (shortness of breath), and confusion, reflecting systemic effects of DIC.
6. Observe the Lochia. Lochia, the postpartum vaginal discharge, is a normal process but must be carefully monitored. In the first few days postpartum, lochia is typically rubra (red) and may resemble a heavy menstrual flow. However, saturating more than one perineal pad per hour, passing large blood clots, or a sudden increase in lochia volume or return to bright red bleeding after it has lightened are abnormal findings requiring immediate nursing intervention.
Alt text: Nurse carefully examines postpartum pad to assess lochia characteristics, crucial for detecting abnormal postpartum bleeding.
Diagnostic Procedures
1. Obtain Samples for Lab Tests. Laboratory investigations are essential to quantify blood loss and assess the patient’s hematological status. Key lab tests include:
- Complete blood cell (CBC) count: To monitor hemoglobin (Hgb), hematocrit (Hct), and platelet levels. Serial CBCs are crucial to track ongoing blood loss and guide transfusion needs.
- Blood typing and screening: Essential for preparing for potential blood transfusion. Crossmatching is performed if transfusion is anticipated or imminent.
2. Perform Coagulation Studies. Initial coagulation tests may be within normal limits, especially in early PPH. However, abnormalities can emerge rapidly, particularly in conditions predisposing to DIC. Coagulation studies are crucial in certain clinical contexts, such as:
- Abruptio placenta
- HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count)
- Fatty liver of pregnancy
- Intrauterine fetal death
- Embolic events (amniotic fluid embolism, pulmonary embolism)
- Septicemia
- DIC
3. Investigate for Elevated INR and aPTT. If initial coagulation screening (INR – International Normalized Ratio and aPTT – activated Partial Thromboplastin Time) is elevated, further investigations are warranted to assess specific clotting factors and fibrinolysis. These may include:
- Fibrinogen levels: Fibrinogen is a key clotting protein; low levels are indicative of consumptive coagulopathy like DIC.
- Thrombin time measurement: Prolonged thrombin time suggests fibrinogen deficiency or the presence of heparin.
- D-dimer: Elevated D-dimer levels indicate fibrinolysis and are often high in DIC.
- Blood film (peripheral smear): To assess for schistocytes (fragmented red blood cells), which can be seen in DIC and microangiopathic hemolytic anemia.
4. Assist the Patient with an Ultrasound. Bedside ultrasound (sonography) is a valuable tool in PPH management. It can help identify:
- Retained placental tissue: Ultrasound can visualize placental fragments remaining in the uterus.
- Uterine atony: While not directly visualized, ultrasound can confirm an empty uterus after delivery, indirectly supporting atony if bleeding persists.
- Hematomas: Pelvic hematomas can be identified and their size estimated via ultrasound.
Nursing Interventions
Prompt and effective nursing interventions are critical in managing postpartum hemorrhage and ensuring patient recovery. These interventions focus on managing active bleeding, preventing further hemorrhage, and addressing the underlying causes.
Manage the Bleeding
1. Treat the Causative Factors. Effective PPH management necessitates identifying and treating the underlying cause while simultaneously resuscitating the patient. Treatment strategies are tailored to the etiology of the hemorrhage.
2. Ensure Continuous Organ Perfusion. Maintaining hemodynamic stability is paramount to ensure adequate perfusion of vital organs. Key interventions include:
- Ensure large-bore intravenous (IV) access: At least two IV lines (16-18 gauge) are essential for rapid fluid and blood product administration.
- Elevate the patient’s legs: Trendelenburg or leg elevation improves venous return and can transiently increase blood pressure.
- Administer supplemental oxygen as needed: To optimize oxygen saturation, especially if signs of hypovolemia or shock are present.
3. Begin IV Fluids. Rapid volume replacement is crucial. Infuse large volumes of crystalloid solutions such as isotonic normal saline (0.9% NaCl) or Lactated Ringer’s solution. The choice depends on institutional protocols and patient-specific factors.
4. Initiate Blood Transfusions. Early transfusion of blood products should be prioritized, alongside meticulous monitoring of cumulative blood loss. Transfusion protocols may include:
- Packed red blood cells (PRBCs): To improve oxygen-carrying capacity.
- Fresh frozen plasma (FFP): To replace clotting factors, especially if coagulation abnormalities are present.
- Platelet transfusions: If thrombocytopenia or platelet dysfunction is contributing to bleeding.
- Cryoprecipitate: To provide fibrinogen and factor VIII, especially in DIC or hypofibrinogenemia.
5. Closely Monitor Vital Signs and Urine Output. Continuous monitoring of vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation) and hourly urine output is crucial to assess perfusion status and response to treatment. Decreasing blood pressure, increasing heart rate, and reduced urine output are indicators of ongoing hypovolemia or inadequate resuscitation.
6. Repair Trauma. Immediate surgical procedures may be necessary to address traumatic causes of PPH:
- Exploration of the uterus for rupture: In cases of suspected uterine rupture, surgical exploration is essential.
- Repair of lacerations: Perineal, vaginal, or cervical lacerations should be promptly repaired to control bleeding.
- Correction of uterine inversion: Uterine inversion requires immediate manual or surgical replacement.
7. Treat Uterine Atony. Atony management is multifaceted and may include:
- Bimanual massage: Vigorous massage of the uterine fundus stimulates contractions.
- Surgical management: Procedures like B-Lynch suture, uterine artery ligation, or hysterectomy may be required if medical management fails.
- Uterine tamponade: Insertion of a balloon tamponade device (e.g., Bakri balloon) into the uterus can provide mechanical pressure to control bleeding.
- Pelvic artery embolization: Interventional radiology procedure to selectively embolize pelvic arteries supplying the uterus to reduce blood flow.
- Uterotonic medications: First-line pharmacologic agents to stimulate uterine contractions include:
- Oxytocin (Pitocin): IV or IM administration.
- Methylergonovine (Methergine): IM injection (contraindicated in hypertension).
- Carboprost tromethamine (Hemabate): IM injection (contraindicated in asthma).
- Misoprostol (Cytotec): Rectal or oral administration.
8. Assist in Removing Retained Tissue. If retained placental tissue is suspected, manual removal or dilation and curettage (D&C) may be necessary to evacuate the uterine cavity.
9. Prepare for Surgical Procedures. In cases of persistent or recurrent bleeding, or when medical management fails, surgical interventions are essential. These may include:
- Ligation of bleeding artery: Surgical ligation of uterine or internal iliac arteries to reduce blood flow to the uterus.
- Hysterectomy: As a last resort in life-threatening PPH unresponsive to other measures. Laparotomy (open abdominal surgery) may be necessary for uterine rupture or hysterectomy.
Alt text: Healthcare provider performs uterine massage on postpartum patient, a critical nursing intervention to address uterine atony and postpartum hemorrhage.
Prevent Further Bleeding
1. Identify Bleeding Risk. Proactive risk assessment is crucial. Identifying high-risk patients antenatally allows for preparedness and optimization of delivery management. Antenatal ultrasound evaluation can help identify conditions like placenta previa or accreta.
2. Give Iron Supplements as Recommended. Anemia management is important in postpartum recovery, especially after PPH. Oral or parenteral iron supplements should be administered to anemic patients, particularly if hematocrit is below 30%.
3. Administer Erythropoietin-Stimulating Agents as Prescribed. In high-risk patients who decline blood transfusion (e.g., due to religious reasons), erythropoietin-stimulating agents may be considered, along with hematological consultation, to stimulate red blood cell production.
4. Collaborate with the Healthcare Provider. Interdisciplinary collaboration is key to optimize patient care during labor and delivery. Factors that increase bleeding risk and require careful consideration include:
- Cesarean delivery: Associated with higher PPH rates compared to vaginal delivery.
- General anesthesia: May contribute to uterine atony.
- Prolonged labor: Uterine fatigue can increase atony risk.
- Infection during labor and delivery (chorioamnionitis): Increases risk of atony and coagulopathy.
- History of PPH in previous deliveries: Recurrence risk is elevated.
5. Breastfeed Right Away. Encourage immediate breastfeeding after delivery. Breastfeeding stimulates oxytocin release, which promotes uterine contractions and helps control bleeding physiologically.
6. Educate on Signs of Secondary PPH. Patient education is vital, particularly regarding secondary PPH, which can occur up to 12 weeks postpartum. Educate patients to monitor for:
- Change in lochia: Increased bleeding, return to bright red bleeding after lightening, or foul odor.
- Severe abdominal cramping or pelvic pain
- Fever
- Dizziness or lightheadedness
Patients should be instructed to immediately contact their healthcare provider if any of these symptoms occur. Treatment for secondary PPH mirrors that of primary PPH, focusing on identifying and managing the cause of bleeding.
Nursing Care Plans
Once nursing diagnoses are identified, nursing care plans guide the prioritization of assessments and interventions for both short-term and long-term care goals in postpartum hemorrhage. Several common Nursing Diagnosis For Postpartum Haemorrhage include:
Acute Pain
Acute pain is a common sequela of postpartum hemorrhage, often related to perineal trauma, lacerations, or uterine interventions.
Nursing Diagnosis: Acute Pain
Related to:
- Tissue damage (perineal lacerations, episiotomy)
- Hematoma formation
- Surgical interventions (repair of lacerations, cesarean delivery)
- Uterine atony (uterine cramping)
As evidenced by:
- Reports of pain intensity (using pain scales)
- Diaphoresis (sweating)
- Expressive behavior (grimacing, guarding)
- Guarding behavior (protective posture)
- Protective behavior (reluctance to move)
- Positioning to ease pain
- Abdominal cramping
- Pelvic pain and heaviness
Expected outcomes:
- Patient will identify and demonstrate appropriate interventions for pain relief (e.g., medication, relaxation techniques).
- Patient will report a reduction in pain intensity to a tolerable level.
Assessment:
1. Conduct a Comprehensive Pain Assessment. Use a standardized pain scale (numeric rating scale, visual analog scale) to quantify pain intensity, and assess pain characteristics (quality, location, duration, aggravating/relieving factors). Uterine atony may manifest as lower back pain or cramping. Internal bleeding can cause diffuse abdominal pain or tenderness.
2. Assess for the Extent of Perineal Trauma. Approximately 20% of PPH cases are associated with perineal and/or vaginal lacerations. Assess the degree of laceration and episiotomy if present. Increased perineal pressure and discomfort without visible trauma may indicate a developing hematoma.
3. Assess the Patient’s Fundal Height After Childbirth. Persistent acute pain or pelvic heaviness with postpartum bleeding can be indicative of subinvolution of the uterus, a less common cause of secondary PPH where the uterus fails to return to its normal size.
Interventions:
1. Encourage Relaxation Techniques and Diversional Activities. Non-pharmacologic pain management is crucial. Relaxation techniques such as deep breathing exercises, meditation, guided imagery, and back rubs can help reduce pain perception. Diversional activities (reading, listening to music) can refocus attention away from pain.
2. Administer Pain Medications as Indicated. Pharmacologic pain management is often necessary. Administer analgesics as prescribed, considering the severity of pain and patient-specific factors. Options include NSAIDs (if not contraindicated due to bleeding risk), acetaminophen, and opioid analgesics for severe pain.
3. Encourage the Use of a Cold Compress or Sitz Bath to the Perineum. Cold compresses applied to the perineum can reduce edema, hematoma formation, and provide localized pain relief, especially in the immediate postpartum period. Warm sitz baths promote circulation, reduce episiotomy pain, and encourage perineal muscle relaxation.
4. Prepare for Surgical Intervention. Pain, especially if severe or worsening, can be a symptom necessitating surgical intervention. This may include repair of perineal or cervical lacerations, laparotomy for uterine rupture repair, artery ligation, or incision and drainage of pelvic hematomas.
Anxiety
The experience of postpartum hemorrhage can be traumatic and life-threatening, leading to significant anxiety and potentially post-traumatic stress disorder (PTSD).
Nursing Diagnosis: Anxiety
Related to:
- Traumatic delivery experience
- Perceived or actual threat to life
- Fear of unknown outcomes
As evidenced by:
- Expresses feelings of fear, worry, or apprehension
- Sense of impending doom
- Awareness of physiological symptoms of anxiety (palpitations, shortness of breath)
- Expression of helplessness or loss of control
- Restlessness and agitation
Expected outcomes:
- Patient will report a decrease in anxiety levels and an increased sense of control.
- Patient will verbalize and implement at least two strategies to manage anxiety (e.g., deep breathing, talking to support person).
Assessment:
1. Determine Physiologic vs. Psychologic Symptoms. Differentiate between symptoms of anxiety (restlessness, tachypnea, tachycardia) and those directly related to PPH and hypovolemia. This distinction is crucial for accurate diagnosis and management.
2. Assess the Patient’s Thoughts and Feelings. Encourage the patient to verbalize their feelings, thoughts, and perceptions of the situation. Active listening and empathetic communication are essential. Clarify any misconceptions or misinformation to reduce panic and anxiety.
Interventions:
1. Maintain Clear Communication. Provide consistent, clear, and honest information about the patient’s condition, interventions being implemented, and expected outcomes. Maintain a supportive and empathetic approach. Calm reassurance can significantly reduce anxiety.
2. Involve Support System. Actively involve the patient’s spouse/partner, family members, or other support persons in communication, teaching, and care planning. They can provide emotional support and reinforce the nurse’s reassurance and treatment plan.
3. Keep Baby and Mother Together When Possible. Separating a mother and newborn can exacerbate anxiety and stress. Whenever medically feasible and safe, keep the baby with the mother to promote bonding and provide distraction.
4. Provide Therapy Resources. Experiencing a life-threatening event like PPH can have long-term psychological effects. Provide information about counseling services, postpartum support groups, and mental health resources. Postpartum depression and PTSD are more likely after PPH, necessitating ongoing support.
Deficient Fluid Volume
Postpartum hemorrhage directly leads to a decrease in circulating blood volume, resulting in deficient fluid volume and reduced organ perfusion.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Excessive blood loss after birth (hemorrhage)
As evidenced by:
- Changes in mental status (confusion, disorientation)
- Hypotension (systolic blood pressure < 90 mmHg)
- Tachycardia (heart rate > 100 bpm)
- Decreased urine output (oliguria < 30 mL/hour)
- Decreased hemoglobin and hematocrit levels
Expected outcomes:
- Patient will maintain systolic blood pressure above 90 mmHg and diastolic blood pressure above 60 mmHg, indicating adequate organ perfusion.
- Patient will exhibit urine output of at least 30 mL per hour, reflecting adequate renal perfusion.
- Patient will demonstrate stable hemoglobin levels within acceptable limits for postpartum status.
Assessment:
1. Monitor Vital Signs and LOC. Closely monitor vital signs (blood pressure, heart rate, respiratory rate) and level of consciousness (LOC) frequently, at least every 15 minutes initially and more frequently as needed. Hypotension, tachycardia, confusion, lightheadedness, and weakness are key signs of hypovolemia and impending hypovolemic shock.
2. Assess the Uterus. Determine the source of bleeding. Assess uterine tone by palpating the fundus. A soft or “boggy” uterus indicates atony, the most common cause of PPH. An inverted uterus will not be palpable abdominally and may protrude through the cervix or vagina. Internal examination may be needed to evaluate for cervical or vaginal lacerations or uterine rupture.
3. Obtain Lab Work. Laboratory data is essential to quantify blood loss and guide management. Low hemoglobin and hematocrit are expected. Coagulation studies (platelets, PT/INR, PTT, fibrinogen, D-dimer) may be abnormal depending on the underlying cause and severity of bleeding, especially in DIC.
4. Monitor Lochia and Characteristics. Continuously monitor the amount, color, and characteristics of lochia. Quantify blood loss by weighing perineal pads (1 gram = 1 mL of blood). Note the presence of large clots, saturation frequency of pads, and any changes in color or odor.
Interventions:
1. Massage Uterus. Perform uterine massage immediately and frequently after delivery to stimulate uterine contractions and reduce bleeding. Teach the patient and family how to perform fundal massage.
2. Administer Oxytocin. Administer oxytocin intravenously or intramuscularly as per protocol to promote uterine contraction and prevent/treat atony.
3. Maintain Bed Rest. To ensure patient safety in the context of hypovolemia, maintain strict bed rest to prevent orthostatic hypotension, dizziness, and falls. Elevate the patient’s legs to promote venous return and improve cerebral perfusion.
4. Administer IV Fluids. Initiate rapid intravenous fluid resuscitation with isotonic crystalloids (normal saline or Lactated Ringer’s) to expand intravascular volume and improve blood pressure.
5. Administer Blood Products. Administer blood products (packed red blood cells, plasma, platelets, cryoprecipitate) as ordered based on laboratory values, ongoing blood loss, and clinical status to replace blood volume and clotting factors.
6. Prepare for Surgery. If hemorrhage is due to lacerations, hematoma, trauma, uterine rupture, or retained placental tissue, prepare the patient for potential surgical interventions as indicated.
Deficient Knowledge
Lack of adequate information about childbirth, postpartum recovery, and potential complications can contribute to delayed recognition and management of PPH.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Lack of prior childbirth education
- Unfamiliarity with postpartum complications
- Information misinterpretation
As evidenced by:
- Expresses concerns or misconceptions about postpartum bleeding
- Asks frequent questions about postpartum care and PPH signs
- Statements reflecting misinformation about normal postpartum changes
- Development of PPH complications due to delayed recognition
Expected outcomes:
- Patient will verbalize understanding of postpartum hemorrhage, its signs, and required treatments.
- Patient will verbalize signs and symptoms of PPH that necessitate prompt follow-up care.
- Patient will actively participate in the plan of care to minimize the risk of PPH complications and ensure timely intervention.
Assessment:
1. Identify Risk Factors. Assess the patient’s understanding of their individual risk factors for PPH (e.g., placenta previa, multiple gestation, prior PPH, prolonged labor).
2. Assess the Patient’s Understanding. Evaluate the patient’s current knowledge about normal postpartum changes and abnormal signs/symptoms, especially related to vaginal bleeding. Review warning signs of PPH and when to seek immediate medical attention.
Interventions:
1. Provide Discharge Education. Comprehensive discharge teaching is crucial. Educate patients and their families about:
- Normal postpartum lochia progression (color, amount, duration).
- Abnormal bleeding patterns (saturating a pad in an hour, passing large clots, return to heavy bleeding).
- Other warning signs of PPH (dizziness, fatigue, new or worsening abdominal or pelvic pain, fever).
- Importance of prompt reporting of any concerning symptoms to their healthcare provider.
2. Breastfeed Immediately. Educate and encourage immediate breastfeeding post-delivery, explaining its role in stimulating oxytocin release and promoting uterine contraction, which helps reduce bleeding.
3. Review Follow-Up Care. Explain the importance of postpartum follow-up appointments. PPH may necessitate follow-up lab work (CBC, iron levels) to monitor for anemia and guide further management. Discuss potential need for iron supplements or dietary modifications.
Imbalanced Nutrition: Less Than Body Requirements
Postpartum hemorrhage can lead to significant blood loss and iron deficiency, predisposing the client to imbalanced nutrition and anemia.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Blood loss and iron depletion
- Potential inadequate food intake postpartum
- Fatigue and weakness
- Possible nausea or decreased appetite
As evidenced by:
- Laboratory values indicating anemia (low hemoglobin, hematocrit, ferritin)
- Reports of fatigue and weakness
- Pallor (pale skin)
- Lightheadedness or dizziness
- Delayed wound healing
Expected outcomes:
- Patient will verbalize knowledge of nutrients and food sources high in iron to include in their postpartum diet.
- Patient will demonstrate improvement in red blood cell count, hemoglobin, and iron levels towards normal limits.
Assessment:
1. Assess Laboratory Values. Monitor CBC, iron studies (serum iron, ferritin, transferrin saturation) to assess for anemia and iron deficiency. Serial monitoring is important to track recovery.
2. Assess the Patient’s Fluid Status. PPH can impact fluid and electrolyte balance. Assess for dehydration signs (dry mucous membranes, poor skin turgor, concentrated urine). Monitor intake and output and electrolyte levels if indicated.
3. Assess for Signs of Anemia. Evaluate for clinical signs of anemia, including fatigue, pallor, weakness, shortness of breath, and dizziness.
4. Assess for a Lack of Appetite or Symptoms Preventing Adequate Intake. Explore factors that may impede adequate nutritional intake, such as pain, nausea, fatigue, postpartum depression, or lack of appetite.
Interventions:
1. Encourage Adequate Fluid Intake Orally or Intravenously. Ensure adequate hydration to correct fluid deficits from blood loss and support bodily functions. Encourage oral fluid intake. IV fluids may be needed initially or if oral intake is insufficient.
2. Instruct on Sources of Iron in Food. Provide dietary education on iron-rich foods. Heme iron (from animal sources) is more readily absorbed. Examples include lean meats, poultry, seafood. Non-heme iron (plant-based) sources include beans, lentils, spinach, fortified cereals. Advise combining non-heme iron sources with vitamin C to enhance absorption.
3. Educate on Taking Iron Supplements as Indicated. If iron deficiency anemia is diagnosed, educate the patient on prescribed iron supplements. Provide instructions on:
- Taking iron supplements with vitamin C-rich juice or food to improve absorption.
- Avoiding taking iron with calcium-rich foods or antacids, which can impair absorption.
- Taking iron on an empty stomach if tolerated, or with food if GI upset occurs.
- Potential side effects of iron supplements (constipation, dark stools) and strategies to manage them.
4. Refer the Patient to a Dietitian. Consider referral to a registered dietitian for personalized meal planning and nutritional counseling, especially for patients with significant anemia or complex dietary needs.
References
(Note: The original article does not list specific references. In a real-world scenario, evidence-based references would be essential to support the content.)
