Postpartum Hemorrhage (PPH) remains a critical obstetric emergency, defined by the American College of Obstetricians and Gynecologists (ACOG) as a blood loss exceeding 1,000 mL or any blood loss accompanied by signs of hypovolemia within 24 hours after birth. Affecting 1-5% of postpartum women, PPH can be categorized as primary (occurring within 24 hours of delivery) or secondary (occurring 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. This lack of contraction leads to continued bleeding from the placental site. Unaddressed PPH can rapidly progress to maternal shock and death, contributing to a staggering 25% of maternal deaths globally.
For nurses in labor and delivery and postpartum care settings, a thorough understanding of PPH, including its risk factors, signs and symptoms, and immediate management strategies, is paramount. This guide delves into the essential aspects of PPH, focusing on the nursing process, assessment techniques, key interventions, and relevant nursing diagnoses to equip nurses with the knowledge to provide optimal care and improve patient outcomes.
Nursing Assessment for Postpartum Hemorrhage
The cornerstone of effective nursing care begins with a comprehensive nursing assessment. This involves gathering subjective and objective data to identify women at risk for or experiencing postpartum hemorrhage.
Health History Review
1. Identify Acute Postpartum Bleeding Symptoms: Recognizing early signs of PPH is crucial for timely intervention. Subjective and objective symptoms to assess include:
- General: Reports of weakness, lightheadedness upon standing (orthostatic intolerance), chills, and restlessness.
- Central Nervous System (CNS): Dizziness and episodes of syncope or 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: Oliguria (decreased urine output) or anuria (absent urine output), indicating reduced organ perfusion.
2. Detailed Medical History: A thorough review of the patient’s medical history is essential to identify pre-existing conditions that elevate PPH risk:
- Pre-existing hypertension or pregnancy-induced hypertension (preeclampsia, eclampsia).
- Pre-existing infections or infections developed during pregnancy (chorioamnionitis, endometritis).
- Coagulation disorders (Disseminated Intravascular Coagulation – DIC, von Willebrand disease, hemophilia).
- Pre-existing bleeding disorders or a history of easy bruising or prolonged bleeding.
- Anemia (pre-existing or developed during pregnancy).
- Obesity (BMI ≥ 30 kg/m²).
- Advanced maternal age (typically considered ≥ 35 years).
3. Obstetric History: Reviewing the patient’s obstetric history helps pinpoint factors related to previous pregnancies or the current pregnancy that increase PPH likelihood:
- Placental abnormalities: placenta accreta, placenta previa, placental abruption.
- History of retained placenta in previous deliveries.
- Multiparity (five or more previous pregnancies).
- Multiple gestation (twins, triplets, or higher-order multiples).
- Fetal macrosomia (birth weight > 4000g or ~ 8 lbs 13 oz).
- Polyhydramnios (excessive amniotic fluid).
4. Medication Review: Certain medications can predispose women to postpartum bleeding. A careful medication reconciliation should include:
- Anticoagulants (heparin, aspirin, warfarin, enoxaparin).
- Nonsteroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, naproxen, diclofenac).
- Corticosteroids (prednisone, dexamethasone).
- Selective serotonin reuptake inhibitors (SSRIs) (sertraline, fluoxetine, citalopram).
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) (venlafaxine, duloxetine, desvenlafaxine).
Physical Assessment for Postpartum Hemorrhage
1. Vital Signs and Vaginal Bleeding: Continuous monitoring of vital signs, particularly heart rate and blood pressure, is critical. Tachycardia and hypotension are hallmark signs of significant blood loss. Assess the amount and nature of vaginal bleeding (lochia).
2. Genital Examination: Inspect the perineum, vagina, and cervix for:
- Lacerations (perineal, vaginal, cervical).
- Hematomas (vulvar, vaginal, retroperitoneal).
- Signs of uterine rupture (though less common, consider in cases of severe pain or risk factors).
Alt text: Nurse palpating and massaging the uterine fundus of a postpartum woman to assess for firmness and control bleeding.
3. Placental Examination: Verify complete placental expulsion within 30 minutes of delivery. Inspect the placenta for intactness and missing cotyledons, which may indicate retained placental fragments.
4. Uterine Tone and Size: Palpate the uterine fundus to assess tone. Uterine atony is characterized by a soft, “boggy,” or non-contracted uterus. A non-contracted uterus cannot effectively compress blood vessels at the placental site, leading to excessive bleeding.
5. Assessment for Disseminated Intravascular Coagulation (DIC): Be vigilant for signs of DIC, a severe complication of PPH, characterized by:
- Generalized bleeding from multiple sites (IV sites, gums, nose).
- Bruising (ecchymosis) and petechiae.
- Hypotension.
- Dyspnea (shortness of breath).
- Confusion or altered mental status.
6. Lochia Assessment: Evaluate the amount, color, and consistency of lochia:
- In the initial postpartum period, lochia rubra (red) is expected and may resemble a heavy menstrual flow.
- Saturation of more than one perineal pad per hour or passage of large blood clots is indicative of excessive bleeding and requires immediate intervention.
Diagnostic Procedures for Postpartum Hemorrhage
1. Laboratory Tests: Essential blood tests include:
- Complete Blood Count (CBC): To monitor hemoglobin (Hgb), hematocrit (Hct), and platelet count.
- Blood type and screen: In preparation for potential blood transfusion.
- Coagulation studies: Prothrombin Time (PT), Partial Thromboplastin Time (PTT), Fibrinogen, D-dimer (especially if DIC is suspected).
2. Coagulation Studies Interpretation: While initial coagulation tests may be within normal limits, abnormalities may emerge in conditions predisposing to DIC, such as:
- Placental abruption.
- HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count).
- Acute fatty liver of pregnancy.
- Intrauterine fetal demise (IUFD).
- Amniotic fluid embolism.
- Septicemia.
3. Elevated INR and aPTT Investigation: If International Normalized Ratio (INR) and activated Partial Thromboplastin Time (aPTT) are prolonged, further investigate:
- Fibrinogen levels (decreased in DIC).
- Thrombin time measurement.
- D-dimer (elevated in DIC).
- Blood smear to assess for schistocytes (fragmented red blood cells) seen in DIC.
4. Ultrasound: Bedside ultrasound can be a valuable tool to:
- Identify retained placental tissue.
- Detect uterine clots.
- Assess for uterine atony (indirectly by visualizing uterine cavity).
Nursing Interventions for Postpartum Hemorrhage
Prompt and effective nursing interventions are crucial to managing PPH and preventing life-threatening complications.
Bleeding Management
1. Address Underlying Cause: Treatment focuses on resuscitation and simultaneously identifying and treating the cause of PPH. The “4 Ts” are helpful to remember the common causes: Tone (uterine atony), Trauma (lacerations, hematomas, rupture), Tissue (retained placenta), and Thrombin (coagulation disorders).
2. Optimize Organ Perfusion: Maintaining hemodynamic stability is paramount to ensure adequate perfusion to vital organs:
- Ensure patent large-bore intravenous (IV) access (at least two IV lines, 16-18 gauge).
- Elevate the patient’s legs (Trendelenburg position is no longer routinely recommended, leg elevation is sufficient).
- Administer supplemental oxygen via face mask or nasal cannula as needed.
3. Intravenous Fluid Resuscitation: Initiate rapid infusion of crystalloid solutions, such as normal saline (0.9% NaCl) or Lactated Ringer’s (LR).
4. Blood Transfusion: Early administration of blood products is critical, guided by ongoing assessment of blood loss and laboratory results. Consider:
- Packed red blood cells (PRBCs) for significant blood loss and low hemoglobin.
- Fresh frozen plasma (FFP) and platelets for coagulopathies or DIC.
5. Vital Signs and Urine Output Monitoring: Continuously monitor blood pressure, heart rate, oxygen saturation, and urine output as indicators of perfusion and response to treatment. Urine output should be maintained at least 30 mL/hour.
6. Trauma Repair: Surgical interventions may be necessary to address trauma:
- Exploration of the uterus for rupture and repair if possible.
- Repair of cervical, vaginal, and perineal lacerations.
- Evacuation of hematomas.
- Correction of uterine inversion (if present).
7. Uterine Atony Management: Strategies to manage uterine atony include:
- Bimanual uterine massage: A primary nursing intervention to stimulate uterine contractions.
- Uterotonic Medications: Administer medications to promote uterine contraction, such as oxytocin (Pitocin), misoprostol (Cytotec), methylergonovine (Methergine – contraindicated in hypertension), carboprost tromethamine (Hemabate – contraindicated in asthma).
- Uterine tamponade: Insertion of a balloon device (Bakri balloon) into the uterus to apply pressure and control bleeding.
- Pelvic artery embolization: Interventional radiology procedure to selectively embolize pelvic arteries supplying the uterus to reduce blood flow.
- Surgical Management: In severe cases, surgical options may include uterine artery ligation, B-Lynch brace suture, or hysterectomy (as a last resort).
8. Retained Tissue Removal: Manual removal of retained placental fragments or dilation and curettage (D&C) may be necessary.
9. Surgical Preparation: Prepare the patient for potential surgical procedures, including:
- Ligation of bleeding vessels.
- Uterine artery embolization.
- Laparotomy or hysterectomy for uterine rupture or intractable atony.
Prevention of Further Bleeding
1. Risk Assessment and Identification: Proactive identification of high-risk patients antenatally and intrapartum is key to preventing PPH. Antenatal ultrasound can help identify placental abnormalities.
2. Iron Supplementation: Address pre-existing anemia or anemia identified during pregnancy with oral or parenteral iron supplementation, especially if hematocrit is < 30%.
3. Erythropoietin-Stimulating Agents: In high-risk patients who decline blood transfusions, erythropoietin-stimulating agents may be considered in consultation with hematology.
4. Collaborative Care: Close collaboration with the healthcare provider during labor and delivery is essential to manage risk factors and make timely decisions regarding:
- Mode of delivery (vaginal vs. Cesarean section).
- Use of general anesthesia (increases risk of uterine atony).
- Management of prolonged labor or induction of labor.
- Prevention and treatment of intrapartum infections.
- Prophylactic uterotonics (oxytocin) in the third stage of labor.
5. Early Breastfeeding: Encourage immediate breastfeeding after delivery. Breastfeeding stimulates oxytocin release, promoting uterine contraction and minimizing bleeding.
6. Patient Education on Secondary PPH: Educate women about the signs and symptoms of secondary PPH, which can occur up to 12 weeks postpartum. Instruct them to report immediately any:
- Change in lochia (increased bleeding, return to red bleeding after it lightened).
- Severe abdominal cramping or pelvic pain.
- Fever or chills.
- Dizziness or lightheadedness.
Postpartum Hemorrhage Nursing Care Plans and Diagnoses
Nursing care plans provide a framework for organizing care and addressing specific patient needs based on identified nursing diagnoses. Common nursing diagnoses related to postpartum hemorrhage include:
Acute Pain
Nursing Diagnosis: Acute Pain
Related To: Tissue trauma (perineal lacerations, episiotomy), hematoma formation, surgical interventions, uterine atony and contractions.
As Evidenced By: Patient reports of pain intensity, diaphoresis, expressive pain behaviors (grimacing, moaning), guarding behavior, protective positioning, abdominal cramping, pelvic pain or pressure.
Expected Outcomes:
- Patient will verbalize a decrease in pain intensity.
- Patient will demonstrate non-pharmacological and pharmacological pain relief measures.
- Patient will participate in self-care activities with minimal pain.
Nursing Assessments:
- Comprehensive Pain Assessment: Assess pain location, quality, intensity (using a pain scale), onset, duration, and aggravating/relieving factors. Differentiate between pain from perineal trauma, uterine contractions, or potential hematoma.
- Perineal Trauma Assessment: Assess for the extent of perineal lacerations or episiotomy, presence of edema, ecchymosis, and signs of infection.
- Fundal Height and Tone Assessment: Persistent pain or heaviness with bleeding may indicate subinvolution or retained products of conception.
Nursing Interventions:
- Non-pharmacological Pain Relief: Encourage relaxation techniques (deep breathing, guided imagery), massage (back rub), and diversional activities.
- Pharmacological Pain Management: Administer analgesics as prescribed (NSAIDs, opioids) considering breastfeeding safety.
- Perineal Comfort Measures: Encourage ice pack application to the perineum for the first 24 hours to reduce edema and pain, followed by warm sitz baths to promote healing and comfort.
- Prepare for Interventions: Pain may indicate ongoing bleeding or complications requiring further interventions such as surgical repair of lacerations or hematoma evacuation.
Anxiety
Nursing Diagnosis: Anxiety
Related To: Traumatic birth experience, perceived or actual threat to life, fear of unknown, situational crisis.
As Evidenced By: Verbalization of fear or worry, expressed feelings of impending doom, awareness of physiological symptoms (tachycardia, tachypnea), restlessness, distress, apprehension.
Expected Outcomes:
- Patient will report a decrease in anxiety level.
- Patient will demonstrate coping mechanisms to manage anxiety.
- Patient will verbalize feelings and concerns related to the postpartum hemorrhage.
Nursing Assessments:
- Differentiate Physiological vs. Psychological Symptoms: Distinguish anxiety symptoms from PPH symptoms (e.g., restlessness, tachycardia, tachypnea can be due to both).
- Assess Patient’s Perceptions: Explore the patient’s understanding of the situation, fears, and concerns. Provide opportunities for open communication.
Nursing Interventions:
- Therapeutic Communication: Maintain clear, calm, and reassuring communication. Explain procedures and treatments in understandable terms. Provide emotional support and active listening.
- Involve Support System: Encourage the presence of a support person (partner, family member). Include them in education and provide reassurance.
- Mother-Baby Bonding: Facilitate skin-to-skin contact and keep mother and baby together whenever medically stable to promote bonding and reduce maternal anxiety.
- Referral to Resources: Provide information about postpartum support groups, counseling services, or mental health professionals for ongoing emotional support and management of potential postpartum PTSD or depression.
Deficient Fluid Volume
Nursing Diagnosis: Deficient Fluid Volume
Related To: Excessive blood loss during and after childbirth (postpartum hemorrhage).
As Evidenced By: Hypotension, tachycardia, decreased urine output, changes in mental status (confusion, dizziness), prolonged capillary refill, decreased hemoglobin and hematocrit.
Expected Outcomes:
- Patient will maintain stable vital signs (blood pressure, heart rate) within acceptable limits.
- Patient will exhibit adequate urine output (≥ 30 mL/hour).
- Patient will demonstrate improvement in laboratory values (Hgb, Hct) towards baseline.
- Patient will verbalize understanding of fluid replacement therapy.
Nursing Assessments:
- Monitor Vital Signs and Level of Consciousness (LOC): Frequent monitoring of blood pressure, heart rate, respiratory rate, oxygen saturation, and LOC to detect signs of hypovolemia and shock.
- Uterine Assessment: Assess uterine tone (firm vs. boggy) and location of fundus to identify uterine atony as a potential cause of bleeding.
- Lochia Assessment: Quantify and characterize lochia (amount, color, clots).
- Laboratory Data Review: Monitor trends in hemoglobin, hematocrit, and coagulation studies.
Nursing Interventions:
- Uterine Massage: Perform fundal massage to promote uterine contraction and reduce bleeding.
- Uterotonic Medication Administration: Administer prescribed uterotonic medications (oxytocin, misoprostol, etc.) as per protocol.
- Fluid Replacement: Administer IV fluids (crystalloids, colloids, blood products) as ordered to restore intravascular volume.
- Positioning: Maintain patient in a supine position with legs elevated to promote venous return.
- Bed Rest and Safety: Ensure bed rest to minimize orthostatic hypotension and risk of falls.
- Prepare for Interventions: Prepare for potential procedures such as manual removal of placenta, D&C, uterine tamponade, or surgical interventions.
Deficient Knowledge
Nursing Diagnosis: Deficient Knowledge (related to postpartum hemorrhage)
Related To: Lack of prior experience with PPH, misinformation, inadequate information provided regarding risk factors, signs, and management of PPH.
As Evidenced By: Expressed concerns or questions about PPH, inaccurate statements about PPH, development of PPH complications (indicating lack of preventive knowledge), failure to follow recommendations for postpartum care.
Expected Outcomes:
- Patient will verbalize understanding of postpartum hemorrhage, its risk factors, and signs and symptoms.
- Patient will describe appropriate self-care measures to monitor for and report signs of PPH.
- Patient will identify when to seek medical attention for postpartum bleeding concerns.
Nursing Assessments:
- Risk Factor Identification: Assess patient’s understanding of their individual risk factors for PPH.
- Knowledge Assessment: Evaluate the patient’s current knowledge about postpartum hemorrhage, normal postpartum changes, and danger signs.
Nursing Interventions:
- Discharge Education: Provide comprehensive discharge instructions on normal postpartum changes and danger signs of PPH, including increased vaginal bleeding, large clots, dizziness, fatigue, and abdominal pain. Emphasize the importance of seeking immediate medical attention if these occur.
- Breastfeeding Education: Encourage and educate on the benefits of early and frequent breastfeeding to promote uterine contraction.
- Follow-up Care Instructions: Review scheduled postpartum follow-up appointments and the importance of attending them. Discuss potential need for follow-up lab work (CBC, iron levels) and iron supplementation if indicated.
- Provide Resources: Offer written materials, websites, or support groups related to postpartum health and PPH.
Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related To: Blood loss and iron deficiency secondary to postpartum hemorrhage, fatigue, potential nausea or decreased appetite postpartum.
As Evidenced By: Laboratory evidence of anemia (low hemoglobin, hematocrit, iron levels), fatigue, pallor, lightheadedness, reported decreased appetite or food intake.
Expected Outcomes:
- Patient will verbalize understanding of nutritional needs in the postpartum period, particularly iron-rich foods.
- Patient will demonstrate improved dietary intake to meet nutritional needs.
- Patient will exhibit improvement in laboratory values (Hgb, iron levels) over time.
- Patient will report increased energy levels.
Nursing Assessments:
- Laboratory Value Assessment: Monitor CBC, iron studies (serum iron, ferritin, transferrin saturation) to assess for anemia and iron deficiency.
- Fluid Status Assessment: Assess for signs of dehydration and monitor intake and output.
- Anemia Symptom Assessment: Assess for symptoms of anemia such as fatigue, pallor, weakness, and dizziness.
- Appetite and Intake Assessment: Evaluate patient’s appetite, dietary intake, and any factors affecting intake (nausea, pain, fatigue).
Nursing Interventions:
- Hydration Promotion: Encourage adequate oral fluid intake. Administer IV fluids as prescribed.
- Dietary Education: Educate the patient on iron-rich food sources (lean meats, seafood, beans, lentils, fortified grains) and the importance of a balanced postpartum diet.
- Iron Supplement Education: If iron supplements are prescribed, educate on proper administration (with vitamin C to enhance absorption, avoid taking with calcium or tea/coffee), potential side effects (constipation, GI upset), and importance of adherence.
- Referral to Dietitian: Consider referral to a registered dietitian for individualized meal planning and nutritional counseling, especially if significant nutritional deficits are identified.
This comprehensive guide provides nurses with the knowledge and tools necessary to effectively assess, manage, and care for women experiencing or at risk for postpartum hemorrhage. By understanding the nursing diagnoses associated with PPH and implementing appropriate interventions, nurses play a vital role in ensuring positive maternal outcomes.
