Risk for Bleeding Nursing Diagnosis Postpartum: Comprehensive Guide for Nurses

This article provides a detailed guide for nurses on creating a care plan for patients with a risk for bleeding, specifically in the postpartum period. Understanding and addressing the risk for bleeding is crucial in postpartum care, as it remains a significant cause of maternal morbidity and mortality worldwide. Risk for bleeding is defined as the vulnerability to a decrease in blood volume that may compromise health. By implementing thorough risk assessments and targeted interventions, nurses can significantly improve patient outcomes and ensure timely identification and management of postpartum bleeding complications.

Note: It’s important to acknowledge that the nursing diagnosis “Risk for Bleeding” has been updated to “Risk for Excessive Bleeding” by NANDA International. While the updated terminology is essential for standardized language, this article will continue to use “Risk for Bleeding” to maintain broader recognition and accessibility for nurses familiar with the previous term, especially in practice and education settings where adoption of the new label may still be ongoing.

Risk Factors for Postpartum Bleeding

Identifying specific risk factors is paramount in developing effective nursing interventions to mitigate the risk of postpartum bleeding. Recognizing these factors allows for proactive planning and preventative strategies tailored to each patient’s needs.

Common risk factors for postpartum bleeding include:

• Uterine Atony: Failure of the uterus to contract adequately after delivery, often due to overdistention (multiple gestation, polyhydramnios, macrosomia), prolonged or rapid labor, grand multiparity, or use of certain medications (e.g., magnesium sulfate, tocolytics).
• Retained Placental Fragments: Incomplete expulsion of the placenta or placental fragments remaining in the uterus can impede uterine involution and lead to prolonged or excessive bleeding.
• Lacerations of the Genital Tract: Tears in the perineum, vagina, cervix, or uterus during delivery, especially with operative deliveries or precipitous births.
• Episiotomy: Although less common now, episiotomies can contribute to blood loss and potential hematoma formation.
• Coagulation Disorders: Pre-existing conditions like von Willebrand disease or acquired coagulopathies such as HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count) and DIC (Disseminated Intravascular Coagulation) increase bleeding risk.
• Preeclampsia and Eclampsia: These hypertensive disorders of pregnancy can affect coagulation and increase the risk of postpartum hemorrhage.
• Operative Delivery: Cesarean sections, forceps, or vacuum-assisted deliveries are associated with a higher risk of bleeding due to surgical interventions or trauma.
• Multiple Gestation: Overdistention of the uterus increases the risk of uterine atony.
• Grand Multiparity: Repeated pregnancies can weaken uterine muscle tone, increasing the risk of atony.
• Prolonged Labor: Uterine fatigue from prolonged labor can contribute to atony.
• Infection (Chorioamnionitis, Endometritis): Infections can interfere with uterine contractility and increase bleeding risk.
• History of Postpartum Hemorrhage: Women with a previous postpartum hemorrhage are at higher risk in subsequent pregnancies.

Note: A risk diagnosis, like “Risk for Bleeding,” is based on the presence of risk factors, not on existing signs and symptoms of bleeding. Nursing interventions are focused on prevention.

Expected Outcomes for Postpartum Patients at Risk for Bleeding

Care goals for postpartum patients identified as being at risk for bleeding are centered on preventing postpartum hemorrhage, ensuring timely recognition if bleeding occurs, and providing comprehensive patient education.

Expected outcomes for a postpartum patient with a “Risk for Bleeding” diagnosis include:

• Patient will not experience excessive postpartum bleeding, as evidenced by:
  • Lochia within normal limits (scant to moderate, rubra to serosa, decreasing amount over time).
  • Stable vital signs, including blood pressure and heart rate within normal postpartum ranges.
  • Uterine fundus firm and at or below the umbilicus, as appropriate for postpartum day.
  • Hemoglobin and hematocrit levels within normal postpartum range or patient’s baseline.
• Patient will verbalize understanding of postpartum bleeding precautions and warning signs.
• Patient will demonstrate appropriate self-care measures to promote uterine involution and minimize bleeding risk.
• Patient will promptly report any signs of excessive bleeding or concerning symptoms to healthcare providers.

Nursing Assessment for Postpartum Bleeding Risk

A thorough nursing assessment is the cornerstone of effective care. In the postpartum period, this assessment must be focused on identifying risk factors and early signs of potential bleeding complications.

1. Review the patient’s prenatal and intrapartum history for risk factors associated with postpartum hemorrhage. (Relates to Risk Factors section above.)

• Identifying predisposing factors allows for anticipatory planning and targeted preventative interventions.

2. Assess uterine fundus for firmness and position immediately after delivery and regularly thereafter (typically every 15 minutes for the first hour, every 30 minutes for the second hour, and then every 4 hours or as per protocol).

• A firm, contracted uterus is essential to compress blood vessels at the placental site and prevent excessive bleeding. A boggy or poorly contracted uterus (uterine atony) is a primary cause of postpartum hemorrhage.

3. Evaluate lochia for amount, color, and presence of clots.

• Lochia provides valuable information about uterine involution and potential bleeding. Excessive lochia (soaking more than one pad per hour), bright red bleeding after the first few days, or large clots can indicate postpartum hemorrhage or subinvolution.

4. Monitor vital signs closely, including blood pressure, heart rate, and respiratory rate.

• Tachycardia and hypotension are late signs of postpartum hemorrhage. Early subtle changes such as a slight increase in heart rate or decrease in blood pressure should be noted and investigated in conjunction with other assessment findings.

5. Assess for signs of orthostatic hypotension.

• Dizziness or a significant drop in blood pressure when changing position may indicate decreased blood volume from bleeding. It also increases the risk of falls in the postpartum period.

6. Inspect the perineum for hematoma, edema, and signs of infection if laceration or episiotomy repair was performed.

• Perineal hematomas can be a source of hidden blood loss and significant pain. Edema and infection can impair healing and potentially contribute to bleeding.

7. Review laboratory values, including hemoglobin and hematocrit levels, especially if risk factors are present or if excessive bleeding is suspected.

• These values provide a baseline and help quantify blood loss. Serial measurements are crucial in monitoring the patient’s status if bleeding occurs.

8. Assess patient’s understanding of postpartum bleeding warning signs and self-care measures.

• Patient education empowers women to actively participate in their care and promptly seek help if needed.

Alt text: Postpartum nurse educating a new mother about newborn care and maternal recovery in a bright hospital room, emphasizing patient education for postpartum well-being.

Nursing Interventions for Postpartum Bleeding Risk

Prompt and effective nursing interventions are critical to preventing and managing postpartum bleeding. These interventions range from preventative measures to emergency management.

1. Implement preventative measures to minimize bleeding risk.

• Proactive measures reduce the likelihood of postpartum hemorrhage and promote optimal recovery.

• Active Management of the Third Stage of Labor: This is a crucial preventative strategy and includes:

  • Routine administration of uterotonic medications (e.g., oxytocin) immediately after delivery of the infant and/or placenta.
  • Controlled cord traction.
  • Uterine massage after placental delivery.

• Encourage early and frequent breastfeeding: Breastfeeding releases oxytocin, which promotes uterine contractions and involution.

• Ensure complete placental expulsion: Careful inspection of the placenta after delivery is essential to confirm intactness. If fragments are suspected, manual exploration or uterine curettage may be necessary.

• Promote bladder emptying: A full bladder can displace the uterus and interfere with uterine contraction. Encourage frequent voiding or catheterization if needed.

2. Provide immediate postpartum care focused on uterine tone and lochia monitoring.

• Vigilant monitoring allows for early detection of bleeding complications.

• Fundal Massage: If the uterus is boggy, initiate fundal massage immediately and continue until firm. Teach the patient and family how to perform fundal massage and encourage frequent self-massage.

• Monitor Lochia: Assess lochia amount, color, and clots with each fundal check. Weigh perineal pads if quantitative blood loss assessment is needed (1 gram = 1 mL of blood).

• Vital Sign Monitoring: Continue frequent vital sign monitoring as per protocol or as indicated by patient status.

3. Administer uterotonic medications as ordered to promote uterine contraction.

• Uterotonics are the first-line treatment for uterine atony and postpartum hemorrhage.

• Oxytocin (Pitocin): Usually administered intravenously or intramuscularly as a prophylactic or treatment measure.

• Misoprostol (Cytotec): Can be administered rectally, orally, or sublingually.

• Methylergonovine (Methergine): Given intramuscularly; contraindicated in patients with hypertension.

• Carboprost tromethamine (Hemabate): Given intramuscularly; contraindicated in patients with asthma.

4. Educate the patient and family about postpartum bleeding warning signs and when to seek immediate medical attention.

• Empowering patients and families to recognize danger signs is critical for timely intervention after discharge.

• Instruct on signs of excessive bleeding: Soaking more than one pad per hour, passing large clots, return to bright red bleeding after it has become pink or brown.

• Explain other concerning symptoms: Dizziness, lightheadedness, palpitations, weakness, blurred vision.

• Provide clear instructions on who to contact and where to go (e.g., labor and delivery unit, emergency department) if warning signs occur.

5. Ensure adequate intravenous access and be prepared to administer intravenous fluids and blood products if hemorrhage occurs.

• Prompt resuscitation is essential in managing postpartum hemorrhage.

• Establish large-bore intravenous access.

• Administer crystalloid intravenous fluids (e.g., Lactated Ringers, Normal Saline) to maintain circulatory volume.

• Prepare for possible blood transfusion based on blood loss and patient status.

6. Provide emotional support and reassurance to the patient and family.

• Postpartum hemorrhage can be a frightening experience. Providing calm reassurance and clear communication is vital.

• Explain all procedures and treatments to the patient and family.

• Offer emotional support and address anxieties and concerns.

7. Prepare for and assist with advanced interventions if postpartum hemorrhage is severe or unresponsive to initial measures.

• In severe cases, more aggressive interventions may be required.

• Bakri Balloon or other intrauterine tamponade devices: To physically compress the uterine cavity.

• Uterine artery embolization: A radiological procedure to selectively block blood flow to the uterus.

• Surgical interventions: Uterine compression sutures, B-Lynch sutures, or as a last resort, hysterectomy.

Postpartum Nursing Care Plan Examples for Risk for Bleeding

Postpartum care plans for “Risk for Bleeding” should be individualized based on the patient’s specific risk factors and assessment findings. Here are examples of care plan focuses:

Care Plan #1: Risk for Bleeding related to Uterine Atony

Diagnostic statement:

Risk for bleeding related to uterine atony as evidenced by grand multiparity and prolonged labor.

Expected outcomes:

• Patient will maintain a firm uterine fundus postpartum.
• Patient will exhibit lochia within normal limits.
• Patient will verbalize understanding of fundal massage and warning signs of uterine atony.

Assessment:

1. Assess uterine risk factors: Grand multiparity and prolonged labor increase risk of atony.
2. Assess uterine tone immediately postpartum and frequently thereafter. Identify early signs of atony (boggy uterus).
3. Monitor lochia amount and characteristics. Detect excessive bleeding or clots.
4. Monitor vital signs closely. Identify trends indicative of hypovolemia.
5. Assess patient’s understanding of fundal massage. Evaluate knowledge deficit in self-care.

Interventions:

1. Administer prophylactic uterotonic medication (oxytocin) as ordered. Prevent uterine atony proactively.
2. Perform fundal massage immediately after delivery and regularly. Promote uterine contraction.
3. Teach patient and family how to perform fundal massage. Empower patient for self-care and early intervention.
4. Monitor lochia and vital signs frequently. Enable early detection of bleeding.
5. Educate patient and family about warning signs of postpartum hemorrhage. Ensure prompt recognition of complications at home.
6. Encourage early breastfeeding. Stimulate oxytocin release and uterine contraction.

Care Plan #2: Risk for Bleeding related to Retained Placental Fragments

Diagnostic statement:

Risk for bleeding related to potential retained placental fragments as evidenced by manual placental removal.

Expected outcomes:

• Patient will experience normal uterine involution.
• Patient will exhibit lochia within normal limits without prolonged heavy bleeding.
• Patient will report any signs of prolonged or excessive bleeding.

Assessment:

1. Assess for risk factors: Manual placental removal increases risk of retained fragments.
2. Assess uterine tone and involution progress. Identify subinvolution which can indicate retained fragments.
3. Monitor lochia for amount, color, and odor. Prolonged rubra lochia or foul odor may suggest retained fragments or infection.
4. Monitor for signs of infection (fever, uterine tenderness). Retained fragments can predispose to endometritis.
5. Review placental examination report. Confirm if placenta was complete or if fragments were noted.

Interventions:

1. Monitor uterine involution and lochia closely. Detect early signs of subinvolution or prolonged bleeding.
2. Administer uterotonic medications as ordered. Promote uterine contraction and expulsion of any retained fragments.
3. Educate patient about signs of subinvolution, prolonged bleeding, and infection. Ensure patient can recognize and report potential complications.
4. Prepare patient for potential diagnostic procedures (ultrasound) or interventions (uterine curettage) if indicated. Address retained fragments if conservative measures are insufficient.
5. Instruct patient to report any fever, increased pain, or foul-smelling lochia. Facilitate prompt treatment of potential infection.

Care Plan #3: Risk for Bleeding related to Lacerations

Diagnostic statement:

Risk for bleeding related to lacerations of the genital tract as evidenced by operative vaginal delivery (forceps).

Expected outcomes:

• Patient will experience minimal bleeding from laceration repair site.
• Patient will report minimal perineal pain and discomfort.
• Patient will demonstrate understanding of perineal care to promote healing and prevent infection.

Assessment:

1. Assess for risk factors: Operative delivery increases risk of lacerations.
2. Inspect perineal repair site for signs of bleeding, hematoma, edema, and infection. Identify complications at the laceration site.
3. Assess patient’s pain level and need for pain relief. Manage discomfort associated with laceration repair.
4. Monitor lochia amount and characteristics. Differentiate between lochia and bleeding from the laceration site.
5. Assess patient’s understanding of perineal care. Evaluate knowledge for self-management of perineal healing.

Interventions:

1. Assess perineal repair site regularly for bleeding and hematoma formation. Detect early complications at the repair site.
2. Apply ice packs to the perineum for the first 24 hours. Reduce edema and pain.
3. Encourage sitz baths after the first 24 hours. Promote healing and comfort.
4. Administer pain medication as ordered. Manage perineal pain effectively.
5. Teach patient perineal hygiene: Wiping front to back, use of peri-bottle, frequent pad changes. Prevent infection and promote healing.
6. Educate patient about signs of infection at the laceration site. Ensure patient can recognize and report potential infection.

References

1. Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
2. Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
3. Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
4. Gulanick, Meg, and Judith L. Myers. Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier/Mosby, 2014.
5. Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b-000000928
6. American College of Obstetricians and Gynecologists (ACOG). (2017). Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics & Gynecology, 130(4), e168-e186.
7. World Health Organization (WHO). (2023). Maternal mortality. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality

This comprehensive guide equips nurses with the knowledge and tools necessary to effectively assess, plan, and intervene for postpartum patients at risk for bleeding. By prioritizing preventative measures, vigilant monitoring, and patient education, nurses play a vital role in reducing the incidence and severity of postpartum hemorrhage, ultimately contributing to safer and healthier outcomes for mothers and their newborns.