Nursing Care Plan (NCP) for Postpartum Hemorrhage (PPH)
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Outline
Lesson Objective
The objective of this lesson is to equip nursing students and practitioners with a comprehensive understanding of postpartum hemorrhage (PPH), including its pathophysiology, etiology, assessment, diagnosis, and management.
By the end of this lesson, learners should be able to identify risk factors for PPH, recognize its signs and symptoms, implement effective nursing interventions, and contribute to the prevention and management of this potentially life-threatening condition.
Pathophysiology for Postpartum Hemorrhage (PPH)
Postpartum hemorrhage (PPH) is defined as a blood loss of more than 500 mL after vaginal delivery or more than 1000 mL after a cesarean section, occurring within 24 hours of birth. PPH can be classified into primary, occurring within the first 24 hours post-delivery, and secondary, occurring from 24 hours to 12 weeks postpartum. The pathophysiology of PPH involves four main causes, commonly referred to as the “Four T’s”:
- Tone: Uterine atony (the inability of the uterus to contract effectively) is the most common cause. Without proper contraction, the blood vessels within the uterine wall remain dilated, leading to continued bleeding.
- Tissue: Retention of placental fragments or other tissue within the uterus can prevent uterine contraction and cause bleeding.
- Trauma: Injury to the genital tract, such as lacerations, uterine rupture, or episiotomy, can cause significant bleeding.
- Thrombin: Coagulopathies (disorders of blood clotting) can result in excessive bleeding post-delivery.
Etiology for Postpartum Hemorrhage (PPH)
Normally, the uterus continues to contract after the delivery of the baby and placenta. These contractions help close the vessels that supplied blood from mother to baby. If these contractions cease or are not strong enough, hemorrhage occurs. A tear in the cervix, placenta, or the blood vessels within the uterus may also cause hemorrhage. Risk factors include obesity, multiple births (twins or more), many previous pregnancies, blood clotting disorders, infection, prolonged labor, or use of assistive devices in delivery such as forceps or a vacuum.
- Uterine Atony:
- Primary cause of PPH, accounting for the majority of cases.
- Risk factors include prolonged labor, uterine overdistension (multiple gestation, polyhydramnios), and magnesium sulfate administration during labor.
- Retained Placental Fragments:
- Incomplete placental expulsion can occur due to placenta accreta, increta, or percreta.
- Previous uterine surgeries, such as cesarean sections, increase the risk of abnormal placental attachment.
- Uterine Trauma or Inversion:
- Uterine trauma can result from instrumental deliveries, forceps or vacuum extraction, or manual removal of the placenta.
- Uterine inversion, though uncommon, can be associated with rapid and severe hemorrhage.
- Coagulation Disorders:
- Conditions such as DIC, hemophilia, or thrombocytopenia can predispose individuals to abnormal bleeding during childbirth.
- Anticoagulant therapy or certain medical conditions may contribute to coagulation dysfunction.
- Uterine Artery Injury:
- Vascular injuries may occur during cesarean sections or other surgical interventions.
- Improper ligation of blood vessels, trauma during surgery, or abnormal anatomy can lead to uterine artery injury.
Desired Outcome for Postpartum Hemorrhage (PPH)
A patient will maintain optimal fluid balance and vital signs within normal limits
- Hemodynamic Stability:
- Achieve and maintain stable vital signs within normal ranges, including blood pressure, heart rate, and respiratory rate.
- Ensure effective tissue perfusion and oxygenation.
- Return of Uterine Function:
- Attain effective uterine contraction to control and reduce excessive bleeding.
- Monitor and quantify postpartum bleeding to ensure it is within acceptable limits.
- Restoration of Blood Volume:
- Restore and maintain adequate blood volume to prevent or address hypovolemia.
- Monitor laboratory values, including hemoglobin and hematocrit, to assess for improvements.
- Prevention of Complications:
- Prevent or promptly address complications associated with PPH, such as disseminated intravascular coagulation (DIC) or infection.
- Monitor for signs of coagulopathy and initiate appropriate interventions.
- Psychosocial Support:
- Provide emotional support and reassurance to the individual and their family.
- Address any psychological impact of PPH, promoting a positive birthing experience.
Postpartum Hemorrhage (PPH) Nursing Care Plan
Subjective Data:
- Pain in the vaginal area (if due to hematoma)
- Dizziness
Objective Data:
- Uncontrolled bleeding
- Excessive saturation of perineal pads
- Hypotension
- Tachycardia
- Low hematocrit
Nursing Assessment for Postpartum Hemorrhage (PPH)
- Vital Signs:
- Monitor blood pressure, heart rate, respiratory rate, and oxygen saturation at frequent intervals.
- Identify and respond promptly to any signs of hemodynamic instability.
- Uterine Assessment:
- Assess uterine tone and fundal height regularly to detect signs of atony or inadequate contraction.
- Palpate for uterine tenderness or abnormalities.
- Bleeding Assessment:
- Quantify and document postpartum bleeding, including the amount, color, and presence of clots.
- Monitor for any sudden increase in bleeding or signs of persistent hemorrhage.
- Laboratory Values:
- Monitor hemoglobin and hematocrit levels to assess for changes in blood volume.
- Check coagulation studies, including prothrombin time (PT) and partial thromboplastin time (PTT), to identify coagulopathy.
- Fluid Balance:
- Evaluate fluid balance, including input and output.
- Monitor urine output and assess for signs of dehydration or fluid overload.
- Pain Assessment:
- Assess pain levels and discomfort associated with interventions and uterine contractions.
- Administer analgesics as prescribed to ensure the individual’s comfort.
- Psychosocial Assessment:
- Evaluate the emotional well-being of the individual and their family.
- Identify any signs of distress or anxiety related to the experience of PPH.
- Risk Factors and History:
- Review the individual’s obstetric history, including any previous episodes of PPH.
- Identify and assess for risk factors that may contribute to the development of PPH.
Continuous and thorough nursing assessment is crucial for early detection of PPH and prompt initiation of appropriate interventions. Monitoring vital signs, bleeding, and laboratory values, along with providing psychosocial support, contributes to achieving optimal outcomes in the management of postpartum hemorrhage.
Implementation for Postpartum Hemorrhage (PPH)
- Uterine Massage and Contraction:
- Perform uterine massage to stimulate contraction and maintain uterine tone.
- Encourage the individual to breastfeed, as nipple stimulation releases oxytocin, promoting uterine contraction.
- Administration of Uterotonic Medications:
- Administer uterotonic medications promptly as prescribed (e.g., oxytocin, misoprostol) to enhance uterine contractions and reduce bleeding.
- Monitor for side effects and effectiveness of the medication.
- Fluid Replacement:
- Initiate intravenous (IV) fluid replacement with crystalloids or blood products as indicated to restore and maintain blood volume.
- Adjust fluid therapy based on ongoing assessment and laboratory values.
- Surgical Interventions:
- Collaborate with the healthcare team for surgical interventions if conservative measures are insufficient (e.g., exploration of the uterus, ligation of blood vessels, or hysterectomy).
- Ensure informed consent and provide pre- and post-operative care.
- Psychosocial Support and Communication:
- Provide emotional support, reassurance, and clear communication to the individual and their family.
- Involve them in decision-making and address any concerns or fears related to the PPH episode.
Nursing Interventions and Rationales
| Nursing Intervention (ADPIE) | Rationale |
| Assess vital signs and monitor for signs of shock | The decreased fluid volume will cause blood pressure to drop and the patient will go into shock |
| Monitor blood loss:
Site Type Amount- should be no more than 1 perineal pad per hour Presence of clots |
The amount of blood loss and the presence of blood clots can help determine treatment. |
| Monitor intake and output | 30ml – 50 ml/hr urine output; may require indwelling catheter insertion for accurate measurement
Decreased urine output may be a sign of hematomas that put pressure on the urethra, or maybe a late sign of hypovolemic shock. |
| Assess for vaginal hematoma | If bleeding is due to a vaginal hematoma, rest and application of an ice pack may be sufficient treatment |
| Monitor lab values to determine the need for transfusions or signs of complications | Watch hematocrit and clotting levels to know if blood transfusion is necessary and for signs and severity of DIC. |
| Administer IV fluids, medications and blood products as necessary:
Oxytocin Antibiotics Analgesics |
Fluid replacement may be necessary and, depending on the amount of blood lost and hematocrit level, a blood transfusion may be required.
Oxytocin is sometimes given to initiate contractions that will help stop bleeding. |
| Perform uterine massage to stimulate contractions following delivery | Begin fundal massage and educate patients on how to massage the abdomen to stimulate contractions. These contractions may help stop bleeding. |
| Monitor and manage pain | Continued, unrelieved pain may be due to hematomas or lacerations within the vagina |
| Place the patient on bed rest with legs elevated | Rest and elevation of legs helps venous return and slows bleeding |
| Prepare patient for surgery if indicated; remain on NPO status | If bleeding can’t be managed otherwise, surgery may be required |
Evaluation of Nursing Care Plan (NCP) for Postpartum Hemorrhage (PPH)
- Effectiveness of Uterine Massage and Contraction:
- Evaluate the response to uterine massage, assessing for improved uterine tone and contraction.
- Monitor for signs of uterine atony resolution.
- Response to Uterotonic Medications:
- Assess the effectiveness of uterotonic medications in promoting uterine contraction and reducing bleeding.
- Monitor for any adverse reactions or side effects.
- Fluid Volume Restoration:
- Evaluate the individual’s response to fluid replacement, assessing for improvements in blood pressure, heart rate, and urine output.
- Monitor laboratory values to assess for changes in hemoglobin and hematocrit.
- Surgical Intervention Outcomes:
- If surgical interventions are performed, assess the outcomes, including the resolution of bleeding and any complications.
- Monitor for signs of infection, wound healing, and psychological recovery.
- Psychosocial Well-being:
- Assess the individual’s emotional well-being and provide ongoing psychosocial support.
- Evaluate coping mechanisms and provide resources for addressing any psychological impact of PPH.
Frequently Asked Questions
What are the most common risk factors for postpartum hemorrhage (pph)?
The most common risk factors for postpartum hemorrhage (pph) are obesity, multiple births (twins or more), many previous pregnancies, blood clotting disorders, infection, prolonged labor, or use of assistive devices in delivery such as forceps or a vacuum.
What is Postpartum Hemorrhage (PPH)?
Postpartum hemorrhage is a complication of pregnancy defined as severe bleeding post-delivery.
How long can postpartum hemorrhage occur after delivery?
Postpartum hemorrhage can occur up to 2 weeks post-delivery.
What are the steps or parts of a Nursing Care Plan (NCP)?
- Nursing Diagnoses
- Desired Outcomes
- Nursing Interventions
- Nursing Rationales
References
- https://www.chop.edu/conditions-diseases/postpartum-hemorrhage
- https://www.aafp.org/afp/2017/0401/p442.html
- https://childrenswi.org/medical-care/fetal-concerns-center/conditions/pregnancy-complications/postpartum-hemorrhage
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Transcript
Hey everyone. Today, we are going to be creating a care plan for postpartum hemorrhage. So, let’s get started. First, we’re going to go over the pathophysiology of postpartum hemorrhage: excessive bleeding, following delivery of a baby vaginal delivery; excessive bleeding would be more than 500 mL and a cesarean delivery would be more than 1,000 mL. Nursing considerations: you want to assess vital signs, monitor blood loss, assess for hematoma, monitor I & O, monitor lab values, administer IV fluids, medications, or blood products, fundal massage, manage pain, keep the patient on NPO status, and prepare the patient for surgery, if needed. Some desired outcomes: a patient will remain in optimal fluid balance and vital signs will be within normal limits.
So, we’re going to go ahead and start a care plan. We’re going to go over some of the subjective data, and we’re going to go over some of the objective data that you’re going to see with these patients. One of the main things of subjective data we’re going to see is they’re going to have a lot of pain in the vaginal area, which is usually due to a hematoma that is present. Some objective data that you’re going to see is going to be some uncontrolled bleeding. And then you will also see that the patient will have hypotension. So decreased BP, they will have an increased heart rate and they will have a low hematocrit.
So, some interventions that we’re going to look at for some of these patients, we’re going to assess their vital signs. We want a baseline of where their vital signs are at. See if they are hypertensive or tachycardic. Usually with these patients, their blood pressure can drop so much, they can go into shock. We want to monitor blood loss; so, when we monitor blood loss, we want to know the site, we want to know the type, the amount. We don’t want to have more than one peri pad an hour. We want to look for any sort of presence of clots and the amount of blood loss and presence of blood clots can help determine the type of treatment for the pain. We want to assess any sort of hematoma. So, if they have a hematoma, we want to assess that. So, if bleeding is due to a vaginal hematoma, usually resting and an application of an ice pack on the peritoneal area may be sufficient enough for treatment. We want to make sure that we’re going to be assessing intake and output. Usually, you want to have about 30 to 50 mL per hour minimum – a foley may be required and able to get an accurate measurement. And of course, making sure you’re doing foley care, decreased output could be a sign of a hematoma, which is going to be putting pressure on that urethra or a late sign of hypovolemic shock. We want to make sure we’re monitoring lab values and determining if a blood transfusion is needed and any sort of complications. So, we’re going to see about a low hematocrit. We’re going to be checking any sort of clotting factors. See if blood transfusions are necessary and look for any sort of signs of DIC. Some other interventions that we’re going to be doing are we’re going to be administering IV fluids, medications, and possible blood products as necessary. So certain medications would be oxytocin, which is sometimes given and able to initiate those contractions, but also helps stop the bleeding for the patient. Also given are some antibiotics, some analgesics for pain, and obviously some fluid replacements may be necessary. We’re going to perform a uterine massage. So fundal massages help stimulate uterine contractions after birth and assist to stop the bleeding.
Other things that we may want to consider is managing the patient’s pain, especially if the hematoma is present and or lacerations within the vagina after birth. When appropriate, place the patient on bedrest with the legs elevated. So, you want to make sure their legs are upright and not straight down like that. So, rest and elevation of the legs helps prevent venous return and slows the bleeding down. That’s the important part. It’s going to help slow the bleeding. And if the patient is having surgery, we want to make sure we’re keeping them on NPO status. If the bleeding cannot be managed, they will have to have surgery to stop the bleeding.
So key points we want to go over here. Postpartum hemorrhage is excessive bleeding following the delivery of a baby. So, 500 mL for the vaginal, and about 1,000 mL for a cesarean section. Contractions after birth aren’t strong enough to help close the vessels, supplying the blood from mother to baby or tears in the cervix, placenta, or blood vessels within the uterus can be possible. Some subjective and objective data. You’ll see they’re going to be dizzy and complain of pain in the vaginal area. If a hematoma is present, there could be uncontrolled bleeding. So excessive saturation of one peri pad an hour, hypotension, tachycardia, and low hematocrit. You want to monitor the blood loss, the amount you want to assess for hematoma. And we want to do fundal massages. That helps the contraction after the birth of the baby. And that helps stop and prevent more blood loss. We want to do IV fluids, meds, or blood transfusion if needed. We want to make sure that we’re keeping the patient on bedrest, keeping up NPO in case they end up needing surgery because they can’t stop the blood loss. And there you guys have it. That was an excellent care plan.
I hope you guys have a good rest of your day and as always happy nursing.
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