Nursing Care Plan (NCP) for Postpartum Hemorrhage (PPH)

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

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

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)? 

1. Nursing Diagnoses
2. Desired Outcomes
3. Nursing Interventions
4. 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