Postpartum Hemorrhage (PPH) is a serious complication occurring after childbirth. 1-5% of mothers will experience PPH which is defined as a blood loss of greater than 1,000 mL of blood along with signs of hypovolemia. Primary PPH can occur up to 24 hours after delivery while secondary PPH occurs anywhere from 24 hours to 12 weeks postpartum.
The most common cause of PPH is uterine atrophy, which is when the uterus does not contract following delivery of the placenta, leading to abnormal blood loss. If not recognized and corrected promptly, the mother may experience shock and death. PPH is responsible for 25% of maternal deaths worldwide.
The Nursing Process
Nurses working in labor and delivery and postpartum settings must understand the signs and symptoms of postpartum hemorrhage and react immediately. Nurses can also educate patients on their risk factors for experiencing this complication and provide effective teaching on monitoring their recovery at home along with follow-up care.
Nursing Care Plans Related to Postpartum Hemorrhage
Deficient Fluid Volume Care Plan
A drop in circulating blood volume decreases perfusion to vital organs.
Nursing Diagnosis: Deficient Fluid Volume
- Blood loss after birth (hemorrhage)
As evidenced by:
- Changes in mental status
- Decreased urine output
- Decreased hemoglobin
- Patient will maintain blood pressure above 90/60 mm Hg for perfusion to vital organs
- Patient will not experience more than 1000 mL of blood loss following vaginal birth
- Patient will maintain hemoglobin level within normal limits
Deficient Fluid Volume Assessment
1. Monitor vital signs and LOC.
The nurse should monitor vital signs closely during and after delivery. Hypotension, tachycardia, confusion, faintness, and weakness, are signs of hypovolemia and impending shock from blood loss.
2. Assess the uterus.
The first step is to locate the source of the bleeding. A soft or “boggy” uterus signals it isn’t contracting and is the main cause of postpartum hemorrhage. If the uterus is round or bulging this signals uterine inversion. An internal exam may be needed to assess for lacerations or other signs of uterine rupture.
3. Obtain lab work.
Lab work may further diagnose PPH. Low hemoglobin levels are expected and platelets or coagulation studies may also be abnormal depending on the cause of bleeding.
4. Monitor lochia and characteristics.
Some bleeding is expected after delivery. The amount of lochia should decrease after a few hours and there should not be large clots.
Deficient Fluid Volume Interventions
1. Massage uterus.
Massaging of the uterus after delivery can promote contractions and prevent PPH.
2. Administer oxytocin.
Oxytocin is routinely administered immediately following birth to prevent and/or treat PPH.
3. Maintain bed rest.
To maintain the safety of the patient with hypovolemia, encourage bed rest to prevent orthostatic hypotension, dizziness, and falling. This can also decrease bleeding. Keep legs elevated to promote venous return.
4. Administer IV fluids.
Administration of IV fluids will be a priority intervention to increase the intravascular volume. Normal saline is usually ordered.
5. Administer blood products.
Packed red blood cells and/or plasma may be ordered to replace blood loss.
6. Prepare for surgery.
If hemorrhage is due to lacerations, hematoma, trauma, or retained tissues (placental fragments) surgery may be required.
Anxiety Care Plan
Traumatic birthing experiences can cause anxiety and even post-traumatic stress disorders.
Nursing Diagnosis: Anxiety
- Traumatic delivery
- Threat of death
As evidenced by:
- Expresses feelings of fear, sense of impending doom
- Awareness of physiological symptoms
- Expression of helplessness
- Restlessness and distress
- Patient will report decreased anxiety and feeling in control
- Patient will implement two strategies to decrease anxiety
1. Determine physiologic vs. psychologic symptoms.
Restlessness, tachypnea, and tachycardia are symptoms of anxiety but are also symptoms of PPH. The nurse must differentiate between the two to properly assess and treat the patient.
2. Assess the patient’s thoughts and feelings.
Encourage the patient to express their thoughts and perceptions of the situation. The nurse can dispel any misconceptions and clarify information to prevent panic.
1. Maintain clear communication.
The nurse should communicate the interventions taken and outcomes. The nurse should remain supportive and empathetic and provide calm reassurance to decrease anxiety.
2. Involve support system.
The patient’s support system such as the spouse/partner and family should be included in teaching and instruction. They can support the nurse in reducing the fear of the patient and supporting the treatment plan.
3. Keep baby and mother together when possible.
Separating the mother from their newborn can cause unnecessary stress. If the mother is being treated in her room, try and keep the baby with her to promote bonding and distraction.
4. Provide therapy resources.
Experiencing a life-threatening situation can cause long-term stress and anxiety. Additional counseling following the event can assist the patient and family in coping. Post-partum depression is also more likely to occur after PPH.
Deficient Knowledge Care Plan
Providing education on childbirth and delivery expectations can prepare the mother and support person for complications before they arise.
Nursing Diagnosis: Deficient Knowledge
- Lack of information provided
- Unfamiliarity with situation
As evidenced by:
- Exaggerated behaviors
- Information seeking
- Statements reflecting misinformation
- Development of PPH
- Patient will verbalize an understanding of the situation and treatments
- Patient will verbalize signs and symptoms of PPH that require follow-up
- Patient will participate in the plan of care to decrease the risk of PPH complications
Deficient Knowledge Assessment
1. Identify risk factors.
Placenta abruption, placenta previa, an overdistended uterus, multiple-gestation pregnancy, preeclampsia, prolonged labor, and obesity are risk factors for PPH.
2. Assess the patient’s understanding.
Review possible complications with the patient and signs and symptoms to be aware of at discharge to know when to seek prompt treatment.
Deficient Knowledge Interventions
1. Provide discharge education.
Patients should have an understanding of what is considered normal after delivery. PPH usually occurs very quickly after delivery but can occur up to 12 weeks later. Instruct the patient to call their healthcare provider for increased vaginal bleeding (saturating a sanitary pad in an hour) or passing large clots, feelings of dizziness, fatigue, and new or worsening abdominal pain.
2. Breastfeed immediately.
Breastfeeding is often encouraged immediately as it stimulates the oxytocin reflex which can stimulate uterus contraction, reducing bleeding. Educate and encourage the mother to request to breastfeed if they desire.
3. Review follow-up care.
PPH may require follow-up lab testing to monitor blood counts and iron levels to check for anemia. Iron supplements or diets high in iron may be recommended.
References and Sources
- Association of Ontario Midwives. (n.d.). Life after postpartum hemorrhage. Ontario Midwives. Retrieved May 12, 2022, from https://www.ontariomidwives.ca/sites/default/files/CPG%20client%20resources/Life-after-PPH-English.pdf
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Evensen, A., Anderson, J., & Fontaine, P. (2017, April 1). Postpartum Hemorrhage: Prevention and Treatment. American Family Physician. https://www.aafp.org/afp/2017/0401/p442.html
- Infant and Young Child Feeding: Model Chapter for Textbooks for Medical Students and Allied Health Professionals. Geneva: World Health Organization; 2009. SESSION 2, The physiological basis of breastfeeding. Available from: https://www.ncbi.nlm.nih.gov/books/NBK148970/
- March of Dimes. (2020, March). Postpartum hemorrhage. March of Dimes. Retrieved May 12, 2022, from https://www.marchofdimes.org/pregnancy/postpartum-hemorrhage.aspx
- Postpartum Hemorrhage – Health Encyclopedia – University of Rochester Medical Center. (n.d.). URMC. Retrieved May 12, 2022, from https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P02486
- Wormer KC, Jamil RT, Bryant SB. Acute Postpartum Hemorrhage. [Updated 2022 Jan 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499988/