Notes
Description
- Early postpartum hemorrhage is defined as blood loss of 500 mL or more during the first 24 hours after delivery.
- Post partum hemorrhage is the leading cause of maternal death worldwide and a common cause of excessive blood loss during the early postpartum period.
- Approximately 5% of women experience some type of postdelivery hemorrhage.
Etiology
- Major causes of postpartum hemorrhage are uterine atony (responsible for at least 80% of all early postpartum hemorrhages); laceration of cervix, vagina, or perineum; and retained placental fragments.
- Predisposing factors include hypotonic contractions, overdistended uterus, multiparity, large newborn, forceps delivery, and cesarean delivery.
Pathophysiology
- The uterus is unable to contract effectively and maintain hemostasis.
Assessment Findings
Clinical manifestations include:
- Vaginal bleeding.
- Hypotonic uterus.
- Excessive blood loss, which may produce hypotension, thread pulse, pallor, restlessness, dyspnea, and chills.
Nursing Management
1. Assist with appropriate treatment to prevent complications.
- Determine the presence of uterine firmness and location and amount of vaginal bleeding immediately after delivery.
- Measure and record serial maternal vital signs after delivery- every 5 to 15 minutes until stable; increase or decrease the frequency of assessment relative to baseline and amount of bleeding.
- Notify the practitioner of abnormal assessment findings.
- Massage the fundus gently, taking care to support the uterus with the hand just above the symphysis pubis.
- Administer medications as prescribed.
- Keep an accurate pad count (100 mL per saturated pad).
- Assess condition of skin, urine output, and level of consciousness.
2. Provide physical and emotional support.
3. Provide client and family education.
Exam
Postpartum Hemorrhage Practice Exam (PM)*
Choose the letter of the correct answer. Good luck!
Congratulations - you have completed Postpartum Hemorrhage Practice Exam (PM)*.
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Nursing Care Plan
Ineffective Tissue Perfusion
Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.
May be related to
- Hypovolemia (a decreased volume of circulating blood in the body).
Possibly evidenced by
- Diminished arterial pulsations, cold extremities.
- Decreased capillary refill.
- Decreased milk production.
- Changes in the vital signs.
- Changes in the neurologic status.
Desired Outcomes
- Patient will demonstrate blood pressure, pulse, arterial blood gasses (ABGs), and Hematocrit/hemoglobin level within the expected range.
- Patient will demonstrate normal hormonal functioning by adequate milk supply for lactation (as appropriate) and resumption of normal menstruation.
| Nursing Interventions | Rationale |
|---|---|
| Monitor vital signs closely; record the degree and duration of any hypovolemic episodes. | Extent of pituitary involvement may be related to the degree and duration of hypotension. A respiratory difficulty may indicate an effort to combat metabolic acidosis. |
| Observe the color of the nail beds, gums, tongue and buccal mucosa; Note the temperature of the skin. | With the vasoconstriction compensation and shunting to vital organs, circulation in the peripheral blood vessels is diminished, resulting in cyanosis and cold skin temperatures. |
| Evaluate the neurologic status and observe for any behavioral changes. | Changes in the mentation is an early sign of hypoxia. Cyanosis, on the other hand, is a late sign which may not appear until the PO2 levels drop below 50 mm Hg, |
| Check the breast at least daily; Inspecting for changes in breast size and the presence or absence of lactation. | Sheehan’s syndrome, also known as postpartum hypopituitarism reduces prolactin levels, resulting in agalactorrhea (absence of lactation) and a decrease in breast tissue. |
| Monitor Hemoglobin and hematocrit values before and after blood loss. Check for the height and weight; Assess the nutritional status of the client. | Such values indicate the severity of blood losses. Preexisting poor health status increases the extent of injury brought about by the oxygen deficits. |
| Monitor arterial blood gasses (ABGs) and PH levels. | To determine the degree of tissue hypoxia or acidosis, indicating the build uo of lactic acid resulting anaerobic metabolism. |
| Administer sodium bicarbonate as indicated. | To correct metabolic acidosis. |
| Insert airway; suction as indicated. | Facilitates oxygen administration in presence of retained secretions. |
| Provide supplemental oxygen as indicated. | Maximizes available oxygen for circulatory transport to tissues. |
Risk For Infection
Risk For Infection: At increased risk of being invaded by pathogenic organisms.
Risk factors
- Decreased hemoglobin.
- Invasive procedures.
- Stasis of body fluids (lochia).
- Traumatized tissues.
Possibly evidenced by
- [Not applicable]
Desired Outcomes
- Patient will state an understanding of individual causative/risk factors.
- Patient will display white blood cell count and vital signs within expected ranges.
- Patient will display a lochia free odor.
| Nursing Interventions | Rationale |
|---|---|
| Monitor rate of uterine involution and nature and the amount of lochial discharge. | Infection of the uterus delays involution and lengthen the flow of the lochia. |
| Observe for signs of fever, chills, body malaise, anorexia, pelvic pain or uterine tenderness. | These symptoms reflect systemic involvement, possibly leading to bacteremia, shock or even death if left untreated. |
| Check the episiotomy site and abdominal wound (for caesarian) for signs of edema, erythema, separation of wound edges, purulent drainage. | These indicates localized infection requiring immediate intervention to prevent systemic involvement. |
| Check for other possible sources of infection such as urinary tract infection(urinary frequency/pain, cloudy and odoriferous urine), mastitis (swelling, erythema, pain) or respiratory infection (productive cough, purulent sputum, fever). | Differential diagnosis is critical for effective management. |
| Teach and demonstrate proper hand-washing and self-care techniques. Review appropriate handling and disposal of contaminated materials (eg., dressings, peripads, linens). | To prevent the spread of infectious organisms. |
| Review WBC count, hemoglobin and hematocrit levels. | Increased white blood cell count indicates an infection. Anemia often accompanies infection, delays the wound healing, and weaken the immune system. |
| Administer iron supplement as indicated. | To correct anemia. And possibly improves wound healing. |
| Obtain a gram’s stain or culture and sensitivity if lochia is noted to have an odiferous smell or purulent wound discharge is observed. | Gram stain identifies the type of infection while cultures and sensitivity identify the specific pathogen and can indicate which antibiotic is suitable to fight the organism. |
| Administer IV antibiotics as ordered. | Broad spectrum antibiotic may be ordered until the results from culture and sensitivity is available at which time organism-specific antibiotic may be started. |
Deficient Fluid Volume (isotonic)
Deficient Fluid Volume: It is defined as decreased intravascular, interstitial, and intracellular fluid.
May be related to
- Excessive blood loss after birth.
Possibly evidenced by
- Changes in the mental status.
- Concentrated urine.
- Delayed capillary refill.
- Decrease in the red blood cell count (hematocrit).
- Decrease blood pressure (hypotension).
- Dry skin/mucous membrane.
- Increase heart rate (tachycardia).
Desired Outcomes
- Patient will maintain a blood pressure of at least 100/60 mm Hg.
- Patient will maintain a pulse rate between 70-90 beats per minute.
- Patient will have a balanced 24-hour intake and output.
- Patient will have a cognitive status within expected range.
- Patient will have a lochia flow of less than one saturated perineal pad per hour.
- Patient will demonstrate improvement in the fluid balance as evidenced by a good capillary refill, adequate urine output, and skin turgor.
| Nursing Interventions | Rationale |
|---|---|
| Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and if possible save blood clots to be evaluated by the physician. | The amount of blood loss and the presence of blood clots will help to determine the appropriate replacement need of the patient. |
| Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis. | The degree of the contractility of the uterus will measure the status of the blood loss. Placing one hand just above the symphysis pubis will prevent possible uterine inversion during a massage. |
| Review the records and note certain conditions such as retained placental fragments, any laceration, abruptio placenta, etc. | This will help in determining the management of the situation thus preventing further complications. |
| Monitor vital signs including systolic and diastolic blood pressure, pulse and heart rate. Check for the capillary refill and observe nail beds and mucous membranes. | Increased heart rate, low blood pressure, cyanosis, delayed capillary refill indicates hypovolemia and impending shock. Decrease fluid volume of 30-50% will reflect changes in the blood pressure. |
| Note for the presence of vulvar hematoma and apply an ice pack if indicated. | Small hematoma can be managed by an ice pack and rest. |
| Measure a 24-hour intake and output. Observe for signs of voiding difficulty. | This will help in determining the fluid loss.A urine output of 30-50 ml/hr or more indicates an adequate circulating volume. Voiding difficulty may happen with hematomas in the upper portion of the vagina causing pressure in the urethra. |
| Observe for reports of persistent perineal pain or feeling of vaginal fullness. Apply counterpressure on labial or perineal lacerations. | Hematomas often result from continued bleeding from laceration of the birth canal. |
| Use caution when performing vaginal and rectal examinations. | May increase hemorrhage if cervical, vaginal, or perineal lacerations or hematomas are present. Note: Careful examination may be required to monitor status of the hematoma. |
| Monitor clients with placenta accreta (condition that occurs when blood vessels and other parts of the placenta grow too deeply into the uterine wall.), PIH or abruptio placenta for signs of Disseminated intravascular coagulation (DIC). | Thromboplastin released during attempts at manual removal of the placenta may result in coagulopathy as manifested by continued vaginal bleeding; epistaxis; oozing from incisions, mucous membranes, gums, IV site. |
| Measure hemodynamic parameters include central venous pressure (CVP) or pulmonary artery wedge pressure (PAWP) if available. | This will provide direct measurement of circulating volume, replacement needs, and response to therapy in case of a life-threatening situations. |
| Maintain a nothing-by-mouth status (NPO) while assessing client status. | This will prevent aspiration of gastric contents in case that the mental status is impaired and also if a surgical management is required. |
| Maintain a bed rest with an elevation of the legs by 20-30° and trunk horizontal. | The position increases venous return, making sure a greater availability of blood to the brain and other vital organs. Bleeding may be decreased with the bed rest. |
| Start 1 or 2 IV infusion(s) of isotonic or electrolyte fluids with an 18-gauge catheter or via a central venous line. Administer fresh whole blood or other blood products (e.g., platelet concentrate, plasma, cryoprecipitate) as indicated | This is important for rapid or multiple infusions of fluids or blood products to increase circulating volume and enhance clotting. Note: Each unit of whole blood increases the hematocrit level by three percentage points. |
| Administer medications as ordered: | |
|
Increases contractility of the boggy uterus and myometrium, closes off exposed venous sinuses, and stops hemorrhage in the presence of atony. |
|
Antibiotics act as prophylaxis to prevent infection or may be needed for an infection that caused or contributed to uterine subinvolution or hemorrhage. |
| Insertion of indwelling Foley catheter (IFC). | This will provide an accurate measurement of the renal status and perfusion with regards to fluid volume. Note: Pressure on the urethra may obstruct urine flow/cause bladder distention if vaginal packs are inserted. |
| Insertion of a large indwelling catheter into the cervical canal. | Insertion of an indwelling catheter into the cervical canal and injecting the balloon with 60 ml of a saline solution that acts as a tamponade have some reports of success in limiting the hemorrhage caused by implantation of the placenta into a noncontractile cervical segment. |
| Monitor laboratory values as indicated such as: | |
|
|
|
Measures severity of Disseminated intravascular coagulation (DIC); determines replacement needs and effects of therapy. |
| Prepare for surgical intervention if indicated; e.g., evacuation of hematoma and ligation of a bleeding point, laceration or episiotomy extension, D & C, abdominal hysterectomy or bilateral ligation of hypogastric artery. | Surgical repair of lacerations/episiotomy, evacuation of hematoma and removal of retained tissues will stop the bleeding;Immediate abdominal hysterectomy is indicated for the abnormally adherent placenta.
Note: D & C may not be indicated if there is a concern that the procedure may traumatize the implantation site and increase bleeding. |
| Assist with procedures as indicated such as manual separation and removal of placenta. | Hemorrhage stops once placental fragments are removed and uterus contracts, closing venous sinuses. |
| Uterine replacement or packing if inversion seems about to recur. | Replacement of the uterus allows it to contract, closing venous sinuses and controlling the bleeding. |
Risk for Excess Fluid Volume
Risk for Excess Fluid Volume: Defined as increased isotonic fluid retention.
Risk factors
- Excessive/rapid replacement of fluid losses, intravascular fluid shifts (PIH).
Possibly evidenced by
- [Not applicable]
Desired Outcomes
- Patient will demonstrate pulse, blood pressure, urine specific gravity and neurologic signs within expected ranges and without any respiratory complications.
| Nursing Interventions | Rationale |
|---|---|
| Assess neurologic status, observing for any behavioral changes and increasing irritable episodes. | Changes in the neurologic status or behavior may serve as early signs of cerebral edema caused by the fluid retention. |
| Monitor for signs of hypertension and tachycardia; Observe for signs of dyspnea; Auscultate for signs of stridor, rhonchi or moist crackles. | Symptoms of circulatory overload and respiratory difficulties may occur as a result of excessive fluid replacement. |
| Monitor for the intake/output, urine specific gravity if indicated. Check the infusion rate of the fluids manually or preferably through the use of infusion pumps. | With the stabilization of fluid levels, intake should approximate/equal to the output; Urine specific gravity results change inversely to output so that as kidney function improves, specific gravity readings decreases, and vice versa. Note: In the client with glomerular spasms caused by pregnancy-induced hypertension (PIH), the output may reduce until extracellular fluids return to the general circulation. |
| Monitor the hematocrit levels. | As plasma volume is restored, the hematocrit level decreases. |
Risk For Pain
Risk For Pain: Defined as an increased risk of having an unpleasant sensory and emotional experience arising from potential tissue damage.
Risk factors
- Tissue damage.
Possibly evidenced by
- [Not applicable]
Desired Outcomes
- Patient will identify appropriate methods to provide relief from pain.
- Patient will demonstrate use of relaxation skills and diversional activities as indicated.
- Patient will verbalize relief from pain and discomfort.
| Nursing Interventions | Rationale |
|---|---|
| Assess psychological causes of pain and discomfort. | Emergency situations may precipitate fear, anxiety which can raise perception of pain and discomfort. |
| Perform pain assessment by identifying the type, location, characteristic, severity, and duration of the pain. Use a pain scale of 0-10; | This will help in differential diagnosis and in determining the applicable treatment method. |
| Encourage the use of relaxation techniques (e.g., deep breathing exercise) and diversional activities (e.g., watching TV). | To assist the client in exploring methods for the control of pain. |
| Provide comfort measures such as application of ice pack into the perineum, use of sitz bath or heat lamp to episiotomy extension. | Ice compress decreases edema and minimizes hematoma and pain sensation while heat promotes vasodilation which facilitates resorption of hematoma. |
| Administer pain medication (analgesic, narcotic or sedative) as prescribed. | Decreases pain and anxiety; Helps promote relaxation. |
Risk for Altered Parent-Infant Attachment
Risk for Altered Parent-Infant Attachment: Defined as a disruption of the interactive process between a parent and infant that promote the development of a protective and sustaining reciprocal relationship.
May be related to
- Anxiety associated with the parent role.
- Inability of parents to meet personal needs.
- Interruption in the bonding process.
- Physical barriers.
- Perceived threat to own survival.
Possibly evidenced by
- [not applicable]
Desired Outcomes
- Parent will express comfort with the parenting role.
- Parent will assume responsibility for the physical and emotional well-being of the infant.
- Parent will demonstrate appropriate behaviors associated with positive attachment to the infant.
- Parent will engage in mutually satisfying interaction with the child.
| Nursing Interventions | Rationale |
|---|---|
| Discuss client’s view of infant care responsibilities and parenting role. | To provide information about how a client perceive these role changes that will help in identifying areas of learning need. |
| Explain the factors that lead to the separation of mother and infant brought about by the postpartum hemorrhage. | To minimize anxiety and feelings of helplessness related to the mother’s inability to assume the role expected to her. |
| Provide information regarding the use of community resources and with follow-up health care referrals such as well-baby clinics, parenting classes. | To reduce anxiety and reinforce positive information previously given by the health team. Promotes self-sufficiency and personal growth. |
| Encourage contact with infant (e.g.,photos, information from the other people who have seen the infant) until the client can see and start to care for the infant. | To reassure the mother of the health status of the infant and of the proper care being given to the infant. |
| Evaluate the attachment process, bonding behaviors, and parenting capability once client assumes care of her infant. | To provide information on the physical, psychological and physiological capabilities of the parent. |
Anxiety
Anxiety: Defined as the uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual).
May be related to
- Situational/maturational crisis.
- Interpersonal transmission.
- Threat of change in the health status.
- Physiological factors (release of catecholamines, drug therapy).
- Unmet needs.
Possibly evidenced by
- Increased apprehension, uncertainty, feelings of helplessness.
- Expressed concerns due to the changes in the life events.
- Sympathetic stimulation.
- Restlessness and distressed.
- Preoccupation; impaired attention.
Desired Outcomes
- Patient will verbalizes awareness of feelings of anxiety.
- Patient will identify health ways to deal with and express anxiety.
- Patient will appear relaxed, and can able to sleep appropriately.
- Patient will report decreased anxiety episodes.
| Nursing Interventions | Rationale |
|---|---|
| Encourage the client and or the family to identify feelings of anxiety. | Verbalization of anxiety provides an opportunity to clarify information, correct misconceptions and gain perspective, facilitating the problem-solving process. |
| Stay with the client by providing a calm, empathic and supportive attitude. | To help in maintaining emotional control in response to the changing physiological status. Helps in lessening interpersonal transmission of feelings. |
| Provide information about the treatment regimen and effectiveness of the interventions. | Giving accurate information can lessen the anxiety and to identify what is reality based. |
| Assist in developing skills (e.g.,awareness of negative thoughts, saying “Stop” and replacing it with a positive thought). | To eliminate negative thoughts and to promote wellness. |
| Evaluate physiological response to postpartum hemorrhage (e.g. restlessness, irritability, tachypnea, tachycardia, hypotension) | Changes in the vital signs may be due to physiologic responses, but they can be aggravated by psychological factors. |
| Evaluate the psychological response of the client to the postpartum hemorrhage and perception of the events happening. | This can help in determining the plan of care. Client’s view of the event may be twisted, aggravating her levels of anxiety. |
Deficient Knowledge
Deficient Knowledge: Absence of cognitive information related to the specific topic.
May be related to
- Cognitive limitation.
- Unfamiliarity with information resources.
- Lack of exposure to information.
Possibly evidenced by
- Statement of misconceptions.
- Request for information needed.
- Inappropriate behaviors.
Desired Outcomes
- Patient will participate in the learning process.
- Patient will verbalize in simple terms the pathophysiology, signs and symptoms and implications of her disease condition.
- Patient will identify behaviors and lifestyle changes to enhance recovery.
| Nursing Interventions | Rationale |
|---|---|
| Assess the client’s level of knowledge, ability to learn. Talk and listen to the client in a calm demeanor. Provide time for questions and clarifications. | Provides information necessary to develop an individual plan of care and engage in problem-solving techniques. Reduces anxiety and stress, which can block learning, and provides clarification and repetition to enhance understanding. |
| Explain predisposing factors and treatment related to the cause of hemorrhage. | To provide information in helping the client cope up with the situation. |
| Instruct the client to report inability to breastfeed, fatigue, amenorrhea, loss of pubic/axillary hair, premature aging and genital atrophy. | These are the signs of Sheehan’s syndrome which is caused by the destruction of cells of the anterior pituitary gland by oxygen starvation, usually at the time of childbirth. The condition may also result from septic shock, or a massive hemorrhage. It often results in premature aging, irreversible fertility, decreased resistance to infection, or increased risk of shock. |
| Determine the availability of personal resources/support groups. Explain the importance of having an adequate rest, healthy living and pacing of activities. | Fatigue related to hemorrhage will slow down the client’s resumption of normal activities, necessitating problem solving and dependence on others for a period of time. |
| Explain short term implications of postpartum hemorrhage such as an interruption in the process of mother-infant bonding and inability to assume care of self and infant as soon as desired. | It can reduce anxiety and provides a realistic time frame for resumption of bonding and infant/self-care activities. |
| Explain long term implications of postpartum hemorrhage such as uterine atony, infertility if hysterectomy is done, or risk of having a postpartum hemorrhage in the future pregnancies. | This will give the autonomy to the client to make informed decisions and to begin resolve feelings about current and past events. |
| Recommend client be seated when holding the infant and to change position slowly when lying down or seated. | To prevent orthostatic hypotension, because it puts the client at risk of falls. |
| Refer to a support group(s) as indicated. | Specific groups such as hysterectomy support group may provide supplemental information regarding the situation they faced before and how they were able to manage it. This will facilitate positive adaptation of the client. |