Postpartum Hemorrhage (PPH) is a serious complication occurring after childbirth. 1-5% of mothers will experience PPH which the American College of Obstetrics and Gynecologists (ACOG) defines 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 atony, 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.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Anxiety
- Deficient Fluid Volume
- Deficient Knowledge
- Imbalanced Nutrition: Less Than Body Requirements
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 Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to postpartum hemorrhage.
Review of Health History
1. Assess for acute postpartum bleeding symptoms.
Symptoms of acute postpartum bleeding include:
- General: weakness, feeling faint while standing up, feeling cold, restlessness
- CNS: dizziness, loss of consciousness
- Cardiovascular: palpitations, tachycardia, decreased blood pressure
- Respiratory: tachypnea
- Integumentary: diaphoresis, pallor
- Genitourinary: decreased or absent urine output
2. Obtain a detailed medical history.
Review the patient’s medical records. Determine if the patient has any bleeding histories or conditions that increase the risk for PPH, which include:
- High blood pressure
- Preeclampsia
- Eclampsia
- Infection
- Blood clotting disorders (DIC)
- Bleeding disorders
- Anemia
- Obesity
- Advanced maternal age
3. Review obstetric history.
Note for conditions that increase the risk of bleeding, such as:
- Placental problems:
- Placenta accreta
- Placenta previa
- Placental abruption
- Retained placenta
- Multiple pregnancies ( > 5)
- Multiple births (twins, triplets, or more)
- Fetal macrosomia (baby over 9 pounds)
- Excessive amniotic fluid
4. Review the patient’s medication list.
Look for medications that may contribute to bleeding. Some of these medications include:
- Anticoagulants: heparin and aspirin
- NSAIDs: diclofenac and ibuprofen
- Oral steroids: dexamethasone and prednisone
- Selective serotonin reuptake inhibitors (SSRIs): citalopram and fluoxetine
- Serotonin-norepinephrine reuptake inhibitors (SNRIs): desvenlafaxine and duloxetine
Physical Assessment
1. Closely observe the maternal vital signs and vaginal blood loss.
Tachycardia and hypotension are two symptoms that correlate with blood loss in postpartum women. Note the changes in the heart rate and blood pressure in response to significant blood volume loss (more than 25% of total blood volume).
2. Examine the genitalia of the patient.
The genitalia should be examined for lacerations, hematomas, or uterine rupture. Inspect and palpate the cervix and vagina after vaginal deliveries.
3. Assist in checking for retained placental tissue.
The entire placenta is expelled from the vagina within 30 minutes after delivery of the baby. The placenta should be intact, and the nurse can inspect the placenta for any missing pieces. If placenta tissue remains within the body, it may cause fever, foul-smelling discharge, bleeding, and pain.
4. Palpate the uterine tone and size.
Uterine atony is described as a soft, “boggy,” or non-contracted uterus and is the most common cause of PPH. A non-contracted uterus will fail to stop bleeding.
5. Assess for DIC.
Disseminated intravascular coagulation (DIC) is a disruption in clotting factors causing widespread bleeding from different areas of the body (nose, gums, IV sites) and may cause bruising, hypotension, dyspnea, and confusion.
6. Observe the lochia.
After delivery, some vaginal bleeding is expected. Lochia within the first few days after birth is red in color and is described as a heavy flow menstrual cycle. If the patient is saturating more than one pad per hour and passing large clots, intervention is required.
Diagnostic Procedures
1. Obtain samples for lab tests.
Laboratory tests to be done include:
- Complete blood cell (CBC) count to monitor hemoglobin, hematocrit, and platelets
- Blood typing and screening in the event of a blood transfusion
2. Perform coagulation studies.
Initial coagulation testing results are frequently within the reference ranges. However, abnormalities may be seen in conditions such as:
- Abruptio placenta
- HELLP syndrome
- Fatty liver of pregnancy
- Intrauterine fetal death
- Embolic events
- Septicemia
- DIC
3. Investigate for elevated INR and aPTT.
Consider the following if the international normalized ratio and activated partial thromboplastin time are elevated:
- Fibrinogen levels
- Thrombin time measurement
- D-dimer
- Blood film
4. Assist the patient with an ultrasound.
A bedside ultrasound can locate clots or retained placenta tissue.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with postpartum hemorrhage.
Manage the Bleeding
1. Treat the causative factors.
Postpartum hemorrhage treatment and management aim to resuscitate the patient while determining and addressing the underlying cause.
2. Ensure continuous organ perfusion.
Maintaining the patient’s hemodynamic stability is crucial to ensure sustained perfusion of the patient’s vital organs. Ensure large-bore intravenous (IV) access is patent. Elevate the patient’s legs to improve venous return. Administer supplemental oxygen as needed.
3. Begin IV fluids.
Infuse large volumes of crystalloid solutions such as normal saline or Lactated Ringer’s.
4. Initiate blood transfusions.
The early implementation of blood products should be prioritized, along with careful direct monitoring of cumulative blood loss. Fresh frozen plasma or platelet transfusions may be necessary with coagulation abnormalities.
5. Closely monitor vital signs and urine output.
Monitor blood pressure, pulse, oxygen saturation, and urine output for signs of perfusion and response to treatment.
6. Repair trauma.
Immediate surgical procedures include:
- Exploration of the uterus for rupture
- Repair of lacerations
- Correction of uterine inversion
7. Treat uterine atony.
Treatment options for PPH caused by uterine atony include bimanual massage, surgical management, uterine tamponade, pelvic artery embolization, and uterotonic medications like oxytocin or intramuscular carboprost.
8. Assist in removing retained tissue.
Manual removal or dilation and curettage should be used to remove any retained tissue.
9. Prepare for surgical procedures.
When there is recurrent bleeding in a stable patient, ligation of the bleeding artery is necessary. Fluoroscopy is used to locate and seal off bleeding vessels. Uterine rupture may require laparotomy or hysterectomy if repair is nonviable.
Prevent Further Bleeding
1. Identify the bleeding risk.
One of the key elements in avoiding morbidity and death linked to PPH is identifying high-risk patients prior to delivery. To help choose the most suitable method for delivery, patients should have an ultrasound evaluation before giving birth.
2. Give iron supplements as recommended.
Anemic patients should be treated with oral or parenteral iron supplements, especially if their hematocrit is less than 30%.
3. Administer erythropoietin-stimulating agents as prescribed.
High-risk patients, particularly those who decline a blood transfusion, should be given erythropoietin-stimulating drugs with hematological counseling.
4. Collaborate with the healthcare provider.
Collaboration with the healthcare provider helps make the right decisions for the patient during labor and delivery. These factors are considered as they may increase the bleeding risk:
- C-section delivery
- General anesthesia
- Prolonged labor
- Infection during labor and delivery
- History of PPH in previous deliveries
5. Breastfeed right away.
Encourage the patient to start breastfeeding as soon as possible after delivery. Breastfeeding triggers the natural release of oxytocin, causing uterine contraction and control of bleeding.
6. Educate on signs of secondary PPH.
Secondary PPH may occur up to six weeks after giving birth. Educate the patient to monitor for signs of bleeding such as a change in lochia, severe abdominal cramping, fever, or dizziness and to alert the healthcare provider immediately. Treatment remains the same.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for postpartum hemorrhage, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for postpartum hemorrhage.
Acute Pain
Acute pain can occur in patients with postpartum hemorrhage, especially if related to perineal trauma or lacerations.
Nursing Diagnosis: Acute Pain
Related to:
- Tissue damage
- Hematoma
- Surgical interventions
- Uterine atony
As evidenced by:
- Reports of pain intensity
- Diaphoresis
- Expressive behavior
- Guarding behavior
- Protective behavior
- Positioning to ease pain
- Abdominal cramping
- Pelvic pain and heaviness
Expected outcomes:
- Patient will identify and demonstrate appropriate interventions for pain relief.
- Patient will report relief from pain or discomfort.
Assessment:
1. Conduct a comprehensive pain assessment.
A comprehensive pain assessment can help identify the pain level, characteristics, location, and duration to determine the appropriate treatment regimen. Uterine atony may cause lower back pain. Internal bleeding may cause abdominal pain or tenderness.
2. Assess for the extent of perineal trauma.
20% PPH occurs from perineal and/or vaginal lacerations. These lacerations may be uncomfortable or painful. If there is increased pressure and discomfort between the patient’s legs without noticeable trauma, this can signal a hematoma developing due to injury to the blood vessels in the perineum during childbirth.
3. Assess the patient’s fundal height after childbirth.
Acute pain or heaviness with postpartum bleeding can signal subinvolution, which is a delay in the uterus returning to its normal size. This is a rare cause of postpartum hemorrhage.
Interventions:
1. Encourage relaxation techniques and diversional activities.
Relaxation techniques like deep breathing, meditation, back rubs, and diversional activities can refocus the patient’s attention to reduce discomfort.
2. Administer pain medications as indicated.
Pain medications are indicated to help provide pain relief to patients with acute pain from perineal trauma or surgical interventions to stop hemorrhaging.
3. Encourage the use of a cold compress or sitz bath to the perineum.
Cold compresses can reduce the formation of hematomas in the perineal area and vulva and promote pain relief. A warm sitz bath can reduce episiotomy pain and provide relaxation.
4. Prepare for surgical intervention.
Pain can signal the need for surgical intervention, such as laceration repair, laparotomy for uterine repair or Cesarean incision repair, artery ligation, or incision and drainage of large hematomas.
Anxiety
Traumatic birthing experiences can cause anxiety and even post-traumatic stress disorders.
Nursing Diagnosis: Anxiety
Related to:
- 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
Expected outcomes:
- Patient will report decreased anxiety and feeling in control.
- Patient will implement two strategies to decrease anxiety.
Assessment:
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.
Interventions:
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 Fluid Volume
A drop in circulating blood volume decreases perfusion to vital organs.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Blood loss after birth (hemorrhage)
As evidenced by:
- Changes in mental status
- Hypotension
- Tachycardia
- Decreased urine output
- Decreased hemoglobin
Expected outcomes:
- 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.
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. An inverted uterus isn’t palpable through the abdomen and may protrude through the cervix or vagina. 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.
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.
Deficient Knowledge
Providing education on childbirth and delivery expectations can prepare the mother and support person for complications before they arise.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Lack of information provided
- Unfamiliarity with situation
As evidenced by:
- Exaggerated behaviors
- Information seeking
- Statements reflecting misinformation
- Development of PPH
Expected outcomes:
- 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.
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.
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.
Imbalanced Nutrition: Less Than Body Requirements
Complications of postpartum hemorrhage can predispose the client to anemia and iron loss.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Blood loss
- Inadequate food intake
- Altered taste perception
- Food aversion
- Nausea/vomiting
- Pain
- Inadequate interest in food
- Insufficient knowledge of nutrient requirements
- Misperception about the ability to ingest food
As evidenced by:
- Hypoglycemia
- Delayed wound healing
- Fatigue
- Altered lab values
- Lightheadedness
Expected outcomes:
- Patient will verbalize nutrients and food sources high in iron to include in their diet.
- Patient will demonstrate red blood cell (RBC) count, hemoglobin, and iron levels within normal limits.
Assessment:
1. Assess laboratory values.
Anemia and iron loss are the most common problems following PPH. Assessing a CBC (complete blood count) for RBC, hemoglobin, iron, and ferritin levels can uncover the cause of symptoms.
2. Assess the patient’s fluid status.
Postpartum hemorrhage can affect the patient’s fluid and electrolyte balance. Assess for signs of dehydration and monitor intake and output along with electrolyte levels.
3. Assess for signs of anemia.
Signs of anemia include fatigue, pallor, and weakness. Anemia is a common complication of PPH.
4. Assess for a lack of appetite or symptoms preventing adequate intake.
Pain, nausea, or depression can decrease appetite and prevent proper intake, all of which can be prevented or treated appropriately through medications or nonpharmacological methods.
Interventions:
1. Encourage adequate fluid intake orally or intravenously.
Adequate hydration is essential in correcting fluid balance due to blood loss, ensuring body organs function properly and delivering nutrients to cells. Being well-hydrated improves appetite, promotes sleep, and improves the patient’s general well-being.
2. Instruct on sources of iron in food.
Lean meats and seafood contain the highest amounts of iron. Foods like beans, lentils, and vegetables contain non-heme iron, which isn’t absorbed as well as heme iron but is still vital to a well-rounded diet. Bread and grain products may also be fortified with iron.
3. Educate on taking iron supplements as indicated.
Iron supplements may be necessary following PPH. Instruct on the following with iron supplements:
- Take iron supplements with vitamin C for better absorption
- Do not take iron supplements with calcium (antacids or calcium supplements)
- Take iron at least an hour before bed
- Do not drink tea or coffee within an hour of taking iron supplements
4. Refer the patient to a dietitian.
A dietitian can help plan meals appropriate for the postpartum patient’s individual needs.
References
- 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
- Cleveland Clinic. (2022, January 3). Postpartum hemorrhage: Causes, risks, diagnosis & treatment. Retrieved May 2023, from https://my.clevelandclinic.org/health/diseases/22228-postpartum-hemorrhage#prevention
- 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
- MedlinePlus. (2022, October 15). Diclofenac and Misoprostol: MedlinePlus drug information. MedlinePlus – Health Information from the National Library of Medicine. Retrieved May 2023, from https://medlineplus.gov/druginfo/meds/a699002.html
- Papadakis, M., Meiwandi, A., & Grzybowski, A. (2019). The WHO safer surgery checklist time out procedure revisited: Strategies to optimise compliance and safety. International Journal of Surgery, 69, 19-22. https://doi.org/10.1016/j.ijsu.2019.07.006
- 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
- Smith, J. R. (2022, May 7). Postpartum hemorrhage workup: Laboratory studies, imaging studies, diagnostic procedures. Diseases & Conditions – Medscape Reference. Retrieved May 2023, from https://emedicine.medscape.com/article/275038-workup#showall
- 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/
- Wormer, K. C., Jamil, R. T., & Bryant, S. B. (2022, October 25). Acute postpartum hemorrhage – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved May 2023, from https://www.ncbi.nlm.nih.gov/books/NBK499988/
