Pathophysiology
Postpartum hemorrhage is the excessive bleeding following delivery of a baby. For vaginal delivery, excessive bleeding would be more than 500ml and for cesarean delivery, more than 1000ml. This may happen with vaginal or cesarean delivery and occurs in 1-5 out of 100 women. The hemorrhage may occur immediately after birth, or over several hours following delivery.
Etiology
Normally, the uterus continues to contract after the delivery of the baby and placenta. These contractions help close the vessels that supplied blood from the mother to the baby. When these contractions do not continue or are not strong enough, hemorrhage occurs. Sometimes, a tear in the cervix, placenta, or the blood vessels within the uterus may 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 such as forceps or vacuum to deliver the baby.
Desired Outcome
A patient will maintain optimal fluid balance and vital signs within normal limits
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 Interventions and Rationales
- 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.
- Assess for vaginal hematoma
If bleeding is due to a vaginal hematoma, rest and application of an ice pack may be sufficient treatment
- Monitor intake and output for 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.
- 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.
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
References
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell
