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

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Outline

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. 

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 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.

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

Nursing Intervention (ADPIE) Rationale
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. 
Monitor intake and output  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. 

Assess for vaginal hematoma If bleeding is due to a vaginal hematoma, rest and application of an ice pack may be sufficient treatment  
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.  
Monitor and manage pain 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

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

A Nursing Care Plan (NCP) for Postpartum Hemorrhage (PPH) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

Hey everyone. Today, we are going to be creating a care plan for postpartum hemorrhage. So, let’s get started. First, we’re going to go over the pathophysiology of postpartum hemorrhage: excessive bleeding, following delivery of a baby vaginal delivery; excessive bleeding would be more than 500 mL and a cesarean delivery would be more than 1,000 mL. Nursing considerations: you want to assess vital signs, monitor blood loss, assess for hematoma, monitor I & O, monitor lab values, administer IV fluids, medications, or blood products, fundal massage, manage pain, keep the patient on NPO status, and prepare the patient for surgery, if needed. Some desired outcomes: a patient will remain in optimal fluid balance and vital signs will be within normal limits. 

So, we’re going to go ahead and start a care plan. We’re going to go over some of the subjective data, and we’re going to go over some of the objective data that you’re going to see with these patients. One of the main things of subjective data we’re going to see is they’re going to have a lot of pain in the vaginal area, which is usually due to a hematoma that is present. Some objective data that you’re going to see is going to be some uncontrolled bleeding. And then you will also see that the patient will have hypotension. So decreased BP, they will have an increased heart rate and they will have a low hematocrit. 

So, some interventions that we’re going to look at for some of these patients, we’re going to assess their vital signs. We want a baseline of where their vital signs are at. See if they are hypertensive or tachycardic. Usually with these patients, their blood pressure can drop so much, they can go into shock. We want to monitor blood loss; so, when we monitor blood loss, we want to know the site, we want to know the type, the amount. We don’t want to have more than one peri pad an hour. We want to look for any sort of presence of clots and the amount of blood loss and presence of blood clots can help determine the type of treatment for the pain. We want to assess any sort of hematoma. So, if they have a hematoma, we want to assess that. So, if bleeding is due to a vaginal hematoma, usually resting and an application of an ice pack on the peritoneal area may be sufficient enough for treatment. We want to make sure that we’re going to be assessing intake and output. Usually, you want to have about 30 to 50 mL per hour minimum – a foley may be required and able to get an accurate measurement. And of course, making sure you’re doing foley care, decreased output could be a sign of a hematoma, which is going to be putting pressure on that urethra or a late sign of hypovolemic shock. We want to make sure we’re monitoring lab values and determining if a blood transfusion is needed and any sort of complications. So, we’re going to see about a low hematocrit. We’re going to be checking any sort of clotting factors. See if blood transfusions are necessary and look for any sort of signs of DIC. Some other interventions that we’re going to be doing are we’re going to be administering IV fluids, medications, and possible blood products as necessary. So certain medications would be oxytocin, which is sometimes given and able to initiate those contractions, but also helps stop the bleeding for the patient. Also given are some antibiotics, some analgesics for pain, and obviously some fluid replacements may be necessary. We’re going to perform a uterine massage. So fundal massages help stimulate uterine contractions after birth and assist to stop the bleeding. 

Other things that we may want to consider is managing the patient’s pain, especially if the hematoma is present and or lacerations within the vagina after birth. When appropriate, place the patient on bedrest with the legs elevated. So, you want to make sure their legs are upright and not straight down like that. So, rest and elevation of the legs helps prevent venous return and slows the bleeding down. That’s the important part. It’s going to help slow the bleeding. And if the patient is having surgery, we want to make sure we’re keeping them on NPO status. If the bleeding cannot be managed, they will have to have surgery to stop the bleeding. 

So key points we want to go over here. Postpartum hemorrhage is excessive bleeding following the delivery of a baby. So, 500 mL for the vaginal, and about 1,000 mL for a cesarean section. Contractions after birth aren’t strong enough to help close the vessels, supplying the blood from mother to baby or tears in the cervix, placenta, or blood vessels within the uterus can be possible. Some subjective and objective data. You’ll see they’re going to be dizzy and complain of pain in the vaginal area. If a hematoma is present, there could be uncontrolled bleeding. So excessive saturation of one peri pad an hour, hypotension, tachycardia, and low hematocrit. You want to monitor the blood loss, the amount you want to assess for hematoma. And we want to do fundal massages. That helps the contraction after the birth of the baby. And that helps stop and prevent more blood loss. We want to do IV fluids, meds, or blood transfusion if needed. We want to make sure that we’re keeping the patient on bedrest, keeping up NPO in case they end up needing surgery because they can’t stop the blood loss. And there you guys have it. That was an excellent care plan. 

I hope you guys have a good rest of your day and as always happy nursing.

 

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