Postpartum hemorrhage (PPH) is a significant complication that can occur after childbirth, putting the mother’s health at risk. PPH is medically defined as a blood loss of 500 mL or more during a vaginal delivery or 1000 mL or more during a cesarean section within the first 24 hours following birth. Recognizing and addressing this issue early is crucial for the well-being of the mother and requires a comprehensive nursing diagnosis and care plan.

Nurses play a vital role in managing PPH by closely monitoring the mother’s vital signs, assessing blood loss, and implementing appropriate interventions. A nursing diagnosis for postpartum hemorrhage typically includes fluid volume deficit, which is linked to blood loss and the subsequent risk of hypovolemia. Identifying the possible causes and contributing factors to PPH, such as uterine atony, retained placental fragments, or lacerations, is essential for timely and effective treatment.

Developing a nursing care plan for postpartum hemorrhage aims to mitigate the risk of complications while ensuring the mother’s comfort and emotional well-being. Nursing interventions can include administering prescribed medications, such as oxytocin, to encourage uterine contractions and reduce bleeding, closely monitoring the mother’s vital signs and lochia output, and providing supportive measures, such as emotional support and restorative care, to promote recovery.

Postpartum Hemorrhage Overview

Postpartum hemorrhage (PPH) is a serious obstetric emergency, and it’s considered one of the top five causes of maternal mortality in both resource-abundant and resource-limited countries [source] (https://www.uptodate.com/contents/overview-of-postpartum-hemorrhage). It is essential to recognize and rapidly respond to this condition to ensure a favorable outcome for the mother. This section covers the causes and risk factors associated with PPH.

Causes

There are various causes of PPH, including:

Uterine atony: This is the most common cause, which occurs when the uterus fails to contract properly after delivery. As a result, blood vessels in the placental bed remain open and bleed.
Retained placenta: If the placenta isn’t entirely expelled from the uterus after childbirth or during the third stage of labor, it may lead to excessive bleeding.
Lacerations: Tears in the vagina, cervix, or perineum can result in hemorrhage if not detected and treated promptly.
Coagulopathy: Disorders that affect the body’s ability to form clots can increase the risk of PPH.

Risk Factors

Numerous factors increase the likelihood of experiencing postpartum hemorrhage, such as:

Prolonged labor: A longer-than-average labor is associated with a higher risk of PPH due to uterine exhaustion and reduced ability to contract effectively.
Overdistended uterus: Overdistension can result from multiple pregnancies, a large baby, or excess amniotic fluid, making the uterus more likely to become atonic.
Previous history of PPH: A woman who has experienced PPH in a prior delivery is at a higher risk for recurrence in subsequent deliveries.
Induced or augmented labor: The use of medications to initiate or strengthen contractions may increase the risk of uterine atony after childbirth.
Pre-existing conditions: Maternal conditions such as anemia, hypertension, or blood clotting disorders may contribute to a greater risk of PPH.

Recognizing and monitoring these risk factors during pregnancy and childbirth can help healthcare providers manage and prevent postpartum hemorrhage in affected individuals.

Nursing Diagnosis

Assessment

Postpartum hemorrhage (PPH) is a severe complication that can occur after childbirth. It is essential to assess the mother for early signs of PPH, such as lochia rubia exceeding 500 mL within the first 24 hours post-delivery, decreased red blood cell count, hemoglobin or hematocrit levels, and skin pallor¹. Monitoring blood loss and vital signs are crucial steps in overall assessment. Additionally, identifying potential risk factors, such as uterine atony, which contribute to PPH can facilitate prompt and appropriate intervention².

Identification

Once a thorough assessment is completed, appropriate nursing diagnoses can be identified. A common nursing diagnosis for PPH patients is Deficient Fluid Volume¹. This diagnosis relates to excessive bleeding during birth, which ultimately results in decreased blood volume. Furthermore, a nursing diagnosis of Risk for Imbalanced Fluid Volume may also be applicable, as there’s a potential for significant blood loss in PPH patients¹. By identifying these nursing diagnoses, healthcare professionals can tailor interventions and nursing care plans to address the specific needs of the patient.

Nursing Intervention Strategies

Nursing interventions for postpartum hemorrhage are crucial in managing and preventing complications. In this section, we will discuss the primary and secondary management strategies that nurses can employ to address this issue.

Primary Management

The primary management of postpartum hemorrhage focuses on preemptive actions to reduce the risk of excessive bleeding. These strategies include:

Active management of the third stage of labor: This involves the administration of oxytocin between the delivery of the infant and the placenta, which is the most effective intervention to prevent postpartum hemorrhage.
Uterine massage: Gently massaging the uterus can help stimulate contractions and expel blood clots.
Monitoring blood loss: Keeping track of blood loss during and after delivery can help detect any abnormal volume of blood loss.
Close monitoring of the patient’s vital signs: Monitoring the patient’s pulse, blood pressure, and respiratory rate can detect early signs of hypovolemia and ensure timely intervention.

Secondary Management

Secondary management strategies involve interventions to address postpartum hemorrhage once it has already occurred. Key measures to be taken include:

Administration of uterotonics: Medications like oxytocin, methylergonovine, and misoprostol can be used to contract the uterus and control bleeding.
Bimanual uterine compression: This technique involves compressing the uterus between the nurse’s hands to control bleeding and stimulate contractions.
Intravenous fluid replacement: Administering IV fluids can help replace the blood loss and maintain the patient’s blood pressure.
Tranexamic acid: GIven within three hours of delivery, tranexamic acid is an antifibrinolytic drug that can help reduce bleeding.

In summary, nursing intervention strategies for postpartum hemorrhage involve both primary and secondary management approaches. Through early recognition, prevention, and timely treatment, nurses can help reduce the risk of complications and ensure the well-being of both the mother and the newborn.

Monitoring and Evaluation

Monitoring and evaluation are crucial components in managing postpartum hemorrhage (PPH). Nurses and healthcare providers must closely observe the patient’s vital signs, blood loss, and overall condition to ensure appropriate interventions and care are provided in a timely manner.

One of the primary objectives in monitoring a patient with PPH is to maintain stable vital signs. This includes closely observing maternal blood pressure, pulse, and respiratory rate, aiming to maintain a blood pressure higher than 100/60 mmHg. Continuous monitoring can help detect early signs of hypovolemia, enabling prompt and appropriate interventions.

Evaluating the amount and appearance of blood loss is important to determine the severity of PPH. Blood loss greater than 500 mL in a vaginal delivery or 1000 mL in a cesarean delivery within 24 hours is considered postpartum hemorrhage. Accurate measurement and assessment of blood loss can assist healthcare providers in determining the appropriate course of action and interventions.

Assessment of uterine tone is an essential aspect of monitoring and evaluation. A boggy, poorly contracted uterus may indicate ongoing blood loss, requiring immediate interventions, such as uterine massage or administration of uterotonic medications like oxytocin.

In addition to physical assessments, laboratory tests such as complete blood count, coagulation profile, and blood typing may be necessary to identify the underlying causes of PPH and guide treatment plans accordingly. For instance, a decrease in hemoglobin and hematocrit levels may indicate anemia due to excessive blood loss, while an abnormal coagulation profile might suggest a clotting disorder.

In summary, monitoring and evaluation of patients with postpartum hemorrhage involve vigilance and attention to vital signs, blood loss, uterine tone, and relevant laboratory findings. Timely and accurate assessments can greatly impact the patient’s outcomes and overall recovery process.

Prevention Strategies

Preventing postpartum hemorrhage (PPH) begins with early recognition of risk factors and proper management during labor and delivery. Some common preventative measures include the use of oxytocin, active management of the third stage of labor, and administration of tranexamic acid.

Oxytocin is a highly effective treatment for PPH, even if it was previously used for labor induction or augmentation AAFP. Administering oxytocin between the delivery of the infant and the placenta is the most effective intervention to prevent PPH FIGO.

Active management of the third stage of labor (AMTSL) involves concurrent administration of uterotonic drugs, controlled cord traction, and uterine massage. This approach has been shown to reduce the incidence of PPH by ensuring proper uterine contraction and placental separation.

Tranexamic acid, an antifibrinolytic drug, can be administered within the first three hours following childbirth to reduce the risk of PPH when given alongside standard uterotonic agents FIGO. The timely use of tranexamic acid can significantly decrease the probability of postpartum hemorrhage and the need for blood transfusions.

In addition to these interventions, a multidisciplinary team approach is crucial in the prevention and early recognition of PPH ASH. This involves collaboration between obstetricians, anesthesiologists, nursing staff, and other healthcare professionals to ensure that high-risk patients are closely monitored, and necessary interventions are implemented promptly.

Addressing modifiable risk factors such as anemia, obesity, and smoking cessation can also contribute to PPH prevention. Encouraging pregnant women to maintain a healthy lifestyle, attend regular antenatal checkups, and receive appropriate prenatal care can help minimize their chances of experiencing postpartum hemorrhage.