Nursing Care Plan for Postpartum Hemorrhage (PPH)

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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 actually 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 the 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 delivery the baby.

Desired Outcome

Patient will maintain optimal fluid balance and vital signs within normal limits

Postpartum Hemorrhage (PPH) Nursing Care Plan

Subjective Data:

  • Pain in 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

 

Decreased fluid volume will cause blood pressure to drop and patient will go into shock

 

  • Monitor blood loss
    • Site
    • Type
    • Amount- should be no more than 1 perineal pad per hour
    • Presence of clots

 

Amount of blood loss and presence of blood clots can help determine treatment.

 

  • Assess for vaginal hematoma

 

If bleeding is due to 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 may be a late sign of hypovolemic shock.

 

  • Monitor lab values to determine 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 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 patient on how to massage 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 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

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