Postpartum hemorrhage

Nursing Diagnosis, & Interventions for PPH-Student Guide

Introduction

Postpartum hemorrhage is defined as bleeding after the birth of a baby that is excessive and cannot be managed with usual methods. In the setting of a low-resource hospital, postpartum hemorrhage can be life-threatening.

This article aims to provide more information about this topic to guide nursing students. As you read, keep in mind that our top writers are ready to help in case you get stuck or cannot complete your nursing assignment due to other reasons such as a busy schedule. All you need to is place an order with us!

Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Causes of Postpartum Hemorrhage

Several factors can cause postpartum hemorrhage.

  • As the uterus contracts to decrease the size of space in which the baby was located, it pulls on vessels leaving a torn blood vessel wall.
  • Birth defects such as placental abnormalities and uterine rupture.
  • Medical diseases such as a clotting disorder or heart problem.
  • Birth complications such as prolonged labor and malposition of the baby upon birth can result in postpartum hemorrhage.
  • Infection, as well as retained products of pregnancy such as the placenta or membranes.
  • Obstetric emergencies have been reported to be a direct cause of postpartum hemorrhage. Emergencies include placental abruption and uterine atony.

Risk Factors for Postpartum Hemorrhage

Risk factors for postpartum hemorrhage include:

  • Heavy maternal bleeding might be a warning of placental abruption or other serious problems.
  • Postpartum hemorrhage may result in shock and hypovolemic shock.
  • Pre-delivery anemia or hypertension.
  • Prolonged labor
  • Stillbirth of the newborn
  • Inadequate uterine contraction
  • Placental abruption (separation of the placenta from the uterus before birth)
  • Uterine atony (failure of the uterine muscle to contract after delivery). Some cases are not due to overt trauma but are associated with a history of endometritis.
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Signs and Symptoms of Postpartum hemorrhage

  1. Bleeding after childbirth
  2. Discomfort in the lower abdomen or pelvic region.
  3. Foul-smelling vaginal discharge coming from the vagina that was previously clear before childbirth.
  4. A decrease in pulse rate and a drop in blood pressure are also signs of postpartum hemorrhage.
  5. An increase in heart rate may be present if there is strain due to heavy bleeding.
  6. Anxiety or restlessness may be present as well.
  7. If the postpartum hemorrhage is severe, confusion and even coma may result.

Postpartum Hemorrhage Nursing Care and Diagnosis

C- section delivery bleeding after childbirth.

NURSING DIAGNOSIS: Continuous bleeding after C-section delivery.

Immediate interventions:

  • monitor vital signs
  • reduce bleeding after C-section delivery using uterotonics or replacement.

Monitoring: pulse rate, blood pressure, and temperature are the most common methods of monitoring. Urinary output is also monitored as this can indicate a need for additional fluid support. Other methods that may be used include measuring hematocrit levels and administering blood transfusions.

Interventions: To control the excess amount of blood loss. Several interventions may be used to stop bleeding. These include:

Abdominal packing; Liquid infusion; injection of uterotonic agents (to cause the uterus to contract and stop excessive bleeding); surgical intervention such as a hysterectomy or a surgical repair of the uterine tear.

Interventions to stop bleeding after childbirth:

1st step – Control blood loss by placing towels and pressure over the site of bleeding. A uterotonic drug may be given if bleeding continues despite these interventions, such as Pitocin or Syntometrine via an intravenous line.

2nd step: Uterine packing; This may include placing gauze or cotton wool into the vagina to control bleeding.

3rd step: Blood transfusion (In cases where the mother has lost a considerable amount of blood, it may be necessary to replace that blood); A transfusion can be given either peripherally or in the central vein.

Deficient fluid volume

Nursing Diagnosis: Deficient fluid volume that is highly related to excessive blood loss through bleeding.

Nursing care goals:

  • To provide sufficient replacement fluids for the mother.
  • To ensure the safety of the mother during replacement.
  • Prevent complications such as hemorrhage, shock, hypovolemic shock, and infection.

Interventions to prevent complications:

1- administer IV fluids using crystalloids or colloids at a proportional rate to the blood loss. The fluid should never exceed 10% of the mother’s blood volume. Hypotension (low blood pressure) can be treated by administering fluid at a rate that is not over 20% of the bodyweight per day.

2- monitor intake and output, frequency of urination, as well as vital signs. This will allow for adjustments in IV fluids to be administered accordingly (in cases where the mother is unable to void due to sedation, intravenous fluids may be administered via an indwelling urinary catheter).

3- inform the doctor of any complications that occur.

4- monitor for signs and symptoms of infection such as fever, chills, increased white blood cells, or bacteria in the urine.

5- assess intake and output to ensure that the mother is keeping up with her fluid replacement.

6- monitor maternal vital signs to ensure proper oxygenation and circulation of blood

7- administer medication such as antibiotics if there are signs of infection or fever (this is especially common in postpartum infections)

8- at the end of the replacement, administer fluid inhibitors to prevent life-threatening complications such as pulmonary edema (fluid from IV fluids can be taken up by the lungs).

Risk of excess fluid volume

Nursing Diagnosis: Risk of excess fluid volume related to administration of IV fluids.

Nursing care goals:

To eliminate any complications resulting from administering IV fluids, including electrolyte imbalance, hypovolemic shock, and pulmonary edema.

Nursing Interventions:

1- ensure that the mother is lying in a flat position before administering IV fluids (in cases where the mother is unable to lie flat, ensure she is on her side).

2- monitor vital signs, including blood pressure and heart rate.

3- assess peripheral circulation by checking capillary refill (in cases where peripheral circulation is poor, administer IV fluids slowly to avoid overload or shock).

4- monitor for evidence of fluid overload, including peripheral edema ( swelling), central venous pressure, and pulmonary congestion.

5- monitor urine output hourly to ensure proper functionality of the urinary tract.

6- Assess electrolyte imbalance by monitoring pH, serum glucose, electrolytes, and blood urea nitrogen and creatinine levels.

7- assess intake and output to ensure that the mother is keeping up with her fluid replacement.

8- assess for fever, including auscultation and measuring body temperature via thermometer (in cases where the mother has a fever).

9- if there are signs of infection or systemic inflammatory response, administer antibiotics.

Treatment of Postpartum Hemorrhage

Effective treatment of postpartum hemorrhage is solely dependent on early diagnosis and quick action. The treatment to be applied depends on the cause of bleeding, although in most cases, general measures are necessary for immediate control of bleeding.

1) Medication: Several kinds of medication can be administered to control bleeding. Local hemostatic agents are usually applied externally, while systemic medications (oral and intravenous) may require monitoring of blood coagulation tests.

2) Adjuvant therapies: These are especially useful in hemodynamically unstable cases of postpartum hemorrhage where local hemostasis is inadequate. This may include hysterectomy, surgical ligation, and embolization, or a combination of these methods.

3) Surgery: May be required for severe cases of bleeding that do not respond to other treatments. It involves ligating the internal and external iliac arteries, ligating the uterine arteries, or removing an entire organ.

4) Removing retained placental fragments manually by a procedure known as “sharp curettage.”

5) Blood transfusion: Blood transfusion may be needed in cases where there is a significant decrease in the number of red blood cell count or if bleeding does not stop despite other treatments.

6) Compressive pad/tampon: This is useful for localized postpartum hemorrhage on the perineum and vaginal wall. It is placed by pressing hard on the bleeding area and is left for several minutes to absorb blood.

7) Additional supportive measures are also required, such as managing fluid and electrolyte imbalances, monitoring vital signs, cardiac monitoring, respiratory support, and prevention of infection.

The following is a list of commonly used medications for postpartum hemorrhage:

  • Heparin injection (usually given intravenously in doses ranging from 500 IU to 5000 IU). It helps control bleeding by preventing clotting factors from binding to each other.
  • Octoxynol-9 injection: Used as an antiseptic and hemostatic agent after giving birth (usually administered in doses ranging from 100 mg to 500mg). It is also used as a spermicidal agent during pregnancy and for postpartum contraception.
  • Heparin and Octoxynol-9 are not recommended for use when the mother is allergic to sulfa derivatives.
  • Antifibrinolytic drugs: These medications allow clotting time to be extended when clotting times are excessively short. They also reduce blood loss following delivery and in cases of postpartum hemorrhage.
  • Prostaglandin E2: It is used for third-stage bleeding, which may occur as a result of incomplete separation of the placenta, uterine atony (failure of the uterus to contract after delivery), and retained placental tissues. The prostaglandin is injected into the uterus in doses ranging from 25mcg to 100 mcg, or it can also be used as a vaginal insert.
  • Tranexamic acid functions similarly to Prostaglandin E2 and is frequently used as an adjunct to local hemostatic agents. It is available in various forms such as tablets or injections, and can be given orally or intravenously in doses ranging from 500mg to 1g.

Other medications that may be administered include oxytocin, misoprostol, transfusion of platelets and red blood cells, and antifungal drugs for cases of postpartum hemorrhage associated with fungal infection or chorioamnionitis.

Postpartum hemorrhage with other complications may require additional treatments such as hysterectomy, surgical ligation, embolization, or a combination of these methods. However, this is not always done depending on the severity of complications and the patient’s condition.

After Treatment/Recovery phase

The recovery phase begins once hemorrhage has stopped. During this period, the mother is closely monitored for complications that may arise as a result of bleeding.

1) Monitor vital signs including heart rate and blood pressure on a frequent basis (at least every 15 minutes) for 24 hours.

2) Administer pain medication for any uterine contraction pain that occurs.

3) Monitor intake and output of urine (every hour, or more frequently if required).

4) Monitor for bleeding from the vagina: keep a sanitary pad beneath the patient at all times, observe and see if vaginal bleeding increases or decreases with the menstruation cycle.

5) Assess the maternal status: check the mother’s mental state (orientation, speech, memory), check for peripheral signs of shock (pallor, coolness to the touch), and monitor capillary refill time (less than 2 seconds).

6) Monitor mother for respiratory depression from pain medication. Give oxygen as needed.

7) Assess for bleeding sites: observe the patient for blood staining on undergarments, sheets, etc.

8) Assess for pain: record method and type of pain medicine prescribed during this period. Use a scale of 0 to 10 to describe the patient’s pain level (0 is no pain; 10 is severe abdominal pain).

9) Provide emotional support by comforting the mother and making sure she is comfortable.

10) Monitor for complications:

a) Pulmonary embolism (PE) PE may occur as a result of postpartum hemorrhage; this can be detected by assessing the patient’s physical condition. Diagnosis may be made with an electrocardiogram (ECG).

b) Infection resulting from vaginal/cervical laceration or separation of the placenta. Antibiotic treatment may be prescribed to treat such an infection; this is usually given for 48 hours after delivery of the child.

If you’ve recently given birth and are experiencing postpartum hemorrhage, rest assured there are medications available to help. You should be able to take advantage of pain medication as well as other treatments such as transfusion or oxytocin injections.

There is no need for worry if your healthcare provider has diagnosed postpartum hemorrhage with complications; they will provide the necessary treatment plans that can include surgery or a combination of methods depending on severity.

After getting through this difficult time, it may be helpful to reach out for emotional support from friends and family members while also dealing with any physical discomfort caused by childbirth-related injuries like lacerations in the vaginal area (which could lead to infection). It’s important to get medical care and take time for yourself and your baby during this period.

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