Early Postpartum Hemorrhage Nursing Care Plan & Management

Description

Early postpartum hemorrhage is defined as blood loss of 500 mL or more during the first 24 hours after delivery.
Post partum hemorrhage is the leading cause of maternal death worldwide and a common cause of excessive blood loss during the early postpartum period.
Approximately 5% of women experience some type of postdelivery hemorrhage.

Etiology

Major causes of postpartum hemorrhage are uterine atony (responsible for at least 80% of all early postpartum hemorrhages); laceration of cervix, vagina, or perineum; and retained placental fragments.
Predisposing factors include hypotonic contractions, overdistended uterus, multiparity, large newborn, forceps delivery, and cesarean delivery.

Pathophysiology

The uterus is unable to contract effectively and maintain hemostasis.

Assessment Findings

Clinical manifestations include:

Vaginal bleeding.
Hypotonic uterus.
Excessive blood loss, which may produce hypotension, thread pulse, pallor, restlessness, dyspnea, and chills.

Nursing Management

1. Assist with appropriate treatment to prevent complications.

Determine the presence of uterine firmness and location and amount of vaginal bleeding immediately after delivery.
Measure and record serial maternal vital signs after delivery- every 5 to 15 minutes until stable; increase or decrease the frequency of assessment relative to baseline and amount of bleeding.
Notify the practitioner of abnormal assessment findings.
Massage the fundus gently, taking care to support the uterus with the hand just above the symphysis pubis.
Administer medications as prescribed.
Keep an accurate pad count (100 mL per saturated pad).
Assess condition of skin, urine output, and level of consciousness.

2. Provide physical and emotional support.

3. Provide client and family education.

Exam

Postpartum Hemorrhage Practice Exam (PM)*

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Nursing Care Plan

Ineffective Tissue Perfusion

Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.

May be related to

Hypovolemia (a decreased volume of circulating blood in the body).

Possibly evidenced by

Diminished arterial pulsations, cold extremities.
Decreased capillary refill.
Decreased milk production.
Changes in the vital signs.
Changes in the neurologic status.

Desired Outcomes

Patient will demonstrate blood pressure, pulse, arterial blood gasses (ABGs), and Hematocrit/hemoglobin level within the expected range.
Patient will demonstrate normal hormonal functioning by adequate milk supply for lactation (as appropriate) and resumption of normal menstruation.

Nursing Interventions	Rationale
Monitor vital signs closely; record the degree and duration of any hypovolemic episodes.	Extent of pituitary involvement may be related to the degree and duration of hypotension. A respiratory difficulty may indicate an effort to combat metabolic acidosis.
Observe the color of the nail beds, gums, tongue and buccal mucosa; Note the temperature of the skin.	With the vasoconstriction compensation and shunting to vital organs, circulation in the peripheral blood vessels is diminished, resulting in cyanosis and cold skin temperatures.
Evaluate the neurologic status and observe for any behavioral changes.	Changes in the mentation is an early sign of hypoxia. Cyanosis, on the other hand, is a late sign which may not appear until the PO2 levels drop below 50 mm Hg,
Check the breast at least daily; Inspecting for changes in breast size and the presence or absence of lactation.	Sheehan’s syndrome, also known as postpartum hypopituitarism reduces prolactin levels, resulting in agalactorrhea (absence of lactation) and a decrease in breast tissue.
Monitor Hemoglobin and hematocrit values before and after blood loss. Check for the height and weight; Assess the nutritional status of the client.	Such values indicate the severity of blood losses. Preexisting poor health status increases the extent of injury brought about by the oxygen deficits.
Monitor arterial blood gasses (ABGs) and PH levels.	To determine the degree of tissue hypoxia or acidosis, indicating the build uo of lactic acid resulting anaerobic metabolism.
Administer sodium bicarbonate as indicated.	To correct metabolic acidosis.
Insert airway; suction as indicated.	Facilitates oxygen administration in presence of retained secretions.
Provide supplemental oxygen as indicated.	Maximizes available oxygen for circulatory transport to tissues.

Risk For Infection

Risk For Infection: At increased risk of being invaded by pathogenic organisms.

Risk factors

Decreased hemoglobin.
Invasive procedures.
Stasis of body fluids (lochia).
Traumatized tissues.

Possibly evidenced by

[Not applicable]

Desired Outcomes

Patient will state an understanding of individual causative/risk factors.
Patient will display white blood cell count and vital signs within expected ranges.
Patient will display a lochia free odor.

Nursing Interventions	Rationale
Monitor rate of uterine involution and nature and the amount of lochial discharge.	Infection of the uterus delays involution and lengthen the flow of the lochia.
Observe for signs of fever, chills, body malaise, anorexia, pelvic pain or uterine tenderness.	These symptoms reflect systemic involvement, possibly leading to bacteremia, shock or even death if left untreated.
Check the episiotomy site and abdominal wound (for caesarian) for signs of edema, erythema, separation of wound edges, purulent drainage.	These indicates localized infection requiring immediate intervention to prevent systemic involvement.
Check for other possible sources of infection such as urinary tract infection(urinary frequency/pain, cloudy and odoriferous urine), mastitis (swelling, erythema, pain) or respiratory infection (productive cough, purulent sputum, fever).	Differential diagnosis is critical for effective management.
Teach and demonstrate proper hand-washing and self-care techniques. Review appropriate handling and disposal of contaminated materials (eg., dressings, peripads, linens).	To prevent the spread of infectious organisms.
Review WBC count, hemoglobin and hematocrit levels.	Increased white blood cell count indicates an infection. Anemia often accompanies infection, delays the wound healing, and weaken the immune system.
Administer iron supplement as indicated.	To correct anemia. And possibly improves wound healing.
Obtain a gram’s stain or culture and sensitivity if lochia is noted to have an odiferous smell or purulent wound discharge is observed.	Gram stain identifies the type of infection while cultures and sensitivity identify the specific pathogen and can indicate which antibiotic is suitable to fight the organism.
Administer IV antibiotics as ordered.	Broad spectrum antibiotic may be ordered until the results from culture and sensitivity is available at which time organism-specific antibiotic may be started.