Postpartal hemorrhage is usually defined as the loss of more than 500 ml of blood during or after delivery. It is one of the leading causes of maternal mortality. Hemorrhage may occur early, within the first 24 hr after delivery, or late, up to 28 days postpartum (the end of the puerperium).
1. Maintain or restore circulating volume/tissue perfusion.
2. Prevent complications.
3. Provide information and appropriate support for client/couple.
4. Have plan in place to meet needs after discharge.
1. Tissue perfusion/organ function WNL
2. Complications prevented/resolving
3. Clinical situation and treatment needs understood
Nursing diagnosis for postpartal hemorrhage: Fluid volume deficit may be related to excessive vascular loss possibly evidenced by hypotension, tachycardia, changes in mentation, decreased/concentrated urine, dry skin/mucous membranes, delayed capillary refill.
Desired Outcome: Demonstrate stabilization/improvement in fluid balance as evidenced by stable vital signs, prompt capillary refill, appropriate sensorium, and individually adequate urine output and specific gravity.
Nursing intervention and rationale
1. Review records of pregnancy and labor/delivery, noting causative factors or those contributing to hemorrhagic situation (e.g., lacerations, retained placental fragments, sepsis, abruptio placentae, amniotic fluid emboli, or retention of dead fetus for more than 5 wk).
Rationale: Aids in establishing appropriate plan of care and provides opportunity to prevent or limit developing complications. Note: Approximately20% of early postpartal hemorrhage is related to lacerations of the perineum, vagina, or cervix. Late postpartal hemorrhage is usually caused by abnormal involution of the uterus or retained placental fragments.
2. Assess and record amount, type, and site of bleeding; weigh and count pads; save clots and tissue for evaluation by physician.
Rationale: Estimate of blood loss, venous versus arterial, and presence of clots helps to make a differential diagnosis and determines replacement needs. Note: One gram of increased pad weight is equal to approximately 1 ml of blood loss. Blood losses of more than 1000 ml lead to shock state and increase risk of other complications, e.g., infection, extensive pelvic thrombophlebitis.
3.Assess location of uterus and degree of uterine contractility. Massage boggy uterus with one hand while placing second hand just above the symphysis pubis.
Rationale: Degree of uterine contractility aids in differential diagnosis. Increasing myometrial contractility may decrease blood loss. Placing one hand above symphysis pubis prevents possible uterine inversion
4. Note presence of vulvar hematoma; apply ice pack as indicated and observe periodically.
Rationale: Small hematomas may be controlled by ice and rest.
5.Monitor BP, pulse; observe capillary refill, nail beds, and mucous membranes.
Rationale: Hypotension, tachycardia, delayed capillary refill; cyanosis of nail beds, mucous membranes, and lips reflects severe hypovolemia and developing shock. Changes in BP are not detectable until fluid volume has decreased by 30%–50%. Cyanosis is a late sign of
hypoxia. Note: Reports of fatigue, headache, thirst, presence of pallor, orthostatic hypotension may be signs of slow moderate blood loss that may be reported during follow-up visit.
6. Measure hemodynamic parameters, such as central venous pressure (CVP) or pulmonary artery wedge pressure (PAWP), if available.
Rationale: Provides more direct measurement of circulating volume, replacement needs, and response to therapy in severe/life-threatening situations.
7.Institute bedrest with legs elevated 20–30 degrees and trunk horizontal.
Rationale: Bleeding may decrease or cease with reduction in activity. Proper positioning increases venous return, ensuring greater availability of blood to brain and other vital organs.
8. Maintain nothing-by-mouth (NPO) regimen while determining client status/needs.
Rationale: Prevents aspiration of gastric contents in the event that sensorium is altered and/or surgical intervention is required.
9.Measure intake and output, and urine specific gravity, as indicated. Investigate reports of difficulty voiding/emptying bladder.
Rationale: Useful in estimating extent/significance of fluid loss. Adequate perfusion/circulating volume is reflected by output 30–50 ml/hr or greater. Note: Difficulty voiding may occur with hematomas in the upper portion of the vagina causing pressure on the urethra or meatus.
10. Monitor clients with placenta accreta (slight penetration of myometrium by placental tissue), PIH, or abruptio placentae for signs of DIC.
Rationale: Thromboplastin released during attempts at manual removal of the placenta may result in coagulopathy as manifested by continued vaginal bleeding; expistaxis; oozing from incisions, mucous membranes, gums, IV site.