6 Best Nursing Care Plans for Postpartum Hemorrhage

This article discusses Nursing Care Plans for Postpartum Hemorrhage plus its causes, symptoms, preventions, treatments, and interventions.

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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.

Introduction

Postpartum hemorrhage is defined as any blood loss from the uterus of more than 500ml during or after delivery. It may occur either early (within the first 24 hours after delivery) or late (anytime after the 24 hours during the remaining days of the six-week puerperium).

It is important to note that vaginal bleeding called lochia is normally heavy from just after delivery until the next few hours and may not stop until the next few days. 

The color of blood will usually change from bright red to brown over a couple of weeks. The full stoppage of lochia normally occurs no more than 12 weeks after delivery.

However, there is either heavy vaginal bleeding of at least 500 mL in the first 24 hours of delivery in postpartum hemorrhage or between 23 hours and 12 weeks of delivery.

Nursing Care Plans for Postpartum Hemorrhage – Types of Lochia

Postpartum hemorrhage may involve excessive bleeding and abnormality of lochia or postpartum vaginal discharge. It is especially important to take note of the duration of lochia rubra to help in the diagnosis of PPH. The following are the normal characteristics of the types or stages of lochia:

Lochia rubra – refers to the first vaginal discharge; Rubra means red; it usually happens from Day 1 to Day 5 after birth

Lochia serosa – the vaginal discharge appears either brownish or pinkish; typically occurs until Day 10 after birth

Lochia alba – the vaginal discharge appears whitish or yellowish; typically happens from the 2nd week to the 6th week after birth, but may also extend to 12 weeks postpartum.

Nursing Care Plans for Postpartum Hemorrhage – Types of Postpartum Hemorrhage

Primary PPH – occurs when the mother loses at least 500 mL or more of blood within the first 24 hours of delivering the baby.

Major Primary PPH – losing 500 mL to 1000 mL of blood

Minor Primary PPH – losing more than 1000 mL of blood

Secondary PPH – occurs when the mother has heavy or abnormal vaginal bleeding between 24 hours and 12 weeks of delivering the baby.

Nursing Care Plans for Postpartum Hemorrhage – Signs and Symptoms of Postpartum Hemorrhage

• Uncontrolled bleeding
• Hypotension – decreased blood pressure
• Tachycardia – increased heart rate
• Anemia – decrease in the red blood cell count or hemoglobin level
• Edema or hematoma – swelling and pain in or around the vaginal area
• Fatigue – extreme tiredness

The patient should also be educated on the following warning signs that would indicate the need to inform their healthcare provider either during a hospital stay or after discharge:

• Excessive or increased vaginal bleeding – if the patient needs a new sanitary pad after an hour or if she passes large blood clots
• Blurry vision or other visual disturbances
• Light-headedness or dizziness
• New or worsening stomach pain
• Fatigue 
• Tachycardia

Nursing Care Plans for Postpartum Hemorrhage – Causes of Postpartum Hemorrhage

The 4 T’s is a mnemonic that can be used to remember the 4 common causes of postpartum hemorrhage:

Tone – uterine atony is the most common cause of PPH; overstretched uterus may cause a soft and boggy tone

Trauma – rupture, inversion, hematoma, and/or laceration

Tissue – retained or invasive placenta

Thrombin – coagulopathy; bleeding disorders or blood clotting problems

Nursing Care Plans for Postpartum Hemorrhage – Risk Factors of Postpartum Hemorrhage

Before Delivery

• Placenta previa – a condition wherein the placenta is situated low near the neck of the uterus.
• Abruptio placentae – a condition wherein the placenta separates from the uterus earlier than expected.
• Multiple pregnancies – carrying twins or more
• History of postpartum hemorrhage
• Pre-eclampsia – high blood pressure
• Obesity or having a BMI of greater than 35
• Anemia
• Thrombocytopenia or other blood clotting problems
• On anticoagulant therapy
• Fibroids

After Delivery

• Delivery by Cesarean section
• Forceps delivery
• Induction of labor
• Delayed delivery of the placenta or retained placenta – not passing the placenta within the hour after birth of the baby
• Tear in the perineum (lacerations) or episiotomy
• Fetal macrosomia – having a baby that weighs more than 9 lbs or 4 kg
• Hyperthermia during labor
• Having had long labor – more than 12 hours
• Age of the mother – having the first baby at age 40 years or above
• Use of general anesthetic during delivery

Nursing Care Plans for Postpartum Hemorrhage – Complications of Postpartum Hemorrhage

• Hypovolemic shock
• Failure of major organs, such as the lungs and kidneys
• Anemia
• Postpartum fatigue

Nursing Care Plans for Postpartum Hemorrhage – Diagnosis of Postpartum Hemorrhage

Measurement of blood loss – PPH is defined as blood loss of more than 500 mL in the first 24 hours post-delivery

Blood tests – include full blood count (particularly hemoglobin and hematocrit), clotting factors, and factor essays.

Pelvic exam – pregnant women who are at risk for PPH will undergo a pelvic exam, which checks the vagina, uterus, and cervix.

Imaging – ultrasound is the first imaging choice to visualize the baby and the pelvic organs.

Nursing Care Plans for Postpartum Hemorrhage – Prevention of Postpartum Hemorrhage

The following measures can be undertaken to prevent the likelihood of postpartum hemorrhage:

• Active management of the third stage of labor

This includes the administration of oxytocin no earlier than the delivery of the anterior shoulder. It also involves controlled traction and a uterine massage after the delivery of the placenta.

• Early recognition of the risk for PPH

Stopping or reducing anticoagulants, oral iron supplementation, coagulation tests, and regular antenatal check-ups help prevent PPH.

Nursing Care Plans for Postpartum Hemorrhage – Treatment for Postpartum Hemorrhage

1. Medications. Several medications may be prescribed to treat PPH:
2. Uterotonic agents – utilized to prevent or control PPH. Oxytocin is the first-line prevention and treatment for PPH. It is used to decrease the blood flow through the uterus after the baby’s delivery.
3. Adjuvant therapies – anti-bleeding drugs can be administered within the first 3 hours of the start of PPH.
4. Antibiotics – may be required if a bacterial infection has caused or contributed to PPH based on the culture results of the lochia.
5. Intravenous fluid replacement
6. Uterine massage
7. Transfusion – low hemoglobin /hematocrit level and excessive blood loss may require transfusion of blood and plasma products.
8. Application of pressure on labial or perineal lacerations
9. Episiotomy Repair – timely repair of lacerations and episiotomy is essential in controlling PPH
10. Reduction of uterine inversion – the Johnson method is a manual procedure wherein the protruding uterus is returned in the normal position by pushing it inside toward the direction of the umbilicus
11. Manual removal of retained placental tissues
12. Surgery– hysterectomy (removal of the uterus) or laparotomy may be needed if the other treatments are not effective in stopping PPH

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Nursing Care Plans for Postpartum Hemorrhage Based on Diagnosis

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 1 – Diagnosis: Ineffective Tissue Perfusion

Ineffective Tissue Perfusion: Decreased in 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

• A patient will demonstrate blood pressure, pulse, arterial blood gasses (ABGs), and Hematocrit/hemoglobin level within the expected range.
• A 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.	The 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 skin’s temperature.	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; Inspect 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 client’s nutritional status.	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 lactic acid build-up resulting in anaerobic metabolism.
Administer sodium bicarbonate as indicated.	To correct metabolic acidosis.
Insert airway; suction as indicated.	Facilitates oxygen administration in the presence of retained secretions.
Provide supplemental oxygen as indicated.	Maximizes available oxygen for circulatory transport to tissues.

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 2 – Diagnosis: 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.

Desired Outcomes

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

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Nursing Interventions	Rationale
Monitor rate of uterine involution and nature and the amount of lochial discharge.	Infection of the uterus delays involution and lengthens 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.	This 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 (e.g., 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 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 antibiotics may be ordered until the results from culture and sensitivity are available, at which time organism-specific antibiotics may be started.

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 3 – Diagnosis: Deficient Fluid Volume (isotonic)

Deficient Fluid Volume: It is defined as decreased intravascular, interstitial, and intracellular fluid.

May be related to excessive blood loss after birth.

Possibly evidenced by:

• Changes in the mental status.
• Concentrated urine.
• Delayed capillary refill.
• Decrease in the red blood cell count (hematocrit).
• Decrease blood pressure (hypotension).
• Dry skin/mucous membrane.
• Increase heart rate (tachycardia).

Desired Outcomes

• A patient will maintain a blood pressure of at least 100/60 mm Hg.
• A patient will maintain a pulse rate between 70-90 beats per minute.
• A patient will have a balanced 24-hour intake and output.
• A patient will have a cognitive status within the expected range.
• Patient will have a lochia flow of less than one saturated perineal pad per hour.
• A patient will demonstrate improvement in the fluid balance as evidenced by a good capillary refill, adequate urine output, and skin turgor.

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Nursing Interventions	Rationale
Assess and record the type, amount, and site of the bleeding; Count and weigh perineal pads and, if possible, save blood clots to be evaluated by the physician.	The amount of blood loss and the presence of blood clots will help to determine the appropriate replacement need of the patient.
Assess the location of the uterus and degree of the contractility of the uterus/ Massage boggy uterus using one hand and place the second hand above the symphysis pubis.	The degree of uterus contractility will measure the status of the blood loss. Placing one hand just above the symphysis pubis will prevent possible uterine inversion during a massage.
Review the records and note certain conditions such as retained placental fragments, lacerations, abruptio placenta, etc.	This will help determine the management of the situation, thus preventing further complications.
Monitor vital signs, including systolic and diastolic blood pressure, pulse, and heart rate. Check for the capillary refill and observe nail beds and mucous membranes.	Increased heart rate, low blood pressure, cyanosis, delayed capillary refill indicate hypovolemia and impending shock. A decreased fluid volume of 30-50% will reflect changes in the blood pressure.
Note for the presence of vulvar hematoma and apply an ice pack if indicated.	An ice pack and rest can manage a small hematoma.
Measure a 24-hour intake and output. Observe for signs of voiding difficulty.	This will help in determining fluid loss. A 30-50 ml/hr or more urine output indicates an adequate circulating volume. Voiding difficulty may happen with hematomas in the upper portion of the vagina, causing pressure in the urethra.
Observe for reports of persistent perineal pain or feeling of vaginal fullness. Apply counterpressure on labial or perineal lacerations.	Hematomas often result from continued bleeding from lacerations of the birth canal.
Use caution when performing vaginal and rectal examinations.	May increase hemorrhage if cervical, vaginal, or perineal lacerations or hematomas are present. Note: Careful examination may be required to monitor the status of the hematoma.
Monitor clients with placenta accreta (a condition that occurs when blood vessels and other parts of the placenta grow too deeply into the uterine wall.), PIH or abruptio placenta for signs of Disseminated intravascular coagulation (DIC).	Thromboplastin released during attempts at manual removal of the placenta may result in coagulopathy as manifested by continued vaginal bleeding; epistaxis; oozing from incisions, mucous membranes, gums, IV site.
Measure hemodynamic parameters include central venous pressure (CVP) or pulmonary artery wedge pressure (PAWP)  if available.	This will directly measure circulating volume, replacement needs, and response to therapy in case of life-threatening situations.
Maintain a nothing-by-mouth status (NPO) while assessing client status.	This will prevent aspiration of gastric contents if the mental status is impaired and if surgical management is required.
Maintain bed rest with an elevation of the legs by 20-30° and trunk horizontal.	The position increases venous return, ensuring greater availability of blood to the brain and other vital organs. Bleeding may be decreased with bed rest.
Start  1 or 2 IV infusion(s) of isotonic or electrolyte fluids with an 18-gauge catheter or via a central venous line. Administer fresh whole blood or other blood products (e.g., platelet concentrate, plasma, cryoprecipitate) as indicated	This is important for rapid or multiple infusions of fluids or blood products to increase circulating volume and enhance clotting. Note: Each unit of whole blood increases the hematocrit level by three percentage points.
Administer medications as ordered:
Oxytocin (Pitocin, Methylergonovinemaleate (Methergine), Prostaglandin F2a (Prostin 15M);	Increases contractility of the boggy uterus and myometrium closes off exposed venous sinuses and stops hemorrhage in the presence of atony.
Antibiotic therapy (based on culture and sensitivity of the lochia)	Antibiotics act as prophylaxis to prevent infection or may be needed for an infection that caused or contributed to uterine subinvolution or hemorrhage.
Insertion of indwelling Foley catheter (IFC).	This will provide an accurate measurement of the renal status and perfusion with regard to fluid volume. Note: Pressure on the urethra may obstruct urine flow/cause bladder distention if vaginal packs are inserted.
Insertion of a large indwelling catheter into the cervical canal.	Insertion of an indwelling catheter into the cervical canal and injecting the balloon with 60 ml of a saline solution that acts as a tamponade have some reports of success in limiting the hemorrhage caused by implantation of the placenta into a noncontractile cervical segment.
Monitor laboratory values as indicated, such as:
Hemoglobin and Hematocrit.	Hgb and Hct determine the amount of blood loss. Each milliliter of blood carries 0.5 mg of hemoglobin.
Platelet count, activated partial thromboplastin time (APTT), fibrinogen, and Fibrin degradation products (FDP).	Measures severity of Disseminated intravascular coagulation (DIC); determines replacement needs and effects of therapy.
Prepare for surgical intervention if indicated, e.g., evacuation of hematoma and ligation of a bleeding point, laceration or episiotomy extension, D & C, abdominal hysterectomy, or bilateral ligation of the hypogastric artery.	Surgical repair of lacerations/episiotomy, evacuation of hematoma, and removal of retained tissues will stop the bleeding; Immediate abdominal hysterectomy is indicated for the abnormally adherent placenta. Note: D & C may not be indicated if there is a concern that the procedure may traumatize the implantation site and increase bleeding.
Assist with procedures as indicated, such as manual separation and removal of placenta.	Hemorrhage stops once placental fragments are removed and uterus contracts, closing venous sinuses.
Uterine replacement or packing if inversion seems about to recur.	Replacement of the uterus allows it to contract, closing venous sinuses and controlling the bleeding.

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 4 – Diagnosis: Risk for Excess Fluid Volume

Risk for Excess Fluid Volume: Defined as increased isotonic fluid retention.

Risk factor

• Excessive/rapid replacement of fluid losses, intravascular fluid shifts (PIH).

Desired Outcome

• Patient will demonstrate pulse, blood pressure, urine specific gravity, and neurologic signs within expected ranges and without any respiratory complications.

Nursing Interventions	Rationale
Assess neurologic status, observing for any behavioral changes and increasing irritable episodes.	Changes in the neurologic status or behavior may serve as early signs of cerebral edema caused by fluid retention.
Monitor for signs of hypertension and tachycardia; Observe for signs of dyspnea; Auscultate for signs of stridor, rhonchi, or moist crackles.	Symptoms of circulatory overload and respiratory difficulties may occur as a result of excessive fluid replacement.
Monitor for the intake/output, urine specific gravity if indicated. Check the infusion rate of the fluids manually or preferably through the use of infusion pumps.	With the stabilization of fluid levels, intake should approximate/equal the output; Urine specific gravity results change inversely to output. As kidney function improves, specific gravity readings decrease, and vice versa. Note: In the client with glomerular spasms caused by pregnancy-induced hypertension (PIH), the output may reduce until extracellular fluids return to the general circulation.
Monitor the hematocrit levels.	As plasma volume is restored, the hematocrit level decreases.

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Nursing Care Plans for Postpartum Hemorrhage: Care Plan 5 – Diagnosis: Risk for Pain

Risk for Pain: Defined as an increased risk of having an unpleasant sensory and emotional experience arising from potential tissue damage.

Risk factor

• Tissue damage.

Desired Outcomes

• A patient will identify appropriate methods to provide relief from pain.
• A patient will demonstrate the use of relaxation skills and diversional activities as indicated.
• A patient will verbalize relief from pain and discomfort.

Nursing Interventions	Rationale
Assess psychological causes of pain and discomfort.	Emergency situations may precipitate fear and anxiety, raising the perception of pain and discomfort.
Perform pain assessment by identifying the type, location, characteristic, severity, and duration of the pain. Use a pain scale of 0-10;	This will help in differential diagnosis and in determining the applicable treatment method.
Encourage the use of relaxation techniques (e.g., deep breathing exercise) and diversional activities (e.g., watching TV).	To assist the client in exploring methods for the control of pain.
Provide comfort measures such as applying an ice pack into the perineum using a sitz bath or a heat lamp to episiotomy extension.	Ice compress decreases edema and minimizes hematoma and pain sensation while heat promotes vasodilation, which facilitates hematoma resorption.
Administer pain medication (analgesic, narcotic, or sedative) as prescribed.	Decreases pain and anxiety; Helps promote relaxation.

Nursing Care Plans for Postpartum Hemorrhage: Care Plan 6 – Diagnosis: Deficient Knowledge

Deficient Knowledge: Absence of cognitive information related to the specific topic.

May be related to:

• Cognitive limitation.
• Unfamiliarity with information resources.
• Lack of exposure to information.

Possibly evidenced by:

• Statement of misconceptions.
• Request for information needed.
• Inappropriate behaviors.

Desired Outcomes

• A patient will participate in the learning process.
• A patient will verbalize the pathophysiology, signs and symptoms, and implications of her disease condition in simple terms.
• A patient will identify behaviors and lifestyle changes to enhance recovery.

Nursing Interventions	Rationale
Assess the client’s level of knowledgeability to learn. Talk and listen to the client in a calm demeanor. Provide time for questions and clarifications.	Provides information necessary to develop an individual plan of care and engage in problem-solving techniques. Reduces anxiety and stress, which can block learning, and provides clarification and repetition to enhance understanding.
Explain predisposing factors and treatment related to the cause of hemorrhage.	To provide information in helping the client cope with the situation.
Instruct the client to report inability to breastfeed, fatigue, amenorrhea, pubic/axillary hair loss, premature aging, and genital atrophy.	These are the signs of Sheehan’s syndrome, which is caused by the destruction of the anterior pituitary gland cells by oxygen starvation, usually at the time of childbirth. The condition may also result from septic shock or a massive hemorrhage. It often results in premature aging, irreversible fertility, decreased resistance to infection,  or increased risk of shock.
Determine the availability of personal resources/support groups. Explain the importance of having adequate rest, healthy living, and pacing of activities.	Fatigue-related to hemorrhage will slow down the client’s resumption of normal activities, necessitating problem solving and dependence on others for a period of time.
Explain short-term implications of postpartum hemorrhage, such as an interruption in the process of mother-infant bonding and the inability to assume care of self and infant as soon as desired.	It can reduce anxiety and provides a realistic time frame for the resumption of bonding and infant/self-care activities.
Explain long-term implications of postpartum hemorrhage such as uterine atony, infertility if hysterectomy is done, or risk of having a postpartum hemorrhage in future pregnancies.	This will give the autonomy to the client to make informed decisions and to begin resolving feelings about current and past events.
Recommend that the client be seated when holding the infant and change position slowly when lying down or seated.	To prevent orthostatic hypotension because it puts the client at risk of falls.
Refer to a support group(s) as indicated.	Specific groups such as the hysterectomy support group may provide supplemental information regarding the situation they faced before and how they were able to manage it. This will facilitate positive adaptation of the client.

Related FAQs

1. What nursing interventions would you consider for a patient with postpartum hemorrhage?

Nursing Interventions

• Save all perineal pads used during bleeding and weigh them to determine the amount of blood loss.
• Place the woman in a side lying position to make sure that no blood is pooling underneath her.
• Assess lochia frequently to determine if the amount discharged is still within the normal limits.

2. What is the nursing diagnosis of haemorrhage?

Risk for Bleeding is a NANDA nursing diagnosis that can be used for the care of patients with increased chances of bleeding, such as those diagnosed with reduced platelets, problems with clotting factors, or those in situations where the patient experiences a traumatic injury or an invasive procedure such as surgery.

3. How do you manage primary postpartum hemorrhage?

Treatment for primary PPH requires a multidisciplinary approach. Any measures and/or drug therapy taken as part of the initial treatment is considered first‐line therapy. In most cases, this includes resuscitation measures, exclusion of genital tract laceration, checking of the placenta and the use of uterotonics.

4. What are the nursing management of menorrhagia?

Medical therapy for menorrhagia may include: Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve), help reduce menstrual blood loss. NSAIDs have the added benefit of relieving painful menstrual cramps (dysmenorrhea).

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