POSTPARTUM HEMORRHAGE CONCEPT MAP

MEDICAL DIAGNOSIS AND DEFINITION

● Postpartum Hemorrhage is a potentially life-threatening complication that can occur after
both vaginal and cesarean births, it is defined as a blood loss greater than 500 ml after
vaginal birth, or more than 1000 ml after a cesarean birth. A more objective definition is
that postpartum hemorrhage refers to any amount of bleeding that places the mother in
hemodynamic jeopardy.

PATHOPHYSIOLOGY AND ETIOLOGY

● The absence of uterine contractions after birth may result in excessive blood loss, as
excess bleeding can occur at any point during the separation, expulsion or removal of the
placenta. In the third stage of labor, as the placenta is being pushed out, the muscles of
the uterus contract downwards causing the constriction of the blood vessels that pass
through the uterine wall to the placental surface, stopping the flow of blood. This action
also causes the separation of the placenta from the uterine wall. The uterus must remain
contracted after birth to control bleeding from the placental site, any factor that causes
uterine relaxation after birth can lead to bleeding.
● The common cause of Postpartum hemorrhage can be identified by the 4 Ts;
- T​one; uterine atony, distended bladder
- T​issue; retained placenta and clots: uterine subinvolution
- T​rauma; obstetric lacerations, hematoma, inversion, uterine rapture
- T​hrombin; Pre-existing or acquired coagulopathy
RISK FACTORS
● Overdistention of uterus ( macrosomia, multiple gestation, polyhydramnios)
● Placenta accreta, placenta previa, placenta abruption
● Surgical/ instrumental birth (cesarean section, vacuum, forceps use)
● Uterine muscle exhaustion (rapid/prolonged labor, pitocin, magnesium sulphate use,)
● Uterine infection (maternal fever, Prolonged rupture of membrane)
● Placenta or blood clots retained in the uterus
● Malposition of fetus
● Previous uterine surgery
● Traction on the cord
● Pre-existing conditions (hemophilia, Diabetes, HTN, )
● history/ family history of PPH
● Preeclampsia

LABS
● Complete blood count; the H&H are helpful in estimating the amount of blood lost, and
also elevated white blood cells might indicate endometriosis or toxic shock syndrome.
Normal reference levels are hematocrit; 37- 47%, and hemoglobin 12-16g/dL.
● Coagulation studies; Usually in the initial coagulation study findings are usually within
reference ranges; however, abnormalities may be noted, and typically include decreased
 platelet and fibrinogen levels, increased prothrombin nad partial thromboplastin time, and
generally increased bleeding time. T​he normal reference range for prothrombin time
(PT),results is: 11 to 12.5 seconds, and INR is 0.8 to 1.1seconds.
● Blood type and crossmatch; usually done in preparation for transfusion of blood products
if indicated

MEDICATIONS
● Uterotonic drugs are used to stimulate contraction of the uterus and control bleeding,
these drugs include;
- Oxytocin (pitocin)​; First line of defense.
- Misoprostol (cytotec)​; use caution in patients with pulmonary, hepatic, and
Cardiac disease.
- Methylergonovine maleate (methergine)​; Contraindicated in hypertensive patients
- Carboprost (Hemabate);​ Side effects include; nausea and vomiting and severe
diarrhea, contraindicated with asthma due to risk for bronchial spasm

1. Nursing diagnosis ​; Fluid volume deficit related to excessive bleeding after birth
as evidence by increase in the mount of lochia, tachycardia, decreased blood
pressure (hypotension) and urine output.
Nursing intervention
❖ Identify the location and contractility of the uterus and massage boggy uterus to
stimulate contraction and expression of any blood clots while supporting lower uterine
segment.
❖ Assess amount, color, and smell of lochia, count and weight peripads
❖ Assess vital signs, monitoring blood pressure and heart rate (for severe hypotension and
rapid heart beat), monitor I&O, assess for diminished urine output
Patient goals
❖ Patient will have a decrease fundal height with uterus palpated below the umbilicus by 3
minutes
❖ Patient will have lochia flow of less than 1 fully saturated peripad per hour
❖ Patient will maintain blood pressure of at least 100/70 mm Hg, and heart rate between
70-80 beats per minute, and will report less concentrated more frequent urination by
reassessment
Evaluation
❖ Noted uterine firmness and decrease fundal height by 2 minutes
❖ Patient had lochia flow of less than 1 partially saturated ( < 50% saturated/25 ml) peripad
per hour
❖ Patient maintained a blood pressure of 118/80 mm Hg, heart rate within 90-100 bpm, and
had a urinary output of approximately 30ml/ per hour.

2. Nursing diagnosis​ ; Ineffective tissue perfusion related to hypovolemia as

evidenced by decreased capillary refill, changes in levels of consciousness, and
decreased pulse Oximetry.
Nursing intervention
❖ Monitor vital signs and labs for arterial blood gases, and hematocrit and hemoglobin
 levels to assess for hypovolemic shock and decreased tissue perfusion.
❖ Assess patient’s level of consciousness for changes related to inadequate cerebral
perfusion or hypoxia
❖ Administer supplemental oxygen therapy as indicated to maintain adequate oxygen
saturation.
Patient goals
❖ Patient will maintain baseline vital signs, with appropriate arterial blood gases, and
adequate hematocrit and hemoglobin levels by reassessment
❖ Patient will remain alert and oriented to at least person, place, and time by reassessment
❖ Patient will maintain pulse oximetry levels >90% by 2 minutes
Evaluation
❖ Patient’s vital signs remained within expected baseline, ABG labs showed no signs of
acidosis, and H&H were within expected range
❖ Patient had a cognitive status within expected range, remained alert and orientated x4
throughout shift
❖ Patient maintained a pulse oximetry level above 98%

3. Nursing diagnosis​; Anxiety related to sudden change in health status as

evidenced by restlessness, and loss of consciousness
Nursing intervention
❖ Use therapeutic communication to evaluate patient’s understanding of events and provide
clarification and support
❖ Encourage patient to acknowledge and express/verbalize feelings of anxiety
❖ Implement comfort measures (calm environment, back rub, warm bath) and competent
attitude to aid in decreasing anxiety
Patient goals
❖ Patient will communicate understanding of events and procedures needed prior to
procedure
❖ Patient will verbalize awareness and feelings of anxiety by reassessment
❖ Patient will appear relaxed and report that anxiety is reduced and is at a manageable level
by reassessment
Evaluation
❖ Patient understood and was able to thoroughly explain her current situation
❖ Patient reported feeling anxious
❖ Patient appeared relaxed and reported a decrease in anxiety level

4. Nursing diagnosis​; Risk for impaired parent- infant attachment related to effects
of postpartum bleeding as evidenced by interrupted bonding, separation from
mother
Nursing intervention
❖ Promote mother- newborn interactions
❖ Encourage adequate rest and sleep to ensure enough energy for healing and reduced pain
❖ Progressively permit patient to care and comfort her newborn
Patient goals
❖ Patient will begin to bond with newborn appropriately with each exposure
❖ Patient will have designated rest and sleep periods, appropriate wound healing by
reassessment and report pain levels less than 5 on pain scale
❖ Patient will actively participate in the care of her newborn as her condition improves with
Q4 breastfeeding
Evaluation
❖ Patient expressed desire to spend time with newborn and expressed positive feeling when
holding baby
❖ Patient reported increase energy levels, and reduces pain and showed confidences in
caring for newborn
❖ Patient actively cared for newborn swaddled and breastfed baby