{
  "name": "Postpartum Hemorrhage",
  "slug": "postpartum-hemorrhage",
  "url": "https://nursingplex.com/care-plans/postpartum-hemorrhage",
  "category": "Maternal & Newborn (OB)",
  "summary": "Excess bleeding after birth; fundal massage, uterotonics and volume replacement.",
  "nursing_diagnoses": [
    "Deficient fluid volume",
    "Risk for shock",
    "Anxiety"
  ],
  "overview": [
    "Postpartum hemorrhage (PPH) is blood loss exceeding 500 mL after vaginal birth or 1000 mL after cesarean birth, or any blood loss accompanied by signs of hypovolemia. It is classified as primary (within 24 hours of birth) or secondary (24 hours to 12 weeks postpartum). The most common cause by far is uterine atony — failure of the myometrium to contract firmly after delivery of the placenta — followed by lacerations, retained placental tissue, and coagulation disorders, remembered as the four T's: Tone, Trauma, Tissue, Thrombin.",
    "Because the uterus receives roughly 500-700 mL of blood flow per minute at term, an atonic uterus can produce catastrophic blood loss within minutes. Nurses are the first line of defense: a fundal check that finds a soft, boggy uterus displaced above or away from the umbilicus is an emergency requiring immediate massage and notification. Risk factors include overdistention (multiples, polyhydramnios, macrosomia), prolonged or precipitous labor, chorioamnionitis, multiparity, and prior PPH, but a substantial share of hemorrhages occur in women with no identifiable risk factors, so every postpartum patient is monitored as if she could bleed.",
    "Nursing management centers on early recognition through quantitative blood loss measurement rather than visual estimation (which consistently underestimates true loss), rapid fundal massage and pharmacologic uterotonics, fluid and blood product resuscitation, and vigilant monitoring for the downstream effects of hypovolemic shock. Timely, coordinated response in the first minutes after atony is identified is the single greatest determinant of outcome."
  ],
  "key_facts": [
    {
      "label": "Most common cause",
      "text": "Uterine atony accounts for roughly 70-80% of postpartum hemorrhages."
    },
    {
      "label": "Quantitative loss",
      "text": "Weighing blood-soaked pads/linens (1 g = 1 mL) is far more accurate than visual estimation."
    },
    {
      "label": "First-line drug",
      "text": "Oxytocin infusion is first-line uterotonic; methylergonovine, carboprost, and misoprostol are second-line options with specific contraindications (hypertension, asthma)."
    },
    {
      "label": "The four T's",
      "text": "Tone (atony), Trauma (lacerations/rupture), Tissue (retained placenta), Thrombin (coagulopathy)."
    },
    {
      "label": "Golden window",
      "text": "Most fatal hemorrhages progress within the first hour; rapid, protocol-driven response saves lives."
    }
  ],
  "nursing_priorities": [
    "Identify uterine atony or excessive bleeding immediately through frequent fundal assessment.",
    "Perform fundal massage and express clots while calling for help.",
    "Establish/maintain large-bore IV access and initiate fluid resuscitation.",
    "Administer uterotonic medications as ordered and monitor response.",
    "Quantify blood loss accurately and monitor vital signs for shock.",
    "Prepare for possible blood transfusion, bimanual compression, or surgical intervention.",
    "Support the patient and family emotionally through a frightening emergency.",
    "Monitor for delayed complications: anemia, infection, Sheehan's syndrome."
  ],
  "assessment": {
    "subjective": [
      "Reports of feeling dizzy, lightheaded, or 'something is wrong'",
      "Complaints of increased perineal pressure or passing large clots",
      "Report of soaking through pads faster than expected",
      "Anxiety, restlessness, or a sense of impending doom",
      "Complaints of cramping or lower abdominal pain",
      "Weakness or air hunger as shock progresses"
    ],
    "objective": [
      "Boggy, soft uterine fundus that is difficult to palpate or higher than expected",
      "Continuous trickle or sudden gush of bright red blood, or heavy lochia saturating a pad in under 15 minutes",
      "Falling blood pressure with rising, then eventually thready, pulse (may be a late sign in young healthy women)",
      "Pallor, cool clammy skin, delayed capillary refill",
      "Decreasing urine output",
      "Visible perineal, vaginal, or cervical laceration or hematoma",
      "Laboratory findings: falling hemoglobin/hematocrit, abnormal coagulation studies",
      "Altered level of consciousness in severe hemorrhage"
    ],
    "related_factors": [
      "Uterine overdistention from multiple gestation, polyhydramnios, or fetal macrosomia",
      "Prolonged, augmented, or precipitous labor leading to uterine muscle fatigue",
      "Retained placental fragments or abnormal placentation (accreta spectrum)",
      "Genital tract trauma from operative delivery, episiotomy, or rapid birth",
      "Coagulation disorders, including pre-eclampsia/HELLP or inherited clotting deficiencies",
      "Grand multiparity and prior history of postpartum hemorrhage",
      "Chorioamnionitis or prolonged rupture of membranes"
    ]
  },
  "goals": [
    "The client will maintain a firm midline fundus and lochia within normal limits within minutes of intervention.",
    "The client will maintain vital signs within normal limits and urine output above 30 mL/hr.",
    "The client will experience total blood loss controlled without progression to hypovolemic shock.",
    "The client will maintain hemoglobin/hematocrit at a level adequate for safe recovery, with transfusion if indicated.",
    "The client and family will verbalize understanding of the emergency and the plan of care.",
    "The client will be free of signs of infection or additional complications at follow-up."
  ],
  "interventions": [
    {
      "title": "1. Immediate recognition and fundal management",
      "points": [
        "Palpate the fundus every 15 minutes in the first hour postpartum, then per protocol; a boggy fundus is the earliest and most reliable sign of atony.",
        "Massage the fundus vigorously with a firm circular motion while supporting the lower uterine segment with the other hand to prevent inversion.",
        "Express clots from the uterus once it is firm, as retained clots can prevent effective contraction.",
        "Encourage the patient to void or catheterize a full bladder, since bladder distention displaces the uterus and impairs contraction.",
        "Reassess the fundus after each intervention and document response, since a uterus that re-softens signals ongoing atony."
      ]
    },
    {
      "title": "2. Rapid resuscitation and hemodynamic support",
      "points": [
        "Call for help immediately and activate the facility's hemorrhage protocol/rapid response team.",
        "Ensure two large-bore IV lines are patent; begin isotonic fluid bolus per order to restore intravascular volume.",
        "Apply oxygen via face mask and place the patient flat or in Trendelenburg to optimize cerebral perfusion.",
        "Monitor vital signs continuously, recognizing that young healthy postpartum women can compensate until sudden decompensation occurs.",
        "Prepare for and administer blood products (packed red cells, FFP, platelets, cryoprecipitate) per massive transfusion protocol as ordered.",
        "Insert an indwelling catheter to monitor hourly urine output as an indicator of renal perfusion."
      ]
    },
    {
      "title": "3. Pharmacologic and mechanical management",
      "points": [
        "Administer oxytocin per protocol as the first-line uterotonic, watching for water intoxication with prolonged high-dose infusions.",
        "Give methylergonovine only after confirming the patient is normotensive, since it is contraindicated in hypertension.",
        "Administer carboprost cautiously, avoiding it in patients with asthma due to bronchospasm risk.",
        "Give misoprostol rectally or orally per order, monitoring for shivering and low-grade fever as expected side effects.",
        "Assist with bimanual uterine compression or preparation for uterine balloon tamponade if medications fail.",
        "Prepare the patient for possible surgical intervention (uterine artery ligation, B-Lynch suture, or hysterectomy) if conservative measures fail."
      ]
    },
    {
      "title": "4. Quantifying loss and ongoing monitoring",
      "points": [
        "Weigh blood-soaked pads, chux, and linens to quantify actual blood loss rather than relying on visual estimation.",
        "Track cumulative estimated blood loss and correlate with vital sign trends and laboratory values.",
        "Monitor hemoglobin, hematocrit, coagulation studies, and platelet counts as ordered.",
        "Assess skin color, capillary refill, and level of consciousness at frequent intervals as indicators of perfusion.",
        "Inspect the perineum, vagina, and cervix for lacerations or expanding hematoma if bleeding continues despite a firm fundus."
      ]
    },
    {
      "title": "5. Psychosocial support and communication",
      "points": [
        "Explain interventions calmly and briefly during the emergency to reduce fear without diverting attention from care.",
        "Keep the partner or support person informed and, when possible, involved rather than excluded.",
        "Facilitate skin-to-skin contact or bonding time once the mother is stabilized, since the emergency can delay attachment.",
        "Debrief with the patient and family after stabilization to answer questions and correct misconceptions about what occurred.",
        "Refer for counseling if the patient displays signs of birth trauma or acute stress reaction after a severe hemorrhage."
      ]
    },
    {
      "title": "6. Preventing recurrence and complications",
      "points": [
        "Continue close monitoring for at least 24 hours after control is achieved, since re-bleeding can occur.",
        "Monitor for signs of infection given the invasive interventions and blood loss-related immune compromise.",
        "Assess for signs of Sheehan's syndrome (failure to lactate, fatigue, amenorrhea) in patients with severe hemorrhagic shock.",
        "Encourage iron-rich diet and administer iron supplementation for postpartum anemia.",
        "Review the hemorrhage event with the care team for quality improvement and future risk stratification."
      ]
    }
  ],
  "patient_teaching": [
    "Report heavy bleeding (saturating a pad in under an hour), large clots, or dizziness after discharge immediately.",
    "Continue taking iron supplements and eat iron- and protein-rich foods to rebuild blood volume.",
    "Understand that fatigue and reduced stamina are expected during recovery from significant blood loss.",
    "Know the signs of postpartum infection: fever, foul-smelling lochia, and abdominal tenderness.",
    "Avoid strenuous activity and heavy lifting until cleared by the provider.",
    "Attend all follow-up appointments to monitor hemoglobin recovery and uterine involution.",
    "Discuss future pregnancy planning with the provider given increased recurrence risk.",
    "Seek support for emotional processing if the birth experience felt frightening or traumatic."
  ]
}