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Understand what a nurse care plan is. Pay close attention to mothers who are predisposed to developing a postpartum hemorrhage. Evaluate the mother’s condition frequently. Monitor the fundus. Look at the bladder. Assess the lochia. Check the mother’s vital signs. Understand that trauma could lead to excessive bleeding. Notify other healthcare providers. Massage the mother’s uterus and keep track of blood loss. Regulate the mother’s blood levels. Put the mother in the Trendelenburg position. Give the mother medications. Monitor the mother’s breathing. Evaluate the mother when the mother is in a safer state. Check on any open wounds the mother may have sustained. Check for side effects of the medications.
The most important thing for decreasing the occurrence of death after childbirth is the ability to catch the signs of bleeding early in its course and pinpoint its cause. Quickly identifying the cause of the bleeding allows for faster intervention.  A nursing care plan is a very useful tool in doing just that. There are five steps in the nursing care plan. These steps are assessment, diagnosis, planning, intervention and evaluation. In order to make a nursing care plan on postpartum hemorrhage, it is important to know what to look for and what to do in each of these steps. Before carrying out an assessment, it is important to take note of the mother’s history. There are several predisposing factors that make the mother more prone to postpartum hemorrhage, as all women who had just given birth are prone to excessive blood loss. If one or more of the following are present in the mother, assessment should be done at least every 15 minutes during and following delivery until the mother is not showing any signs of bleeding.  These predisposing factors include a distended uterus caused by carrying a large infant inside or having excessive fluid in the placenta (the sac surrounding the infant), having given birth to more than five children, rapid labor, prolonged labor, utilization of assistive devices, a caesarean birth, removal of the placenta manually and an inverted uterus. Predisposing factors to excessive bleeding also include mothers who have suffered from conditions such as placenta previa, placenta accreta, utilizing drugs such as oxytocin, prostaglandins, tocolytics, or magnesium sulfate, underwent general anesthesia, if the mother has clotting disorders, have suffered from hemorrhage in the previous childbirth, has uterine fibroids, or has suffered from bacterial infection of the fetal membranes (chorioamnionitis). In assessing the mother, there are certain physical aspects that need to be checked regularly to determine if there is an ongoing postpartum hemorrhage and also to help determine the cause. These physical aspects include:  The fundus (the top part of the uterus opposite the cervix), the bladder, the amount of lochia (the fluid coming out of the vagina that is composed of blood, mucus, and tissue from the uterus), the four vital signs (temperature, pulse rate, respiratory rate and blood pressure) and skin color. When assessing these areas, it is important to note what to look out for. Follow the steps below for more info. it is important to check for the consistency and the location pf the fundus. Normally, the fundus should feel firm upon palpation and the level will be inclined towards the umbilical (belly button) area. Any changes to this - for example if the fundus feels soft or is difficult to locate - could be indicative of postpartum hemorrhage. There might be instances when the bladder is causing the hemorrhaging and this is indicated by the fundus being displaced above the umbilical (belly button) area. Let the mother urinate and if after urinating the bleeding goes away, then it is the bladder causing the displacement of the uterus. In assessing the amount of discharge coming out from the vagina, it is important to weigh the pads being used before and after in order to get accurate documentation. Excessive bleeding should be indicated by saturation of one pad within fifteen minutes. Sometimes, the discharge often goes unnoticed and it can be checked by asking the mother to turn on her side and check underneath her, especially in the buttocks area. The mother's vital signs include her blood pressure, respiratory rate (number of breaths), pulse rate, and temperature. In postpartum hemorrhage, the pulse rate should be lower than normal (60 to 100 in a minute), but could vary depending on the mother’s previous pulse rate.  However, the vital signs may not show abnormality until later the mother is already suffering from excessive blood loss. Therefore, you should assess any deviation from what is normally expected with adequate blood volume, such as warm, dry skin and pink lips and mucous membranes. The nails can also be inspected by pinching and releasing them. There should only be a there second interval for the color of the nail bed to return to pink. If any of these changes have been assessed, the mother could be suffering from postpartum hemorrhage caused by the uterus failing to contract and getting back into its original shape. However, if the uterus has been assessed and it was found to be contracted and not dislocated, and yet there is still excessive bleeding, this could be due to trauma. In assessing for trauma, pain and external color of the vagina have to be considered.  Pain: The mother will be experiencing deep, severe pelvic pain or rectal pain. This can be indicative of internal bleeding. External vaginal orifice: there will be bulging masses and skin discoloration (usually purplish to bluish black hue). This can also be indicative of internal bleeding. If the laceration or wound is found outside, it can be easily assessed upon visual inspection, especially if done under proper lighting. If there is considerable blood loss and the cause have been determined, the next step in the nursing care plan has already been accounted for, which is the diagnosis.  Upon confirmation of the diagnosis of postpartum hemorrhage, the first step in planning is always to inform the physician and other healthcare providers involved in the care of the mother as the nurse cannot use client-centered goals. The nurse’s key roles in this kind of complication is to monitor the mother, implement ways to minimize blood loss and replace it, and to report right away if there are any significant changes in the previously noted condition and if the response from the mother is not what is desired. Nursing interventions appropriate for postpartum hemorrhage will be to continuously monitor the vital signs and the output via weighing blood soaked pads and linens. Massaging the uterus will also aid in getting it to contract and become firm again. Notifying the physicians or midwives when there is still bleeding (even during the massage) is important as well. The nurse should have already notified the blood bank in case there is a need for blood transfusion. Regulation of intravenous flow is also the nurse’s responsibility. The mother should also be positioned in what is called a modified Trendelenburg, where the legs are elevated by least 10 degrees and at most 30 degrees. The body is horizontal and the head elevated a little bit as well. The mother will usually be on a number of medications, such as oxytocin and Methergine, and the nurse should be able to determine the side effects of these medications, as they could also be life threatening to the mother.  Oxytocin is mainly used for labor induction and is safe to be given during labor; however it is also utilized after delivery. The action of the drug is to facilitate the contraction of the smooth muscles of the uterus. It is usually given through an intramuscular (usually in the upper arm) injection with a dose of 0.2 mg given every 2 to 4 hour with a maximum of 5 doses after delivery. Oxytocin has an antidiuretic effect, which means that it will inhibit urination. Methergine is a drug that is never given before labor, but can be given afterwards. This is because the action of Methergine is to promote sustained uterine contractions, and will therefore cause a decrease in the oxygen consumption of a baby still inside the uterus. Methergine is also given by injection intramuscularly with a dose of 0.2 mg every 2 to 4 hours. Methergine’s side effect is an increase in the body’s blood pressure. It should be noted if the blood pressure spikes up more than normal. The nurse should be aware of any buildup of fluids inside the body by consistently listening to breath sounds. This is done in order to identify any fluid in the lungs. The final step in the nursing process is evaluation. Like the assessment, the areas of concern in a mother suffering from excessive bleeding will be checked.  The location of the uterus should be midline, with the umbilicus as the center. The uterus should be firm upon palpation. The mother should not be changing pads as often (using only one pad every hour or so) and there should be no leakage of blood or fluids found on her bed sheets. The mother’s vital signs should have returned to her normal, pre-delivery vital signs. She will not have clammy or cold skin and her lips should be pinkish in color. Because she is no longer expelling fluids in bulk, her urine output should return to 30 ml to 60 ml every hour. This shows that there are enough fluids inside her body for adequate circulation. If her bleeding was due to trauma, any open wounds will have been sutured by the physician. These wounds will need consistent monitoring to ensure that they don't re-open.  There should be no more severe pain, although there may be some local pain coming from the sutured wound. If there was blood pooling inside the mother’s muscles or tissues, the treatment should have eradicated the purplish or black bluish coloring on the skin. The medications that were aforementioned should be routinely checked for any side effects, until the use of the medications is discontinued. Even though managing postpartum hemorrhage is done in cooperation with the physician, the nurse will be able to gauge the effectiveness of the interventions by a consistent improvement in the condition of the mother.