Conditions › Maternity & newborn
Postpartum Hemorrhage Nursing Care Plan and Interventions
The first action for postpartum hemorrhage from a boggy uterus is fundal massage, then oxytocin as ordered; measure blood loss by weighing pads instead of guessing. Know which drugs to hold (methylergonovine with high BP, carboprost with asthma), and check for other causes if the fundus is firm but bleeding continues.
Postpartum hemorrhage nursing care plan
| Nursing problem | Goal | Key interventions |
|---|---|---|
| Deficient fluid volume (blood loss) | Bleeding controlled; stable vital signs. | |
| Risk for uterine atony | Fundus firm and midline. | |
| Health maintenance: needs teaching | Knows late PPH signs to report after discharge. |
Problem wording is plain-language nursing diagnosis style. Your program may require NANDA-I labels and your own assessment data.
What it is
PPH: definition
Blood loss of 1,000 mL or more, or any loss with signs of hypovolemia, within 24 hours of birth, vaginal or cesarean (ACOG reVITALize). 1
More than 500 mL after a vaginal birth still needs the provider to assess.
The four Ts
Tone (uterine atony, the most common), Trauma (lacerations, hematoma), Tissue (retained placenta), Thrombin (clotting problems). 2,1
Atony causes about 70 percent of postpartum hemorrhages.
Why atony bleeds
A contracted uterus clamps the arteries at the placental site. A soft, boggy uterus leaves them open, so blood pours out fast. 2,1
Risks: big baby, twins, extra fluid, long or oxytocin-driven labor, many births, infection, magnesium.
Assessment: what you will see
PPH cues
Boggy fundus, heavy flow or clots, rising heart rate, dizziness, anxiety. BP falls late because pregnancy adds extra blood volume. 2
A normal BP does not rule out PPH: trend the heart rate and the blood loss.
Measure, don't guess
Quantitative blood loss (QBL): weigh pads, underpads and drapes and keep a running total. Eyeball estimates miss big losses. 2
Soaking a peripad in less than 1 hour is a sign bleeding is excessive.
Firm fundus, still bleeding
Think trauma: a laceration, or a hematoma with rising pain and pressure plus falling BP and rising heart rate. Notify the provider. 3,2
Severe perineal pain after birth is not just soreness: check for a hematoma.
Priority: what the nurse does first
First action: fundal massage
Massage the boggy fundus until firm, with the other hand supporting the lower uterus. Call for help while you massage. 2
Massage first, then meds: massage is fast, and it treats the cause.
Boggy and pushed to one side
A full bladder lifts the uterus and keeps it from contracting. Help the client void or catheterize per order, then recheck. 4
Fundus high and right of midline: empty the bladder.
Hemorrhage response
Call for help, give rapid IV fluids, type and crossmatch for blood, track vitals and keep urine output at least 30 mL/hr. 2
Bleeding keeps coming back despite massage and oxytocin: activate the hemorrhage team.
Nursing interventions and treatment
Oxytocin: first-line drug
The first uterotonic for PPH. Given as a diluted IV infusion, or 10 units IM if there is no IV access. 2
Strong cramping is expected: it means the uterus is contracting.
Methylergonovine: hold for high BP
0.2 mg IM; not given IV routinely. It constricts vessels and raises BP, so hold it for hypertension or preeclampsia. Check BP first. 2,5
BP 158/102 mm Hg before the dose: hold and call the provider.
Carboprost: hold for asthma
Strong prostaglandin, 250 mcg IM. Can cause bronchospasm, so avoid it with asthma. Expect diarrhea, fever, nausea. 2
History of asthma? Question the carboprost order.
Misoprostol
Prostaglandin given by mouth, under the tongue or rectally. Safe with asthma or hypertension. Expect chills, fever, nausea, diarrhea. 2
The prostaglandin you can give when carboprost and methylergonovine are both off the table.
Tranexamic acid (TXA)
Keeps clots from breaking down. 1 g IV over 10 minutes, within 3 hours of birth, given with a uterotonic. 2,6
TXA does not firm the uterus, so massage and uterotonics still come first.
Client teaching
Teach: late PPH signs
Late PPH can happen up to 12 weeks after birth. Call for heavy bright red bleeding, a pad soaked in an hour, big clots, foul odor. 7,2
Most common late cause: subinvolution, a uterus that does not shrink back.
Try a postpartum hemorrhage question
NCLEX-style, approved by a licensed RN. Pick an answer, check it, then read the rationale.
Question 1 · Physiological Adaptation
A postpartum client's fundus remains boggy after fundal massage and after the bladder has been emptied. Which actions should the nurse anticipate? Select all that apply.
Select all that apply.
Show answer and rationale
Answer: A, D, E. When uterine atony persists despite massage and bladder emptying, the nurse should anticipate administration of an oxytocic medication to help the uterus contract, along with counting and weighing pads to quantify blood loss and monitoring vital signs closely for signs of hemorrhage and shock. Discontinuing the IV infusion is incorrect because IV access is needed to give fluids and medications in this emergent situation. Hysterectomy is an extreme last-resort intervention used only when all other measures fail to control life-threatening hemorrhage, not an immediate next step.
Checked against: OpenStax Maternal-Newborn Nursing, 21.2; OpenStax Maternal-Newborn Nursing, 18.4
Keep studying postpartum hemorrhage in NurseLingo Pro
Pro has 13 postpartum hemorrhage questions like these, with a rationale for every answer. Everything for postpartum hemorrhage in one place. A free account gets 5 free opens of any condition; Pro opens all 277.
Test yourself: free OB and maternity practice questions with answers and rationales.
Frequently asked questions
What are the priority nursing diagnoses for postpartum hemorrhage?
Common nursing problems for postpartum hemorrhage include deficient fluid volume (blood loss); risk for uterine atony; health maintenance: needs teaching. Choose the ones your assessment supports and rank airway, breathing and circulation problems first.
What does the nurse do first for postpartum hemorrhage?
Massage the boggy fundus until firm, with the other hand supporting the lower uterus. Call for help while you massage. A full bladder lifts the uterus and keeps it from contracting. Help the client void or catheterize per order, then recheck. Call for help, give rapid IV fluids, type and crossmatch for blood, track vitals and keep urine output at least 30 mL/hr.
What are the 4 T's of postpartum hemorrhage?
Tone (a soft, boggy uterus, the most common cause), Trauma (tears or lacerations), Tissue (retained placenta) and Thrombin (clotting problems). They help the team find why a new mother is bleeding and what to treat.
What are the priority nursing interventions for postpartum hemorrhage?
Massage the fundus first if it is boggy, then give oxytocin as ordered. Weigh pads to measure blood loss, check vital signs, keep IV access and call for help. If the fundus is firm but bleeding continues, look for another cause such as a tear.
More maternity & newborn
Sources
- OpenStax Maternal-Newborn Nursing, 19.9
- OpenStax Maternal-Newborn Nursing, 21.2
- OpenStax Maternal-Newborn Nursing, 19.10
- OpenStax Maternal-Newborn Nursing, 20.1
- dailymed.nlm.nih.gov
- OpenStax Maternal-Newborn Nursing, 18.3
- OpenStax Maternal-Newborn Nursing, 20.3
For study only, not medical advice. Follow your program, your facility's policies and the provider's orders.