Postpartum hemorrhage (PPH) remains one of the most time‑critical obstetric emergencies worldwide. Rapid recognition, organized team response, and nurse‑driven interventions save lives. A robust nursing diagnosis and care plan guide the bedside sequence: quantify blood loss, assess physiology, correct uterine tone, give the right medications, activate transfusion pathways, and document precisely. This evidence‑based guide equips clinical teams with high‑yield assessments, medication quick facts, decision algorithms, and NANDA‑NIC‑NOC nursing diagnoses tailored to PPH.

Postpartum Hemorrhage Nursing Diagnosis

Postpartum hemorrhage is a critical and potentially life‑threatening complication of childbirth. Modern definitions emphasize both volume and physiology: cumulative blood loss ≥1,000 mL within 24 hours after birth OR any blood loss with signs of hypovolemia. Primary PPH occurs within 24 hours; secondary PPH occurs from 24 hours to 12 weeks postpartum. Excellence in nursing practice early detection, decisive action, and precise documentation directly improves maternal outcomes.

Definition and Clinical Framing

• Contemporary definition: Cumulative blood loss ≥1,000 mL or blood loss with hypovolemic signs/symptoms within 24 hours after birth (vaginal or cesarean).
• Classification:
  • Primary (early) PPH: ≤24 hours postpartum.
  • Secondary (late) PPH: >24 hours to 12 weeks postpartum.
• Severity indicators:
  • Shock Index (SI = HR/SBP) >0.9 suggests significant hemorrhage.
  • Fibrinogen <200 mg/dL predicts severe bleeding in obstetrics.

Epidemiology and Impact

• Global burden: PPH accounts for a substantial portion of maternal mortality, particularly in low‑resource settings.
• Morbidity: Transfusion, ICU admission, hysterectomy, infection, and thromboembolic risk.
• Systems approach: Implementation of obstetric hemorrhage bundles, readiness drills, and standardized carts reduces adverse outcomes.

Pathophysiology of Postpartum Hemorrhage

PPH results from failure of hemostasis at the placental bed or bleeding from trauma, tissue retention, or coagulopathy. The “4 Ts” framework guides rapid differential diagnosis.

The 4 Ts: Tone, Trauma, Tissue, Thrombin

• Tone (uterine atony)
  • Most common cause.
  • Mechanism: Inadequate myometrial contraction fails to compress spiral arteries at the placental site.
  • Contributors: Uterine overdistension (multiple gestation, polyhydramnios, macrosomia), prolonged/rapid labor, magnesium sulfate, chorioamnionitis, fibroids, general anesthesia.
• Trauma (lacerations, hematomas, uterine rupture, inversion)
  • Lacerations: Cervical, vaginal, perineal tears lead to brisk bleeding with a firm uterine fundus.
  • Hematomas: Concealed bleeding in vulvar, vaginal, or broad ligament spaces.
  • Uterine rupture: Sudden pain, loss of fetal station intrapartum, postpartum instability.
  • Uterine inversion: Sudden hemorrhage and shock; fundus absent on abdominal exam.
• Tissue (retained placenta, placenta accreta spectrum)
  • Retained fragments prevent uterine contraction; bleeding persists despite uterotonics.
  • Accreta spectrum: Abnormally adherent placenta (accreta, increta, percreta) leads to severe bleeding at attempted separation.
• Thrombin (coagulopathy)
  • DIC, severe preeclampsia/HELLP, placental abruption, amniotic fluid embolism, sepsis, inherited coagulation defects.
  • Consumptive coagulopathy decreases fibrinogen and platelets, prolongs PT/aPTT.

Risk Factors

Antenatal

• Prior PPH, prior cesarean delivery, placenta previa or accreta spectrum, grand multiparity
• Multiple gestation, polyhydramnios, fetal macrosomia
• Maternal anemia, obesity, hypertensive disease, coagulopathy, thrombocytopenia
• Uterine fibroids, uterine anomalies

Intrapartum

• Prolonged or precipitous labor, augmented labor (high‑dose oxytocin), infection
• Operative vaginal birth, cesarean birth, chorioamnionitis
• Uterine tachysystole followed by atony
• General anesthesia, magnesium sulfate exposure

Immediate Postpartum

• Retained placenta, manual removal, lacerations/hematomas
• Uterine inversion, uterine rupture
• Inadequate active management of the third stage of labor (AMTSL)

Assessment and Early Recognition

Clinical Signs and Symptoms

• Excessive vaginal bleeding, persistent trickling, or sudden gush
• Soft, boggy uterus (atony) vs firm uterus with ongoing bleeding (trauma)
• Tachycardia, decreasing blood pressure, narrowed pulse pressure
• Pale, cool, clammy skin; delayed capillary refill; dizziness, syncope
• Decreased urine output (<30 mL/hr), rising lactate
• Anxiety, altered mental status in advanced hypovolemia

Objective Metrics

• Quantification of Blood Loss (QBL)
  • Use calibrated drapes, weigh sponges/pads (1 g = 1 mL), measure in canisters.
  • Document cumulative totals and losses by time points (e.g., 15‑minute intervals).
• Shock Index (HR/SBP): >0.9 correlates with increased transfusion and intervention.
• Laboratory markers:
  • CBC, fibrinogen (goal >200 mg/dL; pregnancy baseline elevated), PT/INR, aPTT
  • Type and crossmatch; consider TEG/ROTEM where available.

Staging and Response Framework

Many centers use staged response similar to hemorrhage bundles.

• Stage 0: Routine prophylaxis and surveillance; oxytocin after birth; initial QBL.
• Stage 1: Blood loss >500 mL vaginal or >1,000 mL cesarean OR vital sign changes; activate team; begin algorithm.
• Stage 2: Ongoing bleeding, cumulative >1,500 mL or abnormal labs; escalate medications and procedures; prepare for MTP.
• Stage 3: Hemodynamic instability or >2,500 mL loss; massive transfusion protocol (MTP), operating room interventions, anesthesia and critical care support.

Immediate Management Algorithm (Nurse-Focused Actions)

• Call for help and activate PPH protocol; assign roles (compressor, medication nurse, recorder, runner).
• Ensure large‑bore IV access (at least 18G; consider two lines), draw labs and type/cross.
• Start warmed crystalloids; place urinary catheter for output monitoring.
• Fundal and bimanual uterine massage for atony; expel clots.
• Identify likely etiology via 4 Ts; examine perineum, vagina, and cervix for lacerations; evaluate placenta for completeness.
• Begin uterotonics per standing orders; document dose, route, time, response.
• Quantify ongoing blood loss; update cumulative totals and vital trends frequently.
• Consider early TXA; request hemorrhage cart and balloon tamponade device.
• Communicate SBAR with obstetrics, anesthesia, blood bank, and leadership.
• Prepare for MTP if clinical triggers present; maintain normothermia and correct calcium.

Medications and Dosing Quick Guide

Uterotonics (first-line for Tone)

• Oxytocin (Pitocin)
  • 10–40 units in 1,000 mL NS or LR IV infusion, titrate to uterine tone; and/or
  • 10 units IM if no IV access
  • Adverse effects: hypotension with rapid IV bolus, water intoxication at high cumulative doses
• Methylergonovine (Methergine)
  • 0.2 mg IM every 2–4 hours as needed
  • Contraindication: hypertension, preeclampsia, peripheral vascular disease
  • Adverse effects: hypertension, nausea, vomiting
• Carboprost tromethamine (Hemabate)
  • 250 mcg IM or intramyometrial every 15–90 minutes; maximum total 2 mg
  • Contraindication: asthma; caution in hepatic, renal, or cardiac disease
  • Adverse effects: bronchospasm, diarrhea, vomiting, fever
• Misoprostol
  • 600–1,000 mcg PO/SL/PR (common: 800–1,000 mcg PR)
  • Useful adjunct when other agents are unavailable or insufficient
  • Adverse effects: fever, shivering, diarrhea

Antifibrinolytic

• Tranexamic acid (TXA)
  • 1 g IV over 10 minutes as soon as PPH is diagnosed, ideally within 3 hours of birth
  • Second 1 g dose if bleeding continues after 30 minutes or restarts within 24 hours
  • Mechanism: inhibits fibrinolysis; reduces death due to bleeding when given early

Anesthesia/Additional Agents

• Consider uterine relaxants (e.g., nitroglycerin) for inversion reduction per provider order.
• Antibiotic prophylaxis after manual removal or invasive procedures per protocol.

Procedures and Surgical Interventions

Bedside and Early Operating Room Actions

• Uterine massage and bimanual compression
• Manual removal of retained placental tissue (with analgesia/anesthesia)
• Repair of cervical, vaginal, and perineal lacerations
• Intrauterine balloon tamponade (e.g., Bakri/Ebb)
  • Fill per manufacturer guidance; note volume and adjust to control bleeding
  • Continue uterotonics; monitor output via catheter

Escalation Interventions

• Uterine compression sutures (e.g., B‑Lynch)
• Uterine or internal iliac artery ligation
• Uterine artery embolization by interventional radiology (hemodynamically stable candidates)
• Hysterectomy (life‑saving definitive control when conservative measures fail)
• Special scenarios:
  • Uterine inversion: Immediate Johnson maneuver to replace fundus; uterotonics after reposition; consider tocolysis for reduction.
  • Placenta accreta spectrum: Planned multidisciplinary approach; hysterectomy often required; avoid forcible placental removal.

Fluid, Blood, and Coagulation Management

• Massive Transfusion Protocol (MTP)
  • Balanced components: RBCs, plasma, and platelets commonly in a 1:1:1 ratio (institutional protocols vary).
  • Early fibrinogen replacement via cryoprecipitate or fibrinogen concentrate to maintain >200 mg/dL.
  • Monitor ionized calcium and replace (e.g., calcium gluconate or calcium chloride) due to citrate binding in transfused products.
• Hemodynamic goals
  • Maintain MAP for perfusion, adequate urine output, and mental status.
  • Prevent hypothermia (active warming blankets, warmed fluids).
• Lab guidance
  • Repeat labs at intervals; use viscoelastic testing (TEG/ROTEM) if available to tailor therapy.

Nursing Management: NANDA‑NIC‑NOC Framework

Priority Nursing Diagnoses (examples)

• Deficient Fluid Volume related to acute blood loss as evidenced by tachycardia, hypotension, decreased urine output
• Ineffective Peripheral Tissue Perfusion related to hypovolemia as evidenced by cool, clammy skin and delayed capillary refill
• Risk for Bleeding related to uterine atony/trauma/coagulopathy
• Decreased Cardiac Output related to reduced preload
• Anxiety related to emergency condition and perceived threat
• Acute Pain related to uterine massage, laceration repair, or procedures

Expected Outcomes (NOC examples)

• Hemodynamic Stability: HR <100, SBP ≥100 (context dependent), Shock Index ≤0.9
• Tissue Perfusion: Warm extremities, capillary refill <2 seconds, mental status at baseline
• Uterine Tone: Firm, midline fundus at expected level
• Fluid Balance: Adequate urine output ≥30 mL/hr
• Knowledge: PPH Plan of Care: Patient verbalizes understanding of warning signs and follow‑up (post‑stabilization)

Nursing Interventions (NIC) with Rationales

• Hemorrhage Control: Perform fundal massage and bimanual compression; expel clots to restore uterine tone and compress spiral arteries.
• Medication Administration: Administer uterotonics and TXA per order; verify contraindications (e.g., asthma for carboprost; hypertension for methylergonovine).
• Intravenous Therapy: Establish/maintain large‑bore access; infuse warmed crystalloids and blood products to restore circulating volume.
• Monitoring: Track QBL, vital signs, Shock Index, urine output; obtain serial labs (CBC, fibrinogen, PT/INR, aPTT).
• Oxygen Therapy: Provide supplemental oxygen to optimize tissue oxygenation during resuscitation.
• Thermal Regulation: Apply active warming to prevent coagulopathy exacerbated by hypothermia.
• Pain Management: Provide ordered analgesia; support during laceration repair or balloon placement.
• Anxiety Reduction: Offer concise updates; maintain calm environment; engage support person if appropriate.
• Collaboration: Activate hemorrhage bundle; coordinate with obstetrics, anesthesia, blood bank, pharmacy, and interventional radiology.
• Documentation: Time‑stamped entries for all interventions, responses, and communications; maintain running QBL total.

Sample Nursing Care Plan (PPH due to Uterine Atony)

Assessment

• Subjective: Reports dizziness, “faint” feeling.
• Objective:
  • QBL: 1,100 mL within 45 minutes postpartum
  • Vitals: HR 122, BP 92/58, RR 24, Shock Index 1.33
  • Uterus: Soft, boggy, above umbilicus, deviated right (full bladder)
  • Lochia: Heavy with clots
  • Labs: Hgb 8.2 g/dL, fibrinogen 180 mg/dL

Nursing Diagnosis

• Deficient Fluid Volume related to acute blood loss secondary to uterine atony as evidenced by hypotension, tachycardia, decreased Hgb, and elevated Shock Index.

Goals/Outcomes

• Stabilize hemodynamics within 60 minutes: HR <100, BP ≥100/60, SI ≤0.9
• Achieve firm, midline fundus at/below umbilicus
• Urine output ≥30 mL/hr; warm extremities; capillary refill <2 seconds
• QBL increase <150 mL per 15 minutes

Interventions and Rationales

• Perform fundal massage; implement bimanual compression if atony persists (restores uterine tone; expels clots).
• Empty bladder with straight catheter or Foley (full bladder impedes uterine contraction).
• Administer oxytocin infusion (30 units in 500–1,000 mL LR); titrate to tone (first‑line uterotonic).
• Give methylergonovine 0.2 mg IM unless hypertensive; if contraindicated, administer carboprost 250 mcg IM; add misoprostol 800–1,000 mcg PR as adjunct (multi‑agent approach improves tone).
• Administer TXA 1 g IV over 10 minutes (reduces mortality from bleeding when given early).
• Initiate warmed IV crystalloids; coordinate MTP for balanced blood products; monitor ionized calcium and replace per protocol (restore volume and coagulation).
• Place intrauterine balloon tamponade if bleeding persists (mechanical compression).
• Continuous monitoring: Vitals every 5–15 minutes; strict I&O; maintain active warming (early detection of deterioration; coagulopathy prevention).
• Provide concise explanations; involve support person as appropriate (reduce anxiety; improve cooperation).
• Document all actions, times, doses, responses, and cumulative QBL (communication and legal record).

Evaluation

• Post‑intervention: Fundus firm and midline; QBL stabilized; HR 96, BP 108/66, SI 0.89; urine output 35 mL/hr; extremities warm; patient calmer and oriented.

Documentation Essentials (Quality and Safety)

• Time‑stamped QBL totals and trend lines
• Uterine assessments (tone, position, level) and interventions (massage, bimanual compression)
• Medication doses, routes, response, and adverse effects
• Procedures: laceration repairs, balloon volumes, OR interventions
• Vital signs, Shock Index, urine output, temperature
• Lab results, blood products issued, MTP activation time, calcium replacement
• Provider notifications, SBAR communications, debrief notes
• Patient education provided and comprehension checks (post‑stabilization)

Prevention and Readiness

Antenatal and Intrapartum Prevention

• Correct antenatal anemia; screen and treat iron deficiency
• Risk stratification on admission; notify team for high‑risk cases (placenta previa/accreta, multiple gestation, prior PPH)
• Active Management of the Third Stage of Labor (AMTSL): prophylactic oxytocin after birth, controlled cord traction when indicated, uterine massage after placental delivery
• Avoid unnecessary uterine overdistension with high‑dose oxytocin; monitor tachysystole

Unit Readiness

• Hemorrhage cart stocked with uterotonics, TXA, IV supplies, balloon devices, suture kits
• QBL supplies at every birth (calibrated drapes, scales, standardized worksheets)
• Multidisciplinary drills and debriefs; posted algorithms; rapid access to MTP
• Standing orders and nurse‑driven protocols for first‑line medications and labs

Special Populations and Situations

• Cesarean PPH: Increased risk of atony and surgical site bleeding; utilize intraoperative QBL, uterine massage, and compression sutures.
• VBAC/uterine rupture risk: High‑index suspicion for trauma‑related bleeding; rapid OR access.
• Placenta accreta spectrum: Planned multidisciplinary delivery; blood bank preparation; potential cesarean hysterectomy.
• Adolescent or advanced maternal age: Optimize antenatal counseling and support.
• Patients declining blood products: Early ethics consultation; optimize non‑blood strategies (TXA, fibrinogen concentrate, cell salvage where acceptable).
• Obesity: Anticipate IV access challenges; longer operative times; higher atony risk; proactive planning.

Interprofessional Roles

• Nursing: First detection, QBL, fundal massage, medication administration, documentation, family support, and coordination.
• Obstetrics: Etiology identification and definitive procedures.
• Anesthesia: Hemodynamic management, airway, analgesia/anesthesia, MTP coordination.
• Blood Bank/Transfusion Medicine: Rapid component availability and product guidance.
• Pharmacy: Medication verification, dosing, and double checks; TXA availability.
• Interventional Radiology: Embolization for selected stable patients.
• Leadership: Oversight, resources, debrief, and quality improvement.

Education for Patients and Families (Post‑Stabilization)

• Explain PPH event, cause, treatments performed, and expected recovery.
• Review warning signs after discharge: heavy bleeding soaking pads rapidly, large clots, dizziness, fever, foul discharge, severe pain.
• Arrange close follow‑up, iron therapy if indicated, and mental health support for traumatic birth experience.
• Provide written materials in preferred language; confirm understanding.

Frequently Asked Questions (FAQ)

What are the most common causes of postpartum hemorrhage?

Uterine atony is the leading cause. Other major causes include trauma (lacerations, hematomas, rupture, inversion), tissue (retained placenta or accreta spectrum), and thrombin (coagulopathy). The “4 Ts” mnemonic—Tone, Trauma, Tissue, Thrombin supports rapid bedside thinking.

How is blood loss best measured during and after birth?

Quantification of blood loss (QBL) is preferred: use calibrated drapes, weigh sponges and pads, and measure canister volumes. Visual estimation underestimates bleeding, especially at higher volumes.

When should tranexamic acid be given for PPH?

TXA 1 g IV should be administered as soon as PPH is diagnosed, ideally within 3 hours of birth, with consideration of a second 1 g dose if bleeding persists or recurs within 24 hours. Early use reduces death due to bleeding.

Which uterotonics are first‑line for uterine atony?

Oxytocin is first‑line. Additional agents include methylergonovine (avoid in hypertension), carboprost (avoid in asthma), and misoprostol. Combining agents is common when bleeding continues.

What is the role of the nurse during a hemorrhage event?

Nurses drive recognition, QBL, uterine massage, medication administration, vascular access, monitoring, and documentation, while coordinating with obstetrics, anesthesia, pharmacy, and blood bank according to the hemorrhage bundle.

Conclusion

Postpartum Hemorrhage Nursing Diagnosis anchors a disciplined, life‑saving approach to a time‑sensitive emergency. A nurse’s rapid assessment, hands‑on interventions, evidence‑based medication sequence, and meticulous documentation transform outcomes. By operationalizing the 4 Ts framework, using QBL and Shock Index, initiating TXA and uterotonics without delay, and escalating to balloon tamponade, MTP, and surgical control when indicated, care teams can stabilize physiology and preserve future fertility. Ongoing readiness drills, strong interprofessional communication, and patient‑centered education complete the cycle of safety and compassionate care.

Educational Note: Content is intended for professional education and does not replace local protocols or specialty consultation. Always follow institutional hemorrhage bundles and medication guidelines.