Running Head: MIND MAP
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Mind Map of Postpartum Hemorrhage
Laura M. Varnier
Duke University School of Nursing
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Introduction and Lesson Learned
In the following Mind Map presentation, I have outlined and prioritized key nursing
assessments, plans, diagnoses, and interventions, based upon information grounded in evidence, to
support a postpartum patient experiencing hemorrhage. I drew from the unit policy of Wake Med
Hospital, standard of care from California Maternal Quality Care Collaboration Hemorrhage
Taskforce and evidence based research to illustrate key implementation steps to take, as a nurse,
based on criteria presented in the case study. Furthermore, the outline of my thoughts walks the
reader through the important clinical nursing assessments and diagnoses that led to my prioritized
interventions, while my mind map displays a visual portrayal of these same features.
By means of this project, I was able to learn new ways that my mind was able to connect key
features of the nursing process and allow application of this knowledge in a case study example.
Though I did not enjoy the thought of this project since it was presented in the first semester of the
ABSN program, I am now able to see how applicable it can be to dividing knowledge, arranging that
knowledge and uniting links among key concepts to allow for prioritization of key nursing actions. I
felt that the outline provided me with the opportunity to list out all key nursing steps that I would
implement and the mind map allowed for a visual representation of my thought processes.
This project also highlighted areas that I needed to strengthen within myself, such as my
ability to look beyond minute details and see the larger picture. Often times I find myself caught in
miniscule details of patient care, when I need to step back and take a more holistic look at the whole
patient presentation (for example, not just looking at blood pressure in isolation, but connecting that
to other, more serious consequences). I appreciated this project in that it forces students to look at
nursing in a different way and step outside of the “concept map” comfort zone that we have come
accustomed to.
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Standard of Care from California Maternal Quality Care Collaboration
Attached
Unit Policy from Wake Medicine Hospital in Raleigh
Attached
Nursing Evidence Based Research Article
Attached
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Outline
1) Etiology of case study patient’s postpartum hemorrhage.
Early causes of PPH leading to uterine atony include macrosomia (greater than 4,000 grams),
polyhydramnios, operative vaginal delivery with use of forceps or vacuum extractor, augmented or
induced labor, ineffective uterine contractions during labor resulting in a prolonged first or second
stage of labor, precipitous labor, lacerations, hematomas and or birth or the use of general anesthesia
(Chapman & Durham, 2010).
Our patient displays several early risk factors for PPH:
1. Macrosomic baby- 9lbs 10 oz- approximately 4366 g.
i) Risk factors for PPH: “Neonatoal macrosomia: Birth weight greater than 4000 grams”
(Chapman & Durham, 2010).
2. Small midline episiotomy.
i) “Lacerations are the second most common cause of early PPH” (Chapman & Durham,
2010).
3. Multiple pregnancies- G5P4004
i) Conditions that increase the risk of postpartum hemorrhage includes having many
previous births--greater than 4 (UPMC, 2008).
4. Current labor was the longest among previous labor (15 hours) and this contained the largest
infant to date.
i) Risk factors for PPH: “Ineffective uterine contractions during labor: Prolonged first or
second stage of labor” (Chapman & Durham, 2010). Longer labors suggest that uterine
muscle endured more stress for a longer amount of time and uterine atony may occur due
to uterine exhaustion (Chapman & Durham, 2010).
5. Pitocin use during last part of labor as she “failed to contract adequately”.
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i) Risk factors for PPH: “Augmented or induced labor” (Chapman & Durham, 2010).
Additionally, according to Burke, Pitocin used as an induction strategy early in
pregnancy can lead to higher risk for postpartum hemorrhage because the body is not able
to clamp down on blood vessels appropriately to ensure that bleeding is controlled
(2010).
6. EBL for vaginal delivery was 400 cc.
i) “Early PPH is defined as a blood loss of greater than 500 ML within the first 24 hours,
but in clinical practice it is diagnosed when the health care provider determines that the
blood loss is greater than normal” (Chapman & Durham, 2010).
ii) “Visual estimation of blood loss volume is inaccurate and can underestimate postpartum
blood loss by 33%-50% when compared to the gold standard for quantifying blood loss,
which is photospectrometry or colorimetric measurement of alkaline heamtin in blood.
Visual estimation of blood loss may be complicated by the presence of large volumes of
amniotic fluid, stool or sponges” (CMQCC, 2010).
7. Excess fluid intake without voiding can lead to an overdistended bladder and an inability of
the uterus to contract appropriately.
i) Patient has taken in 1100 cc orally since birth and has had 2000 LR over the course of the
last 12 hours, while compensating once during birth (void amount not recorded) and a
scant amount of approximately 100 cc after birth.
ii) “Assess for a displaced uterus. An overdistended bladder can displace the uterus and
cause it to relax” (Chapman & Durham, 2010).
Late Signs of PPH include hematomas, subinvolution and retained placental tissue (Chapman &
Durham, 2010).
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2) Patient presentation at 1930.
Patient states that she is “feeling lightheaded” and looks pale. She is currently eating a snack.
i) Pale color and clammy skin may be an early assessment finding of uterine atony, the
leading cause of early PPH (Chapman & Durham, 2010).
3) Assessment data at 1930.
1. Patient looks pale.
i) Paleness can be indicative of blood loss and an early sign of uterine atony, the leading
cause of early PPH (Chapman & Durham, 2010).
2. Current BP 78/40 mmHg has fallen significantly from blood pressure at 1800 of 120-130/8084 mmHg.
i) Hypotension can be an early assessment finding of uterine atony (Chapman & Durham,
2010).
3. Current pulse of 124 beats per minute has increased significantly since 1800 to 88 bpm.
i) Tachycardia can be an early assessment finding of uterine atony (Chapman & Durham,
2010).
4. Patient states that she is having “severe cramps”.
i) “Uterine contractions constrict the open vessels at the placental site and assist in
decreasing the amount of blood loss. When the uterus is relaxed the vessels are less
constricted and the woman experiences an increase of blood loss” (Chapman & Durham,
2010). Our patient’s uterine cramping is a good sign her body is attempting to clamp off
bleeding blood vessels, though this mechanism may not be compensating adequately.
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5. Uterus has involuted to 4/U, an increase of two fingerbreadths from her last assessment at
1800 (where it was located at 2/U).
i) “Subinvolution of the uterus occurs when the uterus does not decrease in size and does
not descend into the pelvis. Risk factors include fibroids, endometritis, and retained
placental tissue” (Chapman & Durham, 2010). The woman may need to be examined for
retained placental tissue, by dilation and curettage or a sterilized manual sweep by a
physician/CNM, which may also explain her lochia being heavy and containing clots
(Chapman & Durham, 2010).
6. Uterus is deviated to the right.
i) “Assess for a displaced uterus. An overdistended bladder can displace the uterus and
cause it to relax” (Chapman & Durham, 2010). A uterus displaced to the right is
indicative of an overdistended bladder.
7. Uterus is boggy and does not firm up to massage.
i) A uterus that is boggy and does not firm up to massage is indicative of uterine atony
leading to postpartum hemorrhage without further intervention (Chapman & Durham,
2010).
8. Lochia is characterized by “silver dollar” sized clots.
i) Blood clots found in assessment finding can be indicative of uterine atony: “Express
clots: clots can interfere with uterine contraction” (Chapman & Durham, 2010). Large
clots need to be weighed and assessed to determine EBL.
9. EBL of 750 cc of bright red blood.
i) When adding the amount of blood loss during delivery (400cc), the lochia assessment of
moderate to heavy at 1800, has increased at current assessment to 750cc, with total blood
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loss equivalent to 1150 cc; this categorizes our patient into the greater than 500 cc blood
loss for vaginal delivery and emergency PPH protocol needs to be activated.
10. Allergies- Both the chart and assessment handoff performed by the previous nurse did not
assess allergies. This would be a good question for the incoming nurse to ask the patient.
11. Assessment of lab results: lab results, according to standing orders, are not required until the
morning after delivery. The assessment of the patient Hct/Hgb lab results after delivery is a
critical assessment in relation to the patient’s current status.
i) Normal Hematocrit value- 35-50%; Normal Hemoglobin value 12-17.5.
12. Other assessment item of note: patient does have current heplocked IV access available, if
necessary; patient needs to be placed on high falls precaution related to drop in BP and active
bleeding which can lead to orthostatic hypotension.
4) Collaborative problem list:
1.
Fluid volume deficit related to hypotension, tachycardia, decreased urinary output, uterine
atony, and increased lochia.
2.
Altered tissue perfusion related to pale skin and hypovolemia (blood loss).
3.
Acute pain related to severe cramping and medication interventions necessary to control
bleeding.
4. Delay in mother-infant attachment related to being unable to care for newborn and fatigue
acquired during blood loss.
5. Interrupted breastfeeding related to separation from infant for medical treatment.
i) “Among women with a significant PPH, 63% fully breastfed their babies from birth,
whereas 85% said they had hoped to do so (p < 0.001). Only 52% of mothers who
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intended to either fully or partially breastfeed were able to give their baby the opportunity
to suckle within an hour of the birth. Delays were longer in women with greater estimated
blood loss and women with the longest delays in breastfeeding were less likely to initiate
full breastfeeding” (Thompson et al., 2010).
6. Anxiety related to blood loss and increase in medical professional attention.
7.
Risk for infection related to loss of blood and depressed immunity, especially at episiotomy
suture line.
5) Goal of Nursing intervention:
1. To prevent further hemorrhage and re-establish homeostasis; According to Burke, postpartum
hemorrhage is defined as vaginal delivery accompanied by blood loss greater than 500mL
and caesarean birth by loss greater than 1000 mL blood loss (2010).
6) Plan and Nursing Interventions to prevent postpartum hemorrhage.
*Note: Nursing interventions are based upon evidential support for active management of the third
stage of labor. According to Burke, “evidence-based literature and the WHO support and recommend
the active management of the third stage of labor approach asserting that [in utilizing the active
management protocol] blood loss and the risk of PPR are decreased by 68%” (2010).
1. Call for help while activating Wake Med Hospital postpartum hemorrhage protocol (Wake
Med Raleigh Process Standards, 2010). Stay with the patient throughout all interventions.
Another nurse needs to retrieve all medications and supplies from outside of the patient’s
room.
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(1) According to the California Maternal Quality Care Collaboration protocol on
Obstetric Hemorrhage cases, the patient’s high risk status would have previously
placed her into the category to be T&C for 2 U of blood (CMQCC, 2009). The
woman has entered stage 1 of the Hemorrhage Care guidelines due to her vital
changes by 15% and blood loss greater than >500 mL vaginally, continuing to stage 2
with continued bleeding and total blood loss under 1500mL.
(2) Ensuring a current Type and Screen is also a priority intervention according to Wake
Med Raleigh Process Standards (2010).
(3) Ask another nurse to retrieve the Wake Med postpartum emergency kit from the
centralized nursing station.
2. Begin full vital sign assessments, including BP, HR, RR, O2 saturation level, every 5 minutes
continuously.
i) “Monitor vital signs continuously. Look for tachypnea, tachycardia, pallor, cyanosis, and
shock” (Wake Med Process Standards, 2010).
3. “Assess amount of blood loss, clots, odor, bright or dark color. Check uterus for atony, fundal
height, position and abdominal tenderness” (Wake Med Raleigh Process Standards, 2010).
i) “The physician or midwife is notified when the fundus does not respond to fundal
massage” (Chapman & Durham, 2010). If the fundus is non-responsive, it is necessary to
summon the MD/CNM at this time.
4. Assess patient’s ability to move to bathroom to void (most likely not a possibility) or prepare
patient for a Foley catheter, in order to drain the bladder and allow the uterus to contract
properly.
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i) “Assist the woman to the bathroom to void if the uterus is not midline and then re-assess
the location and firmness of the fundus and the amount and characteristics of the lochia.
Catheterize the woman if she is unable to void and the uterus is displaced by the
overdistention of the bladder (Chapman & Durham, 2010).
ii) Wake Med Raleigh Process Standards states “empty bladder by foley cath or void”
(2010).
5. Open heplocked IV access and, according to doctor’s prescribed orders, begin 20 U IV
Pitocin in 1000 cc lactated ringers (40 U IV Pitocin in 1000 mL LR according to Wake Med
protocol).
i) “Establish IV line with large bore angiocath and bolus fluids as ordered” (Wake Med
Raleigh Process Standards, 2010).
ii) The IV infusion rate of Pitocin is started at 10-40 mL/min and regulated by the firmness
of the fundus (Chapman & Durham, 2010).
6. “Start O2 via face mask, non-rebreather at 10-12 L/min. Assist patient to lateral position if
possible. Elevate legs to a 20-30 degree angle to increase venous return (Trendelenburg)”
(Wake Medicine Process Standards, 2010).
7. Prepare Methergine 0.2 mg IM injection (permitted due to current BP reading of 78/40
mmHg) to promote cessation of bleeding (utertonic medication).
*Stage 2 protocol according to CMQCC, 2009: Continue to call for additional help, while ensuring
that the OB is back at the bedside, and proceed in taking the patient to the OR for further
implementation measures.
8. Access 2nd IV site with an 18 gauge syringe, appropriate for blood transfusions. According to
CMQCC standards, notify blood bank of patient’s OB Hemorrhage situation; if type and
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screen was not previously conducted or has not returned from laboratory, begin O- blood
transfusion of 2 Units of PRBCs (CMQCC, 2009).
9. Continue medication administration, according to MD orders, of Hemabate 250 mcg IM (if
patient does not have a history of asthma) or Misoprostol 800-1000 mcg PR (Chapman &
Durham, 2010).
10. Assist MD in any additional procedures that follow, including repairing any tears, D&C,
intrauterine balloon placement, selective embolization, sterilized uterine sweep, etc.
*Continue to stage 3 of CMQCC protocol, 2009: If vitals continue to be unstable, blood loss reaches
over 1500 mL, there is suspicion of DIC or >2 units of PRBCs are given, “continue to massive
aggressive transfusion protocol and invasive surgical approaches for control of bleeding”, which
includes continued assistance requested, placing a central line, repeat labs, hysterectomy, etc.
According to the routine provider order prioritization (provided in the case study information):
Complete these orders now:
1) Pitocin 20 U in IV (1000 cc LR) for heavy bleeding.
2) Methergine 0.2 mg IM if pressures are normal.
*Continue with hemorrhage protocol according to hospital policy. Obtain an order for a STAT
Hct/Hbg lab, prior to order the morning after delivery.
Once hemorrhage episode has been managed and has ended:
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3) Manage patient pain with Tylenol (325 mg, 1-2 tabs, PO, PRN, as ordered) or Percocet (1-2 tabs,
PO, PRN, as ordered). Further pain reduction medications, such as Morphine, may be needed for
D&C and manual sterile uterine sweep; pain management should be discussed with the medical
team and tailored to fit the patient’s needs.
4) Provide patient and support system an opportunity to ask questions and review what events
occurred; this allows for anxiety to decrease and understanding to develop.
5) Baby to breast every 2-3 hours, around the clock; ensure considerations if the patient is supplied
with additional pain medication (aside from Tylenol and Percocet) for this to influence both the
mother’s mental state and breast milk.
a) “Oxytocin allows for milk ejection and uterine contractions that help to maintain uterine
tone” (Burke, 2010).
6) Ice to perineum for first 12 hours, then may initiate sitz bath PRN.
7) May ambulate and shower when stable (with nurse assist on first OOB).
8) Regular diet, advance as tolerated, fluids as tolerated.
9) Move to PP floor.
10) D/C IV when stable.
11) Hct/Hgb morning after delivery (10-11-2011).
12) For breastfeeding issues, may consult lactation consultant.
PRN Medications:

Tylenol 325 mg. 1-2 tabs PRN for pain.

Percocet 1-2 tabs, PO, PRN for pain.

Lanolin for nipple tenderness PRN.
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13) Evaluation of Intervention Actions:
a) Fluid status returns to baseline as evidence by mental status, skin color, and vital signs return
to stable condition/baseline.
b) Patient does not show signs of increased lochia output or clots, patient does not saturate a
peripad within an hour’s time.
c) Fundus firms to massage and is midline.
d) Pt states pain is adequately managed and pain reassessment occurs within one hour of pain
medication administration.
e) Hct/Hgb are within normal limits.
f) Patient able to provide and bond with child and return to normal ADLs and ambulation.
g) Patient and support system’s anxiety is decreased and emotional support is provided to
supply teaching and allow for questions.
h) Monitor for signs and symptoms of infection: ecchymosis, redness, edema, drainage and
approximation at episiotomy site.
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References
Burke, C. (2010). Active versus expectant management of the third stage of labor and
implementation of a protocol. Journal of Perinatal Neonatal Nursing, 24 (3): 215-228.
California Maternal Quality Care Collaboration (2009). Hemorrhage Taskforce. State of
California, Deparment of Public Health, Center for Family Health; Maternal, Child and
Adolescent Health Division. www.CMQCC.org.
California Maternal Quality Care Collaboration (2010). Blood loss: Clinical techniques for
ongoing quantitiative measurement. State of California, Department of Public Health,
Center for Family Health: Maternal, Child and Adolescent Health Division.
www.CMQCC.org.
Chapman, L. & Durham, R. (2010). Maternal-Newborn Nursing: The critical components of
nursing care. F. A. Davis Company: Philadelphia, PA.
Thompson, J. F., Heal, L. J., Roberts, C. L., & Ellwood, D. (2010). Women’s breastfeeding
experiences following significant primary postpartum haemorrhage: A multicentre cohort
study. International Breast Feeding Journal, 5 (5): 1-12.
UPMC. (2008, February 3). Postpartum hemorrhage. Retrieved from
http://www.chp.edu/CHP/P02486.
Wake Med Raleigh Process Standards (2010). Emergency care of the obstetrical patient. Raleigh,
NC: Wake Med Health System.