Related factors: excessive blood loss secondary to uterine atony, lacerations, incisions, coagulation defects,

retained placental fragments, and hematomas.

Goals, Outcomes, and Evaluation Criteria

The woman will:• Remain oriented to person, place, and time.

• Exhibit moist mucous membranes and elastic skin turgor.

• Remain free from thirst.

• Exhibit vital signs at or near baseline.

• Exhibit capillary refill of 3 seconds or less.

• Exhibit light yellow urine with amount consistent with intake and diuresis.

• Exhibit CBC, Hgb, and Hct consistent with blood loss during birth.

• Exhibit consistently contracted uterus or contract readily with massage.

• Exhibit small to moderate lochia that decreases with healing.

• Exhibit coagulation studies within normal limits.

Nursing Activities and Rationales

Assessments
• Assess blood pressure. Changes in BP pattern often precede hypotension related to blood loss. Because of the
body’s compensatory mechanisms, as much as 1000 mL of blood loss may occur before hypotension develops.

• Assess temperature. Normal body temperature may be as high as 100.4 F (38.0 C) during the first 24 hours
following birth. Body temperature increases with fluid volume loss.

• Assess heart rate and respirations. Mild increases in heart rate and respirations can occur from the stress of
birth; however, a consistently elevated heart rate indicates hypovolemia. The body may not compensate with
tachycardia and tachypnea until a volume loss of at least 1000 mL has occurred.

• Assess for patterns/trends that suggest shock. A drop in BP or change in BP pattern, tachycardia, tachypnea,
thirst, restlessness, decreased urine output, etc., are trends or patterns that suggest shock. Other assessments
include decreased capillary refill time; dry, pale mucous membranes; poor skin turgor; and decreased urine
amount, dark color, and concentration,

• Assess type and amount of bleeding. Inspect perineal pads and perineum every 10 to 15 minutes for the first
hour or until stable, every 30 minutes for second hour, or after 1 hour of being stable. After two 30-minute stable
checks assess every 4 hours for 24 hours, then every 8 hours until discharge or condition changes. This provides an
estimate of blood loss and helps with identification of the source or cause of bleeding. Hourly pad saturation or
visual leakage of bright blood from the vagina is an indication of hemorrhage.

• Assess uterine fundus for firmness and placement. Use the same schedule as previous nursing activity, assessing
for bleeding. This determines if the uterus is relaxed or boggy. Uterine contraction is necessary to control bleeding.
Uterine displacement occurs from filling with blood and/or clots, or bladder distention.
• Assess for fluid volume deficit and excess. Fluid volume excess can occur from fluid replacement during
treatment for fluid volume deficit, causing fluid volume overload.
• Assess and report laboratory findings. This includes reporting the CBC, Hgb, Hct, serum electrolytes, coagulation
studies, etc., to the healthcare provider. Medical care decisions are based on this data.

Independent Nursing Actions

• Apply an ice pack to fundus, hematoma, or laceration. Ice produces localized vasoconstriction, which decreases
blood flow and helps control bleeding.
• Massage relaxed or boggy uterus and express blood and clots, if present. Massaging the uterus stimulates
contraction, which reduces bleeding. Retained clots prevent the uterus from contracting fully. Uterine relaxation
can occur when the uterus is excessively massaged. Once firm, discontinue uterine massage for several minutes.
• Encourage frequent voiding. A distended bladder can displace the uterus to the side, predisposing to uterine
atony and making uterine massage difficult. If the woman is unable to void, catheterization may be necessary.
• Maintain accurate intake and output (I&O). I & O detects changes that indicate hypovolemia. Fluid intake should
normally approximate output. Blood is shunted away from the kidneys during periods of hypovolemia, which
reduces urinary output. Decreased output (less than 30 mL/hr) is an indication of hypovolemia and/or inadequate
fluid volume replacement.
• Promote bed rest if heavy bleeding is present. Bed rest, limiting activity, and elevating the woman’s legs 20 to 30
degrees decrease metabolic demands on the body, increase venous blood return to the heart, protects blood flow
to vital organs, and maintain the woman’s safety.
• Remain with the woman experiencing heavy bleeding. Shock is an emergency situation that can develop rapidly
from hemorrhage. Heavy bleeding may be an indication of hemorrhage. The woman should not be left alone until
stable.
• Encourage breastfeeding within the first 2 hours following the birth. Contact immediately after birth with an
infant who makes sucking sounds on its fists, cries, or breastfeeds causes the release of maternal oxytocin.
Oxytocin promotes uterine contraction and helps the uterus remain contracted during this time of high risk for
hemorrhage.

Collaborative Activities
• Administer oxygen as prescribed. Oxygen may be necessary if blood loss is so excessive that it prevents
adequate tissue perfusion to major organs.
• Maintain patent IV access with a large bore intravenous catheter. Fluids will need to be rapidly infused if
hypovolemic shock occurs. Packed RBCs are highly viscous and require a 16- to 18-gauge catheter for rapid
infusion.
• Administer fluids and electrolytes as prescribed. These help reestablish fluid balance and prevent hypovolemic
shock, dehydration, and electrolyte imbalances. Crystalloid fluid replacement maintains intravascular volume and
prevents hypovolemia.
• Administer packed RBCs or other blood products as prescribed. These products prevent hypovolemic shock by
replacing blood volume or blood components and restore oxygen-carrying capacity.

• Administer medications (oxytocin, methylergonovine maleate) as prescribed. Oxytoxics increase contractility of

the uterus and decrease or stop hemorrhage when uterine atony is the causative factor. Monitor BP prior to
administering methergine; it is contraindicated if BP is elevated. Assess for desired drug actions and side effects.

Patient/Family Teaching
• Teach the woman how to palpate her fundus. Include where the fundus should be located, and the need for it to
remain contracted. This knowledge helps the woman understand how to monitor her own uterus so the nurse can
be summoned if she feels her uterus becoming boggy or soft.
• Teach the woman about the type and amount of lochia. This ensures that the woman will recognize excessive
bleeding and report it immediately whether she is in the birthing unit or at home.
• Teach the woman to call for assistance when ambulating. Weakness, hypotension, lightheadedness, and fatigue
may occur secondary to blood loss, placing the woman at increased risk for falls.