What are three important nursing interventions related to postpartum hemorrhage?

Dida Rosida, Yanti Hermayanti, Sukmawati S

Índice Show

Postpartum Hemorrhage Nursing Care Plan
Deficient Fluid Volume
Nursing Diagnosis
Evidenced by
Desired Outcomes
Nursing Interventions
Ineffective Tissue Perfusion
Nursing Diagnosis
Evidenced by
Desired Outcomes
Nursing Interventions
Risk for Infection
Nursing Diagnosis
Risk Factors
Evidenced by
Desired Outcomes
Nursing Interventions
Post Partum Hemorrhage Nursing Care Plan Sample

Bleeding is the main cause of maternal mortality in the world, the mortality rate due to bleeding about 30.3% in Indonesia in 2013. Dealing bleeding during and after labor is very important for health professionals including nurses. Research on the management of postpartum hemorrhage is still limited. The purpose of this literature review was to determine the management of postpartum hemorrhage from various countries. The method, this literature review involved articles that published in 2008-2018. The articles searched from several databases, including ProQuest, 32 articles, PubMed 22 articles, and Google 21 scholar articles. Keywords for article search included postpartum hemorrhage, nurse, prevention, treatment, management, and intervention. 75 articles were assessed for the quality using the JBI instrument (Joanna Briggs Institute), and finally, 10 articles were found and met the inclusion criteria. The results show that there are two types of actions to deal with postpartum hemorrhage including direct treatment and indirect treatment. The direct treatment includes bimanual compression, maneuvering techniques, balloon tampons, and tools resembling a butterfly shape for bimanual compression. Indirect actions include training of health workers, initiation of early breastfeeding and ice packs. Conclusion, effective management both directly and indirectly is able to overcome postpartum hemorrhage. Health workers are expected to master effective ways to deal with postpartum hemorrhage.

intervention, management, nursing, postpartum hemorrhage, prevention

DOI : https://doi.org/10.24198/.v2i2.18242

As soon as PPH is recognized, treatment must begin. The evidence shows it works best for unit-standard, stage-based obstetric hemorrhage emergency management plans with checklists (Maternal Health, 2019). There are many components to this. Current evidence recommends that oxytocin be given as a third stage of active management (after delivery). This dosage has decreased the chance of PPH (OB Hemorrhage Toolkit, 2019).

It is important to know that signs of hypovolemia may not occur until there is large blood loss (OB Hemorrhage Toolkit, 2019).

Table 2: Signs of Hypovolemia

Amount of Blood Loss	Clinical Signs
1000 mL	Slight change in blood pressure Heart rate normal Palpitations Respiratory rate normal Dizziness Normal urine output
1500 mL	Narrowed pulse pressure* Heart rate over 100 Respiratory rate 20-30 Diaphoretic Weak Urine output 20-30 mL/hr
2000 mL	Hypotension Narrowed pulse pressure Heart rate over 120 Respiratory rate 30-40 Pale Extremities cool Restlessness Urine output 5-15 mL/hr
≥ 2500 mL	Profound hypotension Heart rate over 140 Respiratory rate over 40 Slight urine output or anuria

*Pulse pressure is the difference between the systolic and diastolic blood pressure.

It is also important to remember that when the patient starts bleeding heavier than normal, atony is usually the cause. It is important to perform a thorough assessment, perform fundal massage, ensure her bladder is empty, and stay with the patient while help is called.

Some numerous checklists or algorithms follow the stages of hemorrhage. The checklists are similar, and each hospital should choose one to use. The ideal algorithm has all the stages on one page (OB Hemorrhage Toolkit, 2019). Some algorithms have a page for each stage of hemorrhage and treatment.

Table 3:

There may be some differences in definitions within each algorithm. Generally, stage 1 occurs when there is blood loss > 500mL in vaginal birth and >1000mL in a cesarean section, but under 1500mL blood loss. During stage 1, the RN (or designee) should establish IV access if not present, increase IV oxytocin rate, apply vigorous fundal massage, and start giving medication. Vital Signs, including O2, sat & level of consciousness (LOC), should occur within 5 minutes. Administer oxygen to maintain O2 sats at >95% as needed. The patient should have her bladder emptied with a straight catheter or foley and type and crossmatch for 2 units of red blood cells STAT. Providers and RN should be discussing the cause of PPH.

Stage 2 occurs when the bleeding continues but is <1500ml.>

Stage 3 occurs when blood loss is >1500mL; the patient has had 2 units of blood or is unstable. At this time, all emergency personnel, including anesthesia, should be present. The massive transfusion protocol should be activated. The patient will need blood and blood products. A body and fluid warmer should be used at this time. The patient may need central hemodynamic monitoring. The patient may also need a hysterectomy or uterine artery ligation. This woman is at risk of shock and cardiac arrest (OB Hemorrhage Toolkit, 2019). She may require close observation in the intensive care unit (ICU) once the crisis has passed.

All labor and delivery units should be prepared for hemorrhage. Every unit should have all medications available immediately. Each unit should also have a cart with hemorrhage supplies and checklists ready. A uterine tamponade balloon with instructions should also be included in the cart. Hospitals should also have a response team for this type of emergency, a massive transfusion protocol, and emergency blood release checklists (Maternal Health, 2019). Labor and delivery units should also be conducting hemorrhage drills with L&D staff and providers. Drills allow the staff to improve communication and readiness and determine any barriers to appropriate treatment (Committee Opinion, 2011).

Postpartum hemorrhage (PPH) is the most significant cause of maternal deaths during or after childbirth, as it can lead to severe blood loss that can be life-threatening. It occurs at more than 10% of births and has a fatality rate of 1%. It is also estimated to account for 19.7% of all deaths related to pregnancy globally and it causes 25% of all maternal deaths. Due to the unpredictability of the problem and its rapid progression, reducing the incidence of PPH and improving maternal health outcomes becomes a challenge.

PPH

Traditionally, postpartum hemorrhage is defined as blood loss of 500 ml or more following a vaginal birth; this occurs in as many as 5% to 15% of postpartum women. With a cesarean birth, hemorrhage is present when there is a 1,000-ml blood loss or a 10% decrease in the hematocrit level. Although hemorrhage may occur either early (within the first 24 hours following birth) or late (from 24 hours to 6 weeks after birth), the greatest danger is in the first 24 hours because of the grossly denuded and unprotected uterine area left after detachment of the placenta.

The body initially responds to a reduction in blood volume with increased heart and respiratory rates. These reactions increase the oxygen content of each erythrocyte and cause faster circulation of the remaining blood. Tachycardia is usually the first sign of inadequate blood volume. Blood flow to nonessential organs gradually stops, to make more blood available for vital organs.

The four main reasons for postpartum hemorrhage are uterine atony, trauma, retained placental fragments, and the development of disseminated intravascular coagulation (DIC). These causes are generally referred to as the four T’s of PPH: tone, trauma, tissue, and thrombin. Conditions that increase the client’s risk for postpartum hemorrhage include the following:

Conditions that distend the uterus beyond the average capacity
Conditions that could cause cervical or uterine lacerations
Conditions with varied placental site or attachment
Conditions that leave the uterus unable to contract readily
Conditions that lead to inadequate blood coagulation

When planning care for a client diagnosed with postpartum hemorrhage, provide measures that will restore the client most quickly to health and promote contact among her, her child, and her primary support persons. The following are nursing diagnoses associated with the management of postpartum hemorrhage:

Deficient Fluid Volume
Ineffective Tissue Perfusion
Risk for Infection

Postpartum Hemorrhage Nursing Care Plan

Below are sample nursing care plans for the problems identified above.

Deficient Fluid Volume

As a consequence of increased circulating blood volume during pregnancy, vital signs of hypovolemic shock become relatively insensitive in pregnancy. Tachycardia does not usually develop until blood loss exceeds 1,000 ml, and blood pressure is usually maintained in the normal range. A blood loss of up to 1,500 ml will begin to manifest clinical signs, such as a rise in pulse and respiratory rate, and a slight recordable fall in systolic blood pressure. Hypovolemic clients who begin to decompensate, as evidenced by hypotension, will deteriorate extremely rapidly.

Nursing Diagnosis

Excessive blood loss after birth

Evidenced by

Hypotension
Narrow pulse pressure
Tachycardia
Tachypnea
Decreased urine output
Mental status changes

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

Maintain a blood pressure level within the normal range.
Maintain a pulse rate within the normal limits.
Demonstrate a balanced intake and output.
Exhibit lochia flow less than one saturated perineal pad per hour

Nursing Interventions

Assessment	Rationale
Assess the character, amount, and site of bleeding and document.	Routine frequent assessment of lochia in the fourth stage of labor helps identify early postpartum hemorrhage. when the amount and character of the lochia are normal and the uterus is firm, but signs of hypovolemia are still evident, the cause may be a large hematoma. Excessive bright red bleeding despite a firm fundus may indicate cervical or vaginal laceration.
Assess the characteristics of lochia.	Lochia rubra should be dark red. The amount of lochia during the first few hours should be no more than one saturated perineal pad per hour. a few small clots may appear in the drainage, but large clots are not normal.
Monitor the client’s vital signs.	A rising pulse rate is often the first sign of inadequate blood volume. A rising pulse rate and falling blood pressure also occur. Routine postpartum care involves assessing the vital signs every 15 minutes until stable. the nurse should suspect hypovolemic shock if the pulse rate is greater than 100 beats/min. Decreased blood pressure may be a late sign of hypovolemic shock.
Assess the location of the uterine fundus and its degree of contractility.	The best safeguard against uterine atony is to palpate the client’s fundus’ at frequent intervals to be assured her uterus is remaining contracted. Under usual circumstances, a well-contracted uterus feels firm and is easily recognized because it feels like no other abdominal organ. If unsure whether you have located the fundus’ location on palpation, it means the uterus is probably in a state of relaxation.
Assess for the presence of hematomas.	If the client reports severe pain in the perineal area or a feeling of pressure between her legs, inspect to see if a hematoma could be causing this. It appears as an area of purplish discoloration with obvious swelling. It could be as small as 2 cm or as large as 8 cm in diameter. at first, it may feel fluctuant, but as seepage into the area continues and tissue is drawn taut, it palpates as a firm globe and feels tender.
Measure the client’s intake and output.	Intake and output should be recorded and IV therapy monitored. As the blood flow to the kidneys decreases, they respond by conserving fluid. Urine output decreases and eventually stops.
Count and weigh perineal pads.	By counting the number of perineal pads saturated in given lengths of time, a rough estimate of the amount of blood loss can be formed. Weighing perineal pads before and after use and then subtracting the difference is an accurate technique to measure vaginal discharge: 1 g of weight is comparable to 1 ml of blood volume, so if a pad weighs 50 g more after use, the client has lost 50 ml of blood.
Independent
Massage the client’s boggy uterus to encourage contractions.	In the event of uterine atony, the first step in controlling hemorrhage is to attempt fundal massage to encourage contractions. Ask the client to void first to prevent displacement of the uterus and ensure accurate assessment of uterine tone.
Elevate the client’s lower extremities.	Elevate the client’s lower extremities while lying supine to improve circulation to essential organs. During hypovolemic shock, blood flow to non-essential organs gradually stops, to make more blood available for vital organs, specifically the heart and brain.
Offer a bedpan or assist the client to the bathroom to void.	Offer a bedpan to the client or assist the client to the bathroom at least every 4 hours to be certain that her bladder is emptying because a full bladder predisposes the client to uterine atony.
Apply an ice pack to areas with hematomas.	Applying an ice pack covered with a towel to prevent thermal injury to the skin may prevent further bleeding.
Keep the client in nothing per orem (NPO).	The client who develops a hemorrhagic complication should be kept on NPO status until the healthcare provider evaluates her condition, because she may need general anesthesia for correction of the problem.
Educate the client and significant others regarding the identification of warning signs of bleeding.	Because hemorrhage from retained placental fragments may be delayed until after the client is at home, be certain that the client and her significant others know to continue to observe the color of lochia and to report any tendency for the discharge to change from lochia serosa or alba back to rubra.
Educate the client regarding the importance of breastfeeding.	The infant suckling the breast stimulates the client’s posterior pituitary gland to secrete oxytocin, which causes uterine contraction.
Review the client’s blood typing and crossmatching results for possible blood replacement.	In most agencies, blood typing and cross-matching are done when the client is admitted to the labor service so blood can be rapidly cross-matched.
Dependent
Administer IV fluids using an 18-gauge catheter.	Resuscitation with crystalloids and colloids is effective in optimizing tissue oxygenation preoperatively. IV fluid resuscitation reduces the viscosity of blood and improves cardiac output.
Administer fresh whole blood or other blood products as indicated.	Fresh frozen plasma should be considered in massive ongoing PPH when there is a clinical suspicion of coagulopathy and laboratory tests are not normal. Platelets should be transfused when the count is 75×10⁹/L, aiming to maintain a level >50×10⁹/L during ongoing PPH.
Administer medications as ordered.	When oxytocin is given intravenously, its action on the uterus is immediate. If oxytocin is not effective at maintaining tone, carboprost tromethamine, a prostaglandin F2a derivative, or methylergonovine maleate, an ergot compound, both given intramuscularly, are second possibilities.
Assist in surgical intervention as indicated.	Rarely, a hysterectomy is needed to remove the bleeding uterus that does not respond to any measures. Removal of the retained placental fragment is necessary to stop the bleeding and can usually be accomplished by a dilatation and curettage (D&C). If a hematoma is large or continues to increase in size, the client may have to be returned to the birthing room to have the site incised and the bleeding vessel ligated under local anesthesia.
Administer oxygen by face mask.	Administer oxygen by face mask at a rate of about 10 to 12 L/min if the client is experiencing respiratory distress from decreasing blood volume. Position her supine to allow adequate blood flow to her brain and kidneys.
Insert an indwelling Foley catheter as indicated.	Bladder distention is an easily corrected cause of uterine atony. The nurse should catheterize the client if she cannot urinate on the toilet or bedpan. Most healthcare providers include an order for catheterization to prevent delaying this corrective measure.

Ineffective Tissue Perfusion

The body initially responds to a reduction in blood volume with increased heart and respiratory rate. These reactions increase the oxygen content of each erythrocyte and cause faster circulation of the remaining blood. Blood flow to non-essential organs gradually stops, to make more blood available for vital organs specifically the heart and brain. This change causes the client’s skin and mucous membranes to become pale, cold, and clammy. As blood loss continues, flow to the brain decreases, resulting in mental changes. As blood flow to the kidneys decreases, they respond by conserving fluid.

Nursing Diagnosis

Ineffective Tissue Perfusion

Decreased volume of circulating blood in the body

Evidenced by

Hypotension
Tachycardia
Diminished arterial pulses
Decreased capillary refill
Altered mental status
Decreased urine output

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

Demonstrate vital signs within the normal range.
Exhibit laboratory results within normal limits.
Maintain a normal amount of intake and output

Nursing Interventions

Assessment	Rationale
Assess the client’s vital signs closely.	Tachycardia does not usually develop until blood loss exceeds 1,000 ml and blood pressure is usually maintained in the normal range. A blood loss of up to 1,500 ml will begin to manifest clinical signs, such as a rise in pulse and respiratory rate, and a slight fall in systolic blood pressure. Systolic blood pressure below 80 mm Hg usually indicates a blood loss in excess of 1,500 ml clinically associated with worsening tachycardia, tachypnea, and alteration in mental status.
Monitor the client’s oxygen saturation levels.	The major risk of hemorrhage is hypovolemic shock, which interrupts blood flow to body cells. This prevents normal oxygenation, nutrient delivery, and waste removal at the cellular level. Oxygen saturation levels are monitored in early postpartum hemorrhage.
Monitor the client’s arterial blood gases (ABG) and pH levels.	Due to sympathetic nervous system activation, blood is diverted away from noncritical organs and tissues to preserve blood supply to vital organs such as the heart and brain. While prolonging heart and brain function, this also leads to other tissues being further deprived of oxygen causing more lactic acid production and worsening acidosis.
Assess the client’s mental status.	Blood flow to non-essential organs gradually stops, to make blood available for vital organs. As blood loss continues, flow to the brain decreases, resulting in mental changes, such as anxiety, confusion, restlessness, and lethargy.
Observe for cool and pale skin, nail beds, and oral mucosa, and assess for a delayed capillary refill.	The body compensates for volume loss by increasing heart rate and contractility, followed by baroreceptor activation resulting in sympathetic nervous system activation and peripheral vasoconstriction. Cool extremities and delayed capillary refill are signs of peripheral vasoconstriction.
Independent
Elevate the side rails on the client’s bed as appropriate.	A client with mental health changes may be restless and at risk for falls. Elevating the side rails may reduce the risk for injury
Lower the head of the bed and elevate the client’s legs when lying supine or sitting.	Lowering the head of the bed increases venous return. Raising the legs improves venous return and is consistent with the positioning used to diagnose and treat the underlying causes of bleeding.
Educate the client on how to perform breast self-examination (BSE).	Sheehan’s syndrome has been usually described to affect pregnant women after moderate to profound hypovolemic shock throughout delivery. However, it is usually diagnosed months to years after the hemorrhagic event. Learning how to perform BSE may help determine symptoms such as a decrease in breast tissue.
Dependent
Administer IV fluids as prescribed.	Restrictive crystalloid resuscitation (1-2 ml of crystalloid for every 1 ml of blood loss) as initial resuscitation is recommended according to the clinical condition and the estimated blood loss.
Administer supplemental oxygen, as indicated.	Administer oxygen by face mask at a rate of 10 to 12 L/min if the client is experiencing respiratory distress from decreasing blood volume.
Administer blood and blood products.	Blood transfusion to replace blood loss with postpartum hemorrhage is often necessary. If bleeding continues after administration of 4 RBC units, fresh, frozen plasma transfusion (FFP) of at least 1:2 FFP: RBC ration is recommended.

Risk for Infection

Placental fragments are more likely to be retained if the placenta does not separate cleanly from its implantation site after birth or if there is disruption of the placental scab. Clots form around these retained fragments and slough several days later, sometimes carrying the retained fragments with them. Blockage of the lochial flow because of the retained placenta or clots increases susceptibility to infection.

Nursing Diagnosis

Risk Factors

Stasis of body fluids or lochia
Retained placental fragments
Invasive procedures
Traumatized tissues

Evidenced by

Not applicable on risk diagnosis; the presence of signs and symptoms establishes an actual diagnosis

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

Demonstrate vital signs within the normal range.
Maintain laboratory results with normal limits.
Display a normal amount of lochia which is free from a foul odor.

Nursing Interventions

Assessment	Rationale
Assess the character and amount of lochia.	The nurse should be able to interpret the normal color, quantity, and odor of lochia discharge and the size, consistency, and tenderness of a normal postpartum uterus to recognize if an infection is present. Lochia is usually dark brown and has a foul odor when there is an infection.
Assess the client’s vital signs.	Slight temperature elevations with no other signs of infection often occur during the first 24 hours because of dehydration. The nurse should look for other signs of infection if the client’s temperature is elevated, regardless of the time since delivery. A pulse rate that is higher than expected and an elevated temperature often occur when the client has an infection.
Assess the client’s episiotomy wound or incision from a cesarean birth.	If the client has a suture line on her perineum from an episiotomy or a laceration repair, a ready portal of entry exists for bacterial invasion. Inspection of the suture line may reveal inflammation. One or two stitches may have sloughed away, so an area of the suture line is open with purulent drainage present.
Assess the client’s fundal height.	Subinvolution of the uterus is a slower than expected return of the uterus to its nonpregnant state. Infection and retained fragments of the placenta are the most common causes. Normally, the uterus descends at the rate of 1 cm (1 finger’s width) per day and is no longer palpable by 12 days postpartum.
Independent
Enforce the importance of hand hygiene among the client and her significant others.	The client should be taught to wash their hands before and after performing self-care that may involve contact with secretions. Client hand hygiene may be as important as healthcare worker hand hygiene in preventing the transmission of microorganisms.
Educate the client about proper perineal care.	Instruct the client to wipe front to back after urinating or a bowel movement to prevent bringing contamination forward from the rectum onto the healing area. When the nurse gives perineal care, they must make sure that they perform hand hygiene and wear gloves. Each postpartum client should have their own perineal supplies and should not share them to prevent the transfer of pathogens from one client to another.
Encourage the client to consume vitamin-C-rich foods and foods rich in protein and iron.	The client’s own body must overcome infection and heal any wound. Nutrition is an essential component of her body’s defenses. The nurse should teach her about foods that are high in protein (meats, cheese, milk, legumes) and vitamin C (citrus fruits and juices, strawberries, cantaloupe) because these nutrients are especially important for healing. Foods high in iron, to correct anemia, include meats, enriched cereals and bread, and dark green, leafy vegetables.
Use the aseptic technique in performing procedures for the client.	To help prevent infection, any articles such as gloves or instruments that are introduced into the birth canal during labor, birth, and the postpartum period should be sterile. In addition, adherence to standard infection precautions is essential.
Educate the client about warning signs of infection and when to report them.	Teach the client about signs of infection that should be reported after discharge. The client may be at home when signs of infection occur, therefore, the nurse should be certain that the client is taught about the signs and symptoms of infection before she is discharged.
Educate the client about perineal pad changes.	Remind the client to change perineal pads frequently. Because they are contaminated by drainage, if left in place too long, they might cause vaginal contamination or reinfection.
Caution the client about the effects of antibiotics on the infant if breastfeeding.	Be certain that the client who is breastfeeding is not prescribed antibiotics incompatible with breastfeeding. alert them to observe for problems in their infant, such as white plaques or thrush in their infant’s mouth that can occur when a portion of maternal antibiotic passes into the breast milk and causes an overgrowth of fungal organisms.
Dependent
Administer antibiotics as prescribed.	Intravenous antibiotics are usually prescribed for a postpartum infection. Frequently used antibiotics include ampicillin, gentamicin, and third-generation cephalosporins such as cefixime. If the client will be continuing drug therapy at home, stress that she must take the full course to prevent the infection from recurring.
Administer oxytocic agenst as indicated.	Treatment for retained placental fragments consists of the administration of drugs such as oxytocin, methylergonovine, or prostaglandins to contract the uterus.
Obtain a vaginal culture specimen if indicated.	When taking culture to identify the offending organism, be certain to obtain fluid from the vagina using a sterile swab rather than from a perineal pad to ensure you are culturing the endometrial infectious organism and not an unrelated one from the pad.

Post Partum Hemorrhage Nursing Care Plan Sample

Nursing Diagnosis: Fluid Volume Deficit

Nursing Diagnosis: Fluid Volume Deficit	Goals/ objectives:	Nursing Interventions	Rationale	Evaluation
Possible Etiologies: (Related to) • Uterine Atony • Lacerations • Retained placental fragments • Disseminated intravascular coagulation • Subinvolution of uterus Defining characteristics: (Evidenced by) • Blood loss more than 500 ml • Heavy lochia flow • Increased temperature due to uterine infection predisposing to uterine atony • Elevation of pulse rate indicating hypovolemia • Sudden drop in blood pressure implying hemorrhage • Pain in the perineal sutures • Decreased uterine contractility • Drop in the haemoglobin and hematocrit laboratory results • Decreased urine output • Pallor, easy fatigability, anxiety	Short term goal: Client will maintain fluid volume at a functional level as evidenced by individually adequate haemoglobin, hematocrit laboratory results, stable vital signs, adequate urine output, good uterine contractility, good skin turgor and capillary refill after one week. Long term goal: Client will demonstrate behaviours	Nursing Actions 1.) Assess uterine contraction and lochia flow every 2 hours. 2.) Assess vital signs and note for peripheral pulses. 3.) Note client’s physiologic response to blood loss. 4.) Keep accurate record of subtotals of solutions/ blood products during replacement therapy. 5.) Maintain bed rest and schedule activities to provide undisturbed rest periods. 6.) Keep fluids within reach of client. 7.) Teach client perineal self- care. 8.) Encourage client to do Kegel’s exercises every 4 hours. 9.) Administer fluids/ volume expanders as indicated. 10.) Replace blood products as ordered by the physician. 11.) Administer methylergonovine as prescribed by the physician. 12.) Monitor laboratory studies (haemoglobin and hematocrit, creatinine/ BUN) 13.) Assist in the preparation for surgery specifically hysterectomy.	1.) That is to note how much blood loss the client is experiencing and to prompt for immediate intervention. 2.) Changes in BP and pulse may be used for rough estimate of blood loss. Postural hypotension reflects a decrease in circulating volume. 3.) Symptomatology may be useful in gauging severity of bleeding episode. 4.) Potential exists for over transfusion of fluids, especially when volume expanders are given prior to blood transfusion. 5.) Activity may predispose to further bleeding. 6.) To encourage fluid intake 7.) To prevent development of perineal infections. That is to note how much blood loss the client is experiencing and to prompt for immediate intervention. 8.) Changes in BP and pulse may be used for rough estimate of blood loss. Postural hypotension reflects a decrease in circulating volume. 9.) Symptomatology may be useful in gauging severity of bleeding episode. 10.) Potential exists for over transfusion of fluids, especially when volume expanders are given prior to blood transfusion. 11.) Activity may predispose to further bleeding. 12.) To encourage fluid intake 13.) To prevent development of perineal infections.	Outcome Criteria: • Client’s pulse is between 80 to 100 beats per min and blood pressure is 110/60 mmHg, lochia slows to moderate amount of flow with no large clots, uterus is firm and haemoglobin level is above 11g/L. • Client verbalizes understanding of the causative factors and purpose of interventions and medication; participates in procedures without hesitations; attentive and monitors own vital signs upon assessment; and follows restrictions applied.

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