Hypertensive disorders of pregnancy 

(also known as pregnancy-associated hypertensive disorders,

pregnancy induced hypertension) are the most common complications that occur during pregnancy and
are a major cause of maternal and fetal morbidity and mortality. These disorders include
gestational hypertension, preeclampsia, eclampsia, chronic hypertension, and chronic hypertension with
superimposed preeclampsia. If left untreated, preeclampsia can lead to a life-threatening complication
called HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. It is estimated that
preeclampsia alone complicates 2-8% of pregnancies globally. 

Hypertensive disorders in pregnancy include five categories of hypertension and are defined as such by
the American College of Obstetricians and Gynecologists (ACOG): 

Gestational Hypertensive Disorders

1.Gestational hypertension. Defined as a systolic blood pressure of 140 mm Hg or more,

and/or diastolic blood pressure of 90 mm Hg or more on two blood pressure readings at
least four (4) hours apart after 20 weeks of gestation in a woman with previously normal
blood pressure. Gestational hypertension does not persist longer than 12
weeks postpartum and usually resolves after a week postpartum.
2. Preeclampsia. Preeclampsia is a pregnancy-specific condition and is defined as a new-
onset of hypertension that occurs most often after 20 weeks of gestation. Blood pressure
is elevated more than 140 mm Hg systolic, more than 90 mm Hg diastolic. Hypertension
is usually accompanied by new-onset proteinuria although other signs and symptoms of
preeclampsia (thrombocytopenia, impaired liver function, pulmonary edema, visual
disturbance) may present in some women in the absence of proteinuria.
3. Eclampsia. Eclampsia is the onset of seizure activity or coma in a woman with
preeclampsia with no history of preexisting pathology that can result in seizure activity.
Seizure leads to severe maternal hypoxia, injury, and aspiration pneumonia. Eclampsia has
an increased maternal mortality rate especially in settings with low resources. 
Chronic Hypertensive Disorders

4. Chronic hypertension. Chronic hypertension as hypertension diagnosed or present

before pregnancy or before 20 weeks of gestation. It is more prevalent with increasing
late childbearing and in persons with obesity. Additionally, hypertension that is diagnosed
for the first time during pregnancy and that does not resolve postpartum is also classified
as chronic hypertension. 
5. Chronic hypertension with superimposed preeclampsia. Preeclampsia is considered
superimposed when it complicates preexisting chronic hypertension. About half of
women with chronic hypertension may develop superimposed preeclampsia. It is
associated with increased maternal or fetal mortality.

Nursing Care Plans

Nursing care planning and management for pregnant clients with hypertensive disorders or preeclampsia
involve early detection, thorough assessment, and prompt treatment of preeclampsia. Another priority is
to ensure the mother’s safety and deliver a healthy newborn as close to a full term as possible. 
Here are six nursing diagnoses for your nursing care plans for pregnant patients with hypertensive
disorders, focusing on managing clients with preeclampsia. 

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1. Decreased Cardiac Output UPDATED!

2. Risk for Imbalanced Fluid Volume UPDATED!
3. Ineffective Tissue Perfusion UPDATED!
4. Risk for Injury UPDATED!
5. Imbalanced Nutrition: Less Than Body Requirements  UPDATED!
6. Deficient Knowledge UPDATED!
7. Other Possible Nursing Care Plans
1. Decreased Cardiac Output
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Decreased Cardiac Output

A decrease in circulating blood volume due to the shifting of fluid from the intravascular to the interstitial
spaces occurs in a pregnant client with a hypertensive disorder due to the decrease of the circulating
blood volume and the total vascular volume and an increase in the systemic vascular resistance, the heart
rate decreases as well as the stroke volume. These mechanisms lead to a decrease in cardiac output seen
among clients with hypertensive disorders in pregnancy.

Nursing Diagnosis
 Decreased Cardiac Output
Related factors may include
 Decreased venous return
 Increased systemic vascular resistance
Possibly evidenced by
 Change in blood pressure/hemodynamic readings
 Diminished peripheral pulses
 Tachycardia
 Edema
 Shortness of breath/dyspnea
 Alteration in mental status
 Decreased urine output
Desired Outcomes
 The client remains normotensive throughout the remainder of the pregnancy.
 The client reports absence and/or decreased episodes of dyspnea.
 The client alters activity level as the condition warrants.
Nursing Assessment and Rationales
1. Assess blood pressure and pulse every one (1) hour or as indicated.
Accurate measurement of blood pressure is essential for the early detection of hypertensive disorders.
Hypertension is defined as a systolic blood pressure greater than 140 mm Hg or diastolic blood pressure
greater than 90 mm Hg. Blood pressure may be elevated because of the increase in systemic vascular
resistance whereas decreased cardiac output may also be reflected by diminished peripheral pulses. Rising
blood pressure indicates the progression of preeclampsia. Use a consistent and standardized method when
taking blood pressure measurements to maintain accuracy. 

2. Assess the mean arterial pressure (MAP) at 11-13 and 20-24 weeks gestation. A pressure of 90 mm
Hg is considered predictive of preeclampsia. 
Mean arterial pressure (MAP) is the average arterial pressure throughout one cardiac cycle and is
influenced by cardiac output and systemic vascular resistance. MAP prediction is best when measured
during 11-13 weeks and at 20-24 weeks than at only one of these gestational ranges. MAP is increased
from the first trimester in pregnancies developing preeclampsia (Gallo et al., 2014). Women with early-
onset preeclampsia have higher mean arterial blood pressure levels at 20 weeks of gestation (Mayrink et
al., 2019). 

3. Assess for crackles, wheezes, and dyspnea; note respiratory rate/effort. Note client snoring. 
Pulmonary edema may transpire with modification in peripheral vascular resistance and a drop in plasma
colloid osmotic pressure. Fluid from the intravascular spaces shifts to the interstitial spaces, depleting the
circulating blood volume but overwhelming the important organs of the body, especially
the lungs. Pregnancy-onset snoring may also be a risk factor for developing gestational hypertension and
preeclampsia (O’Brien et al., 2012). 

4. Auscultate for the apical pulse and assess the client’s heart rate and rhythm. 
Tachycardia may be present when the body compensates for the decrease in circulating volume that can
hardly reach the peripheries and distant tissues.

5. Assess the client’s neurological status.

Decreased cardiac output can precipitate alternations in the sensorium due to inadequate cerebral
perfusion. Neurologic complications associated with preeclampsia may also manifest. These symptoms
include cerebral edema,  hemorrhage, irritability, headaches, hyperreflexia, seizures. 

6. Assess the client for visual disturbances. 

Alteration in the sensorium may indicate inadequate cerebral perfusion secondary to decreased cardiac
output. Vision changes are due to arteriolar vasospasms and decreased blood circulation to the
retina. These symptoms may include dimming of vision, blind or dark spots in the visual speed, blurring of
vision, double vision. 

7. Assess the client for indications for an earlier delivery. 

Worsening preeclampsia that may progress to eclampsia warrants the need for an emergency early
delivery. The fetal blood supply can be cut off, resulting in fetal distress and ultimately fetal death if
delivery is not hastened (Sinkey et al., 2020; Espinoza 2012). These symptoms include uncontrolled severe-
range blood pressure, refractory headaches, upper abdominal  pain, visual disturbances,  stroke. 
8. Monitor and measure the client’s urine output as per protocol. Maintain strict intake and
output. 
In preeclampsia, the kidneys respond to reduced cardiac output by retaining water and sodium. Intrarenal
vasospasms cause oliguria in severe preeclampsia due to a reduction in glomerular filtration rate.
Contraction of the intravascular space secondary to vasospasms worsens renal sodium and water
retention (ACOG, 2020). 

9. Monitor and measure the client’s 24-hour urine for proteinuria. 

Proteinuria is ideally determined by the evaluation of a 24-hour urine collection. However, current
guidelines state that massive proteinuria is not considered a severe feature of preeclampsia.
Reduced kidney perfusion causes renal deterioration and damages glomerular endothelial cells allowing
protein molecules to pass into the urine, causing proteinuria. In some instances where it may be difficult to
collect a 24-hour urine sample, preeclampsia may be diagnosed as hypertension with either
thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema. 

Nursing Interventions and Rationales

1. Provide frequent rest periods with bed rest. Restrict activity rather than instituting complete bed
rest. 
Improves venous return, cardiac output, and renal-placental perfusion. Help the client understand the
importance of reduced activity and frequent rest periods and plan ways to manage them. Activity diverts
blood from the placenta, reducing the infant’s oxygen supply. Although frequently recommended by
healthcare providers, no evidence has been found that complete bed rest improves pregnancy outcomes.
Rather, prolonged bed rest can increase the risk of complications due to immobility (e.g., muscle atrophy,
weight loss, cardiovascular deconditioning, psychologic stress, etc.). Therefore, restricted activity rather
than complete bed rest is recommended (Ghulmiyyah et al., 2012).

2. Instruct the client to elevate legs when sitting or lying down. 

Elevating the legs decreases venous stasis and may also reduce the incidence of thrombus and embolus
formation in the client on bed rest.

3. Monitor the client’s BP and instruct monitoring of BP at home. 

Monitor BP every 15 minutes during the critical phase and every 1 to 4 hours as the client’s condition
improves. If the client is an outpatient, instruct both the client and a family member to monitor the BP two
to four times per day in the same arm and the same position. A family member must be taught the
technique to ensure accurate measurements. Rising blood pressure levels may indicate worsening
preeclampsia. 

4. Record and graph vital signs, especially BP and pulse. 

The client with preeclampsia does not display the normal cardiovascular response to pregnancy (left
ventricular hypertrophy, increased plasma volume, vascular relaxation with decreased peripheral
resistance). Hypertension (the second manifestation of preeclampsia after edema) occurs due to increased
sensitization to angiotensin II, which increases BP and promotes aldosterone release to increase
sodium/water reabsorption from the renal tubules constricts blood vessels.
5. Monitor for invasive hemodynamic parameters such as cardiac output, as indicated.
Provides a precise picture of vascular changes and fluid volume. Prolonged vascular constriction,
increased hemoconcentration, and fluid shifts decrease cardiac output.

6. Administer low-dose aspirin as indicated. 

When initiated before 16 weeks gestation, low-dose aspirin effectively prevents preeclampsia, severe
preeclampsia, preterm birth, and intrauterine growth restriction in patients with high-risk pregnancies
(Fantasia, 2018; Xu et al., 2015). It is recommended that daily dose aspirin therapy be initiated late in the
first trimester for women who have a history of early-onset preeclampsia and subsequent preterm birth at
less than 34 weeks of gestation or a history of preeclampsia in more than one previous pregnancy. 

7. Administer antihypertensive medications as ordered. Observe for side effects of antihypertensive

drugs.
If blood pressure does not respond to conservative measures, short-term medication may be needed with
other therapies (e.g., fluid replacement, magnesium sulfate). Antihypertensive treatment should be
initiated as soon as reasonably possible for acute-onset severe hypertension that persists (ACOG, 2020).
Antihypertensive drugs work directly on arterioles to promote relaxation of cardiovascular smooth
muscles and help increase blood supply to the cerebrum, kidneys, uterus, and placenta (Lightstone, 2013).
Intravenous hydralazine, or labetalol, and oral nifedipine are three agents commonly used to
control  hypertension in pregnancy. 

 7.1. Hydralazine (Apresoline, Neopresol). 

Administered intravenously, hydralazine reduces blood pressure by relaxing the smooth
muscles. The vasodilating effect reduces peripheral vascular resistance. Check BP every
minute for 5 mins then every 5 mins for 30 mins. 
 7.2. Labetalol Hydrochloride (Normodyne, Trandate). 
Given intravenously, labetalol is an alpha- and beta-blocker that decreases peripheral
vascular resistance without significant change in cardiac output or causing tachycardia.
Contraindicated with asthma and congestive heart failure. Closely monitor blood pressure
after administration. 
 7.3. Methyldopa (Aldomet). 
Interferes with chemical neurotransmission to reduce peripheral vascular resistance. Can
cause CNS sedation, sleepiness, postural hypotension. 
 7.4. Nifedipine (Adalat). 
Calcium channel blocker that dilates arterioles and decreases systemic vascular resistance
by relaxing arterial smooth muscle. Nifedipine can potentiate the CNS effects of
magnesium sulfate. Closely monitor blood pressure after administration. 
 7.5. Sodium Nitroprusside (Nitropress).
Used in rare scenarios where other antihypertensive agents have failed to control blood
pressure.
8. Prepare for the birth of fetus by cesarean delivery, labor when severe preeclamptic or eclamptic
condition is stabilized, but vaginal delivery is not feasible. 
If conservative treatment is ineffective and labor induction is ruled out, then surgical procedure is the only
means of halting the hypertensive problems. Delivery of the fetus is the cure for preeclampsia. If
preeclampsia is severe, the fetus is often in greater danger from being in the uterus because its oxygen
and nutritional supply may be cut off or its growth can be restricted. Fetal death sometimes can occur.
 ADVERTISEMENTS

1. Decreased Cardiac Output

Risk for Imbalanced Fluid Volume

Postpartum hemorrhage (PPH) is defined as a cumulative blood loss greater

than or equal to 1,000 mL of blood loss accompanied by signs or symptoms of
hypovolemia within 24 hours after the birth process, regardless of route of
delivery. Nevertheless, a blood loss greater than 500 mL in a vaginal delivery
should be considered abnormal (American College of Obstetricians and
Gynecologists [ACOG], 2017). 

Postpartum hemorrhage is the fifth leading cause of maternal mortality in the

United States and causes approximately 11-12% of maternal deaths. It is the
leading cause of maternal morbidity and mortality globally (Nathan, 2019). 

Primary postpartum hemorrhage may occur within the first 24 hours after birth,
while secondary postpartum hemorrhage occurs more than 24 hours and up to
12 weeks after delivery. The four main causes for postpartum hemorrhage are the
four T’s: tone (uterine atony), trauma (lacerations, hematomas, uterine inversion
or rupture), tissue (retained placental fragments), and thrombin (disseminated
intravascular coagulation).

Nursing Care Plans

The primary role of the nurse in caring for patients with postpartum hemorrhage
is to assess and intervene early or during a hemorrhage to help the client regain
her strength and prevent complications. Early recognition and treatment of PPH
are critical to care management. Data such as the amount of bleeding, the
condition of the uterus, checking the maternal vital signs, and observing for signs
of shock would play a vital role in the care of the patient with hemorrhage.

Here are eight nursing care plans and nursing diagnoses for postpartum

hemorrhage:
 1. Deficient Fluid Volume UPDATED!
2. Risk for Imbalanced Fluid Volume UPDATED!
3. Ineffective Tissue Perfusion UPDATED!
4. Risk For Infection UPDATED!
5. Acute Pain NEW!
6. Risk for Impaired Attachment NEW!
7. Anxiety UPDATED!
8. Deficient Knowledge UPDATED!
1. Deficient Fluid Volume
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Deficient Fluid Volume

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.  Blood flow to
nonessential organs gradually stops to make more blood available for vital
organs, specifically the heart and brain. Blood flow to the brain and the kidneys
decreases as blood loss continues and fluid is conserved. Urine output decreases
and eventually stops.

Nursing Diagnosis
 Deficient Fluid Volume
May be related to
 Excessive blood loss after birth
Possibly evidenced by
 Changes in the mental status
 Concentrated urine
 Delayed capillary refill
 Decrease in the red blood cell count (hematocrit)
 Decrease blood pressure (hypotension)
 Dry skin/mucous membrane
 Increase heart rate (tachycardia)
Desired Outcomes
  The client will maintain a blood pressure of at least 100/60 mm Hg.
 The client will maintain a pulse rate between 70-90 beats per minute.
 The client will have a balanced 24-hour intake and output.
 The client will have a cognitive status within the expected range.
 The client will have a lochia flow of less than one saturated perineal
pad per hour.
 The client will demonstrate improvement in the fluid balance as
evidenced by a good capillary refill, adequate urine output, and skin
turgor.
Nursing Assessment and Rationales
1. Assess and record the characteristics, amount, and site of the bleeding,
including the stage of labor.
The amount of blood loss and the presence of blood clots will help determine the
necessary interventions. The characteristics and quantity of blood passed can
suggest excessive bleeding. For example, bright red blood is arterial and can
indicate lacerations of the genital tract; meanwhile, dark red blood is likely of
venous origin and may indicate superficial lacerations or varices of the birth
canal. Spurts of blood with clots can indicate partial placental separation,
excessive traction on the cord, and failure of the blood to clot or remain clotted
may indicate coagulopathy, such as disseminated intravascular
coagulation. Excessive

2. Count and weigh perineal pads and, if possible, preserve blood clots to be
evaluated by the primary care provider.
Be certain to differentiate between saturated and used when counting perineal
pads. 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. Saturation of a peripad within 15 minutes
to 1 hour after delivery must be promptly reported. Always be sure to turn the
client on her side when inspecting for blood loss to be certain a large amount of
blood is not pooling undetected beneath her. 

3. Assess the lochia for color, quantity, and clots.

Observing the lochia provides for an estimate of the actual blood loss. Lochia
rubra should be dark red. During the first few hours, the amount of lochia should
be no more than one saturated perineal pad per hour. Small clots may appear in
the drainage, but large clots are not normal. 

4. Assess the location of the uterus and the degree of contractility of the
uterus.
The degree of uterine contractility will measure the status of the blood loss.
Uterine atony allows the blood vessels at the placenta site to bleed freely and
usually massively because the muscle fibers that compress the bleeding vessels
are flaccid. Large venous areas are exposed after the placenta separates from the
uterine wall and bleeding is controlled by the contraction of smooth muscles in
the uterus. The best safeguard against uterine atony is to palpate the client’s
fundus at frequent intervals to ensure her uterus remains contracted. The fundus
should be firm to compress the bleeding vessels at the placenta site.

5. Assess for additional risk factors for postpartum hemorrhage.

Identifying the presence of risk factors for hemorrhages such as retained
placental fragments, uterine or cervical lacerations, abnormal attachments to the
placental site, uterine atony, or inadequate blood coagulation will help determine
the management of the situation, thus preventing further complications.

6. Monitor vital signs, including systolic and diastolic blood pressure, pulse,
and heart rate. Check for the capillary refill and observe nail beds and
mucous membranes.
Routine postpartum care involves assessing the vital signs every 15 minutes until
stable. If the client has tachycardia and hypotension, suspect for a considerable
amount of blood loss, usually representing 25% of the client’s total blood
volume, or approximately 1,500 mL or more (Brown, 2017). Tachycardia is usually
the first sign of inadequate blood volume (hypovolemia). The first blood pressure
change is a narrow pulse pressure (a falling systolic pressure and a rising diastolic
pressure). The blood pressure may continue to fall and eventually cannot be
detected.

7. Assess for the presence of a vulvar and vaginal hematoma.

A hematoma is a collection of blood within the tissues and may result from birth
trauma, and they appear as a bulging or purplish mass. The client may also
develop signs of concealed blood loss if the hematoma is large. Larger ones may
require incision and drainage of the clots. The client should report signs of
concealed blood loss accompanied by maternal complaints of severe pain,
perineal or vaginal pressure, or inability to void. Small hematomas usually resolve
without treatment or with cold application. 

8. Measure a 24-hour intake and output. Observe for signs of voiding

difficulty.
Assessment of the client’s intake and output will help determine fluid loss.
Monitoring urine output is a good gauge of blood loss because the kidneys need
sufficient arterial blood flow and pressure to function. If they are not producing
urine, it suggests the kidneys are not obtaining adequate blood. Voiding difficulty
may happen with hematomas in the upper portion of the vagina, causing
pressure in the urethra. 

9. Investigate reports of persistent perineal pain or feeling of vaginal

fullness. Apply counterpressure on labial or perineal lacerations.
Hematomas often result from continued bleeding from lacerations of the birth
canal. If the client reports severe pain in the perineal area or a feeling of pressure
between her legs, inspect the perineal area to see if a hematoma could be
causing this. Depending on the amount of blood in the tissues, the client may
describe the pressure in the vulva, pelvis, or rectum. Urination may be difficult or
absent due to the pressure. 

10. Measure hemodynamic parameters, including central venous pressure

(CVP) or pulmonary artery wedge pressure (PAWP)  if available.
Measurement of the hemodynamic parameters will provide a direct measurement
of circulating volume, replacement needs, and response to therapy in case of a
life-threatening situation. Invasive monitoring with an arterial line, central line,
and non-invasive or minimally invasive cardiac output monitoring may be
considered according to PPH severity and availability (Muñoz et al., 2019).

Nursing Interventions and Rationales

1. Massage the boggy uterus using one hand and place the second hand
above the symphysis pubis.
Ask the client to void first before performing the massage, as an
empty bladder prevents displacement of the uterus and ensures
accurate assessment of uterine tone. With a gloved hand, place one hand on the
abdomen just above the symphysis pubis and another hand around the top of
the fundus to anchor the lower uterine segment. Do not overly massage because
the excessive stimulation to contract it will tire the uterine muscle and worsen
uterine atony. Once the uterus is firmly contracted, it should be left alone but still
assessed regularly.

2. Apply an ice pack on the hematomas if indicated.

The cold application can limit small hematoma and reduce blood flow to the
area. Cold also numbs the area and makes the client more comfortable. Apply an
ice pack covered with a towel to prevent thermal injury to the skin to prevent
further bleeding. Larger ones may require incision and drainage of the clots.

3. Exercise extreme caution when performing vaginal and rectal

examinations.
Vaginal and rectal examinations may increase hemorrhage if cervical, vaginal, or
perineal lacerations or hematomas are present. Bimanual clot evacuation can be
done as indicated. This involves cupping the fundus of the uterus with one hand
while performing a vaginal examination to break down and expel any blood clots
digitally. This enhances the effect of uterotonic agents on myometrial tissue by
facilitating the emptying of the uterine cavity (Koh et al., 2020).

4. Monitor clients with placenta accreta, gestational hypertension,

or abruptio placenta for signs of disseminated intravascular coagulation
(DIC).
Thromboplastin released during attempts at manual removal of the placenta may
result in coagulopathy as manifested by continued vaginal bleeding, epistaxis,
oozing from incisions, mucous membranes, gums, IV site. Retained placental
fragments can also be caused by placenta accreta. Placenta accreta is a condition
that occurs when blood vessels and other parts of the placenta grow too deeply
into the uterine wall. Retained placental fragments can remain in the uterus after
spontaneous separation of the placenta causing excessive bleeding and uterine
atony. Manual exploration of the uterine to remove the fragments may be
necessary. Removing such deeply embedded placenta can lead to severe
postpartum hemorrhage.

5. Maintain a nothing-by-mouth (NPO) status while assessing the client’s

status.
In case of a need to repair the laceration using a general anesthetic, the client
should be kept on NPO until further orders are received. This will
prevent aspiration of gastric contents if the mental status is impaired and if
surgical management is required.

6. Maintain bed rest with an elevation of the legs by 20-30° and trunk
horizontal.
Elevation of the lower extremities increases venous return, ensuring greater
availability of blood to the brain and other vital organs. Bleeding may be
decreased with bed rest.

7. Recommend the client be seated when holding the infant and change
position slowly when lying down or seated.
To prevent orthostatic hypotension because it puts the client at risk of falls.
Advise the client to dangle their legs first on the side of their bed after sitting up
before attempting to ambulate.

8. Monitor the client’s hemoglobin and hematocrit levels.

The initial hemoglobin level does not accurately reflect blood loss because
compensatory mechanisms that move fluids from the interstitial space require
time and are not apparent in the initial hemoglobin measurement. However, the
initial measurement is useful to determine a baseline hemoglobin level
as anemia is very frequent in parturients (Muñoz et al., 2019).

9. Monitor the client’s platelet count activated partial thromboplastin time

(APTT), fibrinogen, and fibrin degradation products (FDP).
In the presence of DIC, prothrombin will be low because it depends on the
conversion of fibrinogen to fibrin, thrombin time will be elevated because it
measures the time necessary for the conversion of fibrinogen to fibrin, and fibrin
split products will be >40 mcg/mL reflecting the destruction of fibrinogen or
fibrin. Blood needs to be drawn for prothrombin, thrombin time, fibrinogen, and
fibrin split products.

10. Educate the client and significant others on identifying the signs and
symptoms that need to be reported urgently.
Signs and symptoms of a possible cause of bleeding should be reported. A
continuous trickling of blood can result in much or more blood loss than the
dramatic bleeding associated with uterine atony. The nurse should also teach the
client what to expect about changes in the lochia. Instruct the client to report the
following signs of late postpartum hemorrhage: persistent bright red bleeding
and return of red bleeding after it has changed to pinkish to whitish. Once at
home, the client should report fever, persistent pain, or a foul-smelling vaginal
discharge. They should also be taught how to palpate the fundus and what
normal changes to expect.

11. Review the client’s blood typing and crossmatching results before blood
administration.
Blood transfusion to replace blood loss with postpartum hemorrhage is often
necessary. In most agencies, blood typing and crossmatching are done when a
client is admitted to the labor service so blood can be rapidly crossmatched.

12. Administer IV fluids using an 18-gauge catheter or via a central venous

line.
Initial fluid replacement with a balanced crystalloid solution is recommended (102
mL of crystalloid for every 1 mL of blood loss). One randomized controlled trial in
severe PPH found a very low incidence of fibrinogen depletion and coagulopathy
when clients with an estimated blood loss in the range of 1,400-2,000 mL were
resuscitated with crystalloids (Muñoz et al., 2019).

13. 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. RBC
transfusion should only be considered when the hemoglobin concentration is less
than 7 g/dL. Platelets should be transfused when the count is <75×10⁹/L, aiming
to maintain a level >50×10⁹/L during ongoing PPH (Muñoz et al., 2019).

Administer medications as ordered.

14. Uterotonic drugs (e.g., oxytocin [pitocin], methylergonovine maleate

[Methergine], prostaglandin F2a [Prostin 15M].
Intravenous oxytocin acts immediately after administration and helps the uterus
maintain its muscle tone by increasing uterine contractions. Oxytocin has a short
duration of action, and symptoms of uterine atony can quickly recur if it is
administered as a single dose. If oxytocin is not effective, carboprost
tromethamine, a prostaglandin F2a derivative, or methylergonovine maleate, an
ergot compound, are given intramuscularly. Common side effects include
headache, nausea, vomiting, fever, chills, and hypertension. Blood pressure
should be assessed before administering methylergonovine  and should not be
given if BP is more than 140/90 mmHg. 

15. Antibiotics (based on culture and sensitivity of the lochia).

Antibiotics act as prophylaxis to prevent infection or may be needed for an
infection that caused or contributed to uterine subinvolution or hemorrhage. In
clients presenting with secondary PPH, an assessment of vaginal microbiology
should be performed (high vaginal and endocervical swabs), and appropriate use
of antimicrobial therapy should be initiated when endometritis is suspected
(Muñoz et al., 2019).

16. Insert an indwelling Foley catheter (IFC) as ordered.

Catheterization will accurately measure the renal status and perfusion concerning
fluid volume. Additionally, bladder distention is an easily corrected cause of
uterine atony. The nurse should catheterize the client if she cannot urinate on the
toilet or in a bedpan. Most healthcare providers include an order for
catheterization to prevent delaying this corrective measure. After the uterus is
firm from massage, the bladder should be emptied to keep the uterus firm.

17. Prepare for surgical intervention if indicated

Many surgical interventions can be used, such as uterine compression sutures,
selective arterial ligation, or hysterectomy (subtotal or total). These are mostly
used as a last resort because these adversely affect future fertility and pregnancy.
If bleeding is not resolved despite treatment with uterotonics and other available
conservative interventions, invasive surgical interventions are recommended
(Muñoz et al., 2019). Surgical management may include evacuation of hematoma
and ligation of a bleeding point, laceration or episiotomy extension, D&C,
abdominal hysterectomy, or bilateral ligation of the hypogastric artery.

18. Assist with procedures as indicated, such as manual separation and

removal of placenta.
Hemorrhage stops once placental fragments are removed and uterus contracts,
closing venous sinuses. Removing the retained placental fragment is necessary to
stop the bleeding and can usually be accomplished by a dilatation and curettage
(D&C). Methotrexate may also be prescribed to destroy the retained fragment.

19. Uterine replacement or packing if inversion seems about to recur.

Replacement of the uterus allows it to contract, closing venous sinuses and
controlling the bleeding. It is theorized that inward compression of the
vasculature with balloon or packing decreases blood flow and eventually assists
with the clotting cascade. A balloon is placed manually and held in place while
inflating. Ultrasound can help confirm the placement. Once confirmed, the
balloon is inflated with saline until compression is achieved and
decrease/cessation of bleeding is noted (Nathan, 2019).

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Placenta previa is a condition of pregnancy in which the placenta is implanted

abnormally in the lower part of the uterus. It is the most common cause of
painless bleeding in the third trimester of pregnancy. It occurs in four
degrees: low-lying placenta, which is implantation in the lower rather than in the
upper portion of the uterus; marginal implantation, in which the placenta edge
approaches that of the cervical os; partial placenta previa, which is implantation
that occludes a portion of the cervical os; and total placenta previa, in which the
implantation totally obstructs the cervical os.

Increased parity, advanced maternal age, past cesarean births, past uterine
curettage, multiple gestations, and perhaps a male fetus are all associated with
placenta previa.

"Painless vaginal bleeding, usually bright red, is the main characteristic of placenta
previa."

Painless vaginal bleeding, usually bright red, is the main characteristic of placenta
previa. The bleeding in placenta previa doesn’t usually begin, however, until the
lower uterine segment starts to differentiate from the upper segment late in
pregnancy (week 30) and the cervix begins to dilate. At this point, because the
placenta is unable to stretch to accommodate the different shapes of the lower
uterine segment or the cervix, a small portion loosens, and
damaged blood vessels begin to bleed.
Nursing Care Plans
Nursing care management and treatment of placenta previa is designed to
assess, control, and restore blood loss and to deliver a viable infant. Immediate
therapy includes starting an IV line using a large bore catheter.

Here are four (4) placenta previa nursing care plans and nursing diagnoses: 

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1. Deficient Fluid Volume

2. Decreased Cardiac Output
3. Ineffective Tissue Perfusion
4. Risk for Infection
1. Risk for Deficient Fluid Volume
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Risk for Deficient Fluid Volume

The bleeding of placenta previa, like that of ectopic pregnancy, creates an
emergency situation as the open vessels of the uterine decidua place the client at
risk for hemorrhage. Postpartum hemorrhage may occur because the lower
uterine segment, where the placenta was attached, has fewer muscle fibers than
the upper uterus. The resulting weak contraction of the lower uterus does not
compress the open blood vessels at the placental site as effectively as would the
upper segment of the uterus.

Nursing Diagnosis
 Risk for Deficient Fluid Volume
Risk Factors
 Excessive vaginal bleeding
 Damaged uterine blood vessels
Possibly evidenced by
  (Not applicable; the presence of signs and symptoms establishes an
actual diagnosis)
Desired Outcomes
 The client will maintain fluid volume at a functional level, possibly
evidenced by adequate urinary output and stable vital signs.
 The client will display homeostasis as evidenced by the absence of
bleeding.
Nursing Assessment and Rationales
1. Assess color, odor, consistency, and amount of vaginal bleeding.
Inspect the perineum for bleeding and estimate the present rate of blood
loss. The bleeding with placenta previa is usually abrupt, painless, bright red, and
sudden. The bleeding may be provoked by intercourse, vaginal examinations,
or labor, and at times there may be no identifiable cause (Anderson-Bagga & Sze,
2019).

2. Monitor the client’s vital signs.

Obtain baseline vital signs to determine whether symptoms of hypovolemic
shock are present. Continue to assess blood pressure every 5 to 15 minutes or
continuously with an electronic cuff. Signs of hypovolemic shock include
hypotension, tachycardia, and tachypnea.

3. Assess hourly intake and output.

Monitor urine output frequently, as often as every hour, as an indicator that the
client’s blood volume is remaining adequate to perfuse her kidneys.

4. Assess abdomen for tenderness or rigidity- if present, measure abdomen

at the umbilicus (specify time interval).
A thorough abdominal examination to identify uterine tenderness can be useful
in differentiating other causative factors for vaginal bleeding, including uterine
rupture and placental abruption. Measure the abdominal girth to determine if the
bleeding is progressing (Bakker & Smith, 2018).

5. Monitor the fetal heart rate and uterine contractions continuously.

Attach external monitoring equipment to record fetal heart sounds and uterine
contractions; however, avoid the use of an internal monitor for either fetal or
uterine assessment to prevent hemorrhage. Fetal hypoxia may occur if a large
disruption of the placental surface reduces the transfer of oxygen and nutrients.

Nursing Interventions and Rationales

1. Weigh perineal pads to estimate blood loss.
Weighing perineal pads before and after use and calculating the difference by
subtraction is a good method to determine vaginal blood loss.

2. Avoid vaginal examinations.

Because of the risk of provoking life-threatening hemorrhage, a digital
examination of the vagina is absolutely contraindicated until placenta previa is
excluded. Instruments should not be placed near the cervix because uncontrolled
bleeding can result (Bakker & Smith, 2018). If placenta previa is suspected and
ultrasound is unavailable, the provider may perform a vaginal examination with
preparations for both vaginal and cesarean births (a double set-up) in place.

3. Position the client supine with hips elevated if ordered or in a left side-

lying position.
To ensure an adequate blood supply to the client and fetus, place the client
immediately on bed rest in a left side-lying position. The left side-lying position
decreases pressure on the placenta and cervical os and improves placental
perfusion. 

4. Review ultrasound and laboratory results.

Routine sonography in the first and second trimesters of pregnancy provides
early identification of placenta previa. A follow-up sonogram is recommended at
28 to 32 weeks of gestation to look for persistent placenta previa (Bakker &
Smith, 2018). If there is a concern for placenta previa, then a transvaginal
sonogram should be performed to confirm the location of the placenta.
Hemoglobin, hematocrit, prothrombin time, partial thromboplastin time,
fibrinogen, platelet count, type and cross-match, and antibody screen is assessed
to establish baselines, detect a possible clotting disorder, and ready blood for
replacement if necessary.

5. Perform an Apt or Kleihauer-Betke test.

If there is concern about fetal-maternal transfusion, a Kleihauer-Betke test can be
performed. These are test strip procedures that can be used to detect whether
the blood is fetal or maternal in origin.

6. Provide supplemental O2 as ordered via face mask or nasal cannula @ 10-

12 L/min.
Have oxygen equipment available in case the fetal heart sounds indicate fetal
distress, such as bradycardia or tachycardia, late deceleration, or variable
decelerations during the exam. Oxygen supplementation increases available
oxygen to saturate decreased hemoglobin. 

7. Initiate IV fluids as ordered (specify fluid type and rate).

Administer intravenous fluid as prescribed, preferably with a large-gauge catheter
to allow for blood replacement through the same line. Attach Ringer’s lactate
or normal saline at a rapid rate if a shock is present. Reduce the infusion rate to 3
ml/min when the pulse slows down to less than 100 beats/min and systolic BP
increases to 100 mm Hg or higher (World Health Organization, 2015).

8. Administer tocolytic agents as prescribed.

Tocolysis may be considered in cases of minimal bleeding and extreme
prematurity in order to administer antenatal corticosteroids. One study appeared
to suggest that the use of tocolytics increases the pregnancy duration and the
baby’s birth weight without causing adverse effects on the mother and the fetus
(Bakker & Smith, 2018).

9. Administer blood and blood products as indicated.

In instances where significant bleeding ensues, rapid replacement of blood
products is a priority. Activation of the Massive Transfusion Protocol is warranted,
allowing for stabilization of the client’s hemodynamic status by way of a rapid
supply of blood products (Bakker & Smith, 2018).

10. Prepare for a vaginal or cesarean birth.

Vaginal birth is always safest for the infant. If the previa is under 30% by
abdominal or transvaginal ultrasound, it may be possible for the fetus to be born
past it. If over 30% and the fetus is mature, the safest birth method for both
mother and baby is often cesarean birth.

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