Nursing Care Plan for Prenatal Hemorrhage

Prenatal Hemorrhage may occur early or late in pregnancy, owing to certain physiological problems, each with its own signs and symptoms, which help in establishing a differential diagnosis and in creating the plan of care. This general guide for care is meant to treat hemorrhage in the antepartal client. Where appropriate, interventions specific to each physiological problem are identified.

NURSING PRIORITIES
1. Determine client/fetal status.
2. Maintain circulating fluid volume.
3. Assist with efforts to sustain the pregnancy, if possible.
4. Prevent complications.
5. Provide emotional support to the client/couple.
6. Provide information about possible short- and long-term implications of the hemorrhage.

DISCHARGE GOALS
1. Homeostasis achieved
2. Pregnancy maintained
3. Free of complications
4. Client/couple dealing constructively with situation
5. Condition, prognosis, and treatment needs understood

Nursing diagnosis of Prenatal Hemorrhage: Fluid Volume deficit may be related to excessive vascular loss possibly evidenced by hypotension, increased pulse rate, decreased pulse pressure, decreased/concentrated urine, decreased venous filling, change in mentation.

Nursing intervention with rationale:
1. Evaluate, report, and record amount and nature of blood loss. Initiate pad count; weigh pads/underpad.
Rationale: Estimation of blood loss helps in differential diagnosis. Each gram of increased pad weight is equal to approximately 1 ml of blood loss.

2. Institute bedrest. Instruct client to avoid maneuver and intercourse or any sexual activity that could lead to orgasm.
Rationale: Valsalva’s Bleeding may stop with a reduction in activity.Increased abdominal pressure or orgasm (which increases uterine activity) may stimulate bleeding.

3. Position client appropriately, either supine with hips elevated or in semi-Fowler’s position for placenta previa. Avoid Trendelenburg position.
Rationale: Ensures adequate blood available to the brain.Elevating hips avoids compression of the vena cava, while semi-Fowler’s position allows the fetus to act as a tampon, controlling bleeding in placenta previa. Trendelenburg position may compromise maternal respiratory status.

4. Note vital signs, capillary refill of nailbeds, color of mucous membranes/skin, and temperature. Measure CVP, if available.
Rationale: Helps determine severity of blood loss, although cyanosis and changes in BP and pulse are late signs of circulatory loss and/or developing shock. Also monitors adequacy of fluid replacement.

5.Monitor uterine activity, fetal status, and any abdominal tenderness.
Rationale: Helps determine nature of the hemorrhage and possible outcome of hemorrhagic episode. Tenderness is usually present in ruptured ectopic pregnancy or abruptio placentae.

6. Ascertain religious practices and preferences.
Rationale: May prohibit use of blood products and establish need for alternative therapy.

7. Avoid rectal or vaginal examination.
Rationale: May increase hemorrhage, especially if marginal or total placenta previa is present.

8. Record intake/output. Obtain hourly urine samples; measure specific gravity.
Rationale: Determines extent of fluid losses and reflects adequacy of renal perfusion.

9. Obtain/review stat blood work: CBC, type and crossmatch, Rh titer, fibrinogen levels, platelet count, APTT, PT, and HCG levels.
Rationale: Determines amount of blood loss and may provide information regarding cause. Hct should be maintained above 30% to support oxygen and nutrient transport.

10. Prepare for cesarean delivery if any of the following are diagnosed: severe abruptio placentae, DIC; or placenta previa when fetus is mature, vaginal delivery is not feasible, and bleeding is excessive or unresolved by bedrest.
Rationale: Hemorrhage stops once the placenta is removed and venous sinuses are closed.