Postpartum hemorrhage is defined as a loss of blood in the postpartum

period of more than 500 mL. The average, spontaneous vaginal birth will
typically have a 500 mL blood loss. In cesarean births the average blood loss
rises to 800-1000 mL. There is a greater risk of hemorrhage in the first 24
hours after the birth, called primary postpartum hemorrhage. A secondary
hemorrhage occurs after the first 24 hours of birth. In the majority of cases the
cause of hemorrhage is uterine atony, meaning that the uterus is not
contracting enough to control the bleeding at the placental site.
Other reasons for a hemorrhage would include retained placental
fragments (possibly including a placenta accreta), trauma of some form, like a
cervical laceration, uterine inversion or even uterine rupture, and clotting
disorders.
Common Signs and Symptoms:

uncontrolled bleeding

decreased blood pressure

increased heart rate

decrease in the red blood cell count (hematocrit)

swelling and pain in tissues in the vaginal and perineal area

Conditions that may increase the risk for postpartum hemorrhage include the
following:

placental abruption the early detachment of the placenta

from the uterus.

placenta previa the placenta covers or is near the cervical

opening.

overdistended uterus excessive enlargement of the uterus

due to too much amniotic fluid or a large baby, especially with
birthweight over 4,000 grams (8.8 pounds).

multiple pregnancy more than one placenta and

overdistention of the uterus.

pregnancy-induced hypertension (PIH) high blood pressure of

pregnancy.

having many previous births

prolonged labor

infection

obesity

medications to induce labor

medications to stop contractions (for preterm labor)

use of forceps or vacuum-assisted delivery

general anesthesia

Constipation - Impaction; Obstipation

Marian D. Cachero-Salavrakos, RN, BSN
Audrey Klopp, RN, PhD, ET, CS, NHA

NANDA: The state in which an individual experiences a change in normal

bowel habits characterized by a decrease in frequency and/or passage of
hard, dry stools

Constipation is a common, yet complex problem; it is especially prevalent among the

elderly. Constipation often accompanies pregnancy. Diet, exercise, and daily routine are
important factors in maintaining normal bowel patterns. Too little fluid, too little fiber,
inactivity or immobility, and disruption in daily routines can result in constipation. Use of
medications, particularly narcotic analgesics or overuse of laxatives, can cause constipation.
Overuse of enemas can cause constipation, as can ignoring the need to defecate.
Psychological disorders such as stress and depression can cause constipation. Because
privacy is an issue for most, being away from home, hospitalized, or otherwise being
deprived of adequate privacy can result in constipation. Because "normal" patterns of bowel
elimination vary so widely from individual to individual, some people believe they are
constipated if a day passes without a bowel movement; for others, every third or fourth day
is normal. Chronic constipation can result in the development of hemorrhoids; diverticulosis
(particularly in the elderly who have a high incidence of diverticulitis); straining at stool,
which can cause sudden death; and although rare, perforation of the colon. Constipation is
usually episodic, although it can become a lifelong, chronic problem. Because tumors of the
colon and rectum can result in obstipation (complete lack of passage of stool), it is
important to rule out these possibilities. Dietary management (increasing fluid and fiber)
remains the most effective treatment for constipation.
Related Factors

Inadequate fluid intake

Low-fiber diet

Inactivity, immobility

Medication use

Lack of privacy

Pain

Fear of pain

Laxative abuse

Pregnancy

Tumor or other obstructing mass

Neurogenic disorders

Defining Characteristics

Infrequent passage of stool

Passage of hard, dry stool

Straining at stools

Passage of liquid fecal seepage

Frequent but nonproductive desire to defecate

Anorexia

Abdominal distention

Nausea and vomiting

Dull headache, restlessness, and depression

Verbalized pain or fear of pain

Expected Outcomes

Patient passes soft, formed stool at a frequency perceived as "normal" by the

patient.

Patient or caregiver verbalizes measures that will prevent recurrence of constipation.

Ongoing Assessment
Actions/Interventions/Rationale
Key:

(i) independent
(c) collaborative
(i) Assess usual pattern of elimination; compare with present pattern. Include
size, frequency, color, and quality.
"Normal" frequency of passing stool varies from twice daily to once every third or
fourth day. It is important to ascertain what is "normal" for each individual.
(i) Evaluate laxative use, type, and frequency.
Chronic use of laxatives causes the muscles and nerves of the colon to function
inadequately in producing an urge to defecate. Over time, the colon becomes atonic
and distended.
(i) Evaluate reliance on enemas for elimination.
Abuse or overuse of cathartics and enemas can result in dependence on them for
evacuation, because the colon becomes distended and does not respond normally to
the presence of stool.
(i) Evaluate usual dietary habits, eating habits, eating schedule, and liquid intake.
Change in mealtime, type of food, disruption of usual schedule, and anxiety can lead
to constipation.
(i) Assess activity level.
Prolonged bed rest, lack of exercise and inactivity contribute to constipation.
(i) Evaluate current medication usage,
Which may contribute to constipation. Drugs that can cause constipation include the
following: narcotics, antacids with calcium or aluminum base, antidepressants,
anticholinergics, antihypertensives, and iron and calcium supplements.
(i) Assess privacy for elimination (i.e., use of bedpan, access to bathroom facilities
with privacy during work hours).

Many individuals report that being away from home limits their ability to have a
bowel movement. Those who travel or require hospitalization may have difficulty
having a bowel movement away from home.
(i) Evaluate fear of pain.
Hemorrhoids, anal fissures, or other anorectal disorders that are painful can cause
ignoring the urge to defecate, which results over time in a dilated rectum that no
longer responds to the presence of stool.
(i) Assess degree to which patient's procrastination contributes to constipation.
Ignoring the defecation urge eventually leads to chronic constipation, because the
rectum no longer senses, or responds to, the presence of stool. The longer the stool
remains in the rectum, the drier and harder (and more difficult to pass) it becomes.
(i) Assess for history of neurogenic diseases, such as multiple sclerosis,
Parkinson's disease.
Neurogenic disorders may alter the colon's ability to perform peristalsis.

Therapeutic Interventions
Actions/Interventions/Rationale
Key:

(i) independent
(c) collaborative
(i) Encourage daily fluid intake of 2000 to 3000 ml per day, if not contraindicated
medically.
Patients, especially the elderly, may have cardiovascular limitations, which require
that less fluid is taken.
(i) Encourage increased fiber in diet (e.g., raw fruits, fresh vegetables); a
minimum of 20 gm of dietary fiber per day is recommended.
Fiber passes through the intestine essentially unchanged. When it reaches the colon,
it absorbs water and forms a gel, which adds bulk to the stool, and makes defecation
easier.
(i) Encourage patient to consume prunes, prune juice, cold cereal, and bean
products.
These are "natural" cathartics because of their high-fiber content.
(i) Encourage physical activity and regular exercise.
Ambulation and/or abdominal exercises strengthen abdominal muscles that facilitate
defecation.
(i) Encourage a regular time for elimination.
Many persons defecate following first meal or coffee, as a result of the gastro-colic
reflex; depending on the person's usual schedule, any time as long as it is regular, is
fine.
(i) Encourage isometric abdominal and gluteal exercises
To strengthen muscles needed for evacuation unless contraindicated.
(i) Digitally remove fecal impaction.
Stool that remains in the rectum for long periods becomes dry and hard; debilitated
patients, especially the elderly, may not be able to pass these stools without manual
assistance.
(i) Suggest the following measures to minimize rectal discomfort:

Warm sitz bath

Hemorrhoidal preparations

Which shrink swollen hemorrhoidal tissue.

(i) For hospitalized patients, the following should be employed:

Orient patient to location of bathroom and encourage use, unless contraindicated.

o

Offer a warmed bedpan to bedridden patients; assist patient to assume a high

Fowler's position with knees flexed.
o

This position best uses gravity and allows for effective Valsalva's maneuver.

Curtain off the area

o

A sitting position with knees flexed straightens the rectum, enhances use of
abdominal muscles, and facilitates defecation.

To provide privacy

Allow patient time to relax.

Education/Continuity of Care
Actions/Interventions/Rationale
Key:

(i) independent
(c) collaborative
(c) Consult dietitian if appropriate.
Persons unaccustomed to high-fiber diet may experience abdominal discomfort and
flatulence; a gradual increase in fiber intake is recommended.
(i) Explain or reinforce to patient and caregiver the importance of the following:

A balanced diet that contains adequate fiber, fresh fruits, vegetables, and grains
o

Adequate fluid intake

o

Twenty gm/day is recommended.

Eight glasses per day or 2000-3000 ml per day

Regular meals
o

Successful bowel training relies on routine.

Regular time for evacuation and adequate time for defecation

Regular exercise/activity

Privacy for defecation

(i) Teach patients and caregivers to read product labels

To determine fiber content per serving.

(c) Teach use of pharmacological agents as ordered, as in the following:

Bulk fiber (Metamucil and similar fiber products)

o

Stool softeners (e.g., Colace)

o

These irritate the bowel mucosa and cause rapid propulsion of contents of
small intestines.

Suppositories
o

These soften stool and lubricate intestinal mucosa.

Chemical irritants (e.g., castor oil, cascara, Milk of Magnesia)

o

These increase fluid, gaseous, and solid bulk of intestinal contents

These aid in softening stools and stimulate rectal mucosa; best results occur
when given 30 min before usual defecation time or after breakfast.

Oil retention enema

o

To soften stool

NIC
Constipation/Impaction Management; Bowel Training; Teaching:
Prescribed Medication

NURSING DIAGNOSIS: Knowledge Deficit (Specify)

1.

Knowledge: Breastfeeding

2.

Knowledge: Child Safety

3.

Knowledge: Conception
Prevention

4.

Knowledge: Diabetes
Management

5.

Knowledge: Diet

6.

Knowledge: Disease Process

7.

Knowledge: Energy
Conservation

8.

Knowledge: Fertility
Promotion

9.

Knowledge: Health Behaviors

10. Knowledge: Health

Resources
11. Knowledge: Illness Care
12. Knowledge: Infant Care
13. Knowledge: Infection Control
14. Knowledge: Labor & Delivery
15. Knowledge: Maternal-Child
Health
16. Knowledge: Medication
17. Knowledge: Personal Safety
18. Knowledge: Postpartum
19. Knowledge: Preconception
20. Knowledge: Pregnancy
21. Knowledge: Prescribed
Activity
22. Knowledge: Sexual
Functioning
23. Knowledge: Substance Use
Control
24. Knowledge: Treatment
Procedure(s)

25. Knowledge: Treatment

Regimen

OUTCOME: Knowledge: Breastfeeding

Major Interventions

Breastfeeding
Assistance

Lactation Counseling

Suggested Interventions

Childbirth Preparation

Learning Facilitation

Optional Interventions

Health System
Guidance

Infant Care

Learning Readiness
Enhancement

Lactation Suppression

Teaching: Infant Nutrition

Nonnutritive Sucking

Parent Education:
Infant

OUTCOME: Knowledge: Child Safety

Major Interventions

Teaching: Infant
Safety

Teaching: Toddler
Safety

Suggested Interventions

Optional Interventions

Health Education

Counseling

Learning Facilitation

Family Support

Learning Readiness
Enhancement

Health Screening
Parenting Promotion

Parent Education: Infant

Risk Identification

Risk Identification:
Childbearing Family

Surveillance: Safety

Teaching: Group

Teaching: Individual

Vehicle Safety Promotion

OUTCOME: Knowledge: Conception Prevention

Major Interventions

Family Planning:
Contraception

Teaching: Safe Sex

Suggested Interventions

Optional Interventions

Health Education

Behavior Management:

Parent Education:
Adolescent

Sexual
Behavior Modification

Parenting Promotion

Learning Facilitation

Family Planning:
Unplanned Pregnancy

Learning Readiness
Enhancement

Impulse Control Training

Pregnancy Termination
Care

Self-Responsibility
Facilitation

Teaching: Individual

OUTCOME: Knowledge: Diabetes Management

Major Interventions

Teaching: Disease
Process
Teaching: Prescribed
Diet

Suggested Interventions

Hyperglycemia Management

Hypoglycemia Management

Medication Administration:

Optional Interventions

Behavior
Modification

Health Education

Medication

Teaching: Prescribed
Medication

Subcutaneous

Management

Teaching: Prescribed
Activity/Exercise

Nutrition
Management

Teaching: Psychomotor Skill

Referral

OUTCOME: Knowledge: Diet

Major Interventions

Teaching:
Prescribed Diet

Teaching: Infant
Nutrition

Teaching: Toddler
Nutrition

Suggested Interventions

Optional Interventions

Breastfeeding Assistance

Behavior Management

Health Education

Chemotherapy
Management

Lactation Counseling

Eating Disorders
Management

Nutrition Management

Nutritional Monitoring

Learning Facilitation

Learning Readiness
Enhancement

Nutritional Counseling

Patient Contracting

Preconception
Counseling

Prenatal Care

Teaching: Individual

Self-Modification
Assistance

Teaching: Group

Weight Management

OUTCOME: Knowledge: Disease Process

Major Interventions

Teaching: Disease
Process

Suggested Interventions

Optional Interventions

Health System Guidance

Admission Care

Learning Facilitation

Allergy Management

Learning Readiness
Enhancement

Anxiety Reduction
Discharge Planning

Teaching: Individual

Risk Identification

Teaching: Group

Truth Telling

OUTCOME: Knowledge: Energy Conservation

Major Interventions

Teaching: Prescribed
Activity/Exercise

Suggested Interventions

Health Education

Learning Facilitation

Learning Readiness
Enhancement

Optional Interventions

Body Mechanics
Promotion

Energy Management

Exercise Promotion

Teaching: Disease
Process

Progressive Muscle
Relaxation

Teaching: Individual

Recreation Therapy

Simple Relaxation
Therapy

Teaching: Group

OUTCOME: Knowledge: Fertility Promotion

Major Interventions

Suggested Interventions

Family Planning: Infertility

Fertility Preservation

Patients Rights
Protection

Preconception
Counseling

Teaching:
Procedure/Treatment

Reproductive Technology
Management

Optional Interventions

Counseling

Decision-Making
Support

Genetic Counseling

Specimen
Management

OUTCOME: Knowledge: Health Behaviors

Major Interventions

Health
Education

Suggested Interventions

Optional Interventions

Active Listening

Behavior Modification

Anticipatory Guidance

Genetic Counseling

Breast Examination

Health Screening

Health System Guidance

Infection Protection

Learning Facilitation

Oral Health Promotion

Learning Readiness
Enhancement

Preconception
Counseling

Parent Education: Adolescent

Risk Identification

Parent Education:
Childrearing Family

Substance Use
Prevention

Parent Education: Infant

Self Awareness

Enhancement

Teaching: Group

Teaching: Individual

Teaching: Safe Sex

Values Clarification

OUTCOME: Knowledge: Health Resources

Major Interventions

Health System
Guidance

Suggested Interventions

Discharge Planning

Health Education

Learning Facilitation

Learning Readiness
Enhancement

Support System
Enhancement

Teaching: Individual

Optional Interventions

Health Care Information

Exchange

Teaching: Group

Telephone Consultation

OUTCOME: Knowledge: Illness Care

Major Interventions

Teaching: Individual

Suggested Interventions

Teaching: Disease
Process

Optional Interventions

Energy
Management

Teaching:
Procedure/Treatment

Teaching: Prescribed
Activity/Exercise

Health System
Guidance

Teaching: Prescribed Diet

Infection Control

Teaching: Prescribed
Medication

OUTCOME: Knowledge: Infant Care

Major Interventions

Suggested Interventions

Parent Education:
Infant

Optional Interventions

Breastfeeding Assistance

Newborn Care

Lactation Counseling

Parenting Promotion

Teaching: Individual

Teaching: Infant Nutrition

Teaching: Infant Safety

OUTCOME: Knowledge: Infection Control

Major Interventions

Infection
Protection
Risk
Identification
Teaching: Safe
Sex

Suggested Interventions

Optional Interventions

Health Education

Home Maintenance Assistance

Incision Site Care

Immunization/Vaccination
Management

Infection Control

Medication Management

Teaching: Group

Learning Facilitation
Learning Readiness

Enhancement

Teaching: Preoperative

Teaching: Disease
Process

Teaching: Prescribed Medication

Teaching: Individual

Urinary Elimination Management

Teaching:
Procedure/Treatment

Wound Care

Teaching:
Psychomotor Skill

OUTCOME: Knowledge: Labor & Delivery

Major Interventions

Suggested Interventions

Childbirth Preparation

Optional Interventions

Anticipatory Guidance

Intrapartal Care

Teaching: Individual

Labor Induction

Labor Suppression

Teaching: Group

OUTCOME: Knowledge: Maternal-Child Health

Major Interventions

Suggested Interventions

Optional Interventions

Health Education

Childbirth Preparation

Energy Management

Teaching:
Individual

Genetic Counseling

Fertility Preservation

Lactation Counseling

Health System

Parent Education: Infant

Reproductive Technology
Management

Teaching: Infant Safety

Teaching: Prescribed
Activity/Exercise

Guidance

Nutrition Management

Parenting Promotion

Sexual Counseling

Substance Use
Prevention

Teaching: Toddler
Safety

Weight Management

Teaching: Prescribed Diet

Teaching: Safe Sex

Teaching: Sexuality

OUTCOME: Knowledge: Medication

Major Interventions

Teaching:
Prescribed
Medication

Suggested Interventions

Allergy Management

Analgesic Administration

Chemotherapy Management

Optional Interventions

Constipation/Impaction
Management

Pain Management

Preconception Counseling

Prenatal Care

Teaching: Disease Process

Teaching: Group

Hyperglycemia Management

Hypoglycemia Management

Immunization/Vaccination
Management

Learning Facilitation

Learning Readiness
Enhancement

Medication Management

Patient-Controlled Analgesia

(PCA) Assistance

Teaching: Individual

OUTCOME: Knowledge: Personal Safety

Major Interventions

Suggested Interventions

Optional Interventions

Health Education

Counseling

Abuse Protection Support

Teaching: Infant
Safety

Learning Facilitation

Abuse Protection Support:

Child

Teaching: Toddler
Safety

Learning Readiness
Enhancement

Abuse Protection Support:

Domestic Partner

Patients Rights
Protection

Abuse Protection Support:

Elder

Fall Prevention

Infection Protection

Substance Use Prevention

Teaching: Psychomotor
Skill

Vehicle Safety Promotion

Risk Identification
Teaching: Individual

OUTCOME: Knowledge: Postpartum

Major Interventions

Lactation Counseling

Suggested Interventions

Health Education

Optional Interventions

Cesarean Section

Teaching: Prescribed
Activity/Exercise

Care

Learning Facilitation

Health System
Guidance

Learning Readiness
Enhancement

Postpartal Care

Nutritional Counseling

Teaching: Individual

Weight Reduction
Assistance

OUTCOME: Knowledge: Preconception

Major Interventions

Suggested Interventions

Optional Interventions

Health Education

Counseling

Behavior Modification

Preconception
Counseling

Genetic Counseling

Sexual Counseling

Learning Facilitation

Substance Use
Prevention

Learning Readiness
Enhancement

Teaching: Individual

OUTCOME: Knowledge: Pregnancy

Major Interventions

Childbirth

Suggested Interventions

Anticipatory Guidance

Optional Interventions

High Risk Pregnancy

Preparation

Health Education

Learning Facilitation

Learning Readiness
Enhancement

Prenatal Care

Teaching: Individual

Teaching: Prescribed
Medication

Care

Health System
Guidance

OUTCOME: Knowledge: Prescribed Activity

Major Interventions

Teaching: Prescribed
Activity/Exercise

Suggested Interventions

Optional Interventions

Energy Management

Activity Therapy

Exercise Promotion

Behavior Modification

Learning Facilitation

Recreation Therapy

Learning Readiness
Enhancement

Self-Modification
Assistance

Patient Contracting

Teaching: Group

Teaching: Individual

Therapeutic Play

OUTCOME: Knowledge: Sexual Functioning

Major Interventions

Suggested Interventions

Optional Interventions

Teaching: Safe Sex

Teaching: Sexuality

Behavior Management:
Sexual

Family Planning:
Contraception

Learning Facilitation

Learning Readiness
Enhancement

Sexual Counseling

Teaching: Individual

Genetic Counseling

Patient Rights
Protection

Self-Awareness
Enhancement

OUTCOME: Knowledge: Substance Use Control

Major Interventions

Substance Use
Prevention

Suggested Interventions

Optional Interventions

Behavior Management

Analgesic Administration

Health Education

Controlled Substance
Checking

Learning Facilitation

Health Screening

Learning Readiness
Enhancement

Health System Guidance

Mutual Goal Setting

Nutritional Counseling

Patient Contracting

Preconception Counseling

Smoking Cessation
Assistance

Substance Use Treatment

Medication
Management

Teaching: Group

Substance Use Treatment:

Alcohol Withdrawal

Substance Use Treatment:

Drug Withdrawal

OUTCOME: Knowledge: Treatment Procedure(s)

Major Interventions

Preparatory Sensory
Information

Teaching:
Procedure/Treatment

Teaching: Psychomotor
Skill

Suggested Interventions

Optional Interventions

Anticipatory Guidance

Anxiety Reduction

Learning Facilitation

Culture Brokerage

Learning Readiness
Enhancement

Decision-Making
Support

Parent Education:
Adolescent

Examination
Assistance

Parent Education:
Childrearing Family

Parent Education: Infant

Patients Rights Protection

Presence

Teaching: Disease
Process

Teaching: Individual

OUTCOME: Knowledge: Treatment Regimen

Major Interventions

Suggested Interventions

Optional Interventions

Teaching: Preoperative

Anticipatory Guidance

Health System
Guidance

Teaching:
Procedure/Treatment

Chemotherapy
Management

Labor Induction

Learning Facilitation

Prenatal Care

Learning Readiness
Enhancement

Teaching: Group

Medication Management

Weight Gain
Assistance

Nutrition Management

Weight Management

Parent Education:
Adolescent

Weight Reduction
Assistance

Parent Education:
Childrearing Family

Parent Education: Infant

Radiation Therapy
Management

Teaching: Disease Process

Teaching: Individual

Teaching: Prescribed
Activity/Exercise

Teaching: Prescribed Diet

Teaching: Prescribed
Medication

Hemorrhage is one of the common causes of maternal mortality associated with

childbearing and is the major immediate danger during the postpartal
period.Postpartum hemorrhage is defined as any loss of blood from the uterus more
than 500 ml within a 24 hour period.It may be immediate or late occurring from the
first 24 hours of delivery up to the remaining days of the 6- week puerperium. The first

24 hours after delivery is the most dangerous part wherein postpartum hemorrhage
must be monitored closely due to prior detachment of the placenta.
Predisposing factors include:
1. Maternal age more than 30 years
2. Arrest and rapid delivery
3. Anemia in expecting mothers
4. Multiple gestation
5. Increase of amniotic fluid
6. Myoma
7. Difficult labor
8. Sudden separation birth of the placenta
When close monitoring fails to serve its function, hypovolemic shock can happen
which is a very threatening case for the mother, the newly born child as well as to the
family.