Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse on the postpartum unit. Your patient, 12 hours after a vaginal delivery, calls you to the room stating she feels a "gush" of blood. You find her peripad saturated with bright red blood and clots. She appears pale and anxious.
Nursing Intervention Strategy:- 1Immediate Action (ABCs with a maternity twist)
- Airway/Breathing: Ensure patient is patent. Position supine if not already.
- Bleeding/Circulation: Immediately perform bimanual fundal massage. With one hand on the lower abdomen and the other in the vagina (if needed for a very boggy uterus), massage in a circular motion until the uterus is firm. Do not stop.
- Call out for help! Yell for another nurse or hit the call bell. Delegate tasks.
- 2Concurrent Actions (Team Approach)- Colleague #1: Establishes two large-bore IV lines (18-gauge or larger), starts a rapid infusion of Lactated Ringer's or Normal Saline, and draws labs (CBC, type and crossmatch, coagulation panel).
- Colleague #2: Obtains vital signs, applies oxygen via non-rebreather mask at 10-15 L/min, and prepares emergency uterotonic medications (Oxytocin is often kept in the room).
- You (or team leader): Notify the obstetric provider and charge nurse. Continue to assess bleeding, fundal tone, and vital signs every 5-15 minutes.
- 3Ongoing Care & Monitoring- Quantify blood loss: Weigh pads/chux. A 1-gram increase = 1 mL blood loss.
- Monitor for signs of shock: Tachycardia, hypotension, tachypnea, decreased urine output, altered mental status.
- Administer ordered medications (Oxytocin IV infusion, IM Methergine or Hemabate).
- Prepare for possible transfer to OR for surgical intervention (e.g., dilation and curettage for retained placenta, uterine artery embolization).
Patient Safety and Precautions:
• During fundal massage, support the lower uterine segment to prevent Uterine inversion (a rare but serious complication).
• Never leave a patient with active PPH alone.
• Be aware of medication side effects: Oxytocin can cause water intoxication; Methergine causes hypertension; Carboprost can cause bronchospasm (contraindicated in asthma).
• Use universal precautions – this is a high-exposure situation to blood and body fluids.
Nursing Procedure & Medication Flow
Bimanual Fundal Massage:
1. Explain the procedure to the patient quickly.
2. Don gloves.
3. Place one hand (usually the dominant) on the abdomen just above the symphysis pubis to support the uterus.
4. Place the other hand on the fundus (top of the uterus).
5. Massage the fundus in a circular motion, applying firm pressure until it becomes firm and globular. You may feel a gush of blood/clots as it contracts.
6. Continue massage as needed. A well-contracted uterus should remain firm without constant massage.Medication Administration (Example: Oxytocin):
• Route: IV infusion (can also be given IM).
• Dose: Often 10-40 units in 500-1000 mL of IV fluid (e.g., Lactated Ringer's).
• Rate: Infuse at an ordered rate (e.g., 125-200 mL/hr) to maintain uterine contraction. Titrate based on uterine response and bleeding.
• Monitoring: Watch for uterine hyperstimulation (tetanic contraction), water intoxication (headache, nausea, confusion from antidiuretic effect), and hypotension.
A Word from Your Senior Nurse
"In the chaos of a postpartum hemorrhage, your calm, systematic response is what saves lives. Your hands are the first tool. Never underestimate the power of a good fundal massage—it's often the quickest way to turn the situation around. In clinicals and on the NCLEX, remember: when the uterus is boggy and the blood is flowing, your first move is to make that uterus hard. Everything else—the IVs, the calls, the meds—happens around that core action. Think of it as the 'CAB' (Circulation, Airway, Breathing) of maternity nursing. You've got this!"