Capstone Literature Review Example Nursing on Postpartum Hemorrhage Education

Here’s a Capstone Literature Review Example Nursing on Postpartum Hemorrhage Education to Nursing Students: Literature Review

Capstone Literature Review Example Nursing on Postpartum Hemorrhage Education

Literature material on postpartum hemorrhage (PPH) was identified and reviewed. The materials were accessed from both online and library databases. In particular, the information was retrieved from nursing databases such as MEDLINE, the Excerpta Medica Database, Nursing Reference Center Plus, Health and Psychosocial Instruments, and ERIC on EBSCOhost. The sources were arrived at using the Boolean search process. The search method uses a logical approach to finding data based on certain keywords and accepted conjunctions such as AND NOT, AND, NOT, and OR. The method was quite effective in lowering the search duration as it provided hints of what was required for the review. The scholarly sources used in this review were selected based on their relevance to postpartum hemorrhage as the issue of interest, regency, reliability, credibility, and impact they have on the understanding of PPH and training outcomes. The literature review’s significance is highlighted in PPH’s discussion, thereby shedding more light on the ideal ways to manage and prevent the condition. Likewise, the review provides a good background on the role of the cognitive learning teaching model and the impact of education on lowering PPH cases in the society.

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Key Words

Postpartum hemorrhage, PPH, Cognitive Learning Theory, childbirth complications, postpartum hemorrhage risk factors, postpartum hemorrhage studies, postpartum hemorrhage learning studies, Uterine contraction, Simulation learning and PPH.

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The literature reviews section takes a detailed analysis of the different works and studies that have been conducted on postpartum hemorrhage. The purpose of the section is to review theoretical literature on postpartum hemorrhage to establish a general understanding of the condition and prevalence. Likewise, scholarly data about the various challenges faced in dealing with PPH are reviewed. Educating health care workers on PPH preventive and management measures has been highlighted as one of the critical solutions to ending maternal mortality and morbidity associated with the disease. Therefore, the section reviews the cognitive learning theory as the theoretical approach to impart knowledge on learners and the role of education in combating PPH.

The topic of Postpartum hemorrhage (PPT) has slowly gained significance in the medical world. Even though perceived as a less occurring situation, it is the effects associated with the disease that has raised a lot of concern amongst medical practitioners. There is no conclusive definition of PPH as broader aspects are considered to form part of the health complication. Borovac et al. (2018) point out that as of 2015, PPH’s definition failed to include critical components of the disease. He points out that the definition should consist of cardiovascular changes and blood loss in women during childbirth. Newstone (2017) also links PPH with uterine bleeding. However, he states that such bleeding is not familiar with diseases such as fibroids of the uterine walls. Newton specifically focuses on pregnancy-related complications as one of the critical factors that lead to bleeding of the uterine walls.

According to Rong et al. (2017), postpartum hemorrhage refers to excessive bleeding after birth. The definition is further supported by Ononge et al. (2016), who associates PPH with the excessive loss of blood that occurs in women immediately after giving birth. The condition often starts a day after delivery and can continue up to 12 days. While it is common for women to lose blood during childbirth, PPH is signified by an excessive loss that places the mother’s life at risk (Ononge et al. 2016). Women are projected to lose about 500 milliliters of blood during vaginal birth. The quantity of blood lost again increases to 1000 ml in the case of cesarean delivery. PPH is thus said to occur when women continue losing blood beyond the accepted levels. Excessive loss of blood is associated with several health risks. A drop in blood pressure levels is likely to result, thereby leading to shock hence death. Likewise, lack of adequate blood deprives body organs of the much-needed oxygen for respiratory functioning. Excessive loss of blood for long durations thus causes death.

Postpartum hemorrhage is identified by several symptoms that differentiate it from normal bleeding after birth. Failure for the bleeding to be controlled is one of the clear indications of PPH. Difficulties in controlling the bleeding indicate that mothers are heading towards the excessive loss of blood phase that is the crucial symptom and effect of PPH. Likewise, excessive bleeding is considered as physical evidence in PPH cases. Women suffering from PPH also experience an increase in heart rates. Low blood pressure due to excessive blood loss increases the heart’s intensity to supply blood to the oxygen-deprived organs. Apart from the bleeding, a person might also realize swelling around the vagina. Belfort et al. (2016) point out that apart from the bleeding, it is somehow difficult to identify PPT’s existence accurately. Visits to health care institutions are thus necessary for identifying other internal symptoms, for instance, loss of red blood cell count.

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PPH diagnosis entails an investigation of the different symptoms associated with the disease. The diagnosis involves carrying out various measures to determine an individual’s state of health. A person’s blood level is recorded to estimate the quantity lost. Other medical tests for PPOH diagnosis include red cell blood count and blood pressure tests (Snegovskikh et al. 2018).

PPH is linked to different causes. Unusual contraction of the uterus after birth is the primary cause of PPH. It is usual for the uterus to contract after a woman delivers a baby. The uterus’ contraction pushes out the placenta, placing adequate pressure on the blood vessels where it had been attached. However, uterine contractions complications may lead to a lack of inadequate pressure leading to bleeding of the vessels. Likewise, failure to fully eliminate the placenta makes them attached to the uterine walls leading to bleeding at the contact points. Likewise, tears in the uterine blood vessels and the cervix due to birth complications result in bleeding. There are also cases of hidden bleeding in the hematoma. Moreover, PPH can result from placenta and blood clotting complications (Ngwenya, 2016).

Scholars and medical experts have also linked PPH to several risk factors. Women with certain conditions are thus highlighted as having higher chances of suffering from PPH compared to others. Understanding the PPH risk factors is perceived as a positive step in the management and prevention of PPH (Nyfløt, et al. 2017). Women with uterine complications such as uterine atony are depicted as having higher probabilities of PPH suffering during childbirth. Uterine atony is considered the leading cause of PPH (Gill et al., 2020). It occurs when the uterus experiences excess stretching during childbirth, therefore interfering with normal contractions. Abnormal uterine contractions lead to bleeding. Other uterine conditions that pose as PPH risk factors are inversion and rupture. While inversion is the uterus’s inside-out turning, rupture occurs when part of the uterine wall tears during labor (Gilmandyar & Thornburg, 2019). Women with different placenta complications are also at high risk of contracting PPH. Placental abruption, for instance, causes PPH due to the early separation of the placenta from the walls of the uterus. Placenta previa is caused by a low-lying placenta that ends up covering the cervix leading to birth complications. Moreover, women with issues of retained placenta have higher chances of experiencing PPH. The situation occurs when the placenta is not flushed out of the uterus within 30 to 60 minutes after child delivery. The retained portions of the placenta cause bleeding of the uterus. Likewise, the occurrence of different conditions during childbirth increases the chances of suffering from PPH. A C-section and cases of augmented labor are linked to PPH (Claroni et al. 2018).

Recently, postpartum hemorrhage has attracted a lot of attention due to the increasing number of casualties. According to Borovac et al. (2018), the condition was responsible for the death of slightly above 80,000 women globally in 2015. Likewise, the occurrence of the condition does not affect particular groups. PPH affects both developed and developing nations in equal measures, as seen in its categorization into the top five leading causes of maternal deaths for low and high-income countries. However, the rate of death from PPH is lower in the developed nations (Belfort). The World Health Organization projects that PPH occurs in 1% to 6% of global childbirths. Thus, the high percentage makes PPH the leading cause of maternal deaths globally (Andrikopoulou & D’jAlton, 2019). This is highlighted by PPH accounting for a quarter of global maternal deaths. Closer, PPH is responsible for about 12% of maternal deaths in the United States (Evensen at al. 2017).

The critical intervention to postpartum hemorrhage is the early detection and management of the condition. PPH cases can be minimized through preventive mechanisms. According to Evensen et al. (2017), incidences of PPH occurring can be minimized by active management of pregnancy during the third stage. Active management of the third stage of Labor (AMTSL) is considered the right initiative to lower PPH instances in women at the risk of suffering from PPH. Likewise, efficient diagnosis of the condition and the right treatment procedures are required to prevent it from worsening. Administration of oxytocin after delivery helps in treating uterine atony, thus managing the condition. Management of the state also involves the use of the four mnemonic T’s associated with PPH, that is Trauma, Tone uterine walls, Tissue of placenta invasion, and Thrombin coagulopathy (Evensen et al. 2017).

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The Agency supports the argument that preventive mechanisms best manage postpartum hemorrhage for Health Research and Quality (AHRQ). The agency agrees that early diagnosis and treatment are vital in curbing mortalities associated with the condition. While certain women may showcase risk factors of contracting PPH, health care institutions should be prepared to handle the situation in any case. Part of the reason as to why PPH mortalities occur is because health care workers are less ready to handle such situations. The rare occurrence of PPH complications thus catches them unprepared. Therefore, the adequate intervention of the PPH condition involves having advanced plans to handle the difficulties if they occur. The preparations do not just focus on those who indicate risk factors but on women looking forward to delivering. This is because 20% of PPH cases are linked to people without risk factors (Sentilhes et al. 2016).

Lack of adequate knowledge and preparation is illustrated as a critical challenge to fighting and preventing PPH (Cooper et al. 2019). Healthcare practitioners, such as nurses, have little knowledge of handling PPH cases. The lack of knowledge is caused by the low rate of interaction with the condition. Health care practitioners still grapple with handling PPH cases despite the existence of clear medical procedures on diagnosing and treating the condition. The challenge would continue if health care workers are not enlightened on PPH and how to handle it. The Agency for Health care Research and Quality points out that the management of PPH cases depends on the preparation and education levels that patients and health care staff regarding the condition. Lowering PPH cases is a public health issue that will lead to better health outcomes and a reduction in maternal mortality and morbidity. Extensive education on PPH and its management among nursing staff are one of the critical ways to lower its occurrence, thus boosting public health (Sentilhes et al. 2016).

The cognitive learning model has been highlighted as a critical theory in imparting health care workers with the educational skills necessary to prevent and manage PPH. The theory posits that learners become familiar with different exercises due to their brains’ ability to process the information they encounter during training. Knowledge is considered as something that is continuously constructed from learner’s cognitive structures. Moreover, the cognitive approach to learning focuses on the mental processes that take place in learners. The brain is responsible for taking in information in terms of stimulus, interpreting it, storing, and retrieving when needed. Interaction of the mental processes with learning stimulus eventually leads to knowledge acquisition (Tennyson & Rasch, 1988). Knowledge acquisition thus depends on the mental processes of observation, attention, perception, interpretation, information storage, and retrieval, data classification, and ability to make generalizations from different stimuli. The Cognitive Learning Theory (CLT) effectively facilitates knowledge acquisition due to its inductive nature and understanding of complex concepts and specific details (Farber et al., 2017). Simulation training, a key feature of CLT, allows nursing students to familiarize themselves with PPH situations, thus getting the necessary knowledge to help them handle patients with the complication. Likewise, simulation is considered to raise the confidence level of health care workers when dealing with PPH. The confidence arises from trainees’ belief that they are capable of solving the different PPH complications that they once had little knowledge on before the training (Abisogun, 2019).

The lack of qualified health care workers in terms of skills required to handle PPH cases is a detrimental factor to the fight against the condition, as pointed out by (Nellisen et al. 2017). In their study, Nellisen et al. (2017) sought to determine the effect of simulation training on PPH in medical practitioners. It was hypothesized that simulation training on obstetric PPH cases would instill health care workers with knowledge on the condition leading to improvement in service delivery and management of PPH. The entailed PPH treatments such as uterine massage after birth, removal of the placenta and oxytocin administration. Likewise, the educational program involved examination of the uterine wall and birth canal to detect any symptoms of PPH conditions. The research findings illustrated significant improvement in the understanding and handling of PPH cases after the training. Simulation-based training on PPH is thus depicted as an ideal method to lower its occurrence.

Improvement in knowledge about PPH was also mirrored in a 2018 study by Powell. The research investigated the role of educational based interventions on lowering PPH cases. The study was guided by frequent inconsistencies in PPH diagnosis methods, thus leading to untimely treatment. Adult learning theory was perceived as crucial in instilling the participants with knowledge about PPH management. A pretest and posttest design was adopted to test participants’ level of understanding after the project. The findings illustrated that educating health care practitioners on PPH results in early diagnosis of the condition by lowering the numerous cases of inconsistencies (Powell, 2018).

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Training is also illustrated to enhance teamwork among nurses, thus enhancing quality care for PPH patients. Lack of knowledge in PPH exposes nurses to a lot of stress when dealing with the condition. The general effect of working under stress is reduced, thus depicting improvement in the quality of treatment and care for PPH patients. Training nurses on PPH is, therefore, crucial in enlightening them on handling such patients. Likewise, training nurses on PHH informs them of the need for teamwork when handling the cases. Enhanced cooperation while dealing with PHH complications lowers health care perceptions regarding the procedures being stressful. Training nurses on PPH is, therefore, an avenue to make them offer skilled services to mothers during and after childbirth (Egenberg et al. 2017).


Abisogun, E. O. (2019). Impact of Simulation Education on Nurses’ Confidence and Efficacy during Postpartum Hemorrhage (Doctoral dissertation, Grand Canyon University).

Andrikopoulou, M., & D’Alton, M. E. (2019, February). Postpartum hemorrhage: early identification challenges. In Seminars in perinatology (Vol. 43, No. 1, pp. 11-17). WB Saunders.

Belfort, M. A., Lockwood, C., & Barss, V. (2016). Overview of postpartum hemorrhage. UpToDate, Waltham, MA, USA.

Borovac-Pinheiro, A., Pacagnella, R. C., Cecatti, J. G., Miller, S., El Ayadi, A. M., Souza, J. P., … & Winikoff, B. (2018). Postpartum hemorrhage: new insights for definition and diagnosis. American journal of obstetrics and gynecology, 219(2), 162-168.

Claroni, C., Aversano, M., Todde, C., & Frigo, M. G. (2018). Postpartum hemorrhage management, the importance of timing. Clinical Management Issues, 12(1).

Cooper, N., O’Brien, S., & Siassakos, D. (2019). Training health workers to prevent and manage postpartum hemorrhage (PPH). Best Practice & Research Clinical Obstetrics & Gynaecology, 61, 121-129.

Egenberg, S., Karlsen, B., Massay, D., Kimaro, H., & Bru, L. E. (2017). “No patient should die of PPH just for the lack of training!” Experiences from multi-professional simulation training on postpartum hemorrhage in northern Tanzania: a qualitative study. BMC medical education, 17(1), 119.

Evensen, A., Anderson, J. M., & Fontaine, P. (2017). Postpartum hemorrhage: prevention and treatment. American family physician, 95(7), 442-449.

Farber, M. K., Miller, C. M., Ramachandran, B., Hegde, P., Akbar, K., Goodnough, L. T., & Butwick, A. J. (2016). knowledge of blood loss at delivery among postpartum patients. PeerJ, 4, e2361.

Gill, P., Patel, A., & Van Hook, J. W. (2020). Uterine Atony. In StatPearls [Internet]. StatPearls Publishing.

Gilmandyar, D., & Thornburg, L. L. (2019, February). Surgical management of postpartum hemorrhage. In Seminars in Perinatology (Vol. 43, No. 1, pp. 27-34). WB Saunders.

Nelissen, E., Ersdal, H., Mduma, E., Evjen-Olsen, B., Twisk, J., Broerse, J., … & Stekelenburg, J. (2017). Clinical performance and patient outcome after simulation-based training in prevention and management of postpartum haemorrhage: an educational intervention study in a low-resource setting. BMC pregnancy and childbirth, 17(1), 301.

Newsome, J., Martin, J. G., Bercu, Z., Shah, J., Shekhani, H., & Peters, G. (2017). Postpartum hemorrhage. Techniques in vascular and interventional radiology, 20(4), 266-273.

Ngwenya, S. (2016). Postpartum hemorrhage: incidence, risk factors, and outcomes in a low-resource setting. International journal of women’s health, 8, 647.

Nyfløt, L. T., Sandven, I., Stray-Pedersen, B., Pettersen, S., Al-Zirqi, I., Rosenberg, M., … & Vangen, S. (2017). Risk factors for severe postpartum hemorrhage: a case-control study. BMC pregnancy and childbirth, 17(1), 17.

Ononge, S., Mirembe, F., Wandabwa, J., & Campbell, O. M. (2016). Incidence and risk factors for postpartum hemorrhage in Uganda. Reproductive health, 13(1), 1-7.

Powell, J. (2018). Postpartum Hemorrhage Evidenced-Based Registered Nurse Staff Education Project.

Rong, Z. (2017). The application of integrated care intervention in maternity and postpartum hemorrhage care was explored. Health Way, (6), 14.

Sentilhes, L., Vayssière, C., Deneux-Tharaux, C., Aya, A. G., Bayoumeu, F., Bonnet, M. P., Djoudi, R., Dolley, P., Dreyfus, M., Ducroux-Schouwey, C., Dupont, C., François, A., Gallot, D., Haumonté, J. B., Huissoud, C., Kayem, G., Keita, H., Langer, B., Mignon, A., Morel, O., … Goffinet, F. (2016). Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR). European journal of obstetrics, gynecology, and reproductive biology, 198, 12–21.

Snegovskikh, D., Souza, D., Walton, Z., Dai, F., Rachler, R., Garay, A., … & Norwitz, E. R. (2018). Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage. Obstetric anesthesia digest, 38(2), 82-83.

Tennyson, R. D., & Rasch, M. (1988). Linking cognitive learning theory to instructional prescriptions. Instructional Science, 17(4), 369-385.

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