Question

                

Postpartum Case Study

Scenario

RO is a 24-year-old, G4P3003, married-Puerto Rican female. Her oldest child is 3 ½ years old. She delivered a 9 pound 12 ounce baby boy following an 18-hour Pitocin-augmented labor with epidural anesthesia this morning. Her second stage was two hours. She was given a mediolateral episiotomy, and the baby’s head was delivered by vacuum extractor after she experienced difficulty pushing. Her estimated blood loss (EBL) was 400 mL right after delivery. Immediately after delivery her VS were BP 110/70, temperature 98, pulse 68, and respirations 20. She breastfed her first child but is planning on bottle feeding this child.

RO delivered two hours ago and has just been transferred to the postpartum floor. She has an IV of Lactated ringers, which is to be discontinued when it is finished. Upon assessing her, the postpartum nurse notes that RO is trickling blood from the vagina and has soaked a pad about 30 to 40 minutes after she changes it. Her vital signs are BP 90/68, pulse 100, and respiration 28. She appears restless.

QUESTIONS:

             1. Name three common sources of postpartum hemorrhage. Compare and contrast them according to the signs and symptoms, precipitating factors, and treatment for each on the table below.   

	Sign and Symptoms	Precipitating Factors	Treatment
Uterine Atony/ Ineffective contraction
Lacerations
Hematoma

2. What is the normally expected blood loss for a vaginal delivery? What about for a Cesarean Section?        

3. Was RO's blood loss normal?      

4. What factors increase the initial blood loss in any delivery-list at least 5 factors.  

            5. List four history factors that increase RO's risk for postpartum hemorrhage.

   

            6. List four labor and delivery factors that increased her risk?         

7. Assess her vital signs. Are these normal for postpartum?

   If not, what is the significance of them-explain?        

             

8. List 6 other signs of shock related to hypovolemia.      

9. List at least two consequences of postpartum hemorrhage.    

10. When would you expect RO's hematocrit to be checked? If she had a postpartum hemorrhage, how would you expect it to be reflected in the hematocrit?    

12. RO's hematocrit is low, and the CNM prescribes iron supplements. The nurse is discharging her on her third postpartum day. What information about taking iron supplements need to be included in teaching RO? What about RO's culture would indicate she would need more teaching and why?  

13. What other discharge information would be important for the nurse to educate on?

Answer 1

Q1]

Source of PPH	Sign and Symptoms	Precipitating Factors	Treatment
Uterine Atony	Uncontrolled bleeding (Estimation of blood loss (this may be done by counting the number of saturated pads, or by weighing of packs and sponges used to absorb blood). Decreased blood pressure(Hypotension) Increased heart rate (Tachycardia) Decrease in the red blood cell count (hematocrit)	Overdistension of the uterus : Caused by multifetal gestation, fetal macrosomia, polyhydramnios, or fetal abnormality , uterine structural abnormality etc Fatigue due to prolonged labor or rapid forceful labor, especially if stimulated. Inhibition of contractions by drugs such as halogenated anesthetic agents, nitrates, NSAIDs, magnesium sulfate, beta agonists, and nifedipine. Other causes : placental implantation site in the lower uterine segment, bacterial toxins (eg, chorioamnionitis, endomyometritis, septicemia), hypoxia due to hypoperfusion or Couvelaire uterus in abruptio placentae, and hypothermia due to massive resuscitation or prolonged uterine exteriorization.	MANAGEMENT OF PPH 1] CORRECTION OF HYPOVOLEMIA Large bore IV line (two)    Crystalloids (RL)-3ml / ml of blood loss Urine output (desired) –30ml / hr Whole blood / pack cell transfusion. 2] ENSURE UTERINE CONTRACTION Palpate fundus Uterine massage Bimanual compression Compression of Aorta against sacral promontory Foleys catheters. 3] OXYTOCICS Oxytocin: Bolus of 10 units IV followed by Continuous Infusion 100 mu / min Ergometrine 0.2 - 0.5mg IV Prostaglandins:  Carboprost- 0.25mg start, Rpt.15-30 min, Maximum 2.0mg, Route-IM / intramyometrial Sulprostone- 400-600 micro gm.   4] SURGICAL TREATMENT Options are :- Repair of trauma if any Uterine Artery ligation Utero ovarian Artery Ligation Internal Iliac Artery Ligation Brace suturing of Uterus Hysterectomy Angiographic embolisation.
Lacerations	Uncontrolled bleeding Decreased blood pressure(Hypotension) Increased heart rate (Tachycardia) Decrease in the red blood cell count (hematocrit) Decreased Urine output. Swelling and pain in tissues in the vginal and perineal area. Examinination of  perineum, vgina, cervix reveals Lacerations.	Uterine rupture is most common in patients with previous cesarean delivery scars. Total or thick partial disruption of the uterine wall prior to delivery : as a result of myomectomy; uteroplasty for congenital abnormality; cornual or cervical ectopic resection. Perforation of the uterus during dilatation, curettage, biopsy, hysteroscopy, laparoscopy, or intrauterine contraceptive device placement. Trauma may occur following very prolonged or vigorous labor, especially if the patient has ephalopelvic disproportion and the uterus has been stimulated with oxytocin or prostaglandins. Trauma also may occur following extrauterine or intrauterine manipulation of the fetus. Trauma may result secondary to attempts to remove a retained placenta manually or with instrumentation. Cervical laceration i: most commonly associated with forceps delivery. Assisted vaginal delivery (forceps or vacuum) should never be attempted without the cervix being fully dilated. Vginal sidewall laceration : may occur spontaneously, especially if a fetal hand presents with the head (compound presentation). Lacerations may occur during manipulations to resolve shoulder dystocia. Lower vginal tear occurs either spontaneously or because of episiotomy.	1] CORRECTION OF HYPOVOLEMIA Large bore IV line (two)    Crystalloids (RL)-3ml / ml of blood loss Urine output (desired) –30ml / hr Whole blood / pack cell transfusion. 2] REPAIR LACERATIONS BY SUTURING.
Hematoma			1] CORRECTION OF HYPOVOLEMIA Large bore IV line (two)    Crystalloids (RL)-3ml / ml of blood loss Urine output (desired) –30ml / hr Whole blood / pack cell transfusion. 2] EVACUATION OF HEMATOMA ,AND SUTURING

Q2]

The normally expected amount of blood loss after the birth of a single baby in vginal delivery is about 500 ml .

The normally expected amount of blood loss for a cesarean birth is approximately 1,000 ml .

Q3]

The patient has presented with Restlessness , decreased BP and increasing heart rate (compared to previous recordings), 2 hours after delivery.There is ongoing bleed from the vgina and has rapidly soaking pads.

This suggests that the patient has developed PPH and is going into a state of Hypovolemic shock.

Note:

Estimation of blood loss may be done by counting the number of saturated pads, or by weighing of packs and sponges used to absorb blood; 1 milliliter of blood weighs approximately one gram.

If the cause of bleeding is not uterine atony, then blood loss may be slower and clinical signs and symptoms of hypovolemia may develop over a longer time frame.

Bleeding from trauma may be concealed in the form of hematomas of the retroperitoneum.

Therefore, a close watch on the vital signs of the patient is essential.

Q4]

• Tear in the cervix or tissues of the vgina

• Tear in a blood vessel in the uterus.

• Bleeding into a hidden tissue area or space in the pelvis. This mass of blood is called a hematoma. It is usually in the vulva or vgina.

• Blood clotting disorders

• Placental problems(placenta accreta ,placenta increta).

Q5]

RISK FACTORS

a] Multiple births in short span ( the risk for PPH accumulates over multiple pregnancies).

b] Cephalopelvic disproportion (CPD).

c] Ethnicity (Being of Asian or Hispanic ethnic background increases the risk of PPH).

Q6]

1] Pitocin-augmented labour

2] Prolonged second stage of labour

3] Delivery by vacuum extractor.

Q7] VITAL SIGNS

Pulse rate : 100/mt (Normal is 60-100/mt) ; Higher side of normal.Higher value compared to initial recording.

Blood pressure : 90/68 mm Hg. Normal. Lower value compared to initial recording.

Respiratory rate : 28/mt (High)

The change in recordings compared to the initial recordings should alert to the possibility of hypovolemic shock.

Q8]

• Cool, clammy skin.
• Confusion.
• Decreased or no urine output.
• Generalized weakness.
• Pale skin color
• Sweating, moist skin

Q9]

Hemorrhagic shock leading to death.

Multi organ dysfunction syndrome (MODS) (Liver failure, Renal failure etc)

Consumptive coagulopathy (Disseminated intravascular coagulation)

Anterior oituitary ischemia resulting in Hypopituitarism (Sheehan syndrome).

Q10]

The blood loss will be reflected as increase in Hematocrit at 24-48 hours after delivery.

Q12]

PART 1

• Advise patient to take iron supplements an hour before meals for maximum absorption; if gastric distress occurs, suggest taking the supplement with meals — resume to between-meals schedule if symptoms subside.
• Inform patient that iron salts change stool colour to dark green or black.
• Advise patient to take liquid forms of iron via a straw and rinse mouth with water.

PART 2

The patient must be educatedregading the need for birth spacing and family planning.

Q13]

Breastfeeding mothers

Cleani the breasts with water daily .

If nipples are sore, apply a few drops of breast milk after a feeding and let air dry.

If breasts are engorged, apply warm packs and express milk.

Non-breastfeeding mothers

Wear a well-fitting bra for support.

Use ice packs to relieve discomfort from engorgement.

Avoid handling your breasts and do not express milk.

Non-breastfeeding engorgement will subside in 24-36 hours.

Uterine Changes

The uterine cramping sensation is normal. This cramping simply means that the uterus is contracting to return to its non-pregnant size. The uterus takes five to six weeks to return to its non-pregnant size.

Vginal Discharge

It generally lasts about ten days to four weeks. The color of discharge will change from bright red to brownish to tan and will become less in amount and finally disappear.

Menstruation will resume in approximately six to eight weeks, unless breastfeeding.

Care of Episiotomy

Sitz Bath: sitting in a tub of warm water for 15 minutes, two to three times per day, will help relieve the discomfort.

Sutures will dissolve in one to three weeks.

Pain Relief

Use a mild analgesic for breast engorgement, uterine cramping and episiotomy discomfort.

Diet & Nutrition

Continue taking  prenatal iron and vitamin pills until your postpartum visit.

It is important to eat a well-balanced diet and drink plenty of fluids.

Emotional Changes

You may get “baby blues” after delivery. You may feel let down, anxious and cry easily. This is normal. These feelings can begin two to three days after delivery and usually disappear in about a week or two. Prolonged sadness may indicate postpartum depression. Seek professional help if needed.

Activity

Do not do heavy housework or heavy exercise for two weeks. Avoid driving for one to two weeks. Check with your doctor for limitations on activities if you have had a Caesarean section.

Avoid sexual intercourse, douching or tampons until your postpartum visit.

Birth Control

Is advisable as soon as you resume sexual intercourse. Foam and condoms are safe and easy to use. Birth control methods will be discussed further at your postpartum visit.

Postpartum Visit

Call your obstetrician's office two to three days after discharge to make an appointment for six weeks.

Instruct the client to report inability to breastfeed, fatigue, amenorrhea, loss of pubic/axillary hair, premature aging and genital atrophy.These may be the signs of Sheehan’s syndrome which is caused by the destruction of cells of the anterior pituitary gland by oxygen starvation, usually at the time of childbirth. The condition may also result from septic shock, or a massive hemorrhage. It often results in premature aging, irreversible fertility, decreased resistance to infection, or increased risk of shock.

Explain to the client , the short term implications of postpartum hemorrhage, like an interruption in the process of mother-infant bonding, and inability to assume care of self and infant as soon as desired.

Explain the long term implications of postpartum hemorrhage like uterine atony, infertility if hysterectomy is done, or risk of having a postpartum hemorrhage in the future pregnancies.