Question

History/ Information

Past medical history: Patient is apparently healthy woman who has been married for two years. She denies surgery or previous health problems except for occasional episodes of asthma that resolve with albuterol inhaler as needed. Her last inhaler use was 2 weeks ago. She denies smoking, recreational drug use or alcohol use. No known drug allergies.

Familiar history: Mother: hypertension at age 40; hysterectomyat age 42 and diabetes at age 45

Father: myocardial infarction at age 58

Labor and Delivery

This patient is a 35-year-old female gravida 1, para 0. She is 37 weeks and pregnant with twins. Her blood type is A negative. She has a history of occasional episodes of asthma and has used the inhaler three times this pregnancy. The patient was diagnosed with preeclampsia at 30 weeks gestation and is scheduled for an augmentation of labor. The patient had blood pressure reading reaching 150/95 and a trace urine protein noted. A urinary catheter was inserted following the epidural anesthesia and removed prior to the second stage of labor. The patient delivered twins (Twin A-boy and Twin B- girl) vaginally after 16 hours of labor, both cephalic presentations. Twin A weighed 7 pounds 3 ounces and Twin B weighed 7 pounds 6 ounces. She had an episiotomy with a third degree extensionthat was repaired. No other lacerations were indicated on the delivery record. Estimated blood loss was 700ml. There was unusual bleeding or blood clots noted upon fundal massage.

Postpartum Assessment

After 2 hours the patient was transferred to the postpartum unit with husband and twins at bedside. The patient is oriented to the room and a new perineal pad is applied to the patient during the initial assessment. After one hour the patient press the call light and states she feels blood dripping down her leg. Upon assessment you note a boggy uterus deviated to the right side,her pad is saturated, and there is a constant flow of blood. You perform a fundal massage and the uterus is firm after 2 minutes. You apply a new pad and inform the patient that you will return in 15 minutes. After 15 minutes you return to the patient room to assess her bleeding. The pad is saturated again, fundus is boggy, abdomen is distended and you notice blood clots.   The palms of her hands are sweaty , she’s complaining of abdomen pain and feeling dehydrated. The patient and the husband are concern about her condition.

Questions:

1. What is your plan of action of this patient?

2. How would you explain this situation to the patient and her husband?

3. Would you consider calling the physician and why?

4. Would orders do you anticipate the physician to order and why?

5. What would be the primary nursing diagnosis?

Answer 1

1. Here the condition is atony if uterus which may lead to postpartum hemorrhage.

The plan of action for this patient is * monitoring vitals

* assess the root cause of bleeding

* uterine massage

* communication and resucitation

* monitoring and investigations

* measurements to control bleeding ( pharmacological and surgical)

2. The situation can be explained as a complication of delivery which may occur in women's and can be treated immediately to prevent the further complications. The situation can be explained that uterus is not contracted may cause severe bleeding hence proper assessment and care is initiated

3. Yes definitely calling a physician is necessary to prevent the life threatening complications of secondary postpartum hemmorrhage

4. * uterine massage with medication tranxemic acid, misoprostol if other drugs are not acting these may be ordered to contract uterus and prevent further bleeding

5. * Fluid volume deficit related to bleeding

* risk for hypovolemic shock related to bleeding

* risk for prolapse of uterus related to poor contraction

* risk for maternal complications related to bleeding