High Risk Postpartum Pregnancy PDF

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High-Risk Postpartum Case Study: High Risk Postpartum Janelle is a 40-year-old G6 P5. She gave birth to a healthy 9-pound male infant via normal spontaneous vaginal delivery 3 hours ago. She has no medical problems. Her pregnancy history was normal. Her labor course was normal although her membranes were ruptured for 24 hours before delivery. She had no lacerations at delivery. Her BMI is 36. Her vital signs are T 99.6° F, P 118, BP 120/70,and R 20. She has an IV of LR 1000 with 20 units of oxytocin infusing. Question 1 What risk factors does Janelle have for postpartum hemorrhage? Answers Janelle's risk factors for hemorrhage are: multiparity, obesity, large baby, possible chorioamnionitis as evidenced by slight elevated temperature, and history of prolonged rupture of membranes. Rationale Overdistention of the uterus by a large infant makes the rapid involution needed to prevent postpartum hemorrhage more difficult. The repeated stretching of uterine muscle fibers in multiparous women may reduce the efficiency of these muscle fibers to produce the needed sustained contraction of the uterus postpartum. Intrauterine infection is known to decrease effective uterine contraction both during labor and postpartum. Obesity also increases the risk of postpartum hemorrhage. Question 2 The nurse performs an assessment of Janelle with the following additional findings: her uterine fundus is palpable 4 centimeters above the umbilicus and deviated to the right side. It is not firm. A large amount of vaginal bleeding and clots are noted saturating the obstetric pad. What is the nursing priority in this situation? Answers The nurse should firmly massage the uterine fundus, assist the woman to void on a bedpan or catheterize the bladder, and notify the provider. Rationale The most common reason for postpartum hemorrhage is uterine atony. The uterus is often distended and deviated because of a full maternal bladder. Fundal massage and emptying of the maternal bladder can help the uterus contract efficiently. Because a postpartum hemorrhage can result in a large blood loss in a relatively short time, calling the provider to evaluate and treat the patient promptly is essential. Question 3 What etiologies other than uterine atony could be contributing to this postpartum hemorrhage?

Answers Additional etiologies to be considered are retained placental fragments, unrecognized pelvic lacerations (perineal, vaginal, cervical) or a maternal clotting disorder. Rationale No rationale provided. Question 4 The physician evaluates Janelle and finds no lacerations and orders carboprost tromethamine 250 mcg IM. Why is this drug ordered? Answers Carboprost tromethamine (Hemabate) is given in this case to increase uterine contraction to decrease bleeding. Rationale Carboprost tromethamine (Hemabate) is a prostaglandin F2 analogue. It is used as an adjunct treatment to the intravenous oxytocin in this case for uterine contraction. Question 5 What are common side effects with the use of Hemabate? Answers Nausea, vomiting, and diarrhea. Rationale Because these side effects are reported to occur in more than half of patients, many physicians order antidiarrheal and antivomiting medications together with the Hemabate. Question 6 What are the ongoing nursing assessments and education needed with Janelle? Answers Ongoing assessments include: Vital signs, abdominal palpation for uterine tone, position and tenderness and for palpable bladder, vaginal bleeding, pain, adequacy of voiding, dizziness, chest pain, shortness of breath, and CBC results. Education includes instruction to request assistance when getting out of bed for the first few times and instruction to void every 2 to 3 hours, increase oral fluid intake, and eat high iron foods. Breastfeeding should be encouraged. Rationale Janelle remains at risk for continuing postpartum hemorrhage, and assessments must be ongoing. She also must be monitored for increasing temperature. Her tachycardia could be related to blood loss or infection. If an infection develops, she will need antibiotics in addition to continuing oxytocin and possible redosing of Hemabate. Safety

concerns for falls must be addressed, as well as safety in handling the infant if Janelle is dizzy. Chest pain or shortness of breath can be symptoms of blood loss and must be reported. Increasing fluid and high iron foods helps begin the restoration of lost fluids and iron from the blood loss. Breastfeeding causes a release of endogenous oxytocin, which is beneficial to uterine contraction. Janelle can be reassured that the medications she has been given are acceptable in breastfeeding. The oxytocin and Hemabate contribute to increased uterine contraction, which can be painful, so her pain should be evaluated and treated appropriately....