postpartum hemorrhage - Nursing Case Study

Pathophysiology

• Primary mechanism: Uterine Atony - After childbirth, the uterus should contract to help expel the placenta and to close off blood vessels that were open during pregnancy. If the uterus does not contract properly (uterine atony), it can lead to excessive bleeding, the primary cause of postpartum hemorrhage.

• Secondary mechanism: Retained placental tissue - Sometimes, parts of the placenta remain in the uterus after delivery. These retained tissues can prevent the uterus from contracting effectively, leading to heavy bleeding.

• Key complication: Coagulopathy - This is a condition that affects the blood's ability to clot, which can be a result of significant blood loss. This can worsen the hemorrhage, leading to a vicious cycle of more blood loss and less clotting.

Patient Profile

Demographics:

32-year-old female, office worker

History:

• Key past medical history: First-time mother, full-term normal vaginal delivery 1 week ago, no known chronic illnesses

• Current medications: Prenatal vitamins

• Allergies: No known allergies

Current Presentation:

• Chief complaint: Mild abdominal discomfort and unexpected bleeding

• Key symptoms: Mild bleeding, lower abdominal discomfort, fatigue

• Vital signs: Blood pressure 120/80 mmHg, heart rate 80 beats per minute, respiratory rate 16 breaths per minute, temperature 98.6°F.

Section 1

Initial Assessment Findings:

Upon further assessment, the nurse noted the patient's lower abdomen was soft and non-tender, but slightly distended. The patient reported feeling pressure in her lower abdomen and described the discomfort as a 4 on a scale of 0-10, with 10 being the most severe pain. The nurse observed mild bleeding with some small clots, and the patient reported the bleeding had increased slightly over the past 24 hours. The patient also stated that she had been feeling more fatigued than she expected after giving birth. On auscultation, bowel sounds were present and normal in all four quadrants.

In addition to the physical assessment, the nurse also reviewed the patient's lab results. Her complete blood count showed a hemoglobin level of 11 g/dL (normal range: 12-16g/dL) and a hematocrit of 33% (normal range: 37-47%), indicating mild anemia, which could be contributing to her fatigue. Her coagulation profile was within normal limits, with an INR of 1.0 (normal range: 0.8-1.2) and aPTT of 30 seconds (normal range: 25-35 seconds).

The nurse, recognizing the signs of possible postpartum hemorrhage, planned to monitor the patient's bleeding and vital signs closely, alert the healthcare provider of the findings, and prepare for potential interventions. This is a crucial period for the patient, and prompt recognition and treatment of postpartum hemorrhage can prevent severe complications, such as shock or organ failure.

Section 2

Following the initial assessment, the nurse continued to monitor the patient's vital signs every 15 minutes. The patient's blood pressure remained stable at 120/80 mmHg, her pulse was regular at 88 beats per minute, and her respiration rate was 18 breaths per minute. However, the patient reported that her abdominal discomfort was increasing, now rating it as a 6 on the pain scale.

Upon re-assessment of the patient's abdomen, the nurse noted an increase in distension and firmness. The bleeding also seemed to have increased, with the passage of a few more clots. The nurse quickly alerted the healthcare provider of the changes, who ordered an urgent ultrasound to assess the uterus and a repeat complete blood count. The ultrasound revealed an enlarged uterus with retained placental fragments, which is a common cause of postpartum hemorrhage. The repeat complete blood count showed a decrease in hemoglobin to 10 g/dL and hematocrit to 30%, indicating the patient's anemia was worsening.

With these new findings, the healthcare provider decided to perform a manual removal of placental fragments to control the bleeding. The nurse prepared the patient for the procedure, explaining what was happening, and reassured her that this intervention was necessary to manage her postpartum hemorrhage and prevent further complications. The nurse also prepared to administer an IV line for fluid replacement and possible blood transfusion, if needed, to manage the patient's anemia.

Section 3

The nurse began to administer the IV fluids as ordered. She also collected a sample for a cross-match in case a blood transfraction was necessary. The patient's vital signs remained stable throughout this process, with a blood pressure of 120/80 mmHg, pulse of 88 beats per minute and a respiration rate of 18 breaths per minute. However, the patient's pain continued to escalate, now rating it as an 8 on the pain scale.

After the manual removal of placental fragments, the healthcare provider rechecked the patient's uterus. It was noted that the uterus was beginning to contract and soften, which was a positive sign of decreased bleeding. However, the patient still reported a high level of pain and now appeared pale and slightly sweaty. This, along with the decreased hemoglobin and hematocrit levels, suggested that the patient's anemia was affecting her overall condition. The nurse immediately reported these changes to the healthcare provider, who ordered a blood transfusion to combat the patient's anemia. The nurse then began preparing the patient for the blood transfusion, explaining the procedure and its purpose to reassure the patient.

Section 4

During the blood transfusion, the nurse closely monitored the patient's vital signs, which remained stable. However, upon reviewing the recent lab results, the nurse noted that the patient's hemoglobin level was at 9 g/dL and the hematocrit was at 27%, both of which were lower than normal. The nurse also observed that the patient's pulse rate had increased to 92 bpm, a finding that could indicate a compensatory mechanism for the low hemoglobin and hematocrit levels. Nonetheless, the patient's blood pressure remained stable at 120/80 mmHg.

The patient reported a reduction in her pain level to a 5 after receiving analgesics. The nurse continued to assess the patient's skin color and temperature, both of which seemed to improve slightly after the blood transfusion began. However, the patient still appeared slightly pale. The nurse documented these observations and reported them to the healthcare provider. The provider reassured the nurse that these findings were expected and that the patient should continue to improve as the transfusion progressed. The nurse was instructed to continue to monitor the patient closely, paying particular attention to her vital signs, pain level, and overall appearance. The nurse also checked the patient's uterus periodically, ensuring it remained contracted and soft.

Section 5

The patient's vital signs continued to remain stable throughout the blood transfusion. The nurse noticed a slight improvement in the patient's color and her pulse rate decreased to 88 bpm. However, the patient complained of feeling unusually cold and shivery. The nurse checked the patient's temperature, which had dropped slightly to 36.2°C (97°F). The nurse reassured the patient and provided an extra blanket, considering the possibility that the transfusion might be causing a chill.

With the new lab results in, the nurse noted that the patient's hemoglobin level had risen to 10 g/dL and her hematocrit was now at 30%. This indicated that the blood transfusion was indeed helping, but the patient was not out of the woods yet. The nurse continued to monitor the patient closely, particularly her temperature and her responses to the blood transfusion. The nurse communicated these findings to the healthcare provider, who instructed to continue the transfusion and monitor the patient's response. The nurse was also tasked with watching out for signs of transfusion reaction, such as fever, chills, and rashes, and to inform the provider immediately if any of these occurred.