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POSTPARTUM HEMORRHAGE

I. INTRODUCTION

The postpartum period or puerperium refers to the 6-week period after


childbirth. Many physiologic and psychological changes occur during this period,
enabling nurses to play major roles in assessment, comfort promotion and education.
Protecting a woman’s health as these changes occur is important in preserving her future
childbearing function and for ensuring that she is physically well enough to incorporate
her new child into her family.

Although the puerperium is usually a period of health, complications like


hemorrhage, particularly, uterine atony, (which was the case of my patient) can occur,
when they do, immediate intervention is essential to prevent long-term disability and
interference with parent-child relationships.

For this case study, we aim that: 1.) we will have better understanding of
postpartum hemorrhage by reading books, articles and journals that are related with the
disease; 2.) understand clearly the pathophysiology of the disease, risk factors,
manifestations and treatment and modalities of the disease; and 3.) equip ourselves with
skills and health teachings that are appropriate for the care of patients with postpartum
hemorrhage, particularly uterine atony.

II. NURSING ASSESSMENT

A.PERSONAL DATA

The patient is Mrs. X. She was 21 years old, born on October 27, 1986 from San
Jose, Sta. Rita, Pampanga. She is a Filipino, married and a Roman Catholic.

SOCIO-DEMOGRAPHICPROFILE
MRS.X is a pure blooded Capampangan whose main concern is to make a living
for her family and to save money for her future delivery. She works as a bank teller in
one of the rural bank in Sta.Rita. His husband is a farmer and manages one of the family
businesses.

Mrs. X and her husband are religious—that they see to it they both go to church
every Sunday. They believe that God must be the center of their family. Whenever a
family member gets sick, they adhere to self-medication but if the condition is a bit
serious, they go directly to the nearest hospital.

Mrs. X lifestyle include: working for 8 hours, sleeping for <8 hours, eating
nutritious meals (more fruits and vegetables, less in meat and fatty foods, avoids junk
food and soft drinks) 3 times a day, etc. As a recreational activity, she watches television
as soon as she goes home and do some cross-stitching. She does not smoke nor drink any
alcoholic beverages.

ENVIRONMENTAL FACTORS

Their house is situated in San Jose, Sta. Rita, and a place near the main road. And
in just a meter away from their home is a gasoline station. Jenney’s and tricycle are
usually their means of transport. Their water supply comes from NAWASA.
There are lesser pollutants in the air because their area is rural and that few
vehicles are present.

B. Maternal-Child Health History

Mrs.X got married when she was 20 years old after her graduation. She got
pregnant 3 months later. According to her, she visits her doctor every month for pre natal
check-up and that she took all the vitamins prescribed by her doctor.

Aside from urinary tract infection on her first trimester and 2 nd week of the last
trimester, she had never encountered any other problems during the entire course of her
pregnancy. She was screened for hepatitis B, and had several laboratory tests like
complete blood count, blood typing, and fasting blood sugar. She was also given a shot of
tetanus toxoid on her last trimester.

Onset of Menarche: 15 years old

Gravida- 1, Parity- 0/ Term-0, Preterm-0, Abortion-0, Livebirth-0

Family Health Illness History

The different diseases that run in the family of Mrs. X are:


• Father • Mother
Hypertension, Diabetes Mellitus

• Si • B • Si
ster rother ster
hypertension Pulmonary none
tuberculosis

Mrs.X
Legend:
• Parents None
• Si
blings

C. .History of Past Illness

According to the patient she was not sure whether she was fully immunized
during her early years, but as far as she remembers, aside from minor illnesses such as
simple fever, coughs and colds, she never had any major disease such as communicable
diseases neither hospitalized. She has no allergy with food or any allergen in the
environment neither to any medicine. She never experienced any serious accidents such
as vehicular accident and fracture.

History of Present Illness

Mrs. X was admitted to the hospital (Rosario Memorial Hospital) last February
19, 2008, at around 4:50 in the morning because of labor pains.
According to the patient, few hours prior to admission, she was asleep and suddenly felt
some abdominal cramping, since the pain is not that really intense, she ignores it and
went back to sleep. At around 3 am she was awakened by abdominal pain which was
accompanied by flank pain and some vaginal discharge. She told this to her husband and
decided to go to the hospital.
Vital signs upon admission: BP- 100/70, PR-90, RR- 20, TEMP-36.8deg.cel.
She was assessed by the resident on duty and found out she is already in labor. Internal
examination was made and the results were: 6cm, 50% effaced. (+) BOW, FHT-140
beats/minute. Her attending physician was then notified and orders the following; NPO,
IVF: D5LRS 1L + 1 ampule syntocinon, 1 ampule buscopan IV, Monitor FHT.

In the course of labor induction, the cervix was not able to dilate in spite of
uterine contraction, so the Doctors orders to have the patient under cesarean section. She
was transferred to the operating room from the delivery room. After the delivery of the
baby and placenta, the uterus was noticed to be relaxed and the bleeding did not stop. In
spite of the intervention made, such as bimanual uterine massage, injection of methergine
to the uterine muscle, and uterine artery ligation, nothing happened. The bleeding was not
controlled. So, the doctor opted to have the last resort of intervention which is
hysterectomy.

D. Physical Examination (IPPA- Cephalo-caudal Approach)

The patient was admitted last February 19, 2008 at around 3:50 am. I met the
patient last February 20, 2008; unfortunately, I was not there during the operation on
February 19, 2008. When I visited her, she was already on her 1st day post operative. I
introduced my self, told her that I was assign to take care of her for few days. I stated my
purpose and asked permission to do physical examination. Although she seems tired, in
pain and quite depressed, she consented me in doing physical examination.

GENERAL APPEARANCE

The patient is in lying position; she was approximately 130lbs and


approximately 5 feet and 2 inches tall. She was neat, well groomed and no foul odor. She
grimaces every time she moves. She is slightly pale, seems tired, with labored breathing,
because of pain, quite irritable but cooperative. Vital signs upon assessment are as
follows: BP- 100/70mmHG, PR-105, RR-20, Temp- 37 degree Celsius.

Assessment upon Nursing Assessment


RMH
admission
Assessment
Feb. 20, 2008 Feb.21, 2008 Feb 22, 2008

The skin appears pale,


Skin
warm to touch. The
complexion is fair, slightly
(+) Pallor, good skin (+) Pallor, good skin
dry but with good skin
turgor, warm to touch turgor,
turgor. There is no skin
lesions found
The hair is long and black
in color, it is quite oily and I washed the hair and I
Well-combed and
according to the patient, it used anti dandruff
negative for foul odor.
Hair is a little bit itchy. There is shampoo. So the itching
Still with little dandruff.
presence of little dandruff, was lessened.
but no foul odor smelled.
The nails on both hand
and feet are well-trimmed,
slightly pink in color and
Nails are convex curved. Blanch Same findings Same findings
test was made to test for
capillary refill and there is
prompt return of the color.
The head is normal in size.
No lesions neither mass
Head was noted upon
Same findings Same findings
inspection. There is
symmetry in facial
movements.
Black in color. The eyelids
are symmetrically aligned
and there are equal
movements. Conjunctivas
are shiny, smooth and pale
pink in color .Pupils
Eyes and constrict promptly when
vision lighted. I also asked the Same findings Same findings
patient to read the note
posted on the wall which
was approximately 12 feet
away and she read it
correctly. No deviation on
the six occular
movements.
Color is same as the facial Same findings Same findings
Ears and skin. There is symmetry in
hearing size and position. Auricles
are mobile, firm and not
tender. The pinna recoils
after it is folded.
There is wet serumen that
is brown i9n color. The
tympanic membrane is
gray in color and is semi
transparent. The patient
hears and responded well
to whispered voice and
watch tic test.
Color is same of as the
facial color, located in the
middle of the face. It is
symmetric and straight.
No discharge, flaring,
lesions and tenderness
Nose and noted.
Same findings Same findings
sinuses I used cotton balls with
alcohol and asked the
patient to smell it while
pinching each nostril
alternately. The patient
was able to smell on both
nostrils.
The lips is slightly pale in
color, soft, moist and
smooth in texture the
gums are pink and there
Foul odor of the breath was
are 29 adult teeth, the
Mouth and lessened after doing oral
enamel are yellowish in
oropharynx care. I instructed the (-) bad breath
color. Tongue is smooth
patient to do oral care for
and (–) for lesions. The
at least 2times a day.
palate, uvula, oropharynx
and tonsils appear smooth
and pink in color. (+) bad
breath.
I asked the patient to move
the head from left to right
and flexed and hyper
extended the head, (+) for
smooth movements,(-) for
Neck ___________________ ________________
discomfort and the
movements coordinated.
(-) for lymph nodes upon
palpation on the thyroid
gland.
RR-20 RR- 22 breaths/minute RR-18 breaths/minute
Thorax and BREATHS/MINUTE Symmetric and full
lungs I wasn’t able to assess the expansion of the chest. The
posterior thorax since the spine is vertically aligned.
patient is in pain so I just Chest wall is intact, no
observed the movements tenderness and no masses
of the chest and he found.
breathing pattern. (+) for
labored breathing.
BP is 100/70; heart rate is
105 beats/ minute. No
Heart BP is 100/80, PR- 85 BP- 100/80; PR- 88
other abnormal sounds
heard.
(+) symmetric pulse
volume and full pulsation
on peripheral pulses of
Peripheral both upper and lower
vascular extremities. Jugular vein is
Same findings Same findings
system not distended.
Skin is warm to touch, no
edema found on both
upper and lower
extremities.
Breast and I wasn’t able to palpate the The patient was able to
axillae breast since they are very use the breast pump so
painful and very engorge she was a little bit
so I just observed them. relieved. And was able to
The right breast is much feed the baby using a
engorged than the left. The dropper.
areola appears dark brown.
The nipples are round and
everted (+) for colostrums.
Since the baby is cleft lip
and cannot tolerate
sucking, I instructed the
mother to use breast pump
to extract the milk.
Abdomen (+) dry, intact dressing, I asked the permission of With intact and dry
The wound is still painful so the doctor and the patient dressing
I didn’t have the chance to to do wound dressing so
palpate other organ on the that I could observe the
surrounding area. But to wound.
what I had notice, the The incision is found in the
abdomen is slightly midline, just below the
globularly enlarge. No mass umbilicus and just above
and lesions found on other the symphisis pubis. There
areas of the abdomen. are around 15 stitches, no
discharge neither foul odor
noticed on the wound area.

Muskulo- I compared the size, Same findings Same findings


skeletal shape and color of one
system side of the body to the
other side, there is equal
sizes and color on both
sides. (-) for
contractures, tremors,
deformities, swelling,
and tenderness.
Movements are
coordinated and are
normally firm. There is
equal strength on both
sides of the body.
Genital and (+) catheter, The urine is (+) catheter, red to light (-) catheter, urine is
anal area still light red in color, yellow in color around light pink to light
around 500cc in amount 200cc. (+) lochia rubra yellow in color. (+)
(+) lochia rubra moderate mild to moderate in lochia rubra minimal in
in amount and smells like amount. I did a perineal amount. (-) foul odor.
menstrual blood. The care so (-) for foul odor.
perineum is slightly
edematous. No
abnormalities found on the
anal area.

III. ANATOMY AND PHYSIOLOGY


THE FEMALE REPRODUCTIVE SYSTEM

The female organ is composed of external and internal genitalia. External


genitalia comprised the mons pubis, clitoris, vestibule, urinary meatus, labia majora, labia
minora, hymen, fourchete, perineum and the anus. The internal genitalia include the
vagina, ovaries, fallopian tubes, uterus and the cervix.

MONS PUBIS
The mons pubis is a rounded elevation of the skin over the pubis. It is due to a
pad of fat under the skin. The mons pubis is covered with hair at the age of puberty and it
serves as a protection to external genitalia.

CLITORIS
Near the end of the cleft between the labia majora, the clitoris is evident; it is a
small body of erectile tissue. It is a sensitive organ that is very important to the woman’s
sexual response.

VESTIBULE
The urethra and the vagina open into the vestibule. The major vestibular glands
(Bartholin) are tubulo- alveolar glands that secrete mucus.

URETHRAL OPENING
The opening of the urethra, the tubular vessel through which urine passes, is
located midway between the clitoris and the vaginal opening.

LABIA MAJORA
The labia majora are two folds of skin that pass from the mons pubis backward.
They join each other over the ridge formed by the body of the clitoris and unite again
behind the opening of the vagina in the region known as the perineum.

LABIA MINORA
The two folds of delicate skin that arise just anterior to the clitoris are the labia
minora. They cover part of clitoris as the prepuce and pass backward, bonding the
vestibule of the vagina. Although sebaceous glands are present, no hair or sweat glands
are found in the skin of the labia minora.

FOURCHETTE
It is the area where the labia majora join behind the vagina.

PERINEUM
The area of skin between the vaginal opening and the anus is the perineum.

HYMEN
The hymen is a thin membrane that partially covers the vaginal opening. If the
hymen is extensive and still present at first intercourse, it may be broken or stretched as
the penis enters the vagina and some bleeding and pain may occur, although more
typically its presence is unnoticed.

VAGINA
The vagina is a flexible tube-shaped organ that is the passageway between the
uterus and the opening of the vulva. Because during birth, the baby travels from the
uterus through the vagina, the vagina is also known as the birth canal. When a man and a
woman engaged in vaginal intercourse, the penis is inserted into the vagina.

CERVIX
The cervix is located at the bottom of the uterus and includes the opening
between the vagina and the uterus. The cervix is composed of dense, collagenous, elastic
connective tissue with a few smooth muscle fibers. It must become widely dilated at
parturition. The ability to dilate probably is due to the softening of the intercellular
substance, associated with an increased tissue fluid content.

OVARIES
The primary reproductive organs of a female are the ovaries, a pair of almond-
shaped glands. At puberty, ovaries produce about 400,000 eggs. Each month an egg is
released from the ovary and travels one of the fallopian tubes. If the egg is released
around the time of sexual intercourse and it meets and fuses with male’s sperm, it
becomes fertilized. If an egg is not fertilized, it moves from the fallopian tube to the
uterus and passes out of the body in the next menstrual cycle.
The ovaries contain many follicles composed of a developing egg surrounded by
an outer layer of follicle cells. Each egg begins oogenesis as a primary oocyte. At birth
each female carries a lifetime supply of developing oocytes, each of which is in Prophase
I. A developing egg (secondary oocyte) is released each month from puberty until
menopause, a total of 400-500 eggs.

OVARIAN CYCLES

After
puberty the ovary
cycles between a
follicular phase
(maturing follicles)
and a luteal phase
(presence of the
corpus luteum).
These cyclic phases
are interrupted only
by pregnancy and
continue until
menopause, when
reproductive
capability ends. The
ovarian cycle lasts
usually 28 days.
During the first phase, the oocyte matures within a follicle. At midpoint of the cycle, the
oocyte is released from the ovary in a process known as ovulation. Following ovulation
the follicle forms a corpus luteum which synthesizes and prepares hormones to prepare
the uterus for pregnancy.

FALLOPIAN TUBES
The oviducts or fallopian tubes vary from 8 to 14 cm in length. Each tube is
divided into an interstitial portion, isthmus, ampulla and infundubulum. The fallopian
tubes have fingerlike projections at the ends near the ovaries that sweep the egg into the
fallopian tube after it is released from the ovaries. If sperm are present in the fallopian
tube, fertilization (conception) may occur and the fertilized egg will be swept into the
uterus by cilia (hair like projections inside the fallopian tube).

UTERUS
The uterus is a mascular organ that holds and nourishes the developing fetus
during pregnancy. Although the uterus is normally about the size of a fist, during
pregnancy it is capable of stretching to accommodate a fully developed fetus, which is
typically about 50cm (about 20 inches) long and weighs about 3.5 kilograms (about 7.5
pounds). The uterine muscles also produce the strong contractions of labor. The uterus
has three layers, the perimatrium which is the outermost layer, myometrium, the middle
layer and the endometrium which is the innermost layer, and is richly supplied with blood
vessels and glands.

HORMONES AND FEMALE CYCLES


The ovarian cycle is hormonally regulated in two phases. The follicle secretes
estrogen before the ovulation; the corpus luteum secretes both estrogen and progesterone
after ovulation. Hormones from the hypothalamus and anterior pituitary control the
ovarian cycle. The ovarian cycle covers events in the ovary; the menstrual cycle occurs in
the uterus.

Menstrual cycles vary from between 15 and 31 days. The first day of the cycle is
the first day of blood flow (day 0) known as menstruation. During menstruation, the
uterine lining is broken down and shed as menstrual flow. FSH and LH are secreted on
day 0, beginning both the menstrual cycle and the ovarian cycle. Both FSH and LH
stimulate the maturation of a single follicle in one of the ovaries and the secretion of
estrogen. Rising levels of estrogen in the blood trigger secretion of LH, which stimulates
follicle maturation and ovulation (day 14, or mid cycle). LH stimulates the remaining
follicle cells to form the corpus luteum, which produces both estrogen and progesterone.
Estrogen and progesterone stimulate the development of the endometrium and
preparation of the uterine lining for implantation of a zygote. If pregnancy does not
occur, the drop in FSH and LH causes the corpus luteum to disintegrate. The drop in
hormones also causes the sloughing off of the inner lining of the uterus by a series of
muscle contractions of the uterus.
IV.B Diagnostic and Laboratory Procedures
Laboratory
Laboratory Results Analysis and Interpretation:
Procedure 1st test: decrease level of hgb,
02- 02- 02- Normal Values
Hematology
Date 19- 20- 21- hct,pt,ptt indicates bleeding,
Indication: 2008 2008 2008
decrease blood volume.
*CBC Hgb. 100 105 115 115-155 g/L 2nd test: low level of hgb hct.
This blood test
evaluates blood Indicates decrease level of blood
Hct. 31 30 35 .38-.48
loss, anemia, blood volume.
replacement
therapy and fluid 3rd test (post BT): hgb and hct are
WBC 7.5 8 -- 5-10x109/L
balance and within normal value. Compensated
screens red blood
cell status. PMN 55 .62 -- .45-.65 from blood loss.

*PTT & PT
Lymp. 25 .23 -- .20-.35
This test evaluates
coagulation ability 4.3
of blood PT 12-15 sec.
6

2.2 35-45 sec


PTT
0

*BLOOD
TYPING
Involves mixing of maternal serum
with standard reagent red cells that
contain the antigens with which

A+ most of the common clinical


significant antibodies will react,
thus, administration of unscreened
blood may res8ult to adverse
reaction.

No
HBsAG n Hepatitis B is contagious and can
rea be transferred to the baby via
ctiv placental transport. This test will
e alert the caregivers how to handle
blood products and proper care of
the patient including the baby.

Nursing Responsibilities
Explain to client the procedure to be done.
Observe sterile techniques when taking specimen.
Instruct patient to submit specimen immediately to the laboratory.
Explain to client the findings.

Date
Analysis and
Diagnostic ordered/
Result Interpretation of
Procedure Date of
Result
results
Ultrasound Dec. 11,2007 Single live male fetus in
Indications ceplalic presentation. of
Ultrasound is about 29 weeks and 4
used to days AOG.
perform Normohydramnios
noninvasive,
risk-free
abdominal
examinations.
Used to detect
tumors, cyst
obstruction,
and abscesses.
Information
gained from
the use of
ultrasound is
useful
throughout
pregnancy.

Nursing Responsibilities
1. Explain procedure to the patient.
2. Instruct patient to drink at least 6 to eight glasses of water or until she feels the urge to urinate.
3. Tell the patient to inform the nurse as soon as she feels the urge to urinate and hold it until the
procedure was completed.

IV. PATIENT AND HER ILLNESS


A. DEFINITION OF THE DISEASE
Hemorrhage, one of the most important causes of maternal mortality associated
with childbearing, poses a possible threat throughout pregnancy and is a major potential
danger in the immediate postpartal period. Traditionally, postpartal hemorrhage has been
defined as any blood loss from the uterus greater than 500ml within 24-hour period.
(St.John and Rouse, 2003). In specific agencies, the loss may not be considered
hemorrhage until it reaches 1000ml. hemorrhage may occur either early (i.e. within the
first 24 hours), as in the case of my patient, which happens during the operation, where in
she already losses 1500ml of blood), or late (anytime after 24 hours during the remaining
days of the 6-week puerperium). The greatest danger of hemorrhage is in the first 24
hours because of grossly denuded and unprotected area left after detachment of the
placenta.
As a way of remembering the causes of PPH, several sources have suggested
using the 4T’s as a mnemonic. Tone diminished (uterine atony), tissue (retained placenta,
placenta accrete), trauma (uterine inversion, uterine rapture, cervical laceration, vaginal
hematoma) and thrombin (disseminated intravascular coagulation) (Society of
Obstetricians and Gynecologists of Canada, 2002).

INCIDENCE AND PREVALENCE


Pospartum hemorrhage is the leading cause of maternal mortality. All women who carry
a pregnancy beyond 20 weeks’ gestation are at risk of PPH and its sequelae. Although
maternal mortality rates have declined greatly in the developed world, PPH remains the
leading cause of maternal mortality elsewhere.
The direct pregnancy-related maternal mortality rate in the United States is
approximately 7-10 women per 100,000 live births national statistics suggest that
approximately 8% of these deaths are caused by PPH (Berg, 1996). In industrialized
countries, PPH usually ranks in the top 3 causes of maternal mortality, along with
embolism and hypertension. In the developing world, several countries have maternal
mortality rates in excess of 1000 women per 100,000 live births, and the World Health
Organization statistics suggests that 25% of maternal deaths are due to PPH, accounting
for more than 100,000 maternal deaths per year (Abouzahr, 1998).

TONE
This is a failure of the myometrium at the placental site to contract and retract
and to compress torn blood vessels and control blood loss by a living ligature. When the
placenta is attached, the volume of blood flow at the placental site is approximately 500-
800 ml per minute. Upon separation, the efficient contraction and retraction of uterine
muscle staunch the flow and prevent a hemorrhage, which would otherwise ensure with
horrifying speed. Causes of atonic uterine action resulting in PPH are as follows:
1. Incomplete placental separation. If the placenta remains fully adherent to the
uterine wall it is unlikely to cause bleeding. However, once separation has begun,
maternal vessels are torn. If placental tissue remains partially embedded in the in
the spongy decidua, efficient contraction and retraction are interrupted.
2. Retained cotyledon, placental fragment or membranes. These will similarly
impede efficient uterine action.
3. Precipitate labor. When the uterus has contracted vigorously and frequently
resulting in duration of labor that is less than 1 hour, then the muscle may have
insufficient opportunity to retract.
4. Prolonged labor. In a labor where the active phase lasts more than 12 hours
uterine inertia (sluggishness) may result from muscle exhaustion.
5. Polyhydramnios or multiple pregnancies. The myometrium becomes excessively
stretched and therefore less efficient.
6. Placenta previa. The placental site is partly or wholly in the lower segment where
the thinner muscle layer contains few oblique fibers: this result in poor control of
bleeding.
7. Abruptio placenta. Blood may have seeped between the muscle fibers, interfering
with effective action.
8. General anesthesia. Anesthetic agents may cause uterine contraction, in particular
the volatile inhalation agents, for example halothane.
9. Mismanagement of the third stage of labor. It is salutary that this factor remains a
frequent cause of PPH. Fundus fiddling or manipulation of the uterus may
precipitate arrhythmic contraction so that the placenta only partially separates and
retraction is lost.
10. A full bladder. If the bladder is full, its proximity to the uterus in the abdomen on
completion of the second stage may interfere with uterine action. This also
constitutes mismanagement.

Other predisposing factors which might increase the risks of postpartum hemorrhage are:
previous history of postpartum hemorrhage or retained placenta, high parity resulting in
uterine scars tissue, presence of fibroids, maternal anemia and a woman with HIV/AIDS.

TISSUE
The diagnosis is reached when the placenta remains undelivered after a specified
period of time (usually ½ to 1 hour following the baby’s birth). The conventional
treatment is to separate the placenta from the uterine wall digitally, effecting a manual
removal. Selinger et al (1986) noted that waiting for 1 hour before resorting to this
intervention will almost halve the number of woman who will require manual removal
with its accompanying risks.
Failure of complete separation of the placenta occurs in placenta accrete and its
variants. In this condition, the placenta has invaded beyond the normal cleavage plane
and is abnormally adherent. Significant bleeding from the area where normal attachment
(and now detachment) has occurred may mark partial accrete. Complete accrete in which
the entire surface of the placenta is abnormally attached, or more severe invasion
(placenta accrete or pecreta) may not initially cause severe bleeding, but it may develop
as more aggressive efforts are made to remove the placenta. This condition should be
considered possible whenever the placenta is implanted over a previous uterine scar,
especially if associated with placenta previa.
All patients with placenta previa should be informed of the risk of severe PPH,
including the possible need for transfusion and hysterectomy. Blood may distend the
uterus and prevent effective contraction.
Finally, retained blood may cause uterine distention and prevent effective
contraction.

TRAUMA
Damage to the genital tract may occur spontaneously or through manipulations
used to deliver the baby. Cesarean delivery results in twice the average blood loss of
vaginal delivery. Incisions in the poorly contractile lower segment heal well but are more
reliant on suturing, vasospasm, and clotting for hemostatsis.
Uterine rapture is most common in patients with previous cesarean delivery
scars. Any uterus that has undergone a procedure resulting in a total or thick partial
disruption of the uterine wall should be considered at risk of rupture in a future
pregnancy.This admonition includes fibroidectomy; uteroplasty for congenital
abnormality; cervical ectopic resection; and perforation of the uterus during D&C,
biopsy, hysteroscopy, laparoscopy, or intrauterine contraceptive device placement.
Trauma may occur following very prolonged or vigorous labor, especially if the
patient has relative or absolute cephalopelvic disproportion and the uterus has been
stimulated with oxytocin or prostaglandins. Trauma may also occur following
extrauterine and intrauterine manipulation of the fetus. Finally, trauma may result
secondary to attempt to remove a retained placenta manually or with instrumentation.
Cervical laceration is most commonly associated with forceps delivery, mothers
have often been unable to resist bearing down before full cervical dilatation, and manual
exploration or instrumentation of the uterus may result in cervical damage.
Vaginal sidewall laceration is also most commonly associated with operative
vaginal delivery, but it may occur spontaneously, especially if fetal hand presents with
the head. Lacerations may occur during manipulations to resolve shoulder dystocia.
Lower vaginal trauma occurs either spontaneously or because of episiotomy.
Spontaneous lacerations usually involve the posterior fourchete; however, trauma to the
periurethral and clitorial region may occur and can be problematic.

THROMBOSIS
The failure of the blood to clot is such an obvious sign that it can be overlooked
in the midst of the frantic activity that accompanies torrential bleeding. It can occur
following severe pre-eclampsia, antepartum hemorrhage, amniotic fluid embolus,
intrauterine death or sepsis. Fresh blood is usually the best treatment as this will contain
platelets and the coagulation factors V and VIII. The expert advice of a hematologist will
be needed in assessing specific replacement products such as fresh frozen plasma and
fibrinogen.

C. PATHOPHYSIOLOGY:

Over the course of pregnancy, maternal blood volume increases by


approximately 50% (from 4L to 6L). The plasma volume increases somewhat more than
the total RBC volume, leading to a fall in the hemoglobin concentration and hematocrit
value. The increase blood volume serves to fulfill the perfusion demands the low
resistance uteroplacental unit and to provide a reserve for the blood loss that occurs at
delivery.
At term, the estimated blood flow to the uterus is 500-800ml/minute, which
constitute 10-15% of cardiac output. Most of the flow traverses the low resistance
placental bed. The uterine blood vessels that supply the placental site traverse a weave of
myometrial fibers. As these fibers contract following delivery, myometrial retraction
shortened length following each successive contraction. The blood vessels are
compressed and kinked by this crisscross latticework, and, normally, blood flow is
quickly occluded. The arrangement of muscle bundles has been referred to as
“physiologic sutures” of the uterus (Baskett, 1999).
Uterine atony, is failure of the myometrial fibers to contract and retract. The
uterus must remain in a contracted state after birth to allow the vessels at the placental
site to seal. This is the most important cause of PPH and usually occurs immediately
following the delivery of the baby, up to 4 hours after delivery.
Patient actual pathophysiology:

POSTPARTUM HEMORRHAGE

Prolonged and difficult labor


Labor augmented with oxytocin

Myometrium failed to contract and retract

Failure to compress torn blood vessels

UTERINE ATONY

HEMORRHAGE

Boggy Uterus
Bright red blood
Decrease BP
Tachycardia
Pallor
Palpitations

COMPENSATED
D. PREDISPOSING FACTORS OF POSTPARTUM HEMORRHAGE

The factors that predisposed Mrs. X to cause uterine atony are the labor that is
augmented with oxytocin and the labor that is prolonged and difficult. The patient is
nuliparous, so, she doesn’t know how to bear down.

E. SIGNS AND SYMPTOMS

Blood Volume Blood Pressure Signs and Degree of Shock


Loss (systolic) Symptoms

500-1000 Normal Palpitations, compensated


(10-15%) tachycardia,
dizziness
1000-1500ml Slight fall (80- Weakness, Mild
(15-25%) 100mmHG) tachycardia,
sweating
1500-2000ml Moderate fall (70- Restlessness, pallor, Moderate
(25-35%) 80mmHg) oliguria

2000-3000ml Marked fall(from50- Collapse, air Severe


(35-50%) 70mmHg) hunger, anuria

Signs and symptoms appeared to Mrs. X aside from having a boggy uterus,
blood that is bright red in color, are tachycardia as evidenced by PR-110, palpitations,
pallor and BO of 90/60mmHg. These symptoms are compensatory mechanisms of the
heart to pump more blood in response to blood loss. Fortunately, the patient was able to
compensate with this situation.

F. TREATMENT

The following is a plan for managing obstetric hemorrhage if therapeutic


management such as fundal massage or bimanual uterine massage is unsuccessful. This
was adopted from Bonner (2002). The word “ORDER” is a useful mnemonic for
remembering the basic outline

ORGANIZATION
1. Call experienced staff (including obstetrician and anesthetist)
2. Alert the blood bank and hematologist.
3. Designate a nurse to record vital signs, uterine output, and fluids and drugs
administrator
4. Place operating room on standby.
RESUSCITATION
1. Administer oxygen by mask.
2. Place 2 large-bore intravenous lines.
3. Take blood, cross match of 6 U PRBC’S, and obtain a CBC count, coagulation
factor level, creatinine value and electrolyte status.
4. Begin immediate fluid replacement with NS or Ringer lactate solution.
5. Transfuse with PRBCs as available and appropriate.

DEFECTIVE BLOOD COAGULATION


1. Order coagulation screen (International Normalized Ratio, activated partial
thromboplastine time) fibrinogen, thrombin time,blood film, and D-dimer results
are abnormal.
2. Give FFP if coagulation test results are abnormal and sites are oozing.
3. Give cryoprecipitate if abnormal coagulation test results are not corrected with
FFP bleeding continues.
4. Give platelet concentrates if the platelet count is less than 50x10 to the 9/L and
bleeding
5. Use cryoprecipitate and platelet concentrate before surgical intervention.

EVALUATE RESPONSE
1. Monitor pulse, blood pressure, blood gas status, and acid-base status, and consider
monitoring of central venous pressure
2. Measure urine output using indwelling catheter.
3. Order regular CBC counts and coagulation tests to guide blood component
therapy

REMEDY THE CAUSE OF BLEEDING


1. If antepartum, deliver fetus and placenta.
2. If postpartum, use oxytocin, prostaglandin, or ergonovine.
3. Explore and empty the uterine cavity, and consider uterine packing.
4. Examine the cervix and vagina, ligate any bleeding vessels, and repair trauma.
5. Consider arterial embolization.
6. Ligate uterine blood supply (ie, uterine, ovarian,and/or internal iliac arteries).
7. Consider hysterectomy.

V. PATIENT AND HER CARE

A. Medical Management
1. Intravenous Fluid, Blood Transfusion, Oxygen Therapy

Medical Date Ordered/ General Indications/ Client’s Response


Management/ Date Description Purpose to the Treatment
Treatment Performed

Feb.19, 2008/
Feb. 20, 2008 Isotonic This was indicatede
Solution – have to the patient as an
Intravenous
Feb21, 200* the same access for
Fluid
concentration as medications and to
D5LRS 1L x 31- No allergic reaction
blood and restore vascular
32 gtts/min
plasma. Used to volumes since she
restore vascular will undergo
volumes. surgery

Nursing Responsibilities
Determine what type of IVF to infuse.
Always check for IV patency.
Check for IVF’s proper regulation.
Check for fluids to follow.

Feb.19, 2008 4 “u” FWB To replace blood


- RBC and loss during the
plasma. WBC surgery and to
and platelet not prevent
Blood viable after 24 hypovolemia. No allergic reaction
Transfusion hrs. As a compensation
to maintain
adequate supply of
hemoglobin in the
body.

Nursing Responsibilities
Determine what blood products to infuse in the Doctor’s Order sheet.
Check for vital signs of the client before, 15 mins. after starting BT and after BT.
Monitor BT regulation strictly.
Monitor patient for any allergic reactions.
Stop BT if untoward reactions happen such as fever, rashes, etc.
Maintain a KVO regulation for the IVF.

As an assistive way
to help clients with The patient
compromised accepted the
Feb. 19, 200 2-3 LPM via oxygen status. treatment and was
Oxygen Therapy relieved from DOB.
In the OR nasal cannula
For patients with No allergic
breathing and reactions.
airway problems.
Nursing Responsibilities
Determine the amount of oxygen to be given in Doctor’s Order sheet.
Check for the patency of the cannula to be used.
Maintain regulated amount of oxygen given to patient.
Humidify the oxygen to be given to patient.
Observe precautionary measures while giving the therapy like avoiding smoking, preventing static
electricity/ removing combustible and igniting materials.
Indwelling To prevent bladder No allergic
Feb.19,, 2008 Indwelling
Foley Catheter distention and reaction.
Date Removed: Catheter, French
injury during
Feb 21, 2008 18
surgery

Nursing Responsibilities:
Determine Doctor’s order for the insertion of the catheter.
Explain the procedure and the purpose of IFC insertion to the client.
Prepare all the necessary equipments.
Maintain the sterility of the catheter and apply KY gel to lubricate catheter before insertion.
Insert the catheter with the dominant hand while opening the labia with less dominant hand.
Inject 5-10 cc of NSS to keep the catheter anchored, observe for backflow of urine.
Monitor the amount of urine in the urine bag.

2. PHARMACOTHERAPY

Client’s
Generic Name/
Date Ordered/ Route/ Action/ Response the
Brand
Date Dosage/ Mechanism of Medication with
Name/Stock/
Performed Frequency Action Actual Side
Indication
Effects
Causes potent and
Oxytocin/syntocinon
selective
Injecton:10units/ml/ 1amp
stimulation of
indicated to the Feb 19, 2008 incorporate to No reactions.
uterine and
patient to induced IV.
mammary gland
labor.
smooth muscle

Nursing Responsibilities
monitor and record patient’s uterine contractions since it has to be titrated every 15 minutes.
monitor vital signs since it can increase blood pressure.
do not give oxytocin via IV bolus injection. It must be administered by infusion

Bisacodyl/ Feb.21 2008 1 suppository Laxative No reactions.


Dulcolax, Biscolax per rectum Stimulate laxative
To help the patient that increases
in passing out flatus, peristalsis,
probably by direct
to soften stools to effect on smooth
prevent straining. muscle of the
intestine.

Nursing Responsibilities
Before giving for constipation, determine whether patient has adequate
fluid intake, exercise and diet.
Tell patient about dietary sources of bulk including cereals, fresh fruit and
vegetables.
Tell patient to take drug with full glass of water.

CefazolinSodium/
MAXCEP Anti-infective/
Antibiotic
Second generation
Feb.19, 2008
Cefalexine/ 1.gram, IV, q6/ cephalosporin that
indicated to patient Feb. 20, 2008 mg, IV, q6 inhibits cell-wall No reactions.
to prevent infections Feb22,2008 500mg tid. synthesis,
and eventually promoting osmotic
speeding up wound instability; usually
healing. bactericidal.

Nursing Responsibilities
Ask the patient if he is allergic to penicillins or cephlosporins.
Perform skin test prior administering the first dose.
Instruct patient to report adverse reactions promptly.
If a large dose is given, monitor for signs of superinfection.
Tell client to take oral forms with food.
Use cautiously in breast-feeding women and in patients with history of
colitis or renal insufficiency.
If the patient has difficulty in swallowing, crush tablet forms.
Advise lactating mothers not to breast feed.
Methylegonovine
Feb19,2008
maleate/ mathergine Increases motor
0.2mg/ml injection/ activity of the
1ml IV/ uterus No reactions.
indicated to patient uterus by direct
to stimulate uterine stimulation
contractions.

Nursing Responsibilities
Contraindicated for induction of labor, before delivery of placenta; in patients with hypertention and
toxemia.
Monitor and record blood pressure, pulse rate, and uterine response; report sudden change in vital
signs, frequent periods of uterine relaxation, and character and amount of vaginal bleeding.
Use cautiously in sepsis, obliterative vascular disease, and hepatic, renal or cardiac disease.

An amebicide/
antiprotozoals. A
Metronidazole Feb. 19, 2008 direct acting
hydrochloride/ trichomonocide
500mg IV/ q6 No reactions.
Flagyl/ 500mg/vial/ and amebicide
to prevent infection that works at both
intestinal and
extratestinal site

Nursing Responsibilities
Tell patient to avoid alcohol and alcohol containing medications during therapy at least 48 hours
after therapy is completed.
Give oral forms with meals to minimize GI distress.
Tell the patient metallic taste and dark or red-brown urine may occur.
The IV should be administered by slow infusion only. Don’t give IV push.
Do not refrigerate flagyl IV.

Nalbuphine Feb. 19, 2008 10 mg, IV, q4 A narcotic and No reactions.


hydrochloride/ to 6h. for opiod analgesic.
Binds with opiate
receptors in many
sites in the CNS
Nubain/ 10mg/ml/
(brain stem, and
used as a pain
severe pain spinal cord)
reliever to the
altering both
patient
perception and
emotional
response to pain.

Nursing Responsibilities
Contraindicated in patients with hypersensitivity to the drug, emotional instability, history of drug
abuse, head injury, and increase intra cranial pressure.
Use cautiously in hepatic and renal disease. These patients may overreact to customary doses.
Monitor respirations of neonates exposed to the drug during labor.
Monitor circulatory and respiratory status and bladder and bowel function. Hold dose and notify
the doctor if respirations are shallow and rate is below 12 breaths /minute.
Warn the patient to avoid hazardous activities that require alertness until CNS effects of the drugs
are known

An
Tranexamic acid/ antifibrinolytic
Hemostan/ agent used mainly
500mg/5ml IV in the treatment
FEB.19, 2008 500 mg, IV, q8
500mg capsule/ and prophylaxis No reactions.
Feb21, 2008 500mg/tid
indicated to patient of hemorrhage
in order to prevent associated with
hemorrhage. excessive
fibrinolysis.

Nursing Responsibilities
It is contraindicated to patient with active intravenous clotting because of the risk of thrombosis.
Hemorrhage due to DIC should not be treated with anti fibrinolytic compounds unless the condition
is predominantly due to disturbances in fibrinolytic mechanisms.

3 .Diet

Date Ordered/ Client’s Response


General Indications/
Type of Diet Date Started/ &/ or reaction to
Description Purpose
Date Changed the Diet
NPO Feb.19, 2008 Indicated to the No reaction
patient pre and post
op to avoid
vomiting during
surgery and to
prevent aspiration
after surgery and to
avoid abdominal
discomforts.
Sips of water Feb20, 2008/at Pure water Indicated to patient No reaction
4pm to prepare the
stomach for soft
diet and to avoid
abdominal
discomforts

Soft diet Feb.21,2008 Low residue diet To prepare the No reaction


containing very stomach for solid
few uncooked foods.
foods. Is easily
chewed and
digested
DAT if (+) BM Feb.22, 2008 Is ordered when When normal
the client’s intestinal motility
appetite, ability has returned.
to eat, and
tolerance for
certain foods
may change.

Nursing Responsibilities
Determine patient’s diet in the Doctor’s Order sheet.
Instruct client of the appropriate diet.
Enumerate different foods suited for the diet.

4. Activity/ Exercise

Client’s Response
Date Ordered/
Type of General Indications/ &/ or reaction to
Date Started/
Exercise Description Purpose the activity/
Date Changed
exercise
Passive Exercise Feb 19, 2008, Movements with Pre-operative & No reaction
Feb. 22-23, assistance. post-operative
2008 assistance for
patient
Flat on Bed Feb.19, 21, 2008 Person remains To remove effects No reaction
on bed without of spinal
pillow. anesthesia to
prevent spinal
headache and
prevents opening of
the surgical wound.

Nursing Responsibilities
Determine patient’s type of exercise in the Doctor’s Order sheet.
FOB: do not use pillows
Passive ROM: assist client in every activity to prevent him/her from falls.
Assist client in stretching- flexing and extending of extremities. Advice client to dangle feet when
sitting on bed.

B. Surgical Management

Alter native

names
Vaginal hysterectomy; abdominal hysterectomy; Laparoscopic hysterectomy;
Supracervical hysterectomy; Radical hysterectomy; Removal of the uterus

Definition

A hysterectomy is a surgical removal of the uterus, resulting in the inability to become


pregnant (sterility). It may be done through the abdomen or the vagina.

Description
Hysterectomy is an operation that is commonly performed. There are many reasons a
woman may need a hysterectomy. However, there are non-surgical approaches to treat
many of these conditions. Talk to your doctor about non-surgical treatments to try first,
especially if the recommendation for a hysterectomy is for a cause other than cancer.
During a hysterectomy, the uterus may be completely or partially removed. The fallopian
tubes and ovaries may also be removed. A partial (or supracervical) hysterectomy is
removal of just the upper portion of the uterus, leaving the cervix intact.
A total hysterectomy is removal of the entire uterus and the cervix. A radical
hysterectomy is the removal of the uterus, the tissue on both sides of the cervix
(parametrium), and the upper part of the vagina.
A hysterectomy may be done through an abdominal incision (abdominal hysterectomy), a
vaginal incision (vaginal hysterectomy), or through laparoscopic incisions (small
incisions on the abdomen -- laparoscopic hysterectomy).
Your physician will help you decide which type of hysterectomy is most appropriate for
you, depending on your medical history and the reason for your surgery.

Indications

Hysterectomy was indicated to the patient to control bleeding and eventually preventing
other complications like hypovolemia and shock
II. NURSING CARE PLAN (PATIENT-BASED)
2nd Priority: Risk for Infection
NURSING
NURSING SCIENTIFIC RATIONALE EVALUATIO
CUES OBJECTIVE INTERVENTIO
DIAGNOSIS EXPLANATION S N
NS

Subjective Risk for infection Risk for infection is the After 4 hours of • Determine • To be able The patient shows

cues: related to condition wherein the NPI and patient’s level to know where understanding and

(-) presence of person looses his body interventions, of the nurse will appreciation to
incisional defenses that makes patient will be understanding start his health the health
woundsecondary him susceptible/ aware of the of the problem teachings. teachings given.
Objective
to limited making him at risk for possible and establish • To have a
cues:
knowledge different infections and interventions that rapport. baseline data
• Weakness
regarding proper diseases. In the case of could minimize • Assess the and know the
noted
patient and get manifestations
wound care. a one day post-op her risk of having
• Limited
initial vital of the
patient, the primary infection brought
range of
signs. problem.
defense of the body by her condition.
motion
• Aseptic
which is the skin was
• Irritable • Provide techniques
broken allowing
and health teachings help minimize
microorganisms to
restless regarding the
enter in the body and
• Pallor aseptic contamination
cause infections and
• With techniques of the wound
diseases.
intact applicable to by
Manifestations of
dressing. wound care. microorganis
impending infection
• Demonstrate ms.
include elevation of
WBC primarily the proper way of • Betadine is
lymphocytes and fever. cleaning a known
surgical wound. antiseptic that
Use of betadine helps reduce
is advised. microorganis
• Encourage ms.
the use of clean • The
and sterile dressing is a
dressing and good place for
changing it microorganis
regularly or as ms to live.
prescribed. Changing it
• Encourage regularly
proper way of prevents it
hand washing. from
contamination.
• Encourage • Hand
patient to washing is the
maintain good best way to
personal prevent the
hygiene like spread of
doing bed bath infection.
regularly and • Good
oral care. personal
• Encourage hygiene
client to wear removes
clean and loose microorganis
clothes. ms in the
body.
• Promote
comfort • Clean and
measures such loose clothes
as changing of facilitate
linens. aeration of the
wound thus
• Encourage to promoting
have fewer faster healing.
visitors/ • Clean
minimize linens reduce
interaction with the
other people. microorganis
ms in the
• Monitor vital environment.
signs • This
frequently. reduces the
microorganis

• Encourage m that the

client to eat and patient could

drink prescribed get from

diet that is others and

nutritious and promote good

balance. These rest.


include CHON- • To know if
rich, CHO-rich there are
and Vit.-rich deviations
foods like from the
chicken/fish normal range.
and fruits & • Nutritious
vegetables. and balance
• Advise client meals provide
to drink sufficient
medications and energy to
supplements client and
prescribed by good
the physician resistance to
religiously. the body.

• Medicatio
ns and
supplement
help prevent
complications
of the disease
and promote
cure and
recovery to
patient.
1st Priority: Pain
SCIENTIFIC
NURSING NURSING EVALUATIO
CUES EXPLANATIO OBJECTIVE RATIONALES
DIAGNOSIS INTERVENTIONS N
N

Subjective Acute Pain Pain is an After 3 hours of • Perform • Pain is a The patient

cues: related to tissue unpleasant sensory nursing comprehensive subjective verbalizes a

“Masakit ya injury secondary and emotional intervention, the assessment of pain experience and decrease in pain
to surgical experience that is patient will to include location, must be scale of below
ing meopera
intervention. normally associated verbalize characteristic, described by the 5/10, grimaces are
ku.”
with injury to body decrease level onset, duration, client in order to diminished and
tissues. The basic of pain. quality, intensity, plan effective achieved
Objective
treatment.
cues: elements of pain are and its tolerance to

• With the sensory precipitating activity.


limited impulses generated factor.
mobility • Relaxations
by injury-sensitive
techniques help
• Facial receptors in the • Encourage use
grimace reduce skeletal
nervous system. of relaxation
noted muscle tension,
These sense organs, technique such as
• With which will
called nociceptors, focused breathing.
guarding reduce the
behavior convert mechanical,
intensity of pain.
thermal, or
• Irritable
and chemical • Monitor vital
• Personal
restless stimulations that signs. assess
factors can
• Weakness injure or threaten influence pain
noted tissues into • Create a quiet,
impulses that are nondisruptive and pain
• Pain scale transmitted along environment. tolerance.
above
8/10 peripheral nerves to
the spinal cord, and • Administer
from there to higher analgesic as • Comfortable

brain centers. ordered. and quiet


atmosphere
promote a relax
feeling and
permit the client
to focus on the
relaxation
• Provide technique rather
socialization as than external
diversional activity. distraction.

• Keeping the
• Administer pain client busy will
medication as reduce the pain

order. sensation.
Socialization is
a means to
divert the
attention of the
client.
• To alleviate
or if not, reduce
the pain
experience.
SCIENTIFIC
NURSING NURSING RATIONALE EVALUATIO
CUES EXPLANATIO OBJECTIVE
DIAGNOSIS INTERVENTIONS S N
N

Subjective Disturbed Disturbed Sleeping After 4 hours of • Determine • To be able The patient will

cues: Sleeping Pattern Pattern is the NPI and patient’s level of to know where have periods of

“ Eku related to pain condition wherein interventions, understanding of the nurse will rests because of
secondary to the person cannot patient can the problem and start his health the reduction of
making
parenting role. achieve adequate achieve rest establish rapport. teachings. pain and
Mipatudtud”
rest due to different periods due to • Assess the • To have a disruptions in the
Objective
disruptions that reduction of patient and get baseline data environment.
cues:
could be physical pain and initial vital signs. and know the
• Weaknes
(pain), as in the disruptions in • Promote manifestations
s noted
conducive of the
case of my patient. the
• Drowsine
environment for problem.
psychological environment.
ss
sleep such as:
(anxiety),
observed
• Keeping • A
environmental
• Droopy a well-fixed bed. well fixed
(poor
eyes bed reduces
environmental
• Frequent • Keeping the strain
conditions), etc.
yawning a quiet that the
Manifestations are
noted environment by patient
seen during the day
• Limited lowering voice feels.
and theses include
range of during interaction • Le
drowsiness, lack of
motion • Keeping ss
energy, frequent interaction
• Irritable a well-ventilated
yawning, etc. reduces the
and environment by
opening windows, strain that
restless
the patient
• Pallor
• Encourage feels.
• With dry
VII. TEACHING PLAN: CARE OF THE SURGICAL WOUND (CESAREAN SECTION)

I. LEARNER: A POST CESAREAN WOMAN WITH SURGICAL WOUND

II.LEARNING OBJECTIVES: Upon completion of the instructional session, the client will:

1. C-1 Describe signs and symptoms of wound infection.


2. P-2 Identify equipment needed for wound care.
3. P-3 Demonstrate wound cleansing and bandaging.
4. A-4 Describe appropriate action if questions or complications arise.
5. A-5 Identify date and time of follow-up appointment for suture removal

B. CONTENT OUTLINE
I. Wound infection including signs and symptoms
II. Identification of wound care equipment
III. Demonstration of wound cleansing and bandaging on the patient’s wound
IV. Resources available for patient’s questions including health clinic, emergency
department.
V. Follow-up treatment plan; where and when

C. TEACHING METHOD/STRATEGY
1. Lecture/explain
2. Lecture/identify/show/practice
3. Demonstrate/ act out the steps and techniques
4. Lecture/explain
5. Lecture/ when, where/ time of follow-up treatment

D INSTRUCTIONAL MATERIAL
1. Handout
2. Betadine solution, cotton buds, bactroban ointment, sterile gauze, surgical tape.
3. Handout
4. Handout
5. Written instruction

E. EVALUATIVE TOOL
1. Oral questioning
2. Return Demonstration
3. Return demonstration
4. Oral questioning
5. Oral questioning
III. INSTRUCTIONAL PROCEDURE
1. Statement of the objective of teaching surgical wound care
2. Presentation of the subject matter
3. Demonstration of cleansing and dressing wound
4. Facilitate asking questions
5. Evaluation
D. PROCEDURE

TEACHER’S ACTIVITY PATIENT’S ACTIVITY

-Have you been informed of your operation this - Yes, before I signed the consent
afternoon?

-Where you told on what to expect of you after the -Yes, I was told to lie flat on my
operation? back for 6 hours and do deep
breathing, coughing and turning
after 6 hours.
- What else? -I just want to ask about my wound,
What will I expect to my wound and
how can I prevent infection just in
case?
- Wound infection will slow the healing of your -How will I prevent that? What is
wound. Signs and symptoms include wound is the proper way of handling my
warm to touch, malallignment of wound edges and wound?
purulent drainage. Other signs of infection include
fever and malaise.

- That’s my job. I will show you on how to - why do we have to do this


assemble the equipment and the steps and
techniques on proper wound cleansing and
dressing so that you will be doing this on your own - it’s really a value then
when you go home. With this you will minimize
your possible risk of acquiring infection - (patient listen attentively)

- Now I will show you on how to assemble the


equipment and show the steps and techniques on
proper wound cleansing and dressing.
These are the materials: -Now I understand, I will also asked
1.Betadine solution my husband to watch, listen and if
2. Cotton buds he could assist you so that he may
3. Bactroban ointment know how to do this when we get
4. Sterile gauze home.
5. Surgical tape
6. Clean scissor
The steps:
Wash hands before and after cleansing the wound.
Use antiseptic such as alcohol before touching the
wound.
Use cotton balls with betadine in cleaning the
wound from the wound in an outward direction to
avoid transferring of microorganisms/ bacteria
Use cotton buds to apply bactroban ointment to
the wound from top to bottom.
Use sterile gauze to cover the wound. Be sure that
the wound is covered entirely with the sterile
dressing.
Place surgical tape to secure the dressing and in
the opposite direction from the body action.

- What else do you want to know? -My wound is quite big. Is there
possibilities that I will have
complications?
-Yes there are possible complications of operative
wound. Aside from infection, it also bleeds and it
may open. If not cared well. Well, all you have to
do when bleeding occurs is that you must apply
pressure dressing to the wound and go to the
nearest hospital. If it opens, the wound should be
quickly supported by large sterile dressing soaked
in sterile saline. Notify the doctor then go to the
hospital.

- Anyway I will provide you a written instruction - What will I do just in case
on how to handle such cases and I will also give
you the phone number of the hospital so that you
can call immediately.
- Here is your schedule for your follow up -Okay I really appreciate that.
treatment. Go back here on Feb. 23, 2008 at 10am Thanks a lot.
at Rosario Memorial Hospital building 2 room
201.
- Thank you very much also. But before I will end -Thank you very much. This is
our session. Is it okay with you if I will ask you really a big help.
few questions?
-What are again the signs and symptoms of wound
infection? - Yes of course.

-What is the purpose of wound cleansing and - fever, the wound will have
dressing? purulent discharge and it may be
warm to touch.
- Before you leave tomorrow, will it be possible if - to prevent wound infection and
you and your husband will demonstrate to me possible complications.
wound cleansing and dressing? But of course I - Oh yes of course. That would be
will be there to guide and supervise you. great!
- on feb. 23 at 10 am here in the
- Okay, When is your Check-up? hospital at 2nd floor room201.

-Okay then. So thank you very much. I know you - Yes. Thank you very much.
really understood what I’ve thought you. That
ends our session.
- Have a good day!
- okay!

CONCLUSION

Understanding one’s disease is the best way for us to have the best knowledge
and health teachings that we could give to our patient. It is through this case study
that we realized that presence of an infirmity affects the totality of one person. One
might face/accept it very well but others might not. It is our duty as health care
providers to take the initiative to find and provide for possible explanations/ support
that our clients need.
As for this case- Post partum hemorrhage, the pathophysiology of the disease
is the main key to have better understanding of the disease process itself. With this,
risk factors are modified; possible preventions are given and proper treatments and
cure are provided.
It is recommended that:
• Thorough assessment including health histories of the patient must
be done to identify the etiology and manifestations of the problem.
• Reading of various literatures about the disease will provide
additional information of the problem.
• Collaboration with other health care providers such us the attending
physician and other therapist help to gain better understanding of the
disease.
• Health teachings are to be provided to patients in a less technical
way/ or in a simple way that they can understand. It is well appreciated by
the patient if visual presentations/ pamphlets are to be given for them to
read.
• The best way for the nurse to be efficient in his/her care to client is
to gain the trust of the patient and make his/her presence be felt always by
the patient in times he/she needs it.
III. BIBLIOGRAPHY/ REFERENCES

Books

1. Maternal and Child Health Nursing: Care of the Childbearing


and Childrearing Fmily volume 1 5th edition. By Adele Pilliteri
2. Foundation of Maternal- Newborn Nursing 4th edition. By
Sharon Smith Murray, Emily Stone Mc Kinney
3. Maternal and Child Nursing Care 2nd edition. By Marcia L.
London, Patricia W. Ladewig, Jane W. Ball, Ruth Bindler.
4. Progress in Obstetric and Gynecology. Edited by John Studd,
Seang Lin Tan, Frank D. Chervenak
5. Fundamentals of Nursing, Concepts, Process, and Practice
updated 5th edition By Barbara Kozier, Glenora Erb, Kathleenn
Blais, Judith M. Wilkinson
6. Physiology and Anatomy 9th edition by. Esther m. Greisheimer,
Mary P. Weideman
7. Nurse’s Drug Handbook 2004. vol 1 and 2, by Wilson et. Al.

Electronic Media

file://F:\eMedicine-Postpartum Hemorrhage article by John R. Smith, Md, FRSC,FAC


file://F:\the Reproductive system.htm
file://F:\Postpartum Hemorrhage.htm
file://F:\women’s health Advisor 2005_Severe Postpartum Bleeding
MicrosoftEncarta 2006
HOLY ANGEL UNIVERSITY
ANGELES CITY

MASTER OF ARTS IN NURSING


NURSING CONCEPT 1
ADVANCE MATERNAL AND CHILD HEALTH CARE

A CASE STUDY ON
POSTPARTUM HEMORRHAGE

SUBMITTED BY:

CATHERINE P. LANSANG

SUBMITTED TO:

MRS. ELIEZER DIZON