I.

Introduction

The action of the uterus during labor is directed not only towards expelling the baby but
also towards closing down the blood vessels afterwards. Normally the placenta is expelled within
30 minutes of the birth of the baby, and uterine contractions continue so that bleeding soon
stops.(1)
In the case of uterine atony, the myometrium at the placental site fails to contract and
retract and to compress torn blood vessels and control blood loss by a living ligature action.
When the placenta is attached, the volume of blood flow at the placental site is approximately
500 – 800 ml/min. Upon separation, the efficient contraction and retraction of uterine muscle
will staunch the flow and prevent a hemorrhage, which can otherwise ensue with horrifying
speed. (2)
According to a Journal of Pregnancy, Postpartum hemorrhage (PPH) is an important
cause of maternal mortality (MM) around the world. 70% of the PPH corresponds to uterine
atony. (3) Globally, uterine atony is one of the top 5 causes of maternal mortality. (4)
Uterine atony as the cause of primary postpartum hemorrhage is increasing in the United
(5)
States and other countries such as Canada and Australia. In the United States, the absence of
effective contraction of the uterus after delivery complicates 1 in 40 births and is responsible for
(6)
at least 75% of cases of postpartum hemorrhage. The rate of PPH in the United States has
increased from 2.3% in 1994 to 2.9% in 2006. This 26% increase primarily was the result of an
(7)
increase in uterine atony. Further, in developing countries like Malaysia, uterine atony
contributed 37.5% to the 67.7% of PPH associated mortality from 1994-2005. (8)
In the Philippines, according to DOH Region XI (2013), uterine atony is one of the
causes of complications of labor and delivery. (see Figure 1 p. 3)
Risk factors for uterine atony include high maternal parity, chorioamnionitis, prolonged
use of oxytocin, general anesthesia, and conditions that cause increased distention of the uterus
(9)
such as multiple gestation, polyhydramnios, fetal macrosomia, and uterine fibroids.
Additionally, advanced maternal age, prior hemorrhage and prolonged labor have also been cited
as risk factors. (10)
High parity may be a risk factor for uterine atony. Fuchs and colleagues (1985) described
outcomes of nearly 5800 women para 7 or greater. They reported that the 2.7% incidence of

1
postpartum hemorrhage was increased in fourfold compared with that of the general obstetrical
population. Babinzki and colleagues (1999) reported the incidence of postpartum hemorrhage to
be 0.3% in women of low parity, but it was 1.9% in those para 4 or greater. (11)
Another risk factor is advanced maternal age. As a woman ages so is the aging of the
uterus, that is why in one hypothesis of a study it says that with increasing age, the myometrium
is less effective or less responsive to uterotonic agents such as oxytocin or prostaglandins. (12)
Therefore, our patient, being in an advanced maternal age (38 years old) with
grandmultiparity (9 vaginal births) is potentially at risk for uterine atony.

2
 Figure 1

MATERNAL MORTALITY LEADING CAUSES

NUMBER AND RATE PER 100, 000 LIVEBIRTHS
2013
REGION XI, PHILIPPINES

CAUSES 2013 5-YEAR AVERAGE

NUMBER RATE NUMBER RATE

1.Complication of labor & delivery (060- 49 50 49 50

075)*
2.Oedema, Proteinuria & hypertensive 39 40 27 27
disorder in Preg. (010-016)**
3. Other obstetric conditions, not elsewhere 11 11 4 4
classified (095-099)
4. Maternal care related to the fetus & 9 9 6 6
amniotic (030-048)****
5. Complications predominantly related to 5 5 7 7
puerperium (085-084)*****
6. Pregnancy with abortive outcome ( 000- 2 2 8 8
008)***
7.Other maternal disorders predominantly 2 2 1 1
relate to pregnancy (020-
*Includes postpartum hemorrhage, ruptured
uterus, hemorrhage secondary to retained
placenta, uterine atony
**Includes hypertensive disorders, toxemia of
pregnancy, eclampsia
***Includes ectopic pregnancy, all forms of
abortion
*****Includes prolapsed uterus, abruption
placenta, placenta previa and other placental
disorder
*****Includes postpartum sepsis,
complications related to puerperal sepsis
Source: DOH – XI – RHIS & Special Report
2013 livebirth = 98, 715
Average livebirth 2012 – 2008 = 98, 240
http://www.ro11.doh.gov.ph/pdf/maternalmortality.pdf

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II. Objectives

After completing our case study, we will be able to:

 Identify personal and clinical data of our patiently correctly
 Obtain a complete assessment of our patient
 Review the anatomy and physiology of the organ/s involved in uterine atony
 Trace a brief Pathophysiology of uterine atony related to our patient
 Interpret significant laboratory findings in relation to uterine atony
 Discuss the different drugs involved in the study
 Formulate health care plans regarding our case
 Provide discharge planning appropriate for our patient

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II. Patient’s Profile
Biological Data
Name: Patient X
Age: 38 years old
Sex: Female
Address: Purok 19 Malinan Toril District, Catigan, Davao City
Civil Status: Widowed
Nationality: Filipino
Religion: Catholic
Birth date: July 20, 1980
Birth place: Jose Abad Santos, Davao Occidental
Occupation: Housewife
Date of Admission: September 30, 2018

Chief Complaint: labour pains

Last Menstrual Period: December 23, 2017
Age of Gestation: 40 1/7 weeks age of gestation
Expected Date of Confinement: September 30, 2018

Obstetrical History
Age of Menarche: 12 years old, regular, monthly, within 3 – 4 days, ( – ) dysmenorrhea
Obstetrical Score: G1: 1996, NSVD, Term, Maternity Clinic, Female
G2: 1999, NSVD, Term, Home Delivery, Male
G3: 2000, NSVD, Term, Home Delivery, Male
G4: 2004, NSVD, Term, Home Delivery, Male
G5: 2007, NSVD, Term, Home Delivery, Male
G6: 2010, NSVD, Term, Home Delivery, Female
G7: 2013, NSVD, Term, Maternity Clinic, Male
G8: 2015, NSVD, Term, Home Delivery, Female
G9: 2018, NSVD, Term, SMPC, Male

5
Medical Diagnosis: G9P9 (9009) Pregnancy Uterine Delivered a Livebirth Cephalic Baby Boy
by Normal Spontaneous Vaginal Delivery; Grandmultiparity; Gestational
Hypertension

6
III. Medical History
Present History of Medical Condition and Medications
The patient’s previous 8 pregnancies were delivered normally either in a maternity clinic
or home delivery by a midwife as declared by the patient. She had not experienced any
complication that is why most of her children were delivered at home. As far as she can recall,
she was given antibiotics and multivitamins as home medications. But on her latest pregnancy,
because of her history of elevated BP during the first trimester and her advanced maternal age,
her health care provider at Toril Birthing Clinic advised that she transfer to SPMC for the
delivery of her 9th baby. Thus, admitted for labour pains.

Past Medical Condition, Surgery and Medication Management

Patient has had chicken pox, measles and mumps during her childhood. She had no
history of hospitalization or any form of surgery. As per recall by the patient, she had only taken
mefenamic acid for pain and paracetamol when she has fever.

Family Medical History

Paternal side: (+) hypertension
Maternal side: none
Eldest Sibling: (+) hypertension

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IV. Anatomy and Physiology of the Reproductive System (internal genitalia)

The female reproductive system has both external and internal components. The external
components (vulva) include the following: mons pubis, labia majora, labia minora, clitoris,
vestibule, prepuce, clitoris, urethra, vaginal opening, perineum and anus. The internal
components, on the other hand, consist of the following:
a. Ovaries – approximately 4cm long by 2cm in diameter and approximately 1.5cm thick, or
the size of an almond; located close to and on both sides of the uterus in the lower
abdomen; its function is to produce mature, and discharge oocytes; they also produce
hormones estrogen and progesterone which play active roles during menstrual cycle,
pregnancy and development of secondary characteristics
b. Uterine tubes – also known as salpinges, oviducts; arise from each upper corner of the
uterine body and extend outward and backward until each opens at its distal end, next to
an ovary; approximately 10cm long in a mature woman; function to convey the ovum
from the ovaries to the uterus and to provide a place for fertilization of the ovum by
sperm.
c. Uterus – a hollow, muscular, pear – shaped organ located in the lower pelvis, posterior to
the bladder and anterior to the rectum; with maturity, a uterus is approximately 5 – 7cm
long, 5cm wide, 2.5cm deep, weighs 60g in nonpregnant state; after pregnancy, the uterus
never returns to its nonpregnant size but remains approximately 9cm long, 6cm wide,
3cm thick and 80g in weight; functions to receive the ovum from the fallopian tube,
provide a place for implantation and nourishment, furnish protection to a growing fetus
and at maturity of the fetus, expel it from a woman’s body

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 3 layers of uterus:
 Endometrium – the layer that is important for menstrual function; it grows and
become so thick and responsive each month under the influence of estrogen and
progesterone that is capable of supporting a pregnancy, if pregnancy does not
occur, this is the layer that is shed as the menstrual flow
 Myometrium – is the muscle layer of the uterus which is composed of three
interwoven layers of smooth muscle, the fibers of which are arranged in
longitudinal, transverse, and oblique directions; it constricts the tubal junctions
and prevents regurgitation of menstrual blood into the tubes; also, it holds the
internal cervical os closed during pregnancy to prevent a preterm birth; after
childbirth, the interlacing network of fibers is able to constrict the blood vessels
coursing through the layers, thereby limiting the loss of blood in the woman

 Perimetrium – serves the purpose of adding strength and support to the structure
d. Cervix – connects the uterus to the vagina; the lower most part of the uterus that is made
up of strong muscles; its allows flow of menstrual blood from the uterus into the vagina
and direct the sperms into the uterus during intercourse; remains close until the birth
process so that the baby will not be aborted; prevents entry of infection
e. Vagina – an elastic, muscular canal with a soft, flexible lining that provides lubrication
and sensation; it receives the penis during sexual intercourse and also serves as a conduit
for menstrual flow from the uterus; during childbirth, the baby passes through the vagina

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 Physiology of uterine contraction

When labor begins, the cervix is

stretched by the baby

Signals the hypothalamus and

posterior pituitary gland

Stimulates receptors in
Release of hormone oxytocin
the decidua

Travels to the uterus via

bloodstream

Stimulation of prostaglandin
Causes increased myometrial
synthesis
sensitivity to oxytocin

Induce myometrial contractility

Continues to compress, contract and

constrict blood vessels up to the delivery of
the placenta to prevent hemorrhage and
achieve homeostasis

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 Pathophysiology of Uterine Atony

RISK FACTORS

High Maternal Parity Advance Maternal Age

(9 vaginal birth) (>35 years old)

Causes overstretching of the uterus Myometrium becomes old

and formation of scar tissues

Leads to poor elasticity of the Myometrium becomes less

myometrium overtime effective and less responsive to
oxytocin or prostaglandin released
in the course of delivery.

Poor myometrium contractions Myometrium fails to contract,

constrict and compress the spiral
blood vessels in the placental.

UTERINE
ATONY
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12
V. Physical Examination

General Survey:
A 38 year old female, who gave birth to her 9th baby, conscious, awake, oriented to time,
date and location, sitting while breastfeeding her baby, responsive to questions but shows mild
body weakness and poor eye contact during interview through facial expression and body
gestures

Vital Signs:
Temperature - 36.7 deg Celsius
Pulse - 100 bpm
Respiration - 22 cpm
Blood Pressure - 120/80 mmHg

Skin: skin warm to touch, with good skin turgor, nails untrimmed both on the hands and feet;
both skin and nails are slightly pale
Head: normocephalic, face shows symmetry
Hair: hair equally distributed, long brown hair, uncombed
Eyes: anicteric sclera, eyebrows equally distributed, drowsy
Ears: ears symmetrical, without deformities and discharges noted
Nose: no nasal flaring, no deformities, no nasal discharges noted
Mouth: dry lips noted, slightly pale lips, without buccal lesions
Neck: able to flex and extend the neck slowly, no tenderness or swelling noted
Breasts: without retractions, areola very dark brown, both breasts equally produce milk
Chest and Lungs: shows no difficulty breathing, RR – 22 cpm, no productive cough noted
Abdomen: no lesions or inflammation noted, globular in shape; upon palpation, not distended,
well contracted
Extremities: able to sit without difficulty, but stretches legs slowly, able to lift hands
Genito – urinary: voiding freely without burning sensation; with diaper, (+) lochia rubra,
changed diaper once for the 8 – hour shift

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VI. Diagnostic Procedures

A. Complete Blood Count and Blood Chemistry

B. Blood Typing

14
VII. Patient Management

Medical Orders
September 30, 2018
2:25pm
 Please admit under Team A
 Secure consent to care
 IVF: D5LR 1L @ 120cc/hr
 Labs: CBC, HBSag, UA, BT, LDH, SGPT, Crea
 FHT every 5minutes
 Meds:
a. Hydralazine 5mg IVTT PRN for DBP >110
b. Methyldopa 250mg 1 tab every 8 hours
 Monitor intake and output
 Vital signs every hour
 Refer accordingly
 Plan: for NSVD
2:30pm
 Oxytocin 10units IM now
 Carboprost 250mg IM now
 Please incorporate 30units oxytocin to present IVF at 120cc/hr
3:54pm
 Postpartum orders:
a. May transfer to ward 2
b. DAT
c. IVF to consume and discontinue
d. Meds:
 Cefuroxime 500 tab po BID for one week
 MV+FeSO4 tab po OD
 Paracetamol+Tramadol 1 tab po TID

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 e. Vital signs every 15minutes for one hour then every hour for 4hours then every
4hours
f. Keep uterus well contracted
4:00pm
 Discontinue Hydralazine and Methyldopa
 Start Amlodipine 10mg 1 tab PO

Medical Management
A. Intravenous Fluid
 5% Dextrose in Lactated Ringer’s Solution (120cc/hr)
- Is a hypertonic solution to replace extracellular fluid and electrolyte deficits such as
bleeding during delivery of a baby
- Provides modest calories (170kcal) for patients who cannot tolerate feedings or are
not yet allowed to feed orally
- Serves as a medium for administration of intravenous medications

B. Medications
NAME, ACTION INDICATION NURSING CONTRA-
ROUTE, CONSIDERATION INDICATION
DOSAGE
Oxytocin Causes Postpartum -Assess BP and pulse CPD, fetal distress,
10units IM increased bleeding for changes that may prolapsed
uterine indicate hemorrhage umbilical cord,
contractions by - Monitor intake and hypersensitivity
acting on output
myometrial
oxytocin-
receptors
Carboprost Prostaglandins Postpartum - Ask the patient for Severe
250mg IM are potent hemorrhage history of asthma CV/respiratory/
stimulators of caused by before administering renal/hepatic

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 myometrial uterine atony the drug disease, PID,
contractility, not controlled Watch for changes in hypersensitivity
acting via by other BP and pulse that may
cyclic AMP- methods indicate hemorrhage
mediated - Report for increased
calcium blood loss, abdominal
release cramping, increased
temperature and foul-
smelling lochia
Cefuroxime 2nd generation Prevent -Identify allergies Hypersensitivity to
500mg po cephalosporin infection after before use, skin cephalosporins
that inhibits an testing before starting
bacterial cell uncomplicated the medication
wall synthesis, vaginal birth - Emphasize to take
renders cell the drug for 10-14
wall days to ensure
osmotically organism death,
unstable, leads prevent superinfection
to cell death by -Take drug with food
binding to cell for GI symptoms
wall
membrane
MV+FeSO4 Replaces iron Prevent anemia -Advise patient that Thalassemia,
One tab po stores needed from loss of stool will turn black or hemochromatosis
for RBC blood after dark green
development childbirth as -Advise increase OFI
as well as well as meet the if constipation occurs
energy nutrition needs and increase fiber diet
while -To follow a diet rich
breastfeeding in iron including meat,
dark green leafy

17
 vegetables, dried fruits
Tramadol+ Works in the Mild to -Avoid alcohol Hypersensitivity to
Paracetamol brain to change moderate consumption paracetamol
One tab po how the body following -Avoid using if known
feels and delivery of the allergic to
responds to baby paracetamol
pain -Monitor intake and
output for urinary
retention
-Watch out for
respiratory depression
Amlodipine A calcium Management of -Monitor pulse, Hypersensitivity,
10mg po channel postpartum respirations, blood severe obstructive
blocker that hypertension pressure coronary artery
dilates blood -Advise to take the disease
vessels and drug as prescribed,
improves not to double or skip
blood flow dose
-Advise to change
position slowly to
prevent orthostatic
hypotension
Methyldopa Stimulates Hypertension in -Assess BP when Active hepatic
250mg po central pregnancy beginning treatment disease,
inhibitory α- then periodically hypersensitivity
adrenergic afterwards
receptors -Baselines of renal,
resulting in hepatic studies before
reduction of therapy begins
arterial -Discontinue for rash,
pressure fever and pruritus

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 -Not to discontinue
product abruptly
because withdrawal
symptoms may occur
such as increased BP,
headache, nausea
Hydralazine Vasodilates Hypertensive -Monitor BP and Hypersensitivity,
5mg IVTT arteriolar emergency/ pulse mitral valvular
PRN for smooth urgency -Weigh daily, rheumatic disease
DBP > 110 muscle by monitor intake and
direct output, hydration
relaxation status
-Check for presence
of edema in feet and
legs

Surgical Management
No surgical management done to the patient

19