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Awareness in
Understanding Maternal
Death: A Case Study of JBB
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NCM 109 RLE CLINICAL
Saturday 1:00 – 2:00; 4:00 – 8:00
February 6-13-20, 2021
Submitted by:
REGALA, BIANCA YSABELLE M.
BSN II – B
Group 3
Ong, Myra
Clinical Instructor
 Awareness in
=

Understanding
Maternal Death:
A Case Study
of JBB

NCM 109 RLE CLINICAL

Saturday 1:00 – 2:00; 4:00 – 8:00
February 6-13-20, 2021

Submitted by:
REGALA, BIANCA YSABELLE M.
BSN II – B
Group 3

Ong, Myra
Clinical Instructor
 ABSTRACT

Patients with maternal death was unaware of the risks of postpartum bleeding

thus retained placenta can cause their death. The Philippine government routinely

compiles data related to maternal health and maternal health care services including

maternal deaths, birth delivery by attendance and by place, and pre-natal and post-

partum care.

This case study illustrates a mother who suffered from a retained placenta and

died because of hypovolemic shock secondary to severe anemia. This case study is

intended for nursing students who wants to know more about the retained placenta and

how to avoid it. My sample Nursing Care Plan provides knowledge for the other nursing

students and might be use as reference in the future.

The study is a part of a larger research project and a single case was selected

for presentation in this article because it differed from the rest of the data in

understanding maternal death. The case presented was given by our clinical instructor

at Mabini Colleges, Inc. and it is a concrete example of a maternal death. We suggest

that nurses should pay more attention to a mother who is just gave birth to a baby

because different complication may occur during the postpartum of the mother.
 ACKNOWLEDGEMENT

The student would like to thank their clinical instructors, friends and families that helped

the researchers for doing their study.

The student would like to express her special thanks and gratitude to Mrs. Myra Ong for

handling and advising in NCM 109 Related Learning Experience Clinical and for her support to

the case study since from the start.

Her sincere thanks to the, friends, family, relatives and love ones for their shared

support, either morally and financially throughout the study.

Last and furthermost, to Almighty God, the author of knowledge and wisdom, for whom

the student dedicate this case study to help His greatest creation to have a better future.

Thank you very much!

Bianca Ysabelle M. Regala

INTRODUCTION
The retained placenta is a significant cause of maternal mortality and morbidity

throughout the developing world.

The table shows the causes of maternal death in the Philippines in the year
2000, 2005, 2009 and in 2013. Postpartum hemorrhage placed third with 13.9 % of
mortality.

The body typically expels the placenta within 30 minutes of delivery. However, if
the placenta or parts of the placenta remain in your womb for more than 30 minutes
after childbirth, it’s considered a retained placenta. When it’s left untreated, a retained
placenta can cause life-threatening complications for the mother, including infection and
excessive blood loss. Retained placenta can be broadly divided into: failed separation of
the placenta from the uterine lining; placenta separated from the uterine lining but
retained within the uterus.

A retained placenta is commonly a cause of postpartum haemorrhage, both

primary and secondary. Retained placenta is generally defined as a placenta that has
not undergone placental expulsion within 30 minutes of the baby’s birth where the third
stage of labor has been managed actively.

There are three types of retained placenta: Placenta adherens is the most
common type of retained placenta. It occurs when the uterus, or womb, fails to contract
enough to expel the placenta. Instead, the placenta remains loosely attached to the
uterine wall. A trapped placenta occurs when the placenta detaches from the uterus
but doesn’t leave the body. This often occurs because the cervix starts to close before
the placenta is removed, causing the placenta to become trapped behind it. Placenta
accreta causes the placenta to attach to the muscular layer of the uterine wall rather
than the uterine lining. This often makes delivery more difficult and causes severe
bleeding. If the bleeding can’t be stopped, blood transfusions or a hysterectomy may be
required.

SIGNS AND SYMPTOMS

The most obvious sign of a retained placenta is a failure of all or part of the
placenta to leave the body within an hour after delivery. When the placenta remains in
the body, women often experience symptoms the day after delivery. Symptoms of a
retained placenta the day after delivery can include: a fever; a foul-smelling discharge
from the vagina that contains large pieces of tissue; heavy bleeding that persists; and
severe pain that persists.

MANAGEMENT

Manual removal of the placenta carries significant risk of hemorrhage and

infection plus the risks associated with general anesthesia, if used. Transporting the
patient from home or birthing center to hospital or from birthing room to delivery room or
operating room is also disruptive to the patient and the initial parent-infant attachment
process. The injection of oxytocin into the umbilical vein is a safe procedure that can
cause placental separation and delivery, thus preventing the need for manual removal
for some women. This technique can be useful in a nurse-midwifery practice in the
management of a retained placenta or prolonged third stage of labor.

Drugs, such as intraumbilical or intravenous oxytocin, are often used in the

management of placental retention. It is useful ensuring the bladder is empty. However,
ergometrine should not be given as it causes tonic uterine contractions which may delay
placental expulsion. Controlled cord traction has been recommended as a second
alternative after more than 30 minutes have passed after stimulation of uterine
contractions, provided the uterus is contracted. Manual extraction may be required if
cord traction also fails, or if heavy ongoing bleeding occurs. There is currently
uncertainty about the effectiveness of anaesthesia or analgesia for manual extraction, in
terms of pain and the risk of postpartum haemorrhage. Very rarely a curettage is
necessary to ensure that no remnants of the placenta remain (in rare conditions with
very adherent placenta such as a placenta accreta).

However, in birth centers and attended home birth environments, it is common

for licensed care providers to wait for the placenta's birth up to 2 hours in some
instances.
Admission: The patient was palor
October 3, 2013, 3:40 pm Vital signs were taken
IV fluid were administered (not specified)
Medications were given (not specified)
Blood was drawn for CBC and Blood typing
Foley catheter was inserted
Plasma expander was infused as fast drip
During the operaion Spinal anesthesia was induced
Extraction of the placenta was performed
Vital signs were monitored
BP = 100/50 mmHg
HR = 130 bpm
RR = 22 cpm
Oxygen Saturation = 98%.
After the operation Blood pressure were decreased 60/40 mmHg
Intubated
Emergency medications were given (Not specified)
Continuous ambubagging
Transfusion of 2 units of bloods
Laboratory test were performed (BUN, creatinine, sodium,
potassium).
Blood pressure increased to 130/80 mmHg
Transferred to the ward
OB Ward Ongoing blood transfusion
Intravenous fluids hooked on both arms
Intubated
Foley catheter attached to a urine bag
Apneic, with her pupils dilated.
Cardiopulmonary resuscitation was initiated
Administration of emergency medications were done.
Approximately 5 minutes after initiation of resuscitation, JBB
was pronounced dead by the physician-on-duty.
 ASSESSMENT DIAGNOSIS PLANNIN INTERVENTION RATIONALE EVALUATION
G
 Deficit fluid
Objective Data  After 8 hours Pre-operative Care  After 8 hours of
volume
of nursing Independent: nursing intervention
related to
intervention the patient was
Palor excessive
the patient unable to normalize
blood loss.  Assess and  To know the actual
will normalize her blood volume and
document the blood blood loss and to
her blood show unstable vital
loss determine the
V/S taken as volume, show sign. She was
appropriate
follows: improvement announced dead 3
treatment needed by
in her fluid October 2013 at 11:45
the patient.
balance as pm due to retained
BP: 80/60mmHg evidenced by placenta, hypovolemic
HR: 71 bpm a good shock secondary to
 Review the records
capillary refill  This will help in severe anemia.
RR: 12 cpm and note certain
and stable determining the
conditions such as
vital signs. management of the
retained placental
situation thus
fragments, any
preventing further
laceration, abruptio
complications.
placenta, etc.
  Increased heart rate,

 Monitor the Vital low blood pressure,

cyanosis, delayed
Signs and check for
capillary refill
capillary refill.
indicates
hypovolemia and
impending shock.
Decrease fluid
volume of 30-50%
will reflect changes
in the blood
pressure.

 To help expel clots of

blood and it is also
 Massage the
used to check the
uterus.
tone of the uterus
and ensure that it is
clamping down to
prevent excessive
bleeding.
  Encourages venous
return to facilitate
circulation, and
prevent further
 Place the mother in bleeding.
Trendelenberg
position.

 Promotes relaxation
and may enhance
patient’s coping
 Provide comfort abilities by

measure like back refocusing attention.

rubs, deep
breathing. Instruct
in relaxation or
visualization
exercises.
 This is important for
rapid or multiple
Collaborative:
infusions of fluids or
 blood products to
increase circulating
 Start 1 or 2 IV
volume and enhance
infusion(s) of
clotting. Note: Each
isotonic or
unit of whole blood
electrolyte fluids
increases the
with an 18-gauge
hematocrit level by
catheter or via a
three percentage
central venous line.
points.
Administer fresh
whole blood or
other blood
products (e.g.,
platelet
concentrate,
plasma,  To promote

cryoprecipitate) as contraction and

indicated prevents further

bleeding.

 Administer
medication as
indicated (e.g
Pitocin, Methergin)
Post Operative Care

Independent:
 To rule out for shock.

 Monitor the vital

signs (pulse, blood
pressure,
respiration) every
30 minutes for the
next 6 hours or until  To ensure that the
stable.  uterus remains
contracted.
 Palpate the uterine
fundus.
 To determine if the
amount discharged
is still within the
 Check for normal limits.
excessive lochia.
Collaborative:
 To maintain the

 Continue infusion patient’s hydration,

electrolyte and blood
of IV fluids as
sugar level.
indicated.

 To replace the blood

that is lost through
 Transfuse blood surgery and the

as indicated. patient’s bleeding.

 Drug Action Indication Contraindication Nursing Responsibilities
Generic Mechanism of - hypersensitive
Name:Oxytocin action:
-Initiation or to drug when vaginal  Continuously monitor

improvement of delivery is advised contractions, fetal and maternal

Brand Name: By direct action on
uterine contractions to heart rate, and maternal blood
Pitocin, myofibrils, - cephalopelvic
achieve early vaginal pressure and ECG.
Syntocinon produces phasic disproportion is present
delivery for maternal  Discontinue infusion if uterine
contractions -when delivery
or fetal reasons (IV) hyperactivity occurs.
Classification: characteristic of requires conversion as  Monitor patient extremely
Uterine-active normal delivery. -as adjunctive
in transverse. closely during first and second
agents Promotes milk therapy in the
stages of labor because of risk
Dosage: ejection (letdown) management of
of cervical laceration, uterine
10 units/ml in 1ml reflex in nursing inevitable or
rupture and maternal and fetal
ampule, mother, thereby incomplete abortion
death.
increasing flow (not (IV)
 Assess fluid intake and output.
volume) of milk; -stimulation of
Route: Watch for signs and symptoms
also facilitates flow uterine contractions
IV/IM of water intoxication.
of milk during during third stage of
period of breast labor (IV)
engorgement.
-control of
Uterine sensitivity
postpartum bleeding
to oxytocin
or hemorrhage (IV,
increases during
gestation period IM)
and peaks sharply
before parturition.
Not used for
elective induction of
labor.

Adverse
Reactions:
CV:

Hypertension,
increased heart
rate, systemic
venous return,
cardiac output

GI: Nausea,
vomiting

RESPIRATORY:

Anoxia, asphyxia

OTHERS:
Low APGAR
score at 5 mins
CONCLUSION

Based from the case study, the student concluded the following:

1. The retained placenta was still a problem of the postpartum mothers, which in the

low risk setting usually it occur without any prior warning.

2. Minimizing the risk of obtaining retained placenta is very important so the

postpartum mothers will no longer suffer from the postpartum hemorrhage and so

that we can minimize the risks of the postpartum mothers.

3. Support of the family is also needed for faster recovery of the mother.

RECOMMENDATIONS

Based on the case study and conclusions, the student recommended the

following:

1. Nurses who will hold a case similar to this case should specified the medications

administered, it should be properly documented.

2. Document every action to be taken.

3. Results of Laboratory test should be documented too.

4. Give some awareness about what is the risks of postpartum haemorrhage to all

the mothers who will give birth to their child.

5. Postpartum hemorrhage can be a frightening experience for patients. It is

important to provide reassurance and communicate through each step of

emergency care.

6. Make patients aware of what to anticipate through their clinical course including

expected procedures; transport; and the indication, risks, and benefits of

interventions.

7. Health education for the patients.

REFERENCES

Belleza (2017). Postpartum Hemorrhage retrieved online last 11 th day of February 2021
at 8:36pm https://blog.thesullivangroup.com/standardized-patient-education-
postpartum-warning-signs

Nursing Crib (2009). Nursing Care Plan Postpartum Hemorrhage retrieved online last
11th day of February 2021 at 9:34pm
https://www.scribd.com/doc/11847492/NursingCrib-com-Nursing-Care-Plan-
Postpartum-Hemorrhage

Farina (2014) Manual Removal of the Placenta after Vaginal Delivery: An Unsolved
Problem in Obstetrics retrieved online last 12th day of February 7:09pm
https://www.hindawi.com/journals/jp/2014/274651/

Weeks (2001) The Retained Placenta retrieved online last 12 th day of February 8:29pm
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704447/#:~:text=The%20retained
%20placenta%20is%20a,nearly%2010%25%20in%20rural%20areas.