BIODATA OF THE CLIENT:

 Name : Chandani Lodhi

 Age : 30 years
 Sex : Female
 Register no. :34101
 Ward : Postnatal ward
 Cot no : 11
 Admission date : 08/05/2024
 Education : 10th passed
 Occupation : Home maker
 Income :12000/ month
 Address :Kawrdha
 Nationality : Indian
 Marital status : Married
 LMP :01/09/2023
 EDD :10/05/2024
 Obstetrics score : G2P2A0L2 ,
 Diagnosis :Post partum Hamorrhage
 Surgery : No any Surgery in past
PAST HISTORY:

Medical and surgical history

She had no history of TB, hypertension, diabetes mellitus, other medical complains or
surgical history in past.
 She had no history of any surgery in her life.
Past obstetrical history:-

Sr. Year Full Pre Abortion Type of Baby Remarks

no. term term delivery Still
Sex Alive born Weight
Meconium
stained
liquor,
death 2-3
hr. after
1 2013 yes - - NVD+ EPI F No - 2.6 kg delivery

PRESENT OBSTETRICAL HISTORY:

 My patient Chandani Lodhi is second para women and 30years old , on date of
admission morning she is came for routine antenatal examination that time doctors
found that Post partum hemorrhage.
 She was admitted on08/05/2024 in District hospital Kawardha.
 At present she having severe blood loss and atonic uterus.

CHIEF COMPLAIN WITH DURATION:-

 Mrs. Chandani Lodhi having complained pain in lower abdomen.

FAMILY HISTORY:-

Name Age Sex Relationship Education Occupation Income Remark

with patient

Kamlesh Lodhi 34 M Husband 12th Buissness 12000 -

Yrs passed month

Chandani Lodhi 30 F Self 10 passed House wife - -

yrs

Vaishali 06 F Daughter 1st std - - -

yrs
  Except patient, no any family members having disease like T.B, diabetes,
hypertension, heart disease, and asthma.
 There is no history of any blood or psychiatric disorder.

SOCIO ECONOMIC HISTORY:

 Client lives in Nuclear family. She is a housewife & her husband is earning person in
her family. Monthly income are 12000/ month so their economic condition is not very
good.
 Her family members are supportive to her. In the hospital, one member always
remains with client. Her social relations with family members, friends and neighbors
are good and healthy.
 Her social status in her community is good. She participates in all social & family
functions.

MENSTRUAL HISTORY:

 The age of menarche started is 13 years.

 Interval is 28 days. Duration is 4-5 days.
 Before pregnancy, she is having regular menstrual cycle and normal flow.

MARITAL HISTORY

 Age of marriage: She married when she was 20 years old and its consanguineous
marriage.

PRESENT PREGNANCY:-

 Admitted on: 08/07/19 …at 1:00pm

 Height of fund: 33cm
 Presentation: Vertex presentation
 Position: ROA
 Engaged/not engaged/free : Not engaged
 FHR :148 beats / min
HEAD TO TOE EXAMINATION

 Head: No dandruff was present but hairs become rough. Noskull injury or scalp
infection.
 FACE: Face looking anxious by facial expression. Edema is present on face.
 EYES: Eyes were clean, conjunctiva appeared light pink color and sclera appeared
whitish in color. Eyesight of patient was normal. No discharge was present in the
patient‟s eye.
 EAR: Ears were normal in size in shape, hearing was normal, no any discharge was
present in the ear, and both ears were clean.
 NOSE: No septal deviation was there. Curvature of nose appeared normal. No
complication was seen in the patient.
 MOUTH: No cracked lips were present, tongue was appeared pale in color, and
ulcer was not present in the patient‟s mouth. Slight yellow discoloration was seen in
the teeth.
 NECK: No enlargement of the lymph node.
 CHEST: Shape and size of the chest was normal. There was symmetrical movement
of both chests.
 BREAST: Primary andsecondary areolas arePresent. Montego marries tubercles are
prominent. No palpable mass in both breasts. Nipple is retracted.
 ABDOMEN:
- Inspection: lineanigra and strea gravidarum are present on abdomen, abdomen
look ovoid shape, and there is present previous scar marks.
-Fundal Height: 13cm. from symphysis pubis
 BACK: back pain due to labour process
 EXTRIMITIES: Not any abnormality in Extremities. Normal range of motion.
 GENITAL ORGAN:locheadischaregemorethan 500ml

 VITAL SIGNS OF PATIENT :-

Vital signs Patient value Normal value

Temperature 96. 4F 96.8- 97.2 F
Pulse 88 beats / min 80-86 beats/ min
Respiration 20breath/ min 20 breaths/ min
Blood pressure 120/80 mm of Hg 120/ 80 mm of Hg
INVESTIGATION:

Name of investigation Patient value Normal value

Complete blood count

- Hb 7.4 gm % 13 – 15 gm %
- sRBC 3.87million/cumm 4.5 -5.0 million/cumm
- Platelet count 2.72 lakh/ cumm 1.5-4.5 lakh/cumm
Differential count:-
Neutrophils 78% 50- 70%
Lymphocytes 15 % 22-40%
Monocytes 01% 2-6%
Eosinophils 02% 1-6%
Basophils 00 0-2.5%

Blood group B Positive -

HbS Ag Negative Negative
VDRL test Non reactive Non reactive
Abdominal USG Gravid uterus seen
single live intrauterine
fetus with breech
presentation with 27.4
weeks gestation.+mild
oligohydramnios
And amniotic fluid index
10 cm ()
Placenta
locatedposteriourly.
HIV test Non reactive Non reactive
Urine report 04/03/2016
Colour Pale yellow Pale yellow
Odour Aromatic Aromatic
Reaction Acidic (5.5) Slight acidic
Specific gravity 1.029 1.o16-1.026
Urine Albumine Negative Negative
Urine sugar Negative Negative
 POSTPARTUMHAMORRHAGE
DEFINITIO:-
Depending on the primary postpartum bleeding is defined as blood loss in excess of 500ml
following vaginal delivery or 100ml following caesarean section in the 24 hours following
birth.

ETIOLOGY:-
In the book In my patient

Maternal causes

 Tone: uterine atony(70%) Uterine atony is present

 Trauma(20%)
 Retained tissue(10%)
 Coagulopathy(1%)

Pregnancy
 Obesity
 Fever fever
 Heart disease
 Bleeding before delivery

Family history
 Family history of PPH No
CILINICALMANIFESTATION
In Book Picture In my Patient
 Loss of excessive blood Minor
Minor(<1L)
Major (>1L)
Severe(>2L)
 Blood pressure falls 90/60mmHg
 Heart rate Increases
 Red blood count drops
 Swelling and pain around vagina and
Present
constant flow of blood due to
hematoma. Present
 Nausea
 Skin becomes pale

IN MY PATIENT DIAGNOSIS DONE:

LIST OF DIAGNOSIS DONE IN MY PATIENT

 Blood pressure, Proteinuria / yes

urine output
 Serum uric acid / S.
Creatinine/LFT
yes
 HCT & Hb
 Platelet count (life span  to 3-
5 days)
 Coagulation studies. PT, PTT, yes
Fibrinogen,FDP

(platelet count <1,00,000,

D.I.C., Abruptio P.) yes

 Plasma Fibronectin (early

marker)
 Uterine artery doppler flow yes
,resistance to flow
Sterile Speculum Examination 
 MANAGEMENTS:
 Uterine massage is simple first line treatment as it helps the uterus to contract to
reduce bleeding.
 Although the evidence around the effectiveness of uterine massage is in conclusive, it
is common practice after the delivery of the placenta.

Management of PPH invariably involves addressing the causes of bleeding, commonly

known as „the four Ts‟. A fifth „T‟ has been added to emphasise the important role of theatre
and surgery in managing all causes of PPH. There is little randomised control trial (RCT)
evidence to guide the management of PPH. The only Cochrane review on primary PPH
identified only three suitable trials; all concerned the use of misoprostol. There was
inadequate evidence to comment on the utility of surgical, radiological, haemostatic or other
pharmacological interventions.3 Hence most interventions are guided by best practice rather
than high quality evidence.

a. Tone

Uterine atony is the most common cause of primary PPH but clinical assessment should be
used to exclude other causes. The following interventions have all been used to stop the
bleeding, generally in the stepwise progression as presented here. i. Mechanical: • Uterine
massage or bimanual uterine compression (emptying the bladder may assist in this process).
ii. Pharmacological: The following agents are useful in the management of PPH. They are
commonly given in combination and, in the absence of individual contraindications, a patient
may be given all four in the event of severe ongoing atonic bleeding. Because of the
difficulties in undertaking clinical trials in the circumstances of unexpected PPH, the
outcomes of the uterotonics in varying combinations to manage PPH have not been assessed
by sufficiently-powered randomised controlled trials. However, their use is strongly
recommended if the atonic haemorrhage is continuing.

• Oxytocin (Syntocinon) o 5 units by slow intravenous injection (if already administered for
3rd stage management, a repeat dose may be given). o 40 units in an intravenous infusion
over 4 hours • Ergometrine 0.25 mg by slow intravenous or intramuscular injection, repeated
if necessary 5 minutely up to a maximum of 1.0 mg; in the absence of contraindications.

• Misoprostol (up to 1000mcg) rectally. Whilst many studies have studied the use of
misoprostol to manage the third stage of labour, fewer have dealt with using misoprostol to
treat PPH. In the hospital setting, there is evidence to suggest that misoprostol is clinically
equivalent to further oxytocin in women who have already received prophylactic oxytocin
when used for excessive post-partum bleeding due to suspected uterine atony.

• Prostaglandin and its analogues are the most potent of the utero tonics but also have the
most serious adverse effect profile which includes severe hypertension and bronchospasm
(therefore contraindicated where there is a significant history of asthma). In Australia,
following the discontinuation of dinoprost trometamol, alternatives may be accessed through
the TGA Special Access Scheme (SAS). o 15-methyl-PGF2α (carboprost; Prostinfenem)
which may be administered in one of two ways:  Intra-muscular injection of 0.25mg, in
repeated doses as required at intervals of not less than 15 minutes to a maximum total
cumulative dose of 2.0mg (ie up to 8 doses)

Intramyometrial injection of 0.5mg, under the responsibility of the administering clinician as

it is not recommended by the manufacturer for intramyometrial use.

The off-label use of these medications are considered routine for this indication with high
quality evidence to support its use.

b. Trauma of the genital tract.

Thorough assessment of the entire genital tract is essential. The perineum, vagina and cervix
should all be visually inspected for bleeding sources. Pressure should be applied to bleeding
areas and repair attempted, either in the labour ward or the operating theatre if required.

If the patient is shocked and the amount of vaginal bleeding is normal, consider intra-
abdominal sources such as ruptured uterus, broad ligament haematoma, subcapsular liver
rupture, ruptured spleen, and ruptured splenic artery, hepatic artery or pancreatic artery
aneurysm.

c. Tissue (retained products of conception)

This is usually due to retained placenta, cotyledon or membranes. If the placenta has been
delivered assess for obvious missing tissue. If the placenta has not been delivered and cannot
be delivered easily by controlled cord traction, empty the bladder and transfer the patient to
theatre for manual removal of placenta.

Even when the placenta appears complete, there is still the possibility of unrecognised
retention of a cotyledon or segment of a bipartite placenta. Hence, uterine exploration is
indicated for all cases of persistent postpartum haemorrhage.

d. Thrombin(abnormalities of coagulation)

i) Tranexamic Acid The “WOMAN” Trial demonstrated efficacy of the administration of 1g

of tranexamic acid intravenously with a clinical diagnosis of PPH. The dose was repeated
after 30 minutes if bleeding was persistent. The authors concluded that: “Tranexamic acid
reduces death due to bleeding in women with post-partum haemorrhage with no adverse
effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be
given as soon as possible after bleeding onset.”4 Tranexamic acid should only be
administered in the context of overall patient management; the protocol should include strict
attention to the control of bleeding, physiological and metabolic parameters, coagulation
status and temperature maintenance.

ii) Replacement of Platelets and Clotting Factors  Early replacement of clotting factors and
platelets is essential in the management of severe PPH.  “Point of Care” testing has an
increasing role in the assessment of PPH (e.g. ROTEM).6  Particular attention should be
made to the fibrinogen level with replacement (cryoprecipitate or fibrinogen concentrate if
available) where the fibrinogen is < 1.5-2g/L6, 7

iii) Management of specific abnormalities such as Von Willebrand‟s disease or severe

thrombocytopenia is beyond the scope of this guideline.

e. Theatre

Surgical interventions should be initiated sooner rather than later, especially hysterectomy in
cases of uterine rupture, placenta accreta or uncontrolled massive haemorrhage. The
following is a list of some

AVAILABLE PROCEDURES

This should not necessarily be a step-wise progression and both order and utilisation will
depend on the services/ clinical experience available and the individual clinical
circumstances. i. Balloon tamponade. Several case series have been published reporting the
results of using a Foley catheter, Bakri balloon, Rusch balloon or Sengstaken-Blackmore
oesophageal catheter with good results where the uterus is empty and contracting.3
ii.Haemostatic brace suturing (such as the B-Lynch suture). iii. Bilateral ligation of uterine
arteries. iv. Bilateral ligation of internal iliac arteries by an experienced operator. v. Selective
arterial embolisation. This intervention can only be achieved in institutions with timely
access to both radiological expertise and equipment. It is important to note that time delays in
accessing embolisation can occur and should not preclude alternate surgical treatment. vi.
Hysterectomy.

MEDICAL MANAGEMENT

In book Picture In my patient

1.OXYTOCIN
Dose: 10-40 units in1L of crystalloid YES
solution
First line IV second line: IM (10 units)

2.METHARGIN NO
Dose: 0.2 mg
First line IV/IM second line PO
NO
3.15METHYL PGF2α
Dose: 0.25 mg
First line IM second line intra uterine

4.MISOPROSTOL (PGE1) YES

Dose: 600-1000 mcg
First line PR second line P
 Special Consideration
4. Special Consideration
Massage the uterus to make it hard
To add oxytocin 10-20 units in500ml of
normal saline, at the rate of 40 drops per
min
Inj. Methargin 0.2mg IV (slowly)
To examine the expelled placenta
To catheterize the bladder

NURSING DIAGNOSIS:

1. Fluid volume deficit related to uterine atony as evidenced by excessive vaginal

bleeding.
2. Ineffective tissue perfusion related to vaginal bleeding as evidenced by fluctuation of
vital signs.
3. Anxiety / fear related to knowledge deficit regarding procedures, management and
disease condition as evidenced by patient asks many questions about the disease.
4. Risk for infection related to excessive blood loss and exposed placental attachment
site and lacerations.
5. Body weakness related to altered body chemistry (insufficient electrolytes) as
evidenced by inability to maintain usual routines.
Assessment Nursing diagnosis Goal Planning Implementation Evaluation

Subjective data: 1. Fluid volume deficit Prevent -Advise patient to sleep -Advised patient to sleep Mother has feeling
related to uterine dysfunctional with feet higher, while the with feet higher, while the good and fresh.
Verbal complain of bleeding and body remained supine. body remained supine, with
atony as evidenced
mother about dry improve fluid feet higher will increase the
by excessive vaginal
mouth. volume. venous return, and allowing
bleeding.
the blood to brain and other
organs.
Objective data:
-Monitored vital signs when
Facial changes. -monitor vital signs bleeding occurs more
intense.
Mother looks
dehydrated. BP:130/80, P: 72, R: 24

Temp: 98 f

-Monitored intake and

-monitor intake and output of urine.
output every 5-10 minutes

-evaluation of the urinary

bladder. -evaluation of urinary
bladder is done.
-perform urine massage
with one hand and the
other hand placed above
the simpisis.-limitvaginal -Uterine massage done.
and rectal examination.

-Vaginal examination don

 Assessment Nursing diagnosis Goal Planning Implementation Evaluation

Subjective data: 2 Ineffective tissue Mothers vital signs -Monitor vital signs every Monitored the patient blood After 2 days mother‟s
perfusion related to and blood gases 5-10 minutes. pressure, pulse , respiration, vital sign were at
Mother says that I within normal limits. temperature. normal range.
vaginal bleeding as
having fever.
evidenced by
fluctuation of vital -Note the discoloration of
the nail, lip mucosa, gums -Checked mothers nail , lip
signs. mucosa gums , tongue, skin
and tongue, skin
temperature. temperature for
vasoconstriction and
relationship to vital organs,
circulation in peripheral
tissues is reduced, causing
cyanosis and cold skin
temperature.
-Collaboration.
Monitored blood gas level
and pH.

Given oxygen therapy.

-Give Oxygen therapy.
Objective data:

After monitoring
vital signs and
vaginal bleeding I
check for tissue
perfusion.
 Assessment Nursing diagnosis Goal Planning Implementation Evaluation

Subjective data: 3. Anxiety / fear The Mother can  Assess the mothers  Assessed the The patient said
related to verbalize anxiety psychological psychological anxiety is reduced.
Mother says that knowledge deficit and said anxiety is response to the post- response to the child
having fear about regarding reduced or lost. childbirth bleeding. birth bleeding.
excessive bleeding procedures,
management and  Treat the mother  Treated mother calm,
Objective data:
disease condition calm, empathic and empathic and
Patient look very as evidenced by supportive attitude. supportive attitude for
week and anxious patient asks many emotional support.
questions about
the disease.

 Provide information  Provided information

about care and about care and
treatment. treatment.

 Help mother identify  Help mother for she

a sense of anxiety. can reduce feelings of
anxiety.
 Assessment Nursing diagnosis Planning Implementation Evaluation

Subjective data: 4. Risk for infection  Note the changes in  Monitored vital signs. As the five days after
related to excessive vital sign. Temp: 99.06֠ f mother was free from
Mother says having blood loss and Pulse: 82/min infection.
excessive blood loss. exposed placental Resp: 24/min
attachment site and Bp: 130/90 mmHg
Objective data:
lacerations.
Observed for excessive  Note the signs of  Noted the signs of fatigue, chills,
blood loss. fatigue, chills, anorexia, and uterine contractions
anorexia, and uterine were flabby and pelvic pain.
contractions were
flabby and pelvic pain.
 Considered the possibility of
 Consider the infection in other places such as
possibility of infection respiratory infections, mastitis
in other places such as and urinary tract.
respiratory infections,
mastitis and urinary
tract.

 Give antibiotics.
 Given antibiotics.
HEALTH TEACHING:
Given health education regarding:

 Dietary Instruction
 Postnatal care
 Maintaining personal hygiene ,
 Postnatal exercise
 Regular check up and follow up
 Family planning methods

1. Antenatal advise :-
- Advise her to take adequate rest.
- Advise her to drink more water and nutritious diet.
- Advised her to daily pull breast nipple so it helpful for easily breast milk and breast
feeding.
- Advised her to take 8 hrs rest in night and 2 hrs in afternoon.
Advised her to clean and dry pad use for prevent vaginal infection.
2. Dietary Instruction:-
- Advised to eat food containing more iron like drum stick, juggery and green leafy
vegetable.
- Explained for postnatal diet like high calorie and high protein and vitamin reach diet.
- Eat food at regular interval.
3. Maintain hydration status it helpful for increase amniotic fluid volume.
- Advise mother drink coconut water, orange juice and drink more water daily.
4. Maintaining personal hygiene:-
- Advise for daily bath, mouth care hair care.
- Take sits bath.
- Advice her to clean perineal area with soap and water after each urination and
defecation.
5. Regular check up and follow up: - according to doctors orders.
6. postnatal Exercise: Explained and taught about deep breathing kegalexersize
7. Advised her to take all medicine regularly and come for routine checkup according
doctor‟s order.

8. Family planning methods :-

- Advised her to use temporary family planning methods like copper T use after
delivery.
- Advise her conceive pregnancy after 2-3 year it help full for improvement of their
health status.
PROGRESS CHART:-

Day:-1 08/05/2024

My client Chandani Lodhi was admitted in District Hospital kawardha with complains of
Labour pain , she delivered baby with the normal vaginal delivery but there were excessive
bleeding after placental delivery then Diagnosed with the postpartum hemorrhage , High blood
pressure and anxiety.

Management was done by health care team of PPH.

 Done Urine and Blood test for identify the PPH.

 During time of admission his vital sign was :

Patient value Normal value

Vital signs
Temperature 96.4 F 96.8- 97.2 F
Pulse 88 beats / min 80-86 beats/ min
Respiration 20 breath/ min 20 breaths/ min
Blood pressure 160/100 mm of Hg 120/ 80 mm of Hg

Day 2: 09/05/24

Tarabenwas feeling much better on the second day. Her health status was much better.

 Advise to eat more vitamin and iron containing diet.

 Advised her to Take rest.

Vital signs were recorded is.

Vital signs Patient value Normal value
Temperature 97.2 F 96.8- 97.2 F
Pulse 86 beats / min 80-86 beats/ min
Respiration 20 breath/ min 20 breaths/ min
Blood pressure 150/ 100 mm of Hg 120/ 80 mm of Hg
s

 Same medicine was continued on the second day.

Day 3: 10/05/2024

On 3rd day, her health improved much better. She was fully co-operative in all the
procedures.

 Advise her for ambulation.

 The same medications were continued on the third day.
  Following vital sign recorded on 3rd day.

Patient value Normal value

Vital signs
Temperature 97.2 F 96.8- 97.2 F

Pulse 84 beats / min 80-86 beats/ min

Respiration 18breath/ min 20 breaths/ min
Blood pressure 140/ 90 mm of Hg 120/ 80 mm of Hg

 Given health education about personal hygiene and postnatal care.

Summary:

 My Mother has normal vaginal delivery with complain of excessive bleeding.

 She diagnosed as a postpartum hemorrhage.
 During this course postpartum management was done by health care team.
 Massage the uterus to make it hard
 To add oxytocin 10-20 units in500ml of normal saline, at the rate of 40 drops per min
 To examine the expelled placenta
 To catheterize the bladder
 After management mother condition good as much as after 4 days stay in hospital mother
was discharged.

Conclusion:
During my clinical posting in District hospital kawrdha in post natal ward, I got chance to
provide care to, Chandani Lodhi with diagnosis of Normal vaginal dilivaery with
POSTPARTUM HAMMORRAGE by this study I learn in detail about definition, causes
and its management. I thank my client for her cooperation and my clinical coordinator for her
valuable guidance.
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1. BasvanthappaB.T : “TEXT BOOK OF MIDWIFERY AND
REPRODUCTIVE HEALTH NURSING”; fift edition 2019, Jaypee brother
publication, New Delhi.

2. Dutta D.C : “TEXT BOOK OF OBTETRICS” ; 10 TH Edition , 2018;

New central book agency publication, Calcutta.

3. Jacob Anamma : “A COMPREHENSIVE TEXT BOOK OF

MIDWIFEREEY”;1stedition 2020; Jaypee brother medical publication; New
Delhi,

4. Kumari Neelam; (2019); 6st edition; “MIDWIFERY AND

GYNAECOLOGICAL NURSING”; S.vikas and company; Jalandhar city;

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Elsevier publisher, Philadelphia.

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FOR NURSES”; First edition, 2011, Elsevier publisher, Philadelphia.

Internet resources:-

1. https://emedicine.medscape.com/article/275038-treatment
2. https://www.bmj.com/content/358/bmj.j3875
3. https://www.ranzcog.edu.au/.../Postpartum-Haemorrhage,-Management
4. WWW.scribd.com