CASE STUDY

1. Mary Blackhawk was having heavy vaginal bleeding at 4

hours after birth. Because she was sleeping, however,
she was totally unaware of it. What action on your part
would have prevented so much blood loss?

- After birth, standard care requires frequent

measurement of vital signs and fundal massage to
check the location and condition of the uterine
fundus. Most hospitals and birthing centers require
that the registered nurse perform these checks at
least every 15 minutes for the first postpartum hour.
Thereafter, the frequency of assessment varies from
one institution to another. As the primary caregiver
and the one completing these assessments, the
registered nurse may be the first person to identify
excessive blood loss. When identified, immediate
actions are necessary. While another member of the
team calls the physician or nurse midwife, the nurse
can obtain some important assessment data.

Always be sure to turn a woman on her side when

inspecting for blood loss, to be certain that a large
amount of blood is not pooling undetected beneath
her. Palpate a woman’s fundus at frequent intervals
post-partally to be certain that her uterus is
remaining in a state of contraction.

This is the best measure for preventing early

hemorrhage. When palpating a uterine fundus, if you
 are unsure whether you have located it, the uterus is
probably in a state of relaxation. Under normal
circumstances, a well-contracted uterus is firm and
easily recognized because it feels like no other
abdominal organ. Frequent assessments of lochia
(to be certain that the amount of the flow is under a
saturated pad per hour, and that any clots are
small), as well as
vital signs, particularly pulse and blood pressure, are
equally important.
What action would be most appropriate now?
- In the event of uterine atony, the first step in
controlling hemorrhage is to attempt fundal massage to
encourage con traction. Unless the uterus is extremely lacking
intone, this procedure is usually effective in causing
contraction, and, after a few seconds, the uterus assumes its
healthy, grapefruit-like feel.
-If fundal massage doesn’t work in stopping uterine
bleeding, the woman’s physician or nurse-midwife may
attempt bimanual compression.
-Prostaglandin administration. Prostaglandins
promote strong, sustained uterine contractions. Intramuscular
injection of prostaglandin is another way to initiate uterine
contractions. Observe for nausea, diarrhea, tachycardia, and
hypertension, all of which are possible adverse effects of
prostaglandin administration.

-Blood transfusion. To replace blood

loss with post partal hemorrhage may be necessary.

2. Eight hours after birth, Mary Blackhawk tells you that she
has frequency and burning on urination. She had a
urinary tract infection during pregnancy, so she
recognizes the symptoms. She has some medicine left
from pregnancy and tells you that she will take it to cure
the infection. What advice would you give her?

- If an antibiotic contraindicated by breastfeeding is

prescribed, check with a woman’s physician about
possibly changing the antibiotic to one that is safe for
breastfeeding. Otherwise, once she is home, the woman
may decide to breastfeed and not take the prescribed
antibiotic.

-I will encourage Mary Blackhawk to drink large amounts

of fluid (a glass every hour) to help flush the infection
from her bladder. She may need an oral analgesic, such
as acetaminophen (Tylenol), to reduce the pain of
urination for the next few times she voids until the
antibiotic begins to have an effect and the burning
sensation disappears. Otherwise, because
voiding is painful, she may not drink the fluid you
suggest, knowing that it will increase the number of times
she needs to void.

- Although symptoms of urinary tract infection decrease

quickly, I should remind Mary so that understands the
importance of continuing to take the prescribed antibiotic
for the full 5 to 7 days to eradicate the infection
completely.