Postpartum Care: A Case Study

Initial Assessment and Care Instructions for Mrs. P

Case Study
Mrs. P is a 28-year-old female, G1 P1 T1 A0 L1 who is being transferred from the labour room to the postpartum unit.  The labour room nurse reports that Mrs. P had spontaneous rupture of membranes and onset of contractions at home at 38 weeks gestation.  Mrs P had an uneventful spontaneous vaginal delivery of a 3760 g boy 3 hours ago.  She had baby to the breast within 10 minutes after delivery for a total of 20 minutes.  VS have been stable with moderate lochial flow and passage of two clots.   Uterine fundus is 1 cm below the umbilicus, occasionally boggy and firms with massage.  
Initial assessment on arrival to postpartum unit three hours post-delivery:  Alert, T 37.6 °C, P 84, RR 20, SaO2 98% on room air, BP 110/70.  Fundus firm at the level of the umbilicus and midline, lochia moderate rubra, breasts soft, episiotomy stitches intact with moderate swelling to perineum and ice pack applied.  She last voided 45 min ago while in the shower.  She is cuddling her newborn, gazing at him and visiting with her relatives.
Mrs. P had an uneventful pregnancy other than hyperemesis gravidarum during the first trimester.  Past medical history includes mild asthma, which she controls with inhalers.  She denies previous surgery and is a non-smoker.    
1. What 5 instructions will you provide to Mrs. P following your initial assessment?
2. Describe the characteristics of lochia 3 hours post-delivery.
3. Describe the frequency and reason for the ongoing assessments for Mrs P .
Six hours post-delivery, you find Mrs. P sitting up in bed holding her newborn.  She requests a new ice pack for her perineum.  When you return with the ice pack you observe her peri pad is completely saturated and she has also saturated approximately one-third of the soaker pad that was under her buttocks.  There are three visible clots in the blood on the soaker pad.
4. What four assessments would be appropriate at this time?
5. What are your priority interventions related to Mrs. P?
6. How can the nurse accurately estimate blood loss?

Mrs. P’s current VS are TPR 37.6 °C – 104- 22. SaO2 95% on R/A. BP 100/64. The physician is notified and provides the following orders: 
?Oxytocin 40 units/1000 mL
?NS at 150 mL/hr
?Monitor VS, fundus and flow q15 min
7. What is the purpose of the oxytocin infusion?
8. What other information would be important to assess relate to the infusion?

After another hour, Mrs. P’s latest assessment reveals:  Alert, anxious, pale, diaphoretic, T 37.8 °C, P 112,  RR 26, SaO2 91% on room air, BP 90/58.  Lochial flow heavy rubra, fundus 2 cm above the umbilicus, deviated to right and boggy which firms with massage.  After notifying the charge nurse and physician, you receive the following orders:
?Ringers Lactate 1Litre bolus STAT
?Continue oxytocin infusion 40 units/1000 mL NS at 150 mL/hr
?Labs:CBC, Type and cross-match STAT
?Insert a Foley catheter to urometer 
?In/out Q1h
?Oxygen to keep sats > 95%
9. Why might Mrs P’s oxygen saturation be falling?
10. How does inserting a urinary catheter help with postpartum hemorrhage?