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Final OB WARD CASE Study docx

Bachelor of science in nursing, cebu normal university.

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A Clinical Case Study Presented to the faculty of the Department of Nursing In Partial Fulfillment Of the requirement of the Subject NCM 101 RLE (OB-Ward)

Normal Spontaneous Delivery

(post-partum).

A normal spontaneous vaginal delivery (SVD) occurs when a pregnant female goes into labor without the use of drugs or techniques to induce labor, and delivers her baby in the normal manner, without forceps, vacuum extraction, or a cesarean section. A vaginal delivery is the recommended method of childbirth for women whose babies have reached full term. However, vaginal deliveries are not recommended for women who have had cesarean deliveries before, or who have infections that can be transferred to their baby through vaginal delivery.

A cesarean delivery is the alternative to a vaginal delivery. Vaginal delivery is the method of childbirth most health experts recommend for women whose babies have reached full term, or at least 37 weeks. Compared to other methods of childbirth, such as a cesarean delivery and induced labor, it’s the simplest kind of delivery process.

A spontaneous vaginal delivery is a vaginal delivery that happens on its own, without requiring doctors to use tools to help pull the baby out. This occurs after a pregnant woman goes through labor, which opens, or dilates, her cervix to at least 10 centimeters.

Labor usually begins with the passing of a woman’s mucous plug. This is a clot of mucous that protects the uterus from bacteria during pregnancy. Soon after, a woman’s water may break. This is also called a rupture of membranes. As labor progresses, strong contractions help push the baby into the birth canal.

The length of the labor process varies from woman to woman. Women giving birth for the first time tend to go through labor for 12 to 24 hours, while women who have previously delivered a child may only go through labor from six to eight hours.

When gestation has completed, it goes through a process called delivery, where the developed fetus is expelled from the mother’s womb. There are two options of delivery: caesarean section and NSVD

A postpartum period or postnatal period is the period beginning immediately after the birth of a child and extending for about six weeks. Less frequently used are the terms puerperium or puerperal period. The World Health Organization (WHO) describes the postnatal period as the most critical and yet the most neglected phase in the lives of mothers and babies; most deaths occur during the postnatal period.[1] It is the time after birth, a time in which the mother's body, including hormone levels and uterus size, returns to a non-pregnant state. Lochia is postpartum vaginal discharge, containing blood, mucus, and uterine tissue.

STAGE 1: It is usually the longest part of labor. It begins with regular uterine contractions and ends with complete cervical dilatation at10 centimeters. This stage is broken down into three (3) phases: the Early phase, where the contractions are usually very light and maybe approximately 20 minutes or more apart from the beginning, gradually becoming closer, possibly up to five minutes apart; the Active phase, where

The labor and birth process is always accompanied by pain. Several options for pain control are available, ranging from intramuscular or intravenous doses of narcotics, such as Meperidine (Demerol), to general anesthesia. Regional nerve blocks, such as a pudendal block or local infiltration of the perineal area can also be used. Further options include epidural blocks and spinal anesthetics.

Maternal, Newborn, and Child Health and Nutrition Situation in the Country

The Department of Health (DOH) is committed to achieve the Millennium Development Goals (MDGs) of reducing child mortality and improving maternal health by 2015. Although significant gains in maternal and child mortality have been realized in the past four decades, pregnancy and childbirth still pose the greatest risk to Filipino women of reproductive age, with 1:120 lifetime risk of dying from maternal causes Maternal deaths account for 14percent of deaths among women of reproductive age. The Maternal Mortality Ratio (MMR) in the country remains high and decreased very slowly at 162/100,000 live births (LB) in 2006 from 209/100,000 LB in 1990 Although the Under-Five Mortality Rate (UFMR) and Infant Mortality Rate (IMR) have considerably declined (UFMR from 61/1,000 LB in 1990 to 32/1,000 LB in 2008; IMR 42percent in 1990 to 26percent in 2006)3 , the rates of decline have decelerated over the last ten years. The deceleration is driven largely by the high neonatal deaths and slow decline of infant deaths Neonatal Mortality Rate (NMR) is still high, with 17 infants dying per 1,000 LB within the first 28 days of life. In 2000-2003, newborn deaths accounted for 37 percent of all Under- 5 mortalities neonatal deaths occur within the first week after birth, half of which occur in the first two days of life. With the slow decline in MMR for the past two decades and the loss of momentum in rate of decrease in newborn, infant, and child deaths, the Philippines is at risk of not attaining its MDG targets of lowering maternal deaths to 52/100,000 LB and child deaths to 20/1,000 LB in the next five years.

This case were given to us, to have a broader knowledge regarding the Postpartum care for Normal spontaneous vaginal delivery case which we are handling. By this, we are able to discover its process, how it is being managed, the physiology and clinical manifestations, which are being, experience by our patient. By doing so, we are able to fructify our knowledge, enabling us to know the appropriate nursing care for our patient. This study will help us as a student nurse to comprehend not only the procedure and management mentioned but also for the commonalities and differences among other cases for the betterment of this study.

General Objective

This group case study aimed to broaden our knowledge as a student nurse for Normal Spontaneous Vaginal Delivery by obtaining sufficient information, which could serve as a guide for us to enhance our skills and attitudes in the application of nursing process and management of Post-partum care for Normal Spontaneous Delivery patient.

Specific Objective

 To know the client’s personal data, family profile, past health history, current health history, and physical assessment using 13 areas of assessment.  To review the anatomy and physiology of the female reproductive system and the changes after the delivery.  To correlate the results of the diagnostic procedures to its normal values.  To formulate the drug study of normal spontaneous delivery.  To develop an effective nursing care plan in which the client may benefit.  To formulate a post-partum discharge plan for the continuity of care.

II. Nursing process

A. assessment, 1. personal data:.

NAME: Patient X

CASE NUMBER: 327255 DATE OF BIRTH: December 11, 1994 PLACE OF BIRTH: Tarlac City ADDRESS: Aquino Street, Ligtasan, Tarlac City AGE: 21 yrs. old STATUS: Married RELIGION: Roman Catholic DATE ADMITTED: November 8, 2016 5:46 am CHIEF COMPLAINT: Watery vaginal discharge for 12 hours, Labor pain FINAL DIAGNOSIS: G 1 P1, Pregnancy uterine delivered spontaneously to a term cephalic live baby by APGAR score: 8. Baby’s weight 2 kg Environmental Status: She lived in an urban area wherein pollution is very common. They live in a concrete house with 6 occupants. In her hospitalization, she felt some discomfort because of the setting, two person sharing in a single bed. According to her, the room is too crowded for

3. History of past illness

Patient X experienced some common colds before she got pregnant. She has no allergy to any medications or foods. She completed her pre-natal check-ups and she is regularly taking her ferrous sulfate supplement. During her 7 months of conception, she experienced UTI and she immediately went to her doctor and gave her cefalexin. She completed the prescribed dose and she felt better on the following days. She has a regular menstruation, and she also experienced dysmenorrhea. She has no history of bleeding and any discomfort on her pregnancy until she begun to labor and delivered her first baby.

4. Present health history

Few hours prior to admission patient X had watery vaginal discharge for 12 hours. She was admitted with a chief complaint of labor pain with watery vaginal discharge. Her second stage of labor lasted for 20 minutes and the third stage lasted for 5 minutes. At 8:27 am she delivered an alive baby boy via Normal spontaneous delivery. She had to undergo episiotomy to widen the opening of her vagina (primigravida) with 200cc blood loss based on her chart. After the post-natal and early post- partum care in the delivery room, she was transferred to OB- service ward via stretcher. She was conscious and had no complications throughout the delivery.

5. 13 AREAS OF ASSESSMENT

####### 1 STATUS

Mrs. S is 21 years old, born on December 11, 1994 at Tarlac City. She resides at Aquino St. Ligtasan Tarlac City together with her husband and their family. They are Roman Catholic. Mr. S her husband is 23 years old and working at the canteen. Their savings supported the hospitalization of Mrs. S. Mrs. S became lazy during her conception. However, before she works at the canteen together with her husband. They planned for having a baby. Mrs. S admitted on November 8,2016 at 5:46:28 AM (G1P1). NORMS:

Social status includes family relationships that state the patient’s support system in time of stress and in time of need. It meets a fundamental human need for social ties, making life less stressful and social support buffers the negative effects of stress, thus indicating indirectly contributing to good health outcomes.(Fundamentals of nursing, Barbara Kozier,s eventh edition)

ANALYSIS: Because they were extended family, Mrs. S has a good relationship with her family. Mrs. S and his husband have a savings to sustain the hospitalization of Mrs. S yet it’s not enough.

####### II STATUS

Mrs. S is oriented in time, place and person. She can identify things and answers the questions being asked. She can recall recent and remote memories she experienced. She is able to read and write and she can speak different language like kapampangan, tagalog and English. She is very responsive and collaborative.

####### NORMS:

The patient should be oriented to time, place, can identify past and recent memories and should be able to verbalized concrete messages. The patient’s ability to read and write should match her educational level. The patient should be able to respond to questions and identify all the objects presented to him. The patient should be able to evaluate and act appropriately in situation.

(source: estez health assessment and physical examination third edition.) ANALYSIS:

The patient was able to evaluate and act appropriately in situations requiring her judgment.

####### III STATUS

Mrs. S is cooperative while performing the interview. As stated by her husband they are very happy for having their first baby. She also states her feelings about the delivery she felt mad first on herself in the delivery room for not being compliant to the proper pushing of the baby that cause her to undergo episiotomy. But when she saw her baby she begun to felt self-worth because she is now a mother a and she has a responsibility to deal with.

NORMS: Young adult is a time of separation and independence from the family and a new commitments, responsibilities and accountability in social, work, and home relationships and roles.(Health Assessment and Physical Examination, Mary Ellen Zator Estez)

ANALYSIS: Mrs is aware regarding her condition. According to them, they are both willing to bear a child that is why they are very happy to have blessings. Erickson’s industry vs. inferiority reflects on Mrs. S experienced because she learns self-worth as she gains mastery of psychosocial and physiological changes.

####### IV STATUS

Mrs. S has a clear vision no history of eye checkups. Her hearing ability is normal using whisper test with the distance of two feet away. Her sense of smell is normal and she can distinguish foul from fresh odor. Her lips is pink in color and she can taste whatever food she eats. She feels pain “Kumikirot” as stated according to the pain scale rate of 10/10 during the delivery but subsides to 6/10 afterwards. NORMS:

The normal visual acuity is 20/20 as considered normal. The eyes must be symmetrical during the six cardinal gazes test. The sclera should be white with some small blood vessels. Papillary constriction should occur when struck by light. The skin contains receptors for pain, touch, pressure and temperature. Sensory signals are transmitted along rapid sensory pathways, and less distinct signals such as pressure of localized touch are sent via slower sensory pathways. Nose must be symmetrical and align of the face. Each nostril must be patent and recognize the smell of an object. (Health Assessment and Physical Examination, Mary Ellen Zator Estez.) ANALYSIS:

Her sensory transmission functions as well as manifested by the data presented is normal. 12 Cranial Nerves are functioning well but in minimal movement due to pain.

A normal respiratory rate ranges from 12-20 cpm. (Kozier,Fundamentals of Nursing 7th edition)

ANALYSIS: Mrs. S had a normal breath sounds via auscultation no abnormal sounds noted .Mrs. S respiratory rate is in normal range. Elevated at 10am to 24bpm due to transfer from delivery room.

####### VIII STATUS

The circulatory status of Mrs. S as well as the blood pressure noted below:

Date Time Blood pressure Pulse rate Analysis 11/08/16 6:00am 110/70 85 Normal

7:00am 10/70 86 Normal 10:00am 100/80 82 Normal

During the assessment of her capillary refill, it returned to its original color after 2 seconds. NORMS:

The normal cardiac rate or pulse rate is 60-100 bpm. The average blood pressure of a healthy adult is 120/80 mmHg. The normal capillary refill test is 2-3 seconds and upon capillary refill test was done it returns to normal state within 2-3 seconds. (Kozier, Fundamentals of Nursing 7th edition) ANALYSIS:

The data given above shows that Mrs. S pulse rate is in normal range. She also had a normal blood pressure. Her capillary refill is normal.

####### IX STATUS

Mrs. S is able to recognized nutritious food but unable to utilized some of it. She eats 3 times a day with some interval of snacks. Her husband bought her fruits during her pregnancy. She weighs 48 kg. before she got pregnant and gained 4kilos when she got pregnant. She eats variety of vegetables but mostly meats during lunch. She has no allergy to foods.

According to the Health Asian Diet Pyramid ,there should be a daily intake of rice, grains, bread, fruit and vegetables: optional daily for fish, shellfish, and dairy products: weekly for sweets, eggs, and poultry and monthly for meat. There should be an increase intake of a wide variety of fruits and vegetables. Include in the diet foods higher in vitamin C, and E, and omega-3 fatty acids rich foods. (webmd)

####### ANALYSIS:

She has a normal eating pattern.

Mrs. S defecated once during the delivery. She voided once before the delivery, with pinkish color because of blood present in urine. She had a past history of Urinary Tract Infection(UTI). Every time she voids she’s in pain because of the perineal incision.

Normal bowel movement of a person must be 1 to 2 times a day and voiding in 3 to 4 times a day with an output of 1200 to 1500 ml a day. A normal stool is brown in color and well formed, urine is clear to yellowish in color.(Fundamentals of Nursing,Kozier 2007)

Mrs. S had delayed bowel movement due to slow peristalsis movement after the delivery, after 24 hours the patient should demonstrate timely bowel movement.

####### XI STATUS

Some of her reproductive organ is altered especially the external areas (Episiotomy and Episioraphy) but it is considered normal due to the process of delivery. Her menstrual period was regular. She is viable to get pregnant again because there was no birth control procedures noted upon the interview.

NORMS Pregnancy is a normal physiologic process that affect all body systems and results in both subjective and objective changes, it is stressful time requiring many adaptations and may lead to minor discomforts. (Lectures from NCM 101)

Analysis Mrs. S marked the physiologic changes of pregnancy hence, reproductive status is altered but expected to return to normal status after 1 month (approximately)

####### XII OF PHYSICAL REST AND COMFORT:

Mrs. S usually sleep 6-8 hours at night, she stated that sometimes her sleep is interrupted because of the discomfort due to her perinial incision. By the help of her cousin and her husband they simultaneously taking care of the baby as Mrs. S take her rest periods.

Adults average amount of sleep per day is 7 to 8 hours.(Wikipedia)

She consumed the 7 to 8 hours sleep, but the only thing is she felt irritated because of her perineal incision.

 Pelvic Ultrasound Report (Biophysical Profile)

Date: 11/7/ Name: Patient X Age: Pertinent data: 39 weeks by LMP (+) watery vaginal discharge BIOPHYSICAL PARAMETERS No. of Fetus: Singleton Fetal Breathing: 2 Presentation: Cephalic Fetal Movement: 2 Fetal Heart Rate: 142 bpm Fetal Tone: 2 Amniotic Fluid Volume: 7 cm Amniotic Fluid Index: 2 Placenta-Location: Anterior Non-Stress Test: 2 Grade-3 Total score= 10/ Distance from the OS- no previa BIOMETRY NON- BIOMETRIC PARAMETERS

BPD: 85 mm = 34 2/7 wks Cerebellum: 5 cm- 37 weeks

HC: 305 mm = 34 wks Colonic Grade: 2

AC: 316 mm = 35 4/7 Distal Femoral Epiphysis: (+)

FL: 68 mm = 35 wks Proximal Humeral Epiphysis: (-)

Mean Ultrasonic Age: 35 4/

Estimated Fetal Weight: 2598 grams ( 5 lb 12 oz) Ultrasonic EDD: 12/14/ 4 QUADRANT AFI: 2 cm, 0. 2 cm, 2 cm

IMPRESSION: PREGNANCY UTERINE, 34 WEEKS 5 DAYS AOG BY FETAL BIOMETRY. LIVE, SINGLETON FETUS IN CEPHALIC PRESENTATION, MALE. ANTERIOR PLACENTA GRADE 3, NO PREVIA. RELATIVELY LOW AMNIOTIC FLUID VOLUME. GOOD FETAL TONE. ACTIVE FETAL BREATHING AND MOVEMENT. REACTIVE NON-STRESS TEST. BIOPHYSICAL PROFILE SCORE:10/ Please correlate clinically and with earliest scan.

CHRISTINE ROSE ARENZANA-TEJADA,MD,FPOGS,FPSUOG OB-GYN Sonologist

PARAMETERS RESULTS REFERENCE RANGE

Lymphocytes, others: hbsag:nonreactive, 7 and physiology of female and male reproductive system.

An overview of external reproductive system, The mons pubis is a rounded mound of fatty tissue that covers the pubic bone. During puberty, it becomes covered with hair. The mons pubis contains oil-secreting (sebaceous) glands that release substances that are involved in sexual attraction (pheromones). The labia majora (literally, large lips) are relatively large, fleshy folds of tissue that enclose and protect the other external genital organs. They are comparable to the scrotum in males. ---The labia majora contain sweat and sebaceous glands, which produce lubricating secretions. -During puberty, hair appears on the labia majora. The labia minora (literally, small lips) can be very small or up to 2 inches wide. The labia minora lie just inside the labia majora and surround the openings to the vagina and urethra. A rich supply of blood vessels gives the labia minora a pink color. During sexual stimulation, these blood vessels become engorged with blood, causing the labia minora to swell and become more sensitive to stimulation. The area between the opening of the vagina and the anus, below the labia majora, is called the perineum. It varies in length from almost 1 to more than 2 inches (2 to 5 centimeters). The labia majora and the perineum are covered with skin similar to that on the rest of the body. In contrast, the labia minora are lined with a mucous membrane, whose surface is kept moist by fluid secreted by specialized cells. The opening to the vagina is called the introitus. The vaginal opening is the entryway for the penis during sexual intercourse and the exit for blood during menstruation and for the baby during birth. When stimulated, Bartholin glands (located beside the vaginal opening) secrete a thick fluid that supplies lubrication for intercourse. The opening to the urethra, which carries urine from the bladder to

the outside, is located above and in front of the vaginal opening. The clitoris, located between the labia minora at their upper end, is a small protrusion that corresponds to the penis in the male. The clitoris, like the penis, is very sensitive to sexual stimulation and can become erect. Stimulating the clitoris can result in an orgasm.

Male external and internal reproductive system

 Penis : This is the male organ used in sexual intercourse. It has three parts: the root, which

attaches to the wall of the abdomen; the body, or shaft; and the glans, which is the cone-shaped part at the end of the penis. The glans, also called the head of the penis, is covered with a loose layer of skin called foreskin. This skin is sometimes removed in a procedure called circumcision. The opening of the urethra, the tube that transports semen and urine, is at the tip of the penis. The glans of the penis also contains a number of sensitive nerve endings.

The body of the penis is cylindrical in shape and consists of three circular shaped chambers. These chambers are made up of special, sponge-like tissue. This tissue contains thousands of large spaces that fill with blood when the man is sexually aroused. As the penis fills with blood, it becomes rigid and erect, which allows for penetration during sexual intercourse. The skin of the penis is loose and elastic to accommodate changes in penis size during an erection.

Semen, which contains sperm (reproductive cells), is expelled (ejaculated) through the end of the penis when the man reaches sexual climax (orgasm). When the penis is erect, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at orgasm.

empties directly into the urethra. This fluid serves to lubricate the urethra and to neutralize any acidity

that may be present due to residual drops of urine in the urethra.

 Skin Discoloration Some women develop what's called the "mask of pregnancy." That tan-colored area around your eyes will start to fade. Women who suffered from severe acne during pregnancy should see their skin start to clear up. However, other women will begin to experience a red rash that around their mouth and chin or suffer from extremely dry skin. Both of these conditions should be gone within weeks.

 Breast Changes Your breasts will probably become flushed, swollen, sore, and engorged with milk for a day or two after the birth. Once this swelling goes down, in about three to four days (or until you stop breastfeeding), your breasts will probably begin to sag as a result of the stretched skin. You may also experience milk leakage for several weeks, even if you don't breastfeed.

 Stomach Changes Just after giving birth, your uterus is still hard and round (weighing about 2 1/2 pounds) and can be felt just by touching your naval. In about six weeks, it will weigh only 2 ounces and will no longer be felt by pressing on your abdomen. That mysterious brown line that you may have had down the center of your lower abdomen during pregnancy will disappear. But, unfortunately, those stretch marks you developed aren't going anywhere in the near future. Stretch marks tend to be bright red during and shortly after pregnancy, but they will eventually become more of a silver color and begin to blend in with your skin. Also, even the fittest moms will experience some flabbiness in the midsection after giving birth. Sit-ups, certain yoga poses, and other abdominal exercises can get your tummy as flat as it once was.

 Back Pain Because it will take some time for the stretched abdomen muscles to become strong again, your body is putting extra weight on the muscles of your back. This can lead to a backache until the abdominal muscles tighten up again. A new mom can also be suffering from back pain due to poor posture during pregnancy. Generally, these problems should clear up in the first six weeks after giving birth. If not, you may want to see a chiropractor.

 Incontinence

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OBSTETRICS-GYNECOLOGY CASE PRESENTATION

Jul 19, 2014

1.81k likes | 14.38k Views

OBSTETRICS-GYNECOLOGY CASE PRESENTATION. YAMANAKA, Mariko Jennifer L. San Beda College of Medicine Department of Obstetrics and Gynecology Quirino Memorial Medical Center June 28, 2011. GENERAL DATA. J.M. 40 year-old female M arried R esiding at Quezon City

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• pale nail beds
• tubular necrosis
• atony vs vaginal lacerations

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OBSTETRICS-GYNECOLOGY CASE PRESENTATION YAMANAKA, Mariko Jennifer L. San Beda College of Medicine Department of Obstetrics and Gynecology Quirino Memorial Medical Center June 28, 2011

GENERAL DATA • J.M. • 40 year-old female • Married • Residing at Quezon City • Seen for the 1st time at the Quirino Memorial Medical Center-OB-Emergency Room on June 19, 2011

CHIEF COMPLAINT • Labor pain

HISTORY OF PRESENT ILLNESS • 5 hours PTA • Abdominal pain • start from the back running towards her umbilicus • contractions lasting for less than 5 minutes (2x in 5 minutes) • Streak of blood form her vagina • Persistence of the pain Consult

2 hours after consult • NSD to a live baby boy • Blood loss (400-500 cc) •  RR

3 hours after consult • Blood loss(300 cc) • Pale palpebralconjunctivae • Pale nail beds • Tachycardiac • Persistence and progression  Immediate intervention

REVIEW OF SYSTEMS • June 19, 2011 • Unremarkable

PAST MEDICAL HISTORY • No previous surgeries/hospitalizations • No known allergies to food/medications • Immunizations unrecalled • Chicken Pox – elementary • No known co-morbid illnesses • No history of hypertension, Diabetes Mellitus, Pulmonary Tuberculosis, cancer, asthma

FAMILY HISTORY • Cancer - Mother • (-) Diabetes Mellitus, thyroid diseases, cardiac diseases, pulmonary diseases, renal diseases

PERSONAL AND SOCIAL HISTORY • High-school graduate • Housewife • Lives with her husband and 9 children • Nonsmoker, non-alcohol beverage drinker • Denies illicit drug use • Diet - fish, vegetables, and rice • Water source - NAWASA

OBSTETRIC HISTORY • G10P10 (10-0-0-10)

LMP of last pregnancy • September 22, 2010 • AOG • 38 weeks 4/7 by LMP • EDC • June 29, 2011

ANTENATAL HISTORY • 2 prenatal check-ups at health center • No prenatal diseases and infections • Transabdominal ultrasound – 3rd trimester • No abnormalities

MENSTRUAL HISTORY • Menarche - 12 y/o • Regular • Duration - 4-6 days • Interval - 28-30-days • Moderate amount (2-3 pads/day) • No dysmenorrhea/headache

SEXUAL HISTORY • First coitus – 18 y/o • 1 sexual partner • No dysparenuria, post-coital bleeding, history of sexually transmitted diseases

CONTRACEPTIVE HISTORY • 1990 – 1994 - Trust OCPs, discontinued • 1996 – present - Coitus interruptus

PHYSICAL EXAMINATION • June 19, 2011 – Upon Admission • BP: 110/70 mmHg, supine PR: 80 bpm, regular • RR: 18 breaths/min Temp: 36.8 C, per axilla • Conscious, coherent, ambulatory, not in cardio-respiratory distress • HEENT: Anictericsclerae, pink palepebral conjunctiva • Cardiovascular: Adynamicprecordium, normal rate, regular rhythm • Abdomen: Round, FHT auscultated at 140s/minute on left lower quadrant

Internal Exam: • Cervical dilatation: 7-8 cm • Effacement: 70 % • Presentation: Cephalic • Station: -2 • (+) Bag of Water

DIAGNOSTIC EXAMINATIONS • June 6, 2011 • OBSTETRIC TRANSABDOMINAL ULTRASONOGRAPHY • Uterus is regularly enlarged • Single alive fetus, male • Cephalic presentation • Fetal heart rat e-142 bpm • Absence of gross fetal abnormality • Normal Amniotic fluid volume • RUQ- 3.0 cm, LUQ- 3.4 cm, RLQ- 4.0 cm, LLQ- 3.0 cm = 13. 4 cm • Anterior, high-lying, with grade 2 maturity placenta • Adnexaeare clear

Estimated Fetal Weight: 3448 grams Impression: Pregnancy, 37 weeks and 6 days gestational age

LABORATORY TESTS • June 19, 2011

June 20, 2011

June 21, 2011

June 21, 2001

June 22, 2011

June 23, 2011

COURSE IN THE WARDS • June 19, 2011 • Gave birth via normal spontaneous delivery to a baby boy • Oxytocin IM • Total blood loss (400-500 cc) • 10 ”u” of oxytocin - incorporated in IVF • Cefalexin500 mg/capq 8° x7 days • Mefenamicacid 500 mg/capq 6°, PRN for pain • CXR PA view, Na, K, Cl, AST, ALT, LDH, UA • NPO

June 20, 2011 • Blood loss (300 cc) • Pale palpebral conjunctivae, pale nail beds, and tachycardiac (110-120 bpm) • Hemoglobin and hematocrit (99, .030) • For emergency hysterectomy secondary to uterine atony • Ampicillin2 grams/IV, (-) ANST • 1 unitVoluven

Underwent emergency Total Abdominal Hysterectomy under subarachnoid block • Vital signs - stable • 2 units of PRBCs - transfused • Blood loss intra-op - 800-900 cc

Ketorolac30 mg IV loading, then 15 mg IVq 6° x4 doses (-) ANST • Tramadol150 mg loading then Tramadol drip 300 mg in 500 cc D5W at 21 gtts/min • Omeprazole40 mg IV OD while on NPO • Metoclopramide10 mg PRN for vomiting • Ampicillin1 gram IVq 6° (-) ANST • Metronidazole500 mg IVq 8° x3 doses (-)ANST • Cconsciousand coherent, with pallor. UO - adequate

June 21, 2011 and June 22, 2011 • Same management • June 23, 2011 • Hemoglobin and hematocrit - slightly below baseline • Clearance for possible discharge

SALIENT FEATURES • 40 year-old, female • G10P10 (10-0-0-10) • Blood loss of approximately 800 cc • Tachycardic • Pale palpebral conjunctiva • Pale nail beds • Low Hemoglobin and Hematocrit

DIAGNOSIS • G10P10 (10-0-0-10) PUFT, cephalic, delivered via NSD to a live baby boy with AS 9, Postpartum Hemorrhage secondary to Uterine Atony, S/P Total Abdominal Hysterectomy by Subarachnoid Block

DISCUSSION • Uterine Atony is the failure of the uterus to contract properly following delivery. • Failure of contraction and retraction of the myometrium prevents hemostasis and leads to an increase in blood loss.

Predisposing factors: • high parity • precipitous or prolonged labor • general anesthesia • overdistendeduterus (macrosomia, hydramnios, multifetalpregnancy) • oxytocinaugmentation or induction of labor • history of PPH • amniotic fluid embolism • magnesium sulfate in laboring patients • constant kneading and squeezing

Uterine Atony VS Vaginal Lacerations • based on the condition of the uterus • uterus - soft and boggy following infant and placental delivery • once uterus is well contracted, but still (+) bright-red bleeding  lacerations

Complications: • vary, depends on the range of degree of severity • Hypovolemiamaternal hypotension, shock, acute tubular necrosis, dilution coagulopathy, cardiac arrest, and death • BT-related complications – BT reactions, hemolysisd/t ABO incompatibility, viral diseases (hepatitis & HIV infection), acute lung injury, transmission of bacterial endotoxin, transmission of parasitic agents, graft VS host disease, alloimmunization to blood products, and transfusion-related immunosuppression. • shock, anemia, infection, kidney failure, or brain damage

MANAGEMENT • fundal massage is indicated • 20 units of oxytocin in 1 L of LR or PNSS, IV, 10 ml/min • oxytocinshould never be given as an undiluted bolus dose as serious hypotension or cardiac arrhythmias may follow • ergot derivatives: methylergonovine .2 mg, IM • may cause hypertension • prostaglandin: hemabate 250 grams, IM • contraindicated in asthmatic px

if unresponsive to multiple administrations oxytocics: • bimanual uterine compression and fundalmassage • begin blood transfusions • explore uterine cavity manually for retained placental fragments or lacerations • thoroughly inspect the cervix and vagina after adequate exposure • add a second large-bore intravenous catheter at the same time as blood is given • insert a foley catheter to monitor urine output (good renal perfusion measure)

ligation of arteries • B-Lynch suturing of uterus

Intractable uterine atonyhysterectomy

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