case study about primipara

Just so you know. . .these scenarios are deliberately made vague so you have to cover all the important aspects of care. This one is suggesting two biggies: hemorrhage and infection and possibly a third, fluid volume depletion. 400-500cc blood loss during delivery is normal. Look to see if the patient has a history of anemia or long term aspirin use. Postpartal hemorrhage can occur at any time up to 28 days after delivery. Bleeding can come from anywhere in the uterus, lady parts or the episiotomy--anywhere that may have sustained a traumatic nick or tear that got missed, especially if any instruments were used to assist with the delivery or the placenta was removed manually. Secondarily, collections of blood can press on internal structures and create pain. They can press on the urinary bladder and impede urination so that the bladder becomes overdistended and urine retained. Dribbling could be a symptom of this.

For hemorrhage assess:

• Review delivery record-- Was labor prolonged, induced? Were forceps used? Was the placenta delivered manually? (all can cause postpartum bleeding)
  
• BP and pulse (looking for hypotension and tachycardia in hemorrhage or fluid volume depletion)
  
• for cool/clammy skin; pallor
  
• uterus for firmness (boggy uterus can be a sign of bleeding)
  
• lochia--amount, color, number of pads (bleeding can come from uterus, lady parts or episiotomy)
  
• amount and frequency of voiding (postpartum bleeding can obstruct the bladder causing urinary retention)
  
• pain in back, flank, or abdomen (hematoma formation pressing on internal tissues)
  
• level of uterine fundus (if fundus has not reduced hemorrhage is a concern)
  
• Evaulate for evidence of DIC (Disseminated intravascular coagulation)
  
• Blood tests: CBC, platelet count, coag panel, lady partsl culture, UA

For UTI assess:

• Review delivery record-- was patient catheterized before or during labor (a chance to introduce bacteria in the urinary track)
  
• TPR (looking for elevated temp)
  
• aseptic method used to apply any sprays, ointments of medicated compresses to hemorrhoids (incorrect application will introduce bacteria from the rectum into the lady parts and urethra)
  
• Urinary retention (urine sitting around in the bladder increases risk of infection)
  
• dysuria, frequency, urgency (symptoms of UTI)
  
• suprapubic or CVA pain or tenderness
  
• fluid intake

For fluid volume depletion assess:

• that patient is drinking fluids to replace losses
  
• voiding frequency and amounts