Help with Maternity Case Study

[2bNurseCai]

I have a case study for maternity that I am working on and one of the questions has me a bit stumped. I think I have an idea as to what the answer may be, but I'm looking for some feedback.

I have a patient who is G1P1 DOD with a history of mild-moderate pre eclampsia. She is currently on 2 Gms/hr MgSO4 IV, 20 units of pitocin in 1L of D51/2NS over 8 hours IV, and methergine 0.2mg po TID x 24 hours. She also received an IM dose of methergine 0.2mg upon placental delivery. She has only moderate lochia rubra and has moderate-severe uterine pain while breastfeeding.

The question is why the client is on Pitocin given Methergine also does the same thing. The only things I can think of is a) the MgSO4 lessens uterine contractions and maybe the Methergine isn't enough to keep the uterus contracted after birth or, b) since Pitocin also causes a decrease in blood pressure when initially administered that it may be used to help control her blood pressure, which is a major factor in preventing eclampsia.

So does it seem like I'm on the right track? Let me know! Thanks :)

[ejp80]

First of all why is she getting so much iv fluid? She is going to me put into resp distress, lower the d5 so she gets a total (Both mainline and mag) of 125 an hr. methergine shouldn't be used for this case- because of the bp. Sometimes pit alone won't stop bleeding, especially when mag is involved, but there are other options. Mag is a muscle relaxer, the uterus is a muscle- make sense?

[ReneeRN0521]

I have the same question as ejp80. Why is she on 175mL/hr of fluid. Our mag orders are total IV fluid per hour 125 mL/hr and some doctors are even more conservative at 100mL/hr. I also think that hemabate or cytotec rectally would have been a better option for her bleeding. In my experience full-term post partum mag patients have a much higher rate of postpartum hemorrhage than non mag patients. (Both of the postpartum hemorrhage patients I've had have been on mag and were full term at delivery.) We don't usually do any meds besides pitocin for bleeding after delivery even if they are on mag, unless they start to bleed more than we like. With the patient having a HCT of 22 there had to have been some excessive bleeding which would be the reason for the methergine but again not the best choice of drug in this case.

[nurse_maya28]

yeah she should not be on methergine at all with high blood pressure. Cytotec would be a much better and even more effective option

[2bNurseCai]

I agree about the methergine; the risks definitely don't outweigh the benefits. As to why she's on it or why she's on so much fluid, the case study doesn't say and doesn't give me the option of changing it. It's more of a question and answer type study where my prof wants us to get a feel for the different maternity meds and their uses rather than looking at the patient and determining whether or not something needs to be changed. It's frustrating!!

[nurse_maya28]

I agree about the methergine; the risks definitely don't outweigh the benefits. As to why she's on it or why she's on so much fluid, the case study doesn't say and doesn't give me the option of changing it. It's more of a question and answer type study where my prof wants us to get a feel for the different maternity meds and their uses rather than looking at the patient and determining whether or not something needs to be changed. It's frustrating!!

sounds like the prof either didn't think through the senario or is testing you to see if you noticed what's wrong with it.

[Calabria, BSN, RN]

When I see those lab values (platelets, Hct), I'm concerned about HELLP and/or DIC, and would request follow-up labs to monitor. I agree with the previous posters about the Methergine, though. She should be getting Cytotec around the clock if there is concern for additional bleeding.

I also think that her IV fluid rate should come down, especially with Pitocin running. It doesn't happen often, but Pitocin can cause "water intoxication" (and edema in general). And I'd consider discussing a transfusion with the doctor because of the low Hct.