Postpartum Hemorrhage (PPH)
Brenda Jackson, 22 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Clotting
2. Clinical Judgment
3. Patient Education
4. Communication
5. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
,UNFOLDING Reasoning Case Study:
Postpartum Hemorrhage (PPH)
History of Present Problem:
Brenda Jackson is a 22-year-old African American, G-1, now T-1 P -0 A- 0 L-1 who is Group B strep positive and was
treated with four doses of penicillin G. She had a vaginal delivery over an intact perineum after 19 hours of labor at 39
weeks gestation. She has been clinically stable and is about to be transferred to the postpartum unit after a two-hour
recovery period. Oxytocin 20 units in 1000 mL of Lactated Ringer’s is infusing at a fixed rate of 125 mL/hr in a 20 g.
peripheral IV in her left hand. Type and screen done on admission, Hgb 12.6/Hct 38.
Her last set of vital signs were:
T: 99.4 F/37.4 C
P: 95
R: 18
BP: 110/67.
She has gotten up to void once and had 50 mL of blood-tinged urine. Her fundus is firm at the umbilicus, and has a small
amount of dark red lochia. She is physically exhausted and has been anxious since delivery because her labor and
delivery were harder than she ever expected.
Personal/Social History:
Brenda is an advanced nursing student in her final year. She is single and remains in a relationship with her boyfriend,
who is also the father of her baby. She lives at home with her parents, who are supportive.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Group B strep positive and was treated with Group B streptococcus (GBS) is a type of bacterial infection that can be
four doses of penicillin G. found in a pregnant woman’s vagina or rectum. This bacteria is
normally found in the vagina and/or rectum of about 25% of all healthy,
adult women. Women who test positive for GBS are said to be colonized.
A mother can pass GBS to her baby during delivery.
GBS affects about 1 in every 2,000 babies in the United States. Not
every baby who is born to a mother who tests positive for GBS will
become ill. Although GBS is rare in pregnant women, the outcome can
be severe for the newborn. Physicians include testing as a routine part
of prenatal care.
She is a G-1, term 39-week gestational She is a first-time parent, with a low-risk prenatal history, delivery
vaginal delivery without complications, and normal BUBBLE-HE assessment
P: 95 Though this HR is not >100, it is close enough that it must be recognized
as a clinical RED FLAG. This is not an acceptable ambiguity! It may be
due to post-delivery pain or a compensatory response to hypovolemia
based on physiologic compensation to maintain cardiac output.
Remember the patho equation CO=SVxHR! This is now very relevant to
clinical practice!
BP: 110/67. Though this is the first BP in this scenario, emphasize the importance of
TRENDING all clinical data especially in the context of this scenario
when the worst possible/most likely complication is post-partum
hemorrhage. The BP as well as HR are ALWAYS RELEVANT!
IMPORTANT POINT to emphasize: Pregnancy increases circulating
volume by 40% at term. This increase will conceal blood loss by
maintaining the BP longer. Blood pressure in the immediate postpartum
period should be normal; any deviation should be reported. Increased
blood pressure can indicate gestational hypertension. Decreased blood
© 2016 Keith Rischer/www.KeithRN.com
, pressure can be related to orthostatic hypotension, shock, or
dehydration (side effect of epidural anesthesia).
Loss of <1000= orthostatic tachycardia
Loss 0f <1500= resting tachycardia, orthostatic hypotension
Loss of < 2500=resting hypotension
Loss of >2500= oliguria C-V collapse and obtunded.
(CMQCC, 2015)
RELEVANT Data from Social History: Clinical Significance:
Advanced nursing student in her final year Nursing is a stressful major, as every student can testify! She will need
support and a plan to successfully manage and balance the demands of a
new baby and her college education.
She is single who is still in with relationship Because she is single, it is important to assess the degree of social as
with her boyfriend who is also the father of well as family support and to involve social services as needed. Since
her baby. she has a supportive significant other, this will likely not be needed but
must be noted by the nurse.
She still lives at home with her parents who Has adequate support from parents, and/or boyfriend.
are supportive.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
G1-T1-P0-A0-L1 Prenatal vitamin (PVI) 1 tab 1. Vitamins 1. Prevention of deficiency
PO daily 2. Iron supplement or replacement of essential
vitamins
Ferrous gluconate 325 mg 2. Treatment and
PO daily prevention of iron
deficiency in pregnancy
Patient Care Begins:
Brenda arrived in her room ten minutes ago. You were delayed by another mother who
required pain medication, but the nursing assistant collected the first set of vital signs posted
below. You introduce yourself, orient her to the room and unit, and begin your BUBBLE-HE
assessment:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 99.9 F/37.6 C (oral) Provoking/Palliative: Vaginal delivery
P: 105 (regular) Quality: Cramp
R: 22 (regular) Region/Radiation: Lower abdomen
BP: 110/75 Severity: 6/10
O2 sat: 98% room air Timing: Started one hour after delivery
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
P: 105 (regular) This is a clinical RED FLAG. This is not acceptable ambiguity! It may be due to pain post-
delivery or a compensatory response to hypovolemia based on physiologic compensation to
maintain cardiac output. Remember the patho equation CO=SVxHR! This is now very
relevant to clinical practice!
TRENDing all relevant data, including vital signs, is an essential component of clinical
reasoning. The heart rate remains elevated and increased from previous HR of 95.
© 2016 Keith Rischer/www.KeithRN.com
Brenda Jackson, 22 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Clotting
2. Clinical Judgment
3. Patient Education
4. Communication
5. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
,UNFOLDING Reasoning Case Study:
Postpartum Hemorrhage (PPH)
History of Present Problem:
Brenda Jackson is a 22-year-old African American, G-1, now T-1 P -0 A- 0 L-1 who is Group B strep positive and was
treated with four doses of penicillin G. She had a vaginal delivery over an intact perineum after 19 hours of labor at 39
weeks gestation. She has been clinically stable and is about to be transferred to the postpartum unit after a two-hour
recovery period. Oxytocin 20 units in 1000 mL of Lactated Ringer’s is infusing at a fixed rate of 125 mL/hr in a 20 g.
peripheral IV in her left hand. Type and screen done on admission, Hgb 12.6/Hct 38.
Her last set of vital signs were:
T: 99.4 F/37.4 C
P: 95
R: 18
BP: 110/67.
She has gotten up to void once and had 50 mL of blood-tinged urine. Her fundus is firm at the umbilicus, and has a small
amount of dark red lochia. She is physically exhausted and has been anxious since delivery because her labor and
delivery were harder than she ever expected.
Personal/Social History:
Brenda is an advanced nursing student in her final year. She is single and remains in a relationship with her boyfriend,
who is also the father of her baby. She lives at home with her parents, who are supportive.
What data from the histories are RELEVANT and have clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Group B strep positive and was treated with Group B streptococcus (GBS) is a type of bacterial infection that can be
four doses of penicillin G. found in a pregnant woman’s vagina or rectum. This bacteria is
normally found in the vagina and/or rectum of about 25% of all healthy,
adult women. Women who test positive for GBS are said to be colonized.
A mother can pass GBS to her baby during delivery.
GBS affects about 1 in every 2,000 babies in the United States. Not
every baby who is born to a mother who tests positive for GBS will
become ill. Although GBS is rare in pregnant women, the outcome can
be severe for the newborn. Physicians include testing as a routine part
of prenatal care.
She is a G-1, term 39-week gestational She is a first-time parent, with a low-risk prenatal history, delivery
vaginal delivery without complications, and normal BUBBLE-HE assessment
P: 95 Though this HR is not >100, it is close enough that it must be recognized
as a clinical RED FLAG. This is not an acceptable ambiguity! It may be
due to post-delivery pain or a compensatory response to hypovolemia
based on physiologic compensation to maintain cardiac output.
Remember the patho equation CO=SVxHR! This is now very relevant to
clinical practice!
BP: 110/67. Though this is the first BP in this scenario, emphasize the importance of
TRENDING all clinical data especially in the context of this scenario
when the worst possible/most likely complication is post-partum
hemorrhage. The BP as well as HR are ALWAYS RELEVANT!
IMPORTANT POINT to emphasize: Pregnancy increases circulating
volume by 40% at term. This increase will conceal blood loss by
maintaining the BP longer. Blood pressure in the immediate postpartum
period should be normal; any deviation should be reported. Increased
blood pressure can indicate gestational hypertension. Decreased blood
© 2016 Keith Rischer/www.KeithRN.com
, pressure can be related to orthostatic hypotension, shock, or
dehydration (side effect of epidural anesthesia).
Loss of <1000= orthostatic tachycardia
Loss 0f <1500= resting tachycardia, orthostatic hypotension
Loss of < 2500=resting hypotension
Loss of >2500= oliguria C-V collapse and obtunded.
(CMQCC, 2015)
RELEVANT Data from Social History: Clinical Significance:
Advanced nursing student in her final year Nursing is a stressful major, as every student can testify! She will need
support and a plan to successfully manage and balance the demands of a
new baby and her college education.
She is single who is still in with relationship Because she is single, it is important to assess the degree of social as
with her boyfriend who is also the father of well as family support and to involve social services as needed. Since
her baby. she has a supportive significant other, this will likely not be needed but
must be noted by the nurse.
She still lives at home with her parents who Has adequate support from parents, and/or boyfriend.
are supportive.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
G1-T1-P0-A0-L1 Prenatal vitamin (PVI) 1 tab 1. Vitamins 1. Prevention of deficiency
PO daily 2. Iron supplement or replacement of essential
vitamins
Ferrous gluconate 325 mg 2. Treatment and
PO daily prevention of iron
deficiency in pregnancy
Patient Care Begins:
Brenda arrived in her room ten minutes ago. You were delayed by another mother who
required pain medication, but the nursing assistant collected the first set of vital signs posted
below. You introduce yourself, orient her to the room and unit, and begin your BUBBLE-HE
assessment:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 99.9 F/37.6 C (oral) Provoking/Palliative: Vaginal delivery
P: 105 (regular) Quality: Cramp
R: 22 (regular) Region/Radiation: Lower abdomen
BP: 110/75 Severity: 6/10
O2 sat: 98% room air Timing: Started one hour after delivery
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
P: 105 (regular) This is a clinical RED FLAG. This is not acceptable ambiguity! It may be due to pain post-
delivery or a compensatory response to hypovolemia based on physiologic compensation to
maintain cardiac output. Remember the patho equation CO=SVxHR! This is now very
relevant to clinical practice!
TRENDing all relevant data, including vital signs, is an essential component of clinical
reasoning. The heart rate remains elevated and increased from previous HR of 95.
© 2016 Keith Rischer/www.KeithRN.com
