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 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 four doses of penicillin G. She is a G-1, term 39-week gestational vaginal delivery P: 95 BP: 110/67. Group B streptococcus (GBS) is a type of bacterial infection that can be 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 first-time parent, with a low-risk prenatal history, delivery without complications, and normal BUBBLE-HE assessment 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! 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