N 340 Postpartum Case Studies
Please copy these and bring to class. Thanks!
Lochia: goes from really bloody to not so bloody [rubra, don’t call it red, b/c red means blood.] We like to pretend that there’s no blood in it. Which is odd. Serosa [don’t call it pink]. Alba [don’t call it white.]
Ms. R. had her third baby four hours ago. She got up shortly after she delivered and voided 100 ccs. You have been checking her periodically. Her VS have been normal and her uterus has stayed firm and at the umbilicus. You now check her and her fundus is somewhat firm, 2 fingers above her umbilicus and deviated slightly to the right. What's going on? What would you do? Be specific as to the order you would do things in.
Massage a boggy uterus, you want her to empty her bladder so it doesn’t distend and doesn’t interfere with shinking the uterus. Check her for bleeding. May need a cath to empty the bladder. Check for bleeding while massaging the uterus, check for clots. We want some clots but not big clots. Might open up the Iv bag of pit if she’s connected to it. She stands up and: she bleeds to holy hell. Hopefully she’s not in her bunny slippers. Feel her fundus after she voids again, hopefully it’s back down at the belly button. The fundus is high after delivery, at or above the belly button. How fast does it drop? 24 hours later, it should be a centimeter below the umbilicus, so it’s 1-2 cm per day.
Ms. M had her first baby one hour ago. It's a full moon and L&D is bursting at the seams. The L&D nurse wheels the patient over and tells you everything has been normal. She has an IV running (with pitocin in it) and this bag can be d'cd after it runs in. She's voided an adequate amount and is bleeding a normal amount. She had an episiotomy with a third degree extension. She plops the chart down and runs back to L&D. In about 20 minutes you go in to assess Ms. M. Her vital signs are 102/60, P 92, R 16. Her peri-pad is saturated, her fundus is firm and 1 cm below her umbilicus. Ms. M. states she has some throbbing "down there." What would you do? What could you do next time to prevent this confusing situation? What do you hope Ms. M has on her perineum?
Describe how you will assess her.
We hope that she has a peri pad and ice on her. VS could be a problem, but that can be normal after delivery. R/O hypovolemic shock, determine where that blood came from: is it hemorrhage, lochia, or form the epis. Check if she is clammy, cold, dizzy to check for hypovolemia.
She’s got heavy bleeding and it’s probably not her uterus b/c it’s so low and contracted, you want to check on if its cervix tearing or something. Tears look like blood. Lochia comes from the uterus, and it’s different.
Throbbing down there: probably from the epis, check for other tearing, swelling, bruising, check for hemmorhoids: you can get hemmorhoids during the labor process!
HR is the first thing to go up when they are hemorrhaging/hypovolemic. Lots of other things make the HR go up [including pain and movement and anxiety.] You don’t want to jump to conclusions. Look at their VS before now, because a big change recently is a little more of a concern. Mom’s pulse usually goes down after birth.
Moral of this story is: this nurse handed you this pt, and what could be better? Better report, assess sooner, and do a quick assessment with the hand off nurse and the pt. And you don’t know when this pad was changed. LD RN’s and PP Rn’s think they’re better than each other.
Ms. B. had her second baby two days ago is planning to leave the hospital soon. The Family Practice MD has discharged both the mom and the baby after Ms. B. has her rhogam, rubella immunization and if her lab work comes back normal. Her CBC is: Hgb: 12.2 (12-16), HCT: 42 (37-47), WBCs: 21,000 (5,000-10,000). She has Tylenol #3 ordered to take home. You go in and ask her if she would like you to call in her prescriptions to a pharmacy. She says she has had more uterine cramping (especially while nursing) with this baby then she did with her last delivery . She really needs the pain meds, but is hesitant to take them because she is breast feeding. She also doesn't want to get the rubella vaccination because she is breast feeding. Ms. B. asks why she needs the rhogam when she didn't need it last time.
Labs: normal for WBC's to be increased, but we will look out for other signs of infection.
Why rubella: because it's good to have it, if she gets pregnant and gets rubella it's bad bad for her baby.
Refusal for rubella: educate her about safety w/ breast feeding. If she refuses, we document it. And we let the doc know that she's refused, otherwise it will get lost in the shuffle.
If a mom takes IB or percoset or whatever, if she eats her meds 1/2 hr before baby feeds, the drugs don't have time to get into the milk, and will hopefully have passed from the system the next time milk is released.
Rohgam b/c mom has negative rH factors, and we need to protect the future babies
Why more cramping? maybe she didn't breastfeed the first baby? all pregancies are different?
What's up with the lab test results? What would you do? Why the rhogam and rubella? What would you do about her refusing to get the rubella vaccination? Why is she having more uterine cramping this time? How about pain medication and breast-feeding?
Ms. S had her first baby at 6 this morning. She is transferred out to the postpartum unit at 8:30 and immediately gets on the phone with her friends and family talking about her labor. Her husband is sitting on the bed holding the baby. You go in at 10 with some breakfast and to do a quick check and she's still on the phone. When you go back in at 11 she's still on the phone giving a contraction by contraction description of pushing. You ask her to please get off the phone so you can check her and help her to the bathroom. Her husband is still holding the baby. You ask them what the baby's name is and they tell you they can't decide between Heather or Jennifer.
What's going on? Is it okay for her to be taking about her labor so much and ignoring the baby? What would you be looking as evidence of the mother bonding? How about the dad?
She might not know how to interact with her kid yet.
How do we get people to bond? Hold the baby, talk to the baby, eye contact. Find out what the experience of the mommy was, how her labor went and if she's happy about it or not.
The nurse could demo a little bonding and connection, talk a little about where babies see best, how to play with baby a little. Assess her response.
En Fasse/"on foss": this is a white people thing: you put the baby face to face. Some cultures won't do this b/c looking at a baby too much can steal its spirit.
This is also perfectly normal: she took a big trip and wants to tell everyone. We can't have any judgement about a mom's immediate interest in her newborn. Moms w/ C/S also need this, and moms who can't remember it all need us to feed in the blanks. Rita Reuben's theory talks about this behavior. Don't jump to this being pathology.
The name thing: not all parents know their kid's names yet, but if they call the kid 'it' we may have a problem