Tasha is a 28 year old G 6 P 4014 at 41
weeks gestation who has just arrived in
L&D in active labor
 Diagnoses: Active labor, rapid
progression, 8/C/0 on arrival,
membranes intact
 Height: 5’ 8”
 Weight: 210 lb.
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› from prenatal visit 4 weeks ago
She has had only two prenatal visits
beginning at 36 weeks gestation
 She missed her last appointment, and
her glucose screening.
 She has a history of gestational diabetes.
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› Her last 2 infants were large for gestational
age.
› Both had shoulder dystocia at delivery
› postpartum hemorrhage after each of those
deliveries.
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Lab: CBC, RPR, Type & screen drawn on
admission with IV start and sent stat to lab
› Labs from her prenatal visit 4 weeks ago showed Hgb
9.2 g/dl, Hct 25%
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Antepartum Testing: Sonogram at first prenatal
visit to confirm dates – no fetal abnormalities
noted.
Medications: None – she has not taken
prenatal vitamins or other medications.
She denies any drug or alcohol, denies
smoking.
Diet: Regular – she has not followed any
particular diet during pregnancy

Admission VS:
› BP 138/88
› T – 99.1 degrees F
› P – 96 R – 22
IV started in L forearm with #18
intercath, 1000 LR up and running
 She is screaming that she has to push,
has a large amount bloody show
 She is planning a “natural birth” – does
not want an epidural

Early Decels, Fetal HR: 135, Contractions: 60- 70 seconds long, 90-150
seconds between

What assessment data about this patient
is particularly pertinent?

Pertinent Information
› Hx gestational diabetes, shoulder dystocia,
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macrosomia
Non-compliant with prenatal care (vitamins,
glucose testing, etc)
Hgl/Hct levels
Gestational age
ROM, early decels

Is there additional data that you would
like to obtain before you notify the
physician about this patient?
Obtain a blood glucose, GBS status
Continuous FHM orders
Mom/fetus vitals
Question IV site for blood transfusions due to
low hct/hbg r/t past postpartum
hemorrhages
 Fx of bleeding disorders, coagulations
disorders, execessive bleeding w surgical
procedures
 Cultural considerations jehovahs witness
 Family support, living situation
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How quickly do you need to contact the
physician, and what information should
be included in your report?.
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Contact physician immediately
Birth is imminent
8/C/0, presence of early decels,
contractions 90-150 seconds apart lasting
60-70 seconds
Membranes still intact however, she says
she wants to push
HX gestational diabetes, post partum
hemorrhage, macrosomia
G6 P4
Gestational age

What orders might you expect or request
from the physician? How soon would
you want the physician to see this
patient? Continue the role play to
demonstrate orders given and your
request for how soon the physician
should come to see the patient.
Physician to see pt STAT
 High risk with a hx of gestional diabetes ,
macrosomia, hemorrhage, shoulder
dystocia, no prenatal care, and post
term gestional age
 Request/anticipate blood loss and
transfusion post birth
 Orders to insert IV, 18G for blood
 Ask about AROM

A few minutes later, her membranes
rupture, with a moderate amount of
green-tinged amniotic fluid.
 She is screaming that she needs to push,
and the baby’s head is visible at the
perineum.
 The doctor has just walked into the room.
 He quickly delivers the baby’s head, but
encounters a shoulder dystocia.

After several maneuvers, the baby is
delivered and handed to the neonatal
team, and the placenta is delivered.
 The patient has a large amount of blood
and clots pouring out of her vagina.
 The blood pressure monitor shows the
last BP 98/62 HR 132 taken 1 minute
ago.
 The doctor calls for the Postpartum
Hemorrhage cart.
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What interventions would be
appropriate for this patient? Which of
these interventions are highest priority?
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Fundal massage
Hang pitocin, bring baby to the breast (if breast feeding)–
stimulate bonding and release of oxytocin
IV fluids
100% oxygen
NPO
Blood transfusion if necessary
CBC redraw
Perineal pain
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Excessive pain is uncommon and can indicate a hematoma
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Likely for large gestational age infants
Repair lacerations
Foley catheter
If this condition is not corrected, STAT hysterectomy be indicated
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What potential problems or
complications do you need to be
prepared to handle? How would you do
that? Are there other people that need
to be involved to help?
Answered in above questions
 Anticipate
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› Hemorrhage
› Vaginal lacerations
› Shoulder dystocia
› Macrosomia
› Uncontrolled BG in infant
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After appropriate interventions, Tasha’s
bleeding has slowed.
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How often should the nurse
reassess/reevaluate this patient’s status?
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Assess Q15 minutes
Palpate fundas
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Firm, boggy, midline, deviate or below umbilicus
Boggy uterus is indicative of uterine atony, not corrected results in PPH
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Amount of pad saturation, size of clots
1 pad within 15 minutes or 2 saturated pads in an hour suggests PPH
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Assessment of laceration repair, additional tearing
Assess pads for locia
Perineum Assessment/Pain
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Reassess Vitals
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100.4F fever can be indicative of infection, decreasing uterine ability to contract
and susceptible to PPH
Abnormal Vitals: tachycardia, cap refill greater than 3, decreased BP, increases RR
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Color, skin temperature, pallor, cool, clammy skin
Anxiety, loss of consciousness
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Administer analgesics as needed
Redraw CBC and monitor I&Os
Assess signs of Hypovolemic shock
Assess patient anxiety levels and stress
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Discuss appropriate teaching for this
patient/family during and following their
emergent situation.
Encourage voiding, straight cath
Cramping is expected
 Ask nurses for assistance if needed
› Ambulation the first few times out of bed
 Ice packs for perianal area, SITS baths
 Discharge teaching
› Teach how to check own fundal and fundal massage
› Contact PCP if
 Uterus does not become firm with massage
 Excessive bleeding and/or large clots
 Fever greater than 100.4F
 Persistent perineal pain or pressure
 Expect dark stools if prescribed iron supplements
 Constipation prevention
 Fiber, laxatives
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Discuss appropriate documentation for
this patient in an emergent situation.
Document I&O
 Bleeding
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› Estimated blood loss
› Degree of hemorrhage
Instrument counts
 Laceration assessment
 Fundal assessment
 Vitals
 Response to medications
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