Maternity Case 10: Fatime Sanogo (Complex)
Documentation Assignments
1. Document your initial assessment data for Fatime Sanogo, including vital signs, fundal
assessment (consistency, position, location), lochia assessment (amount, color, odor,
consistency), and pain (location, quality, severity).
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HR 104, BP 102/52, RR 18, 97% O2 Sat, Temp 98.6F, AO4, Pain 5/10
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Lochia assessment revealed “a lot of blood and lochia, bleeding at a moderate rate”
-
Fundal assessment found uterus to be soft and boggy, indicative of a PPH
2. Write the situation-background-assessment-recommendation (SBAR) communications
you would use to update the provider on Fatime Sanogo’s status after your first encounter
with her.
Fatime Sanogo is a 23yo primigravida 1 hour post delivery. She was admitted yesterday
at 0600 for an oxytocin induction and following a prolonged second stage, she delivered
a vigorous female infant at 0605 APGAR scores of 9/9 and a weight of 9lb 0oz. Placenta
was delivered manually at 0635 and a second-degree laceration was repaired. Initial
bleeding was controlled through fundal massage and oxytocin administration with the
last fundal assessment exhibiting a firm fundus 1cm above umbilicus with small amounts
of rubra lochia absent of clots.
I am currently with the patient at bedside performing fundal massage after discovering
pt began bleeding again at a moderate rate and the fundus was soft and boggy. VS stable
HR 104, BP 102/52, RR 18, 97% O2 Sat, Temp 98.6F, AO4, Pain 5/10, however pts fundus
has not become firm despite massage. Pt has also expressed she has not voided and
bladder scan revealed 300+mL of urine in the bladder. I would recommend an order for
oxytocin and a straight catheterization and prepare an order of misoprostol and
methylergonovine if the oxytocin is not successful in stopping the bleeding.
3. Document the medication(s) you administered to Fatime Sanogo and evaluate each drug’s
effectiveness.
a. oxytocin 334mL/hr 500mL IVPB - not successful, uterus still boggy and bleeding
perisisted
b. misoprostol 800mcg rectal - not successful, uterus still boggy and bleeding
c. methylergonovine 0.2mg IM - SUCCESS! uterus was firm upon reassessment
4. Document the sequence of events during the simulation (i.e., vital signs, assessment
findings, blood loss, nursing interventions, and patient response).
a. identify pt and allergies, obtained VS
b. layed pt in supine position and followed w a fundal and perineum assessment
c. pt uterus found to be soft and boggy with moderate amounts of rubra lochia
d. concern for PPH identified, called for assistance and began fundal massage
e. fundal massage unsuccessful, uterus still soft and boggy
f.
bladder scan showed 300+ mL, provider notified
g. new orders to administer oxytocin and straight cath were performed alongside
continuous fundal massage - unsuccessful, provider notified
h. new orders for misoprostol 800mcg rectal administered - unsuccessful, provider notified
i.
new orders for methylergonovine 0.2mg IM administered and CBC and H&H drawn successful, pt uterus firm
j.
pads changed and weighed with EBL of 1980mL/hour
k. reassessed VS, fundus, perineum/lochia all now stable and showed hemorrhage has
been resolved
l.
Pt expressed 5/10 pain, 1000mg acetaminophen and 800mg ibuprofen administered to
aid with pain and inflammation
5. Fatime Sanogo is going to be taken back to labor and delivery for a manual examination.
Write the transfer note.
Fatime Sanogo is a 23yo primigravida 1 hour post delivery. She was admitted yesterday
at 0600 for an oxytocin induction and following a prolonged second stage, she delivered
a vigorous female infant at 0605 APGAR scores of 9/9 and a weight of 9lb 0oz. Placenta
was delivered manually at 0635 and a second-degree laceration was repaired. Initial
bleeding was controlled through fundal massage and oxytocin administration with the
last fundal assessment exhibiting a firm fundus 1cm above umbilicus with small amounts
of rubra lochia absent of clots.
At 0700 I began performing fundal massage after discovering pt began bleeding again
with rubra lochia at a moderate rate with fundus being soft and boggy. VS were stable
HR 104, BP 102/52, RR 18, 97% O2 Sat, Temp 98.6F, AO4, Pain 5/10, however pts fundus
did not become firm despite massage. Initial orders were followed with 500mL Oxytocin
at 334mL/hr and a straight cath to empty pts bladder. Despite these efforts and
continued massage, fundus was still soft and boggy. Pt was then administered
misoprostol 800mcg rectally in an attempt to stop the hemorrhage, but bleeding
continued. Finally, following an administration of methylergonovine 0.2mg IM pts
hemorrhage was resolved with reassessment exhibiting a firm uterus and significantly
reduced bleeding. Pads were changed and weighed with an EBL 1980mL/hour and labs
showed another drop in H&H and RBCs. Pts most recent VS were HR 116, BP 101/59, RR
21, SpO2 94%, Temp 98.6, AO4. I administered 1000mg acetaminophen and 800mg
ibuprofen to help reduce pain and inflammation.
I would recommend continuing frequent fundal and perineum checks as we have had to
intervene twice now for PPH. I would apply supp. O2 while pt recovers, as it will
decrease her work of breathing and increase her SpO2 to her baseline around 97/98%. I
would request fluids to replenish lost volume, potentially a 500mL bolus followed by
maintenance as well as review labs and contact provider to see if blood transfusion
seems appropriate.