Report of PPH
Report of PPH
Report of PPH
Objectives
General objectives:
General objectives:-General objectives of case study is to provide
holistic care through nursing process by applying economic, sociocultural background and traditional belief and practice with the
help of knowledge from basic science and fundamental nursing
knowledge.
Specific objectives;1) To identify high risk cases & select the appropriate
them.
2) To collect relevant health history of patient & family in
order to identify need & problem.
3) To gain & upgrade knowledge about disease.
Name
Bimala Bhujel
Husbands name
Hari Bhujel
Age
26 yrs/ female
Ward
Bed no
H1
Inpatient number
Address
Occupation
:
:
17777
Nuwakot- 6
:
Housewife + Agriculture
Education
Illiterate
Date of admission
2067/11/9 at 3pm
Date of discharge
2066/12/15
Provisional diagnosis
: G2P1 at 39+ wop in LPOL with Low
fetal movement with previous CS
with CPD
Final diagnosis
:
condom tamponade
LMP
2067/02/09
EDD
2067/11/16
Delivery date
2067/11/09
Delivered by
FAMILY PEDIGREE
Now she lives in a joint family with mother in law, father in law, one brother in law
and one sister in law and her husband. She has got fully love and affection from her
family.
Fathers Side
Mothers Side
Female :
M
ale :
Patient :
Temperature
Pulse
: 98.4.F
: 140/min
Respiration
: 22/min
PHYSICAL EXAMINATION
General appearance
lethargic
Height
5feet 2 inch
Weight
48 kg
nil
GENERAL MEASUREMENT
Measurement
According
book
to According
neonate
34 cm
Chest
circumference
30.5 cm-33 cm
32 cm
48-53 cm
51 cm
to
Body weight
2700-4000 gm
2750 gm
VITAL SIGN
Respiration
38/m
Pulse
130/m
Temperature
98.6 f
Nose
No nasal discharge
Nasal patency
Mouth and throats
Sucking, rooting and gag reflex present
No presence of precocious teeth, cleft lips and palate
No oral thrush
Neck
Short, thick, skin fold around the neck
Chest
Both chests are symmetrical
Neuro-muscular system
Extremities maintain 60 degree of flexion
Extension of extremities followed by previous position of flexion
Moro reflex present.
I. Eye care
Eye care was done with boiled cotton and advised to mother to
clean babys eyes
Advised the mother to avoid milk getting into eye
II. Cord care
Cleaned the cord with betadine with sterile cotton
Avoid tight napkin
Watch for any discharge bleeding and infection
ACCORDING TO BOOK
ACCORDING TO PATIENT
Becoming
established
in
a
vocation or profession these
provides personal satisfaction,
economic
independence
and
felling of making a worth while
contribution to society.
Becoming
established
in
a
vocation or profession these
provides personal satisfaction,
economic
independence
and
felling of making a worth while
contribution to society.
Formulating
a
meaningful Formulating
a
meaningful
philosophy of life and reassessing philosophy
of
life
and
priorities and values.
reassessing priorities and values.
1
0
Part II
Disease Profile:WHAT IS PPH?
Types
I. Primary PPH
II. Secondary PPH
Primary PPH: Hemorrhage occurs within 24 hours following birth
of baby. These are of two types third stage hemorrhage:
bleeding occurs before the expulsion of the placenta. And true
PPH is bleeding occurs subsequent to expulsion of placenta. In
majority PPH occurs within 2 hours following delivery.
Secondary PPH: If bleeding occurs subsequent to the first 24
hours following birth up until the 6 weeks of postpartum is called
secondary PPH. It is most likely occurs between 10 and 14 days
after delivery.
The patient
that I took for the
presentation has got primary PPH.
case
study
and
Incidence:
The incidence is about 1 % amongst hospital deliveries in
developing countries. In Nepal it is the second cause of high MMR
in PPH.
Causes:
The main cause of primary PPH are:1. Tone (atonic uterus) 70%
Failure of sustained uterine contraction following partial or
complete placental separation may result in massive
haemorrhage from the placental vascular bed. Prolonged
2. Tissue 10%
Trauma from the delivery may tear tissue and vessels
leading to significant postpartum bleeding
3. Trauma 20%
Haemorrhage may result from vulval, perineal, vaginal or
cervical tears. Rupture into the clitoral venous plexus may
cause remarkable loss. Occult bleeding into the para vaginal
space, ischiorectal fossa and broad ligaments may follow
vaginal laceration. Occasionally, uterine rupture presents as
a PPH.
4. Thrombin (blood coagulation defects as in hypofibrin
anaemia)
Clotting dysfunction and disturbance of platelet function are
unusual but important causes of PPH. In the majority of
cases, the clotting disorder is secondary to pre-eclampsia,
abruption or massive blood loss. Almost all maternal
mortalities attributable to PPH are associated with
coagulopathy and, in most cases, the bleeding dysfunction is
recognised late and inadequately treated. Failure to control
PPH quickly with standard measures behoves exclusion of
coagulopathy and full specialist support.
5. Combination of atonic and traumatic causes
PATHOPHYSIOLOGY OF PPPH
FLOW CHART
Due to of various etiological factors
Bleeding occurs
CLINICAL MANIFESTATION
According to book
Visible bleeding
Enlarge uterus, feels boggy
According to patient
Present
present
Sign of shock
Present
I. Pallor,
cold
and
I. Present
clammy skin
II. Present
II. Increased pulse rate
III. Present
III. Falling blood pressure
hg.)
IV. Tachypnoea
IV. Present
V. Decreased urine output V. Present
VI. Altered
level
of VI. Present
consciousness
may
become restless or
drowsy
VII. Absent
VII. Maternal collapse
VIII. Present
VIII. Decreased Hb%
(140/minutes)
(70/30 mm of
(32/minutes)
(200 ml)
she is drowsy
(6.2 gm/dl)
DIAGNOSTIC EVALUATION
According to book
History
Physical examination
Estimation of blood loss
Palpation of uterus size
Vaginal examination
USG to detect any retentined
products and clots in the
uterus
Swab for vaginal discharge for
M/E
According to patient
Not
taken
due
to
operative procedure
Done
Done (800ml)
Done (feel boggy and
around umbilicus)
Done (no trauma)
Not done
Not done
Book value
Patients
Remark
value
-B+ve
Blood
grouping
Hemoglobin Male-13 to 18
gm/ dl
Female
11.5
9.7 gm/dl
to 16.5 gm/ dl
Not done
Low
Blood CBC
HIV, HBsAg
negative
12 sec
Blood
coagulatioin
profile (PT)
150000
Platelet
function
-450000
studies
Platelets
antibodies
Negative
12sec
normal
175000
normal
Not done
Management
Principle of management
1.
2.
3.
According to the
patient
the
placenta:1. Remove the placenta :- If the 2. Removed
Placenta removed after the
placenta
has
not
been
delivery of the baby through
removed from the uterus and
surgical procedure.
the patient's cardiovascular
condition is worrying, remove
- Not done
Not done
Step V
6.Uterine tamponade:1.
Tight
intrauterine
packing done uniformly under
general
anaesthesia.
Intrauterine packing is useful in
case of uncontrolled postpartum
haemorrhage
where
other
methods have failed and the
patient is being prepared for
transport to a tertiary care
centre.
2.
Balloon
tamponade:Tamponade using various types
of hydrostatic balloon catheter
has mostly replaced uterine
packing. Mechanism of action is
similar to uterine packing. Foley
catheter, Barki balloon, Condom
catheter
or
SengstakenBlakemore tube is inserted into
the uterine cavity and the
balloon is inflated with normal
saline(200-500 ml). It is kept for
4-6 hours. It is successful in
atonic PPH. This can avoid
hysterectomy in 78% cases.
7.Aortic
compression:
Transabdominal compression of
the
aorta
against
the
promontorium
is
done
in
preparation for laparotomy if
required. In all cases the uterus
Not done
Not done
Not done
Not done
Not done
c. Ligation
of
anterior
division of internal iliac
artery
(unilateral
or
bilateral) reduces the
distal blood flow. It helps
stable clot formation by
reducing
the
pulse
pressure up to 85%. Due
to
extensive
collateral
circulation, there is no
pelvic
tissue
necrosis.
Bilateral ligation can avoid
hysterectomy
in
about
50% cases.
d. B-lynch
compression
suture
and
multiple
square
sutures:-Both
these surgical methods
work by tamponade (like
bimanual compression) of
the uterus. S uccess rate is
about 80% and it can
avoid hysterectomy.
e. Angiographic
arterial
embolisation
(bleeding
vessels) under fluoroscopy
can be done using gel
foam. Success rate is more
than 90 % and it avoids
hysterectomy.
Step VII
10.
Hysterectomy:rarely
uterus fails to contract and
bleeding continues in spite of
Not done
Not done
the
above
measures.
Hysterectomy has to be
considered
involving
a
second consultant. Decision
of hysterectomy should be
taken earlier in a parous
women. Depending on the
cases it may be subtotal or
total.
SHEME OF MANAGEMENT OF TRUE PPH
Immediate measures
Cell for extea help
Commence I\V line with a wide
bare cannula
Send blood for cross- matching and
ask For 2unit of blood(at least)
Rapidly
infuse
normal
saline
haemaccel and litters till blood in is
available.
To feel the uterus by abdominal palpation
UTERUS ATONIC
EXPLORATION
UTERINE TAMPONDE
Bimanual compression
Tight intrauterine packing under anesthesia
Insertion of sengstaken blak more tube and inflation
SURGICAL METHOD
Stepwise uterine devascularisation procedure
Ligation of uterine artery and utero-ovarine anastomosic
vessels
Unilateral or bilateral
Ligation of another division of internal iliac artery
B-lynch branch sutures
Angiographic aterial embolisation with gelatin sponge
HYSTERECTOMY (REARELY)
Nursing Management
1) Reassure the women and her support person
2) Rub up a contraction by massaging the uterus if it is still
palpable
TH
COMPLICATION
Shock / Pulmonary embolism
Encephalopathy
Acute renal failure
Puerperial sepsis
Coma
Death
PREVENTION
Postpartum hemorrhage cannot always be prevent. However the
incidence and specially its magnitude can be reduced
substantially if the following guideline are as fallowed
POSTPARUM-
Prognosis
90% of cases treated with antibiotics improve within 48-72 hours.
If this is not the case, the patient should be re-evaluated.
Associated diseases
Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP).
DRUGS USED IN MY PATIENT:
1) Injection RL II pint
2) Injection DNS II pint
3) Injection 5% Dextrose
4) Injection syntocin 10 unit
5) Injection Taxim 1gm IV BD
6) Injection Metron 500 mg IV TDS
7) Injection Aciloc 150mg IV BD
8) Injection Gentamycin 1 gm IV BD
9) Injection Voveronn75 mg IM sos
10)
11)
Ferrous sulphate
Nursing
diagnosis
High risk for
haemorrha
gic
and
hypovolemi
c
shock
related
to
postpartum
haemorrha
ge.
Goal
Intervention
Rational
To prevent
from shock
during
hospitalizati
on.
- Assessment - Helps to
fo the patient know
the
condition.
condition of
the patient.
Moniter - Helps to
vital
sign evaluate the
every hour.
patient's
deteroriate
condition.
- Helps to
Evaluation
No
any
complicatio
n
arise
during
hospitalizat
ion so my
goal
was
achieved.
Provide
patient with
complete bed
rest.
IV
replacement
as ordered in
the cardex.
Altered
comfort;
pain related
to surgical
procedure(
ceaserean
section)
Patient will
report relief
from
pain
within
30
minutes
Arranged
and
cross
matching the
blood
grouping.
Assess pain
location,
characteristic
s
and
severity
Assess
vital signs.
Review
intraoperativ
e
room
record
for
medicines
previously
administered.
Reposition
the client to
comfortable
position.
Encourage
prevent from
further
complication
.
- Helps to
maintain
fluid
and
electrolyte
balance.
Help
to
manage
in
emergency
situation.
Provides
basis
for
selection
of
proper
intervention
Signifies the
physiologic
effect of pain
and give clue
for
intervention.
Helps
in
identifying
the type of
analgesics
given.
Relieves
discomfort
from
pressure.
Goal was
met , as
patient
verbalized
about pain
relief and
involved in
her
activities.
use
of
relaxation
technique
and diversion
therapy e.g.
muscle
relaxation,
imagery,
visualization,
autogenic
training,
meditation,
music etc.
Helps
to
divert
her
mind
from
pain to other
pleasant
stimuli.
Induces
relaxation
Administer
analgesics as
prescribed.
It helps to
relief pain by
chemical
effect.
S.
N
Nursing
Diagnosis
Nursing
Goal
Plan of Action
Rationale
Evaluation
Sleep
pattern
disturbance
related
to
unfavorable
hospital
environmen
t
Client will
have sound
sleep
tonight
after
applying
nursing
measures
Determine
normal sleep
habits
and
changes that
are occurring
Obtain
comfortable
bedding.
Establish
sleep routine
suitable to old
pattern
and
new
environment.
Encourage
light physical
work/exercise
during
daytime,
stop activity
several hours
before
bedtime.
Provide warm
massage,
warm milk, at
bed time.
Assess need
for
and
identifies
correct
intervention
increases
comfort
for
sleep.
Related
stress
and
anxiety may
be reduced.
Daytime
activity can
help expend
energy
and
be ready for
night
time
sleep.
Activity
close
to
bedtime may
stimulate
delay
sleeping.
Promotes
relaxing
soothing
effect.
Instruct
relaxation
measures.
Reduce noise Helps
to
and light
induce sleep.
Provide
comfortable
Provides
atmosphere
conductive to
Goal was
met.
Patient
reported
that
her
sleep was
improved
than
last
night
position
for
sleep.
Avoid
interruptions;
postpone
nursing
activities that
fall
at
bedtime.
Consult
physician for
further
management
e.g.
sedatives,
analgesics,
hypnotics etc.
Fear
and To reduce
anxiety
patient fear
related
to and anxiety
PPH.
and provide
comfort.
- Provide fully
psychological
support to the
patient.
- Control the
visitors
and
crowd
to
provide quite
environment.
sleep.
Prevents
pressure,
promotes
rest.
May
be
unable
to
sleep
after
interruption
May require
medicines if
nursing
measures fail
to
induce
sleep.
- Helps to
reduce
the
patient's fear
and anxiety.
Goal was
achieved
as
patients
anxiety
- Helps to was
maintain
reduced
very
clam that
environment verbalized
which allows by patient.
patient
to
have
rest
Ventilate comfortable.
patient's
- Helps to
feeling
and divert
emotion.
patient's
mind
and
help
to
reduce
Need
for
discharge
teaching
related
to
knowledge
deficit.
Potential of
hypothermi
a related to
exposure to
cold
environmen
t.
Maintain emotional
good IPR.
feelings.
- Helps to
Allow develop good
relatives
to trusting
stay close to support.
the patient.
Helps
patient
to
feel
very
secure
and
comfortable.
To provide Explain - It helps to
discharge
about
the prepare
teaching.
discharge
patient
procedure.
mentally .
- Explain the - It help to
patient about maintain
the
dose
maintaining
accurately.
the right dose
of medicine.
- Explain the - It help to
patient about maintain the
the nutritional nutritional
diet.(Iron
status.
containing
diet)
- It help in
- Explain the regulation of
importance of self care.
personal
hygiene.
Temperatur -Temperature -To find out
e will be of body was the
bodys
maintained assessed
temperature
normal
regularly.
accurately.
during
-The window -To make the
hospitalizat and door are room warmth
ion.
closed
but with
ventilation
ventilation.
Discharge
teaching
has given
on
prescribed
time.
Hypotherm
ia
was
prevented
during
hospitaliza
tion.
was
maintained.
-Baby
was
wrapped
properly
-To maintain
body warmth
by
prevent
loss of body
temperature
-Babys
-Kangaroo
temperature
mother care is rise due to
was done
temperature
of mother.
-Wet napkin
-Breast
decreased
feeding
was body
done
temperature
frequently.
by
conduction
Application of Nursing Theory in Nursing Management:
The Nursing practice is the basic purpose of the discipline. As a
profession nursing has the responsibility to assess individual,
groups, families and communities to retain, obtain and maintain a
state of health. In order to assume such a responsibility nursing
must have a foundation of theoretical knowledge which is based
on research findings. It is not good enough to practice based on a
intuition, habit or traditional as a basis for making nursing
decision. Nursing theories identify and define inter related
concept important in nursing and state the relationship between
and among these concepts. Theories describe relationship that
are developed logically and consistently with their basic
assumption. Nursing theory also increase the nursing profession
body of knowledge by generating research to guide and improve
practice. Nursing theory guides nurses by providing guideline for
practice and identifying nursing care goals.
While caring the patient during hospitalization, we have to use
nursing theory so that the care become more effective and helpful
to move the patient toward recovery. I had applied Orems
Nursing theory while giving nursing care to patient. According to
system
Lochia - alba.
Patients general condition improved than before Vaginal
bleeding at small amount. No complain of pain and weakness.
Patient had developed heavy bleeding so highly notorious diet
advised for her better health management. Urine passed and
Stool. Dressing done and the wound is getting better and
removed sutures so patient was discharged today. I provided
discharge teaching and told about medicine. Patient was
discharged on following medication.
DRUGS ON DISCHARGE:
1) Tablet cefixime 200 mg BD for 6 days
2) Tablet metron 400 mg TDS for 4 days
3) Iron fe++ for 1 month
Follow up after 7 days.
1. Injection Cefixine
Pharmacologic class: Third generation cephalosporin
Therapeutic class: Antibiotic
Action: High activity against gram negative bacteria &a variety
of
batalactamaseproducing
organism.
Active
against
pseudomonas & anaerobic bacteria &spirochetes.
Indication: Septicaemia, bacteraemia, RTI including pneumon
a, UTI & gynaecological obstetrical infections including pelvic
cellulites, endometritis, intra- abdominal infections including
peritonitis, meningitis etc.
Dosage:
Adult=1-2gm once a day, not more than 4gm.
Therapeutic actions
Bactericidal: Inhibits DNA synthesis in specific (obligate)
anaerobes, causing cell death; antiprotozoal-trichomonacidal,
amebicidal: Biochemical mechanism of action is not known.
Peak
12 hr
IV
Topic
al
Rapid
Generally
systemic
absorption
12 hr
no
DISCHARGE TEACHING
minor homework etc. But heavy lifting and working in field should
be avoided.
4. Oil massage
Oil massage is not only our traditional practice but also it is
scientific practice for good circulation on the body. If she prefer oil
massage she can carryout in daily basic.
5. Personal hygiene
It prevents infection and helps for health promotion. Inner cloth
should be well cleaned and dry and changed frequently. She
should take bath and hair wash twice a week is recommended.
6. Sexual intercourse
Girja devi Thakur had got delivery episiotomy with tear so sexual
intercourse should be delayed.
7. Medicine
I gave teaching about regular medication time, duration and
certain side effects of medicine. On discharge Dr. ordered
following medicine
Cap. Ferofolic 1 cap. /day for 6 weeks
Tab. Calvit 1 tab/day for 6 weeks
I explained her about why these medicines are needed. It is
necessary to prevent infection and promote health. These
medicines should take after meal and seek medical facilities if nay
side effects occur.
9. Follow up visit
She should have follow up after 6 weeks. Advised her any time
follow up visit if any complication raised .I explained about
importance of follow up visit and come this hospital if possible
otherwise visit other facilities near to her village.
Health teaching
Health teaching plays an important role to prevent disease,
promote health as well as to cure disease more rapidly with out
any complications. One of the most important roles of the nurse is
to provide health education. So I, being a nurse, I had also given
health education to patient and family.
To promote the health
To motivate for early diagnosis and treatment
To help limit the disability
To keep in relationship
I told her about the importance of routine check up and health for
follow up purpose.
OthersImmediate check up if any signs of infection, fever, pain, swelling,
foul discharge, bleeding etc.
If babies have any problem such as dyspnoea fever, not sucking
breast milk, increase respiration etc. to visit the doctor as soon as
possible.
SUMMARY OF THE CASE STUDY
During my 8 weeks posting in Thapathali Maternity hospital, for
practicum, I found a patient with heavy bleeding in emergency
ward and and I selected that case for the case study. The case
was secondary post partum haemorrhage.s
Mr Kamala Rai, 33 yrswas came in emergency on 2066/12/04
because of heavy vaginal bleeding. She has two childrens and
both is home delivery. This is her 1st experience of being
admitted in hospital. Before this occurance to her, she has no any
significant diseases beforehand.
During hospitalization, I provided her a holistic nursing care by
considering her physical, mental, spiritual and socio cultural and
economic aspects. I provided nursing care based on Orem's
nursing system theory. I provided her needed health teaching
regarding health promotion, maintenance, prevention from
complication and discharge teaching. During her hospitalization
she and her family were very co operative and it was not so
difficult for providing care and collecting information.
WHAT I LEARN FROM THIS CASE STUDY
Case study is one of the good source of learning about the
nursing practice as well as the related disease in depth. It gave us
comprehensive study of one selected patient and comparative
with book in real situation.
During my case study, what I learned are listed below:
1)ABOUT THE DISEASE
I gained the knowledge of pneumonia in depth by case study by
using available resources from library, literatures, researches and
internet which I compared to the clinical presentation of patient