3. 1. 3. Prolonged or precipitous labor.

      4. Anesthesia—deep inhalation or regional (particularly saddle block).

      5. Myomata (fibroids).

      6. Oxytocin induction of labor.

      7. Overmassage of uterus in postpartum.

      8. Distended bladder.

   2. Lacerations—cervix, vagina, perineum.

   3. Retained placental fragments—usually delayed postpartum hemorrhag

   4. Hematoma—deep pelvic, vaginal, or episiotomy sit

4. Assessment:

   1. Uterus—boggy, flaccid; excessive vaginal bleeding (dark; seepage, large clots) — due to uterine atony, retained placental fragments.

   2. Late signs of shock—air hunger; anxiety/apprehension, tachycardia, tachypnea, hypotension.

   3. Blood values (admission and postpartal)—hemoglobin (Hgb), hematocrit (Het), clotting tim

   4. Estimated blood loss: during labor/birth; in early postpartum.

   5. Pain: vulvar, vaginal, perineal.

   6. Perineum: distended—due to edema; discoloration—due to hematom May complain of rectal pressur

   7. Lacerations—bright red vaginal bleeding with firm fundus.

5. Analysis/nursing diagnosis:

   1. Fluid volume deficit related to excessive blood loss secondary to uterine atony, retained placental fragments.

   2. Anxiety/fear related to unexpected complication.

   3. Altered tissue perfusion related to decreased oxygenation secondary to blood loss.

   4. Activity intolerance related to fatigu

6. Nursing care plan/implementation:

   1. Medical management:

      1. IV oxytocin infusion; IV or oral ergot preparations (ergonovine [Ergotrate maleate]; methylergonovine [Methergine]; carboprost (Prostin/ M15), an oxytocic; prostaglandin.

      2. Order blood work: clotting time, platelet count, fibrinogen level, Hgb, Het, CB

      3. Type and crossmatch for blood replacement.

      4. Surgical:

         1. (a) Repair of lacerations.

         2. (b) Evacuation, ligation of hematom

         3. (c) Curettage—retained   placental fragments.

   2. Nursing management:

      1. Goal: minimize blood loss.

         1. (a) Notify physician promptly of abnormal assessment findings.

         2. (b) Order lab work stat, as directed—to determine blood loss and etiology.

         3. (c) Fundal massag

            1. Administer medications to stimulate uterine ton For ergot products and carboplast, monitor blood pressure (contraindicated in PIH).

            2. Goal: stabilize status.

               1. (a) Establish IV line—to enable administration of medications and rapid absorption/action. Administer whole blood (with larger catheter).

               2. (b) Administer medications, as ordered to control bleeding, combat shock.

               3. (c) Prepare for surgery, as ordere

            3. Goal: prevent infection. Strict aseptic techniqu

            4. Goal: continual monitorin Vital signs, bleeding (do pad count or weigh pads), fundal status.

            5. Goal: prevent sequelae (Sheehans syndrome).

            6. Goal: health teaching —after episode: Reinforce appropriate perineal care and handwashing techniques.

7. Evaluation/outcome criteria:

   1. Maternal vital signs stabl

   2. Bleeding diminished or absent.

   3. Assessment findings within normal limits.

Subinvolution—delayed return of uterus to normal size, shape, position.

1. Pathophysiology—inability of inflamed uterus (endometritis) to contract effectively —> incomplete uterine involution; failure of contractions to effect closure of vessels in site of placental attachment —> bleedin

2. Etiology:

   1. PROM with secondary amnionitis, endometritis.

   2. Retained placental fragments.

   3. Oxytocin stimulation or augmentation of labor of overdistended uterine muscle may interfere with involution.

3. Assessment:

   1. Uterus: large, boggy; lack of uterine tone; failure to shrink progressively.

   2. Discharge: persistent lochia; painless fresh bleeding, hemorrhagic episodes.

4. Analysis/nursing diagnosis:

   1. Pain related to tender, inflamed uterus secondary to endometritis.

   2. Anxiety/fear related to change in physical status.