Postpartum Hemorrhage With a Retained Placenta
Ms. Adeyemi, 31, G2P1, delivered a 4.1 kg infant 25 minutes ago after a 14-hour labor that was augmented with oxytocin. The placenta has not delivered. She is bleeding moderately from the vagina; the fundus is boggy and above the umbilicus, deviated to the right. Vital signs: heart rate 108/min, blood pressure 104/66 mmHg, respiratory rate 22/min, SpO2 97%. Estimated blood loss 500 mL and rising. She is pale and anxious and says she feels 'wet and dizzy.' She has one IV of lactated Ringer's at 125 mL/hr. The provider is scrubbing for a manual removal.
1. What is your priority assessment and immediate nursing management before manual removal?
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Assessment: This is postpartum hemorrhage with a likely retained placenta and uterine atony. The boggy, displaced fundus suggests a full bladder and poor contraction. Tachycardia with narrowing pulse pressure and pallor signal early compensated shock; ongoing loss can decompensate quickly.
Immediate management:
- Call for help and activate the obstetric emergency team; assign someone to bring the hemorrhage cart and blood products per protocol.
- Massage the fundus and empty the bladder with an indwelling catheter to allow contraction.
- Start a second large-bore IV and begin rapid isotonic fluid resuscitation as ordered; send type and screen or crossmatch, CBC, coagulation studies.
- Administer uterotonics per orders (oxytocin infusion, then additional agents as prescribed).
- Give oxygen, keep her warm, and monitor vital signs every 5–15 minutes.
- Quantify blood loss by weighing pads and using calibrated drapes.
- Prepare for manual removal: consent, analgesia, positioning, and sterile setup.
Reassess fundal tone, lochia, vital signs, and mental status after each intervention. Keep her informed to reduce anxiety.
2. The provider performs manual removal and the bleeding slows. What ongoing risks and monitoring do you plan for the next 24 hours?
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Ongoing risks: recurrent atony, retained fragments, infection, anemia, and delayed hemorrhage; also fluid overload from rapid resuscitation and, later, Sheehan syndrome or coagulopathy if loss was massive.
Monitoring plan:
- Vital signs and fundal check with massage every 15 minutes for the first hour, then per protocol; document tone, position, and lochia amount.
- Quantify blood loss by pad weight and watch for trickling or clots.
- Track urine output with the catheter and remove it when stable per order.
- Monitor hemoglobin, platelets, and coagulation results; watch for signs of transfusion reaction if products were given.
- Assess for infection (temperature, uterine tenderness, lochia odor) and administer prescribed antibiotics.
- Continue oxytocin infusion per order and verify dose and pump settings.
- Encourage early breastfeeding and skin-to-skin if stable to promote contraction, and provide iron and analgesia as ordered.
Educate Ms. Adeyemi to report increased bleeding, dizziness, or fever. Document estimated blood loss, interventions, and responses.