Maternity Nursing: Postpartum Q 4
A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to:
A. Monitor fundal height.
B. Apply perineal pressure.
C. Prepare the client for surgery.
D. Reassure the client.
Correct Answer: C. Prepare the client for surgery.
The use of an epidural, prolonged second-stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding.
Option A: Interestingly, most vulvar hematomas are formed after a normal delivery instead of complicated deliveries. Risk factors for developing vulvar hematoma include instrumental delivery, episiotomy, primiparity, prolonged second stage of labor, macrosomia, use of anticoagulants, coagulopathy, hypertensive disorders of pregnancy, and vulvovaginal varicosity.
Option B: Conservative management usually involves the use of ice packs, local compressions, bed rest, and analgesics. In the event that conservative management has not been effective, surgery may be performed. In fact, conservative management of large hematomas has been found to be associated with a longer period of hospitalization, greater need for antibiotics, and blood transfusion.
Option D: Surgical management includes surgical drainage of the hematoma, evacuation of any clots present, ligation of bleeding points, and the assessment for signs of pressure necrosis (a complication of vulva hematoma). These can be done under local anesthesia. As further blood loss during surgery is anticipated, the necessary investigations such as cross-matching and preparations for a possible blood transfusion should be done.