Maternity Nursing: Postpartum Q 42
The nurse examines a woman one hour after birth. The woman’s fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse’s initial action would be to:
A. Place her on a bedpan to empty her bladder.
B. Massage her fundus
C. Call the physician
D. Administer Methergine 0.2 mg IM which has been ordered prn.
Correct Answer: B. Massage her fundus
A boggy or soft fundus indicates that uterine atony is present. If uterine atony occurs, healthcare providers should be ready for initial medical management which is directed to the use of medications to improve tone and induce uterine contractions. Massaging the uterus is also effective, as is ensuring an empty cavity. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm, followed by options C and D, especially if the fundus does not become or remain firm with massage.
Option A: There is no indication of a distended bladder since the fundus is midline and below the umbilicus. The diagnosis is made during the physical exam immediately upon conclusion of an obstetric vaginal or cesarean delivery. Direct palpation at cesarean delivery (typically after the closure of the uterine incision) or indirect examination at bimanual examination after a vaginal delivery reveals a boggy, soft, and an unusually enlarged uterus, typically with co-existent bleeding from the cervical os (harder to appreciate at cesarean deliveries).
Option C: Diagnosis of diffuse uterine atony is prompted typically by finding of more than usual blood loss during examination demonstrating a flaccid and enlarged uterus, which may contain a significant amount of blood. With focal localized atony, the fundal region may be well contracted while the lower uterine segment is dilated and atonic, which may difficult to appreciate on abdominal examination, but may be detected on vaginal examination.
Option D: Maternal support with intravenous (IV) fluids is commenced through preferably an u8-gauge, intravenous catheter. A team approach is initiated with the summoning of the needed personnel through a standardized built-in alert system. Medications used for postpartum hemorrhage secondary to Uterine atony include the following: oxytocin (Pitocin) can be given IV 10 to 40 units per 1000 ml or 10 units intramuscularly (IM). The rapid undiluted infusion may cause hypotension; methylergonovine (Methergine) given IM 0.2 mg. Given every 2 to 4 hours. Should be avoided in patients with hypertension; misoprostol (Cytotec): 800 to 1000 mg placed rectally. May cause a low-grade fever. It has a delayed action.