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History/Information: This patient is a 28-year-old female, gravida 1 para 1 abortion 0 living 2 with a history of occasional episodes of asthma. She states she has used her inhaler twice during this pregnancy. Her blood type is A-positive. It is two hours post normal spontaneous vaginal delivery of twins at 36-weeks’ gestation. The twin boys are her first children. The patient experienced onset of Pregnancy-Induced Hypertension (PIH) during early labor with blood pressure readings reaching 150/90 and trace urine protein noted. This condition resolved following epidural anesthesia, and there was no further therapy initiated for PIH. Blood pressure was carefully monitored during labor. A urinary catheter was inserted following epidural anesthesia and removed prior to the second stage of labor. Lab values prior to delivery were within normal limits. Following epidural administration at 4cm dilation, oxytocin augmentation of labor was instituted. Sixteen hours following spontaneous onset of labor, she progressed to a spontaneous vaginal delivery of twin boys, both cephalic presentations. Twin A (Apgar 8/9) weighed 5 pounds, 8 ounces and Twin B (Apgar 7/9) weighed 5 pounds, 3 ounces. She had an episiotomy with partial third degree extension that was repaired under epidural anesthesia. No other lacerations were indicated on the delivery record. Estimated blood loss following delivery was 500mL. Postpartum recovery period was within normal limits. There were no episodes of unusual bleeding or clots. The patient is currently on the Postpartum Unit following transfer from the labor and delivery room. Her husband is at her bedside and their newborns are in the well-baby nursery. She plans on breastfeeding her twins. She desires future fertility. Past medical history: Apparently healthy young woman who has been married for two years. She denies surgery or previous health problems except for occasional episodes of asthma that resolve with inhaler use as needed. Her last inhaler use was six months ago. She denies smoking, recreational drug use, or alcohol use. No known drug allergies. Familial history: Mother: hypertension and adult onset diabetes, Father: myocardial infarction at age 58 Father of Babies: Medical history is unremarkable. Questions: How are the baseline vital signs of a postpartum woman different from those of woman who has not had a baby? What is meant by “cephalic delivery”? The twins were born at 36-weeks’ gestation. Is this expected with twins? Do you anticipate the babies requiring a stay in the NICU? Why? What does the presence of lochia mean? Describe the three types of lochia. Describe the characteristics of expected lochia two hours following delivery. What is the purpose of using ice on the perineum? Why should the nurse massage the uterus? What is the correct method to massage the uterus? How can the nurse have more accurate estimates of blood loss? In the case of a post-partum hemorrhage, how would this be reflected in the vital signs? Why is oxytocin given for post-partum hemorrhage? What does it do? How does inserting a urinary catheter help with postpartum hemorrhage? What is the purpose of an urimeter? What should the pulse oximeter reading of a postpartum woman be? What information does the nurse need to convey to the healthcare provider? How often would you expect to assess this patient? Why is the patient’s oxygen saturation falling? Should the husband leave or stay at the bedside? Why? A patient experiencing post-partum haemorrhage may experience neurological changes if her condition worsens. Why does this happen? The physician orders a combination of Carboprost tromethamine, acetaminophen and loperamide for this patient. What is the rationale for this? What nursing interventions have could you anticipate performing in the case of a post-partum hemorrhage and why?

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