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DEMOGRAPHIC DATA

Name

: Mrs. Nishanthi.

Age

: 25 years

Educational level

: BA

Husbands name

: Mr. Kumar

Age

: 29 years

Educational level

: B.SC

Religion

: Hindu

Address

: No.82 , kaliamman kovil st,


Saidapet ,chennai

Occupation

: Electrician

Marital status

: Married

Admitted on

: 14.11.2014

IP no

: 32177

Ward

: Post natal ward

Obstetric score

: G2P1L1A0

LMP

: 08.02.14

EDD

: 15.11.14.

Diagnosis

: Retained placenta.

Reason for Hospitalization:


She was referred from saidapet PHC as she delivered the baby but placenta was not
being expelled and was admitted in IOG on 14.11.2014.

FAMILY HISTORY
PEDIGREE CHART:-

key:Male
female

60 yrs

28 yrs

56yrs

baby

25 yrs

29 yrs

2 days
FAMILY HEALTH HISTORY:There is no significant family history of hereditary diseases
SOCIO ECONOMIC HISTORY:She is living in a joint family. Her husband is the breadwinner of the family. She
is living in a house, which consists of all the adequate facilities such as water supply,
drainage and ventilation.
PERSONAL HISTORY:She is a non-vegetarian & not allergic to any foods. She takes habit of drinking
tea and coffee. She sleeps 6 hours at night. Her bowel and bladder habits are normal, no
habit of smoking and tobacco chewing.
MENSTRUAL HISTORY:Age at menarche

: 14

Menstrual cycle

: Regular 3/30 days

MARITAL HISTORY:-

She is married since 11 months. Her marriage is a non- consanguinous marriage.


PAST MEDICAL AND SURGICAL HISTORY:Nil significant
PRESENT MEDICAL HISTORY:She is admitted in IOG hospital on 14.11.2014 as the placenta was not expelled
after the delivery of the baby and was referred from saidapet PHC.
PRESENT SURGICAL HISTORY:Nil significant
PAST OBSTETRICAL HISTORY:S.
YEAR ABORTI
NO
ON
.
PRETE
RM

TYPE
OF
DELIV
ERY

COMPLICA SEX BIR


TION
TH
DURING
WT.
PUERPERIU
M

CONDIT
ION
AT
BIRTH

HEAL
TH
STAT
US

PRIMI

PRESENT OBSTETRICAL HISTORY:S.


YEAR ABORTI
NO
ON
.
PRETE
RM

TYPE
OF
DELIV
ERY

COMPLICA
TION
DURING
LABOUR

SEX BIR
TH
WT.

CONDIT
ION
AT
BIRTH

HEAL
TH
STAT
US

FTNVD

RETAINED
PLACENTA

GOOD

HEAL
THY

2014

3.1

PHYSICAL EXAMINATION.
Appearence

: Builds thin, healthy, fair in complexion.

Mental status

: conscious and oriented.

Health status

: Healthy and mildly nourished.

S.L.
NO.
1.

ASSESSMENT

PATIENT FINDINGS

Hair

Black, shinny hair present equal distribution

2.

Scalp

Infection absent, normal

3.

Eyes

Normal vision, no any other problems. Sclera is


white in colour& conjunctiva looks very pale.

4.

Ears

Normal hearing capacity present. Absence of other


problems.

5.

Nose

Normal placement, airway patency; No


obstruction and congestion.

6.

Neck

Thyroid glands normal, lymph node enlargement.


Range of movements normal.

7.

Lips

Pale in colour, dryness present.

8.

Tongue

coated tongue and dry not hydrated, taste buds are


normal.

9.

Teeths

Normal teeth, Absence of dental carries, flurosis


absent.

10.

Tonsil

Normal

11.

Lymph nodes

Absent

12.

Chest

Symmetrical chest wall movements bilateral air

entry normal, Normal vesicular breathe sounds


pulse rate regular.s1 s2 heard
13.

Breast

Normal in size,Soft in consistency,Primary and


secondary areola prominent,Montgometry
tubercules evident,Nipples erect

14.

Abdomen

Soft bowel movements heard


Fundal height -20 cms

15.

Extremities

Range motion is normal. Reflexes are normal, no


edema or varicose veins.

16.

Genetalia

Clean ,bleeding present

17.

Lochia amount

70-75 ml fishy odour of lochia

18.

vulva

No odema present

VITAL SIGNS
Temperature

: 98.4 degree f

Pulse

: 82 beats / min

Respiration

: 24 breathes / min

Blood pressure

: 100/80 mm/hg

Pain

: 5/10

Height

: 162 cm

Weight

: 5o kg

INVESTIGATIONS
TEST DONE
Haemoglobin
Pvc
Platelet
Blood area
Sugar
Serum creatinine
OGCT
Urine:Sugar
Albumin

PATIENT
VALUE
8.4gms
26%
1.6 lakh
24 mg | dl
92 mg | dl
0.8 mg | dl
9.2 mg |dl

NORMAL
VALUE
13.5 mg | dl
45 %
1.5 5 lakh | mm
20 40 mg | dl
70 150 mg | dl
0.8 1.4 mg | dl
70 120 mg | dl

Nil
Nil

REMARKS
Anaemia
Anaemia
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

MEDICATIONS
Name of Dose
the drug
Tab.
5mg
Folic acid

Route

Action

P|o

Tab Vit 250 mg


c

P/O

Vitamin
Hypervitaminosi
supplement& s
maturation of
blood cells
Synthesis of
collagen
Hypervitaminsis
maintenance
of connective
tissue

Tab.
Calcium

Side effect

Nurses
Responsibilities
Nurse has to
motivate to take
medicine
Regularly
Advice to drink
more water

200 mg
P/O

Formation of
bone
and Hypercalcemia

Check
serum
electrolyte level

Inj.
Metrogyl

100mg

Inj.cipro

100 ml

IV

IV

maintainance
of coagulation
mechanism
antibiotic

antibiotic

Nausea
vomitting
Allergic
reactions
Nausea
vomitting

Maintain intake
output chart

Check for i/o and


weight daily

NURSING DIAGNOSIS

Deficit fluid volume related to excessive blood loss


Ineffective tissue perfusion related to hypovolemia
Anxiety related to the disease condition
Risk for ineffective tissue perfusion related to low haemoglobulin level.
Imbalanced nutrition related to inadequate food intake of iron.
Risk for infection related to an inadequate secondary defenses.

Subjective data: Mother says that she is very tired


Objective data: Client looks dull
Nursing diagnosis : Deficit fluid related to excessive blood loss.
Goal: to improve the fluid volume
s.no
1

Intervention
Monitor intake output
chart and hydration status

Implementation
Monitored intake output chart

Rationale
Provide baseline data

Document the blood loss

Documentation of blood loss done by


weighing pads

To know the actual blo


loss

Monitor vital signs

Monitored vitals
T-98.4 F
P-70/min
R-20/min BP-100/70mmhg

Place mother in
trendlenburg position

Placed in trendlenburg position

Administer iv fluids and

Administered RLand NS

To rule out for shock

Encourages venous ret


and prevent bleeding

cystalloids as per doctors


order

To improve hydration

Subjective data: Mother verbalized that she is feeling so tired.


Objective data: Mother looks dull and restless
Nursing diagnosis: Ineffective tissue perfusion related to hypovolemia
Goal : Mother will achieve normal blood volume.
s.no
1

Intervention

Implementation

Rationale

Assess the mothers


knowledge level

Assessed mother knowledge .

Provide baseline data

Monitor vital signs

Monitored vital signs

Provide further
information

Provided comfortable position and


provided extra pillows

Promote maternal
comfort

Provided oxygen as needed

To increase the saturati


level

2
Provide comfortable
position
3
Provide oxygen as needed
Reassess the client
4

Reassessed the client

To evaluate the nursing


intervention
5

Subjective data : Mother told that she is afraid of her disease condition.
Objective data: Mother looks restlessness , increased pulse rate
Nursing diagnosis: Anxiety related to the disease condition.
Goal: To decrease anxiety level
s.no

Intervention

Implementation

Monitor anxiety level

Mother anxiety level assessed.

Provided positive reinforcement

Provide positive
information

Rationale
Provide basic for care
planning

To decrease anxiety
Intake output and weight was assessed

Monitor ,weight intake and


output

Provide information
Supported the mother
To decrease anxiety

Support the mother


Provide information

Provided information about iron rich


diet

Decrease anxiety after


discharge

Reassess the client

Reassessed the client

Evaluate the interventio

RETAINED PLACENTA
DEFINITION:
Retained placenta is a condition in which the placenta fails to be expelled within 30 minutes
after delivery of the fetus. The main cause is defective decidual reaction (decidua basalis)
leading to absence of line of cleavage through the spongy layer.
Retained placenta means that all or part of the placenta or membranes are left behind in your
uterus (womb) during the third stage of labour. The third stage is delivery of the placenta and
membranes.
The placenta is considered retained if it remains undelivered after 30 minutes of an actively
managed third stage and 60 minutes of a physiological third stage.
INCIDENCE:
About 0.5% of deliveries
CAUSES:
1) Retention of separated placenta:
Atony of the uterus with failure of expulsion of the separated placenta.
Contraction ring leading to hour glass deformity of the uterus.
Complete rupture of the uterus with passage of the placenta to the peritoneal
cavity.
2) Retention of non-separated placenta:
Atony of the uterus leading to absence of shearing mechanism needed for
placental separation.
Defective placentation in which the decidua basalis is either absent or
defective and so the chorionic villi penetrate the uterine muscles.
1) Placenta accreta.
2) Placenta increta.
3) Placenta percreta.

OTHER CAUSES ARE:


Full bladder
Poor management of an active or physiological third stage
Snapped cord
CLINICAL MANIFESTATIONS:
Vaginal bleeding: occurs only if part or the entire placenta is separated.
Uterine atony: the uterus is lax abdominally and if bleeding occurs it will be severe.
Severe shock : Retention of placenta more than 2 hours may cause shock even in absence
of haemorrhage (Idiopathic obstetric shock)
Vaginal examination can detect:
Hour- glass contraction
Absence of plane of cleavage: placenta accreta.
Rupture uterus.
MANAGEMENT:
IMMEDIATE MANAGEMENT:
As soon as retained placenta is confirmed:
In the community setting, dial 999 and arrange transfer to the obstetric unit immediately. Keep a
clear record of the running total estimated blood loss (EBL) during transfer up until handover in
the acute unit. It is IMPERATIVE that the amount of blood loss is communicated to the acute
unit staff on handover.
In the hospital setting and the third stage has been managed physiologically revert to active
management giving 10 IU of oxytocin IM and follow the Active Management of Third Stage
Clinical Guideline.
DO NOT leave the woman unattended whilst the placenta remains insitu
If the placenta is undelivered after 30 minutes consider:
Emptying bladder
Breastfeeding or nipple stimulation
Change of position - encourage an upright position
If bleeding: immediately
Inform Anaesthetist
Insertion of large bore IV (18g) cannula
Insert urinary catheter
Commence/continue oxytocin infusion 20 units in 1 litre / rate 60drops per min
Measure and accurately record blood loss
Prepare and transfer patient to theatre for manual removal of placenta (MROP)

1. Cases of uterine atony:


a) Gentle abdominal uterine massage: To stimulate uterine contraction.
b) Give ergometrin (I.M.): to ensure contraction of the uterus.
c) Brandt-Andrews maneuver: (Controlled cord traction and suprapubic pressure)
to deliver the placenta.
d) Manual removal of the placenta: under general anesthesia.
2. Cases of contraction ring:
Give the patient deep general anesthesia, and then do manual removal of the
placenta.
MANUAL SEPARATION OF THE PLACENTA
Preparation
1. Quickly draw a sterile glove over your existing glove on your dominant hand.
One size larger than the gloves you are wearing may be put on more rapidly.
2. Fold a sterile towel on the mother's abdomen with the opening facing you. Place
your non-dominant hand between the folds of the towel and grasp the uterus
through the abdominal wall. The side of your hand should be around the fundus
and your thumb just above the symphysis pubis.
3. Draw the uterus downward and continue to hold it stable with your hand.
Extraction of the placental tissue and membranes within the uterus
Make a cone with your dominant hand by holding the tips of your fingers and thumb
together. Enter the vagina and gently push against the cervix to open it further, as you go
into the lower portion of the uterus.
If the placenta is not yet delivered
Trace the umbilical cord with your hand as you enter the uterus and move laterally to identify
the edge of the placenta. The membranes at the margin of the placenta are perforated by a
stripping motion downward with the edge of your fingers directed toward the placenta. Be
careful not to push the tips of your fingers against the wall of the uterus, as it is very thin and
easily ruptured.
Insert the side of your hand between the placenta and the uterine wall. Gently use an up and
down motion to establish a cleavage plane and then sweep behind the placenta and separate it
from the wall of the uterus. Move carefully and sequentially from one side to the other around
the back of the placenta, until it falls into your hand.

An analagous model for doing this may be practiced using a very large tangerine. This fruit
separates very easily from its peel. Cut a 1/2 inch strip of the peel off of the fruit from top to
bottom, then cut off the bottom section of the tangerine. Insert the side of your hand with your
baby fingers between the peel and the fruit. Gently use an up and down sawing motion to
separate the fruit from the peel. Proceed around the inside of the peel until the fruit falls into
your hand.

Another useful way to learn this technique, is to scrub in on a Caesarean birth with an
experienced obstetric surgeon. He or she can guide you in the process of the removal of the
placenta after the birth of the baby.
When the placenta is completely separated, draw it gently through the cervix, giving a slight
forward twist of your hand as you enter the vagina, to help peel the membranes off the wall
of the uterus, and also make a smaller bundle of the placenta as it is drawn out of the uterus
and vagina. Use care in making a thicker cord of trailing membranes, then grasp them with
your hand or a ring forceps to draw them out of the vagina without tearing a segment off and
leaving it behind.
Rapidly examine the placenta and membranes to assure yourself that nothing had been left
behind. It may be appropriate to make a second sweep of the uterus to identify, collect and
remove any clots, membranes or small pieces of tissue left behind. Some practitioners will use a
sterile gauze square in their hand to aid in this procedure. If you use a gauze sponge be sure to
keep it firmly in your grasp and remove it from the uterus and vagina.
If the placenta has already delivered

Start on the lateral side of the uterus and conduct the same careful sweep of the inside wall of
the uterus from side to side and top to bottom. Draw any clots or tissue into your hand in the
lower uterine segment, and out through the cervix and vagina.
In the course of your sweep you may find a cotyledon still attached to the inside wall of the
uterus. Use the same careful up and down sawing motion to establish a cleavage plane
between the tissue and the wall, and separate the cotyledon from its attachment. Do not
persist if it does not come away readily. It may be attached to the uterine muscle. Seek
consultation immediately.
You occasionally might also come across tissue which is attached to the inner wall of the
uterus with one or more "strings." Do not attempt to pull these strings out of the uterine wall.
They may be deeply attached into the myometrium. Instead, attempt to pinch them to
separate the cotyledon and remove it, leaving the string(s) behind. While not an easy
maneuver to accomplish, one can also try using two fingers to tear the string, while buffering
the string coming out of the wall with another finger so it does not put stress on the
attachment. This is done by wrapping the string around the two fingers and then tearing it
apart using two fingers. The strings left behind, or adherent tissue not able to be removed,
will later slough off as long as bleeding is minimal.
After removal of the placenta and membranes

Assist the uterus to contract by firm, not vigorous, massage of the uterus through the
abdominal wall. If bleeding is still brisk, immediately beginbimanual compression of
the uterus.
Once you are assured you do not need to enter the uterus again, anoxytocic agent should
be given This is effectively accomplished by an intravenous infusion of Pitocin, followed
by a course of oral Methergine, e.g. 0.2 mg Methergine tablets by mouth every 4 hours
for 6 doses.
Depending upon the degree of invasion of the uterus, it may be appropriate to give the
mother a course of antibiotic therapy.

POST-PROCEDURE CARE:

Observe the woman closely until the effect of IV sedation has worn off.
Monitor the vital signs (pulse, blood pressure, respiration) every 30 minutes for the next 6
hours or until stable.
Palpate the uterine fundus to ensure that the uterus remains contracted.
Check for excessive lochia.
Continue infusion of IV fluids.
Transfuse as necessary.

3. Cases of adherent placenta


In cases of simple adhesion or partial placenta accreta; manual separation and
removal of the placenta is done.
In cases of placenta complete accreta either:
Abdominal Hysterectomy: as a life saving procedure in cases with shock
and severe hemorrhage, especially multiparous patients.
Rarely may we attempt removing the placenta by morecellation.
In young patients and in primigravidas; the placenta may be left in situ to undergo
autolytic changes after cutting the cord short. Antibiotics and thorough
observation are essential. Such a management is unsafe and may hazardous to
many patients

4. In case of rupture uterus:


Laparotomy is performed after administrating blood transfusion and
antishock measures. Placenta is removed from the peritoneal cavity and the uterus
is either repaired (in non extensive tears) to preserve the patient's fertility, or
removed by subtotal hysterectomy, if rupture was extensive with poor patient's
general condition.
WHO RECOMMENDATIONS FOR REMOVAL OF PLACENTA
UMBILICAL VEIN INJECTION FOR MANAGEMENT OF RETAINED PLACENTA:

Umbilical vein injection of saline solution plus oxytocin appears to be effective in the
management of retained placenta. Saline solution alone does not appear be more effective
than expectant management. The difficulties in implementing this intervention are related
to the training of personnel in the technique of giving injections into the umbilical vein.

UTEROTONICS BE OFFERED AS TREATMENT FOR RETAINED PLACENTA:

If the placenta is not expelled spontaneously, clinicians may offer 10 IU of oxytocin in


combination with controlled cord traction.
Ergometrine is not recommended, as it may cause tetanic uterine contractions, which
may delay expulsion of the placenta
COMPLICATIONS OF RETAINED PLACENTA:
1.
2.
3.
4.
5.

Shock: haemorrhagic or idiopathic obstetric shock.


Postpartum hemorrhage.
Puerperal sepsis
Subinvolution of the uterus.
Retained parts of the placenta may later form a placental polyp and give rise to
choriocarcinoma.
6. Complications of the method done to deliver the placenta and complications of
anesthesia.

HEALTH EDUCATION
DIET:
Educated the mother
To take plenty of oral fulids and friut juices
To take iron rich foods

POSTNATAL EXCERCISES:
Adviced to do post natal exercises regularly and effectively
PERSONAL HYGIENE:
Adviced to maintain proper personal hygiene

BIBILIOGRAPHY:
1.KATHARYGN A MAY LAURA, COMPREHENSIVE MATERNITY NURSING,
SECOND EDITION ,JAYPEE PUBLICATIONS
2.MUDALIAR AND MENON, CLINCAL OBSTETRICS,TENTH EDITION
3. REEDER ET ALL, MATERNITY EDITION,NINEENTH EDITION,LIPPINCOTT
PUBLICATIONS
4.WWW.SCRIBD.COM
5.WHO CLINICAL GUIDELINESS FOR PPH AND RETAINED PLACENTA