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• Exhibit light yellow urine with amount consistent with intake and diuresis.
• Exhibit CBC, Hgb, and Hct consistent with blood loss during birth.
• Assess temperature. Normal body temperature may be as high as 100.4 F (38.0 C) during the first 24 hours
following birth. Body temperature increases with fluid volume loss.
• Assess heart rate and respirations. Mild increases in heart rate and respirations can occur from the stress of
birth; however, a consistently elevated heart rate indicates hypovolemia. The body may not compensate with
tachycardia and tachypnea until a volume loss of at least 1000 mL has occurred.
• Assess for patterns/trends that suggest shock. A drop in BP or change in BP pattern, tachycardia, tachypnea,
thirst, restlessness, decreased urine output, etc., are trends or patterns that suggest shock. Other assessments
include decreased capillary refill time; dry, pale mucous membranes; poor skin turgor; and decreased urine
amount, dark color, and concentration,
• Assess type and amount of bleeding. Inspect perineal pads and perineum every 10 to 15 minutes for the first
hour or until stable, every 30 minutes for second hour, or after 1 hour of being stable. After two 30-minute stable
checks assess every 4 hours for 24 hours, then every 8 hours until discharge or condition changes. This provides an
estimate of blood loss and helps with identification of the source or cause of bleeding. Hourly pad saturation or
visual leakage of bright blood from the vagina is an indication of hemorrhage.
• Assess uterine fundus for firmness and placement. Use the same schedule as previous nursing activity, assessing
for bleeding. This determines if the uterus is relaxed or boggy. Uterine contraction is necessary to control bleeding.
Uterine displacement occurs from filling with blood and/or clots, or bladder distention.
• Assess for fluid volume deficit and excess. Fluid volume excess can occur from fluid replacement during
treatment for fluid volume deficit, causing fluid volume overload.
• Assess and report laboratory findings. This includes reporting the CBC, Hgb, Hct, serum electrolytes, coagulation
studies, etc., to the healthcare provider. Medical care decisions are based on this data.
Collaborative Activities
• Administer oxygen as prescribed. Oxygen may be necessary if blood loss is so excessive that it prevents
adequate tissue perfusion to major organs.
• Maintain patent IV access with a large bore intravenous catheter. Fluids will need to be rapidly infused if
hypovolemic shock occurs. Packed RBCs are highly viscous and require a 16- to 18-gauge catheter for rapid
infusion.
• Administer fluids and electrolytes as prescribed. These help reestablish fluid balance and prevent hypovolemic
shock, dehydration, and electrolyte imbalances. Crystalloid fluid replacement maintains intravascular volume and
prevents hypovolemia.
• Administer packed RBCs or other blood products as prescribed. These products prevent hypovolemic shock by
replacing blood volume or blood components and restore oxygen-carrying capacity.
Patient/Family Teaching
• Teach the woman how to palpate her fundus. Include where the fundus should be located, and the need for it to
remain contracted. This knowledge helps the woman understand how to monitor her own uterus so the nurse can
be summoned if she feels her uterus becoming boggy or soft.
• Teach the woman about the type and amount of lochia. This ensures that the woman will recognize excessive
bleeding and report it immediately whether she is in the birthing unit or at home.
• Teach the woman to call for assistance when ambulating. Weakness, hypotension, lightheadedness, and fatigue
may occur secondary to blood loss, placing the woman at increased risk for falls.