SBAR Report to the MD for Mallory’s Postpartum Assessment

QUESTION

You reevaluate Mallory 10 minutes after your initial nursing actions. Her fundus is firm, midline, and 1 fiber breadth below the umbilicus with scant loch. You continue to monitor Mallory and 15 minutes later her fundus is boggy with heavy loch. The fundus becomes firm after massage. Her pulse is 100 bpm and blood pressure is 100/60 mm Hg. You notify the MD and report your findings. Using the SBAR report format, detail the aspects of your assessment finding that you will report to the MD and what orders you would anticipate.

ANSWER

SBAR Report to the MD for Mallory’s Postpartum Assessment

Situation

I am calling to report on Mallory, a postpartum patient who delivered 10 hours ago. She is currently experiencing some concerning changes in her condition.

Background

Mallory had a normal vaginal delivery without complications. Her fundus was initially firm, midline, and 1 fiber breadth below the umbilicus with scant lochia. She was stable with a pulse of 70 bpm and a blood pressure of 110/70 mm Hg.

Assessment

1. Fundus Change:Ten minutes after my initial assessment, I found Mallory’s fundus to be firm, midline, and 1 fiber breadth below the umbilicus with scant lochia. However, 15 minutes later, the fundus became boggy with heavy lochia. I massaged the fundus, and it regained firmness.

2. Vital Signs: Her pulse has increased to 100 bpm, and her blood pressure has decreased to 100/60 mm Hg.

Recommendation

Considering the changes in Mallory’s condition, I believe it’s necessary to involve the MD. I anticipate that the MD may want to consider the following orders:

1. Uterine Assessment: Assess the uterine tone and position to rule out uterine atony as the cause of the boggy fundus.

2. Hemodynamic Monitoring:Monitor Mallory’s vital signs closely to detect any further changes in her blood pressure and pulse rate.

3. Fluid Replacement: Consider intravenous fluid replacement to address any potential hypovolemia due to excessive bleeding.

4. Medication: Evaluate whether medications, such as oxytocin or methylergonovine, are necessary to promote uterine contractions and control bleeding.

5. Blood Count: Order a complete blood count (CBC) to assess for anemia or other hematologic concerns related to excessive bleeding.

6. Consultation: Consider consulting with a maternal-fetal medicine specialist or a hematologist if necessary.

In conclusion, I am deeply concerned about Mallory’s condition, particularly the sudden change in her fundal status and vital signs. Prompt evaluation and intervention by the MD are essential to ensure her well-being and to address potential postpartum hemorrhage. I will continue to monitor her closely and implement any orders as directed by the MD to manage this situation effectively.