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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A nurse is caring for a client who is 6 hours postpartum following a forceps-assisted vaginal delivery. The client reports severe, unrelenting perineal pressure and pain that has worsened over the last hour, despite having received prescribed oral acetaminophen and ibuprofen. Assessment reveals a firm uterus located midline at the umbilicus, with scant lochia rubra. Which of the following actions should the nurse take first?

  1. A
    Delegate the application of a fresh perineal ice pack to an unlicensed assistive personnel (UAP).
  2. Inspect the client's perineal and vulvar tissues.Answer
  3. C
    Perform continuous uterine fundal massage.
  4. D
    Administer a prescribed intravenous opioid analgesic.

Answer

Inspect the client's perineal and vulvar tissues.
The client's presentation of severe, unrelenting perineal pain and pressure, especially after a forceps-assisted delivery, is the hallmark sign of a developing perineal hematoma. Because the uterus is firm and lochia is scant, the pain is not related to uterine atony or normal postpartum cramping. The priority action is to directly inspect the perineal and vulvar area to confirm the presence of a hematoma so that appropriate medical intervention can be rapidly initiated.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has severe, unrelenting perineal pain and pressure following an operative (forceps-assisted) vaginal delivery.
Operative deliveries significantly increase the risk of tissue trauma and hematoma formation.
2
Evaluate the current assessment findings against potential postpartum complications.
The uterus is firm and midline with scant lochia, effectively ruling out uterine atony as the cause of the client's distress.
Establishing that the uterus is contracted helps isolate the source of the problem to the lower genital tract (vagina or perineum).
3
Determine the priority nursing action based on the suspected complication.
The nurse must visually inspect the perineum to look for swelling, bluish discoloration, or a tense mass.
Assessment must always precede intervention when a new, acute complication (such as a perineal hematoma) is suspected.

Key Concept

Recognition and physical assessment of a postpartum perineal hematoma
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Topics

Ante/Intra/Postpartum and Newborn Care

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