04.08 Hematoma

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Overview

  1. Solid swelling of clotted blood within tissues – NOT where it is supposed to be
  2. Rarely life-threatening

Nursing Points

General

  1. As it relates to OB – blood that escapes into areas of mother’s tissues after delivery has occurred
    1. Vagina
    2. Surgical site post c-section
  2. Most commonly associated with assisted delivery (forceps, vacuum) or episiotomy, and  injured blood vessels

Assessment

  1. Perineal pressure (“I gotta poop!”) from the hematoma
  2. Edematous and sensitive perineal area
  3. Shock signs / changes in hemodynamics
  4. Severe pain
    1. Unable to releave with medications
  5. Cannot void

Therapeutic Management

  1. Monitor appropriately for shock and infection (VS, I&O, CBC)
  2. Treat pain
  3. Restore fluids
  4. Administer blood products as indicated
  5. Administered antibiotics; infection risk increased with hematoma
  6. May need hematoma evacuation if large enough

Nursing Concepts

  1. Perfusion
  2. Clotting
  3. Skin Integrity

Patient Education

  1. Notify if unresolved pain
  2. Perineal care after episiotomy
  3. Cold packs or ice pads to reduce hematoma and swelling for first 24 hours.

Reference Links

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Video Transcript

In this lesson I will explain what a hematoma is and how you should provide care for this patient

A hematoma is a collection of blood under the skin. It is caused by trauma so this could be from a vaginal delivery or c-section. In a vaginal delivery trauma to the tissue could be caused by forceps, vacuum or an episiotomy. Any of these can cause trauma to the tissue and cause the vessels to rupture and bleed. In a c-section there could be surgical trauma caused that will cause a hematoma to form because of the bleeding between the tissue. This will cause pain. We have blood where it should not be. The hematoma could resolve on its own with monitoring or it might need to be surgically removed or drained.

Let’s now talk about symptoms for when a patient has a hematoma. The patient might feel a lot of pressure because of the blood filled tissue in the vagina. The pressure discomfort could make them feel like they have to poop because there is pressure on the rectum from this fluid filled sac in the vagina. The patient will have pain that is unresolved with pain medication. Blood is collecting where is shouldn’t be. Tachycardia occurs because the patient is losing blood so the heart is pumping hard to move the low volume. symptoms will involve pain and possibly hemorrhagic symptoms if the bleeding is excessive.There is low blood pressure because of the blood loss and low volume. The hemoglobin is low because the patient is bleeding into a space where it shouldn’t be so the patient is losing red blood cells.

Our management for this patient will be to monitor her for shock and infection. So we need to watch her vital signs, intake and output, and CBC. We need to treat pain as best we can from the hematoma or from surgical removal of the hematoma. Fluids will need to be restored so either blood products of IV fluids will be needed. The patient may need hematoma evacuation if large enough or causing problems. If an evacuation happens of the hematoma then antibiotics might need to be given because it puts the patient at an increased risk of infection since now there is a wound that has been opened.
The patient should be instructed to notify if there is unresolved pain. This will alert nursing to really check for a hematoma. The patient should be taught how to get perineal care after an episiotomy which will include cold packs or ice pads to help reduce the swelling and hematoma. This should be done for the first 24 hours. In this image you can see how trauma can easily be caused by the delivery of the baby. You can see the locations of where an episiotomy would be cut. These spots will be at risk for infection because an instrument has been used to make the cut and trauma occurs which can cause a hematoma at this site. So if a hematoma develops then there will be a collection of blood in this location that would cause the pressure feeling.
A patient with a hematoma will have nursing concepts of perfusion, clotting, and skin integrity.
The key points to really focus on are that hematomas are a collection of blood under the skin. Blood is where it shouldn’t be. Trauma of the tissue is the cause. This trauma could be from forceps, vacuum, episiotomy, or instruments from a c-section caused. Patients will have pain and pressure that goes unresolved with medication and also shock symptoms. Shock symptoms are the hemodynamic changes so low blood pressure and tachycardia. The patient might need to have it surgically removed.

Make sure you check out the resources and images attached to this lesson Now, go out and be your best selves today. And, as always, happy nursing.

Read more

  • Question 1 of 9

A nurse starting the morning shift is caring for 4 postpartum clients. Which client should be seen first?

  • Question 2 of 9

A nurse is caring for a postpartum mother who delivered a baby 3 days ago. On the first day following delivery, the provider ordered a hemoglobin level for the client. The result was 9.9 g/dL. The provider did not list any other orders in the client’s chart since that time. Which response of the nurse is most appropriate?

  • Question 3 of 9

A nurse is assessing a postpartum client who delivered a baby four hours ago. The client had a complicated delivery and suffered a third degree perineal laceration. The nurse notes that the client has a contracted uterus with excessive, bright red lochia. Which of the following actions is appropriate for the nurse to take?

  • Question 4 of 9

A nurse is caring for a postpartum client with a perineal hematoma. Which of the following should be included in her care? Select all that apply.

  • Question 5 of 9

A nurse is caring for a postpartum client with a suspected hematoma. What vital signs would the nurse expect to find?

  • Question 6 of 9

A nurse is caring for a client postpartum who had a stage 3 laceration during her vaginal delivery. What order should the nurse anticipate?

  • Question 7 of 9

The nurse is caring for a client who just delivered a healthy, 7lb 8 oz baby, assisted by forceps. Which of the following statements by the mother in the postpartum period is most concerning?

  • Question 8 of 9

A nurse is caring for a client 24 hours postpartum who is having perineal pain that is unresolved with ibuprofen and oxycodone. What should the nurse’s next action be?

  • Question 9 of 9

A nurse is working on a postpartum unit and is starting the day shift. The nurse is caring for the following clients. Which of the following clients should the nurse see first?

Module 0 – OB Course Introduction

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