NU 631 Unit 8 maternal morbidity case review example

Systems Review of a Delayed Response to Postpartum Hemorrhage After Vaginal Birth

Student Name

Department of Nursing, Herzing University

NU 631: Healthcare of Women across the Lifespan

Instructor Name

March 16, 2026

Systems Review of a Delayed Response to Postpartum Hemorrhage After Vaginal Birth

The Case in Sequence

This review concerns a composite case built for teaching. Ms. A., a 33-year-old Black woman having her second baby, was admitted in spontaneous labor at 39 weeks to a community hospital with about 1,200 births a year. Her pregnancy was uncomplicated. Her admission hemoglobin was 10.6 g/dL. Her hemorrhage risk assessment on admission was recorded as low.

Hour 0, 21:40: vaginal birth after an eight-hour labor. The placenta delivered complete at 21:52. Oxytocin infusion started. Estimated blood loss, recorded by visual estimate, 400 mL.

Hour 0.5, 22:10: the nurse caring for Ms. A. was also caring for a laboring patient in the next room. Ms. A. told the nurse she felt "lightheaded and not right." Vital signs: heart rate 108, blood pressure 118/72. The fundus was recorded as firm. The nurse documented the symptoms as anxiety and fatigue and planned to recheck.

Hour 1.25, 22:55: the next vital signs were taken 45 minutes later, not the 15 minutes the unit policy required in the first hour. Heart rate 124, blood pressure 102/60. Pads were saturated. The nurse massaged the fundus, found it boggy, and called the midwife, who was at a delivery on another floor.

Hour 1.6, 23:15: the midwife arrived, estimated blood loss at 900 mL, gave misoprostol, and called the obstetrician on call from home. Hour 2.3, 00:00: the obstetrician arrived. Quantitative blood loss by weighing pads and drapes was 1,700 mL. Hemoglobin 6.8 g/dL. Two units of red cells were given; the blood bank took 40 minutes to release them because the type and screen had not been sent on admission. Ms. A. was transferred to the operating room for examination and removal of retained membranes, received a total of four units of blood, and recovered without hysterectomy or intensive care admission.

Recognition

At 22:10, the knowable facts were a heart rate of 108 and a patient reporting that she felt unwell, with a normal blood pressure and a firm fundus. Tachycardia is often the first sign of significant blood loss, and blood pressure may remain normal until substantial volume has been lost, particularly in young healthy women. The visual blood loss estimate of 400 mL was likely an underestimate; visual estimation is known to be inaccurate, and quantitative measurement is recommended (Main et al., 2015). The unit did not use quantitative blood loss routinely. The attribution of her symptoms to anxiety was the decisive recognition failure, and it was made without a recheck of vital signs at the interval the policy required.

Escalation

Escalation occurred at 22:55, 45 minutes after the first abnormal sign. The unit had no maternal early warning criteria that would have triggered an automatic call at a heart rate above 110 or a patient's statement of feeling unwell. The midwife was on another floor, and the obstetrician was on call from home 20 minutes away. The hemorrhage protocol, which existed on paper, was not activated until the obstetrician arrived; no one on the unit was designated to activate it.

Communication

The nurse was assigned to two patients, one in active labor, in the first hour after Ms. A.'s birth, when one-to-one care is recommended. The handoff from the delivering midwife to the nurse did not include a statement of Ms. A.'s low admission hemoglobin, which would have reduced her tolerance for blood loss. Ms. A.'s own report of feeling unwell was not treated as clinical information.

Resources

Blood was delayed because a type and screen had not been sent on admission, which the hospital's policy required only for patients rated medium or high risk. Her low-risk rating did not account for her anemia. A hemorrhage cart existed but was missing misoprostol, which had to be retrieved from pharmacy.

Disparities

Pregnancy-related mortality among Black women in the United States runs roughly threefold higher than among White women, and review committees judge a large share of these deaths preventable (Petersen et al., 2019). Severe maternal morbidity shows similar gaps, and differences in the quality of care received are part of the explanation (Howell, 2018). This review asked whether Ms. A.'s care differed. Two findings suggest it may have: her report of feeling unwell was attributed to anxiety without further assessment, and her anemia, more common in the hospital's Black patients, did not change her risk rating. The review also noted that Ms. A. was not asked, before discharge, how she experienced her care, which is now part of the unit's debriefing practice after any hemorrhage. The review cannot prove that race influenced these decisions, but it cannot dismiss the possibility, and the hospital's data on time to escalation will be examined by race and ethnicity.

Recommendations, With Owners and Timeframes

1. Adopt quantitative blood loss measurement for all births, with scales and training. Owner: nurse manager. Timeframe: 90 days. 2. Implement maternal early warning criteria, including a patient's report of feeling unwell, with automatic notification of the provider. Owner: obstetric quality committee. Timeframe: 120 days. 3. Revise hemorrhage risk assessment to include anemia and repeat it at delivery and at transfer to postpartum care, with type and screen sent for every admission. Owner: medical director and laboratory director. Timeframe: 60 days. 4. Protect one-to-one nursing in the first hour after birth through staffing rules. Owner: director of nursing. Timeframe: 90 days. 5. Stock and check hemorrhage carts daily. Owner: charge nurse each shift, audited monthly. 6. Run quarterly hemorrhage drills that include the on-call obstetrician. Owner: unit educator. These align with the national consensus bundle for obstetric hemorrhage, which addresses readiness, recognition, response, and reporting (Main et al., 2015).

What Was and Was Not Known

At 22:10, the nurse knew of mild tachycardia and a patient who felt unwell; she did not know the blood loss was greater than recorded, because the unit's method could not tell her. The review therefore does not conclude that the nurse should have known; it concludes that the system gave her too little information, too much workload, and no rule that would have made escalation automatic.

References

Howell, E. A. (2018). Reducing disparities in severe maternal morbidity and mortality. Clinical Obstetrics and Gynecology, 61(2), 387-399. https://doi.org/10.1097/GRF.0000000000000349

Main, E. K., Goffman, D., Scavone, B. M., Low, L. K., Bingham, D., Fontaine, P. L., Gorlin, J. B., Lagrew, D. C., & Levy, B. S. (2015). National Partnership for Maternal Safety: Consensus bundle on obstetric hemorrhage. Obstetrics & Gynecology, 126(1), 155-162. https://doi.org/10.1097/AOG.0000000000000869

Petersen, E. E., Davis, N. L., Goodman, D., Cox, S., Mayes, N., Johnston, E., Syverson, C., Seed, K., Shapiro-Mendoza, C. K., Callaghan, W. M., & Barfield, W. (2019). Vital signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR. Morbidity and Mortality Weekly Report, 68(18), 423-429. https://doi.org/10.15585/mmwr.mm6818e1