# A postpartum client who delivered vaginally 12 hours ago after a prolonged second stage of labor reports severe perineal pain rated 8/10 not relieved by analgesics, with significant edema, purple discoloration, and asymmetry of the perineal area. What is the most appropriate initial nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543095 > language: ko > subject: Maternal Newborn Health ## 문제 A postpartum client who delivered vaginally 12 hours ago after a prolonged second stage of labor reports severe perineal pain rated 8/10 not relieved by analgesics, with significant edema, purple discoloration, and asymmetry of the perineal area. What is the most appropriate initial nursing intervention? A 28-year-old woman delivered her first baby vaginally 12 hours ago after a prolonged second stage of labor lasting 3 hours. She now reports severe perineal pain rated 8/10 that is not relieved by prescribed analgesics. Upon assessment, the nurse notes significant perineal edema, purple discoloration, and asymmetry of the perineal area. ## 보기 1. Apply ice packs to the perineal area for 20 minutes every 2 hours 2. Administer the prescribed pain medication and reassess in 1 hour 3. Encourage the client to perform Kegel exercises to improve circulation 4. Notify the healthcare provider immediately about the assessment findings **✔ 정답** **정답: 4** ## 해설 Severe perineal pain with edema and discoloration suggests perineal hematoma, a serious complication requiring immediate notification of the healthcare provider. Other options are inappropriate as initial actions. ## 심화 해설 Understanding the Clinical Presentation The client's report of severe perineal pain rated 8/10 that is unrelieved by analgesics, combined with the physical assessment of significant edema, purple discoloration, and asymmetry, is a classic clinical picture for a developing puerperal hematoma. This is not simple postpartum perineal discomfort. A hematoma represents a collection of blood within the connective tissues of the vulva or vagina, resulting from a ruptured blood vessel following a traumatic delivery. The prolonged second stage of labor is a key risk factor for this injury. The purple discoloration indicates blood tracking into the subcutaneous tissue, and the asymmetry is caused by the expanding mass of the hematoma. The hallmark symptom that differentiates a hematoma from normal perineal trauma is the report of severe, unrelenting pain that does not respond to standard analgesic measures, as the expanding blood collection exerts pressure on surrounding tissues and nerves [1]. Analyzing the Intervention Options The critical decision point here is recognizing that this situation is a medical emergency, not a standard comfort measure. - Option 1 (Apply ice packs): While ice is appropriate for minor perineal edema in the first 24 hours postpartum, it is a conservative measure. A hematoma is an active bleeding event that can rapidly expand, leading to significant blood loss and hemodynamic instability. Applying ice delays definitive treatment and does not address the underlying hemorrhage [1]. - Option 2 (Administer prescribed pain medication and reassess): The client has already reported that prescribed analgesics are not effective. Re-administering medication and waiting an hour would allow a potentially life-threatening hematoma to expand unchecked. This is a dangerous delay in care [1]. - Option 3 (Encourage Kegel exercises): Kegel exercises are beneficial for pelvic floor muscle strengthening in the later postpartum period. In the acute phase of a hematoma, encouraging muscle contractions could increase pressure on the injured vessel, potentially worsening the bleeding and pain. This intervention is contraindicated. - Option 4 (Notify the healthcare provider immediately): This is the correct and most appropriate initial nursing intervention. The assessment findings are indicative of a puerperal hematoma, a potentially life-threatening complication. The case report highlights that prompt recognition and timely surgical intervention, such as incision, drainage, and ligation of the bleeding vessel, are essential for a positive outcome. The nurse's role is to recognize the emergency, stabilize the client by monitoring vital signs for signs of hypovolemia, and immediately escalate the findings to the provider for urgent surgical evaluation and management [1].References (research sources) - [1]Massive Puerperal Vulvovaginal Hematoma Following Vaginal Delivery: A Case Report.Case reportMouna A, Rim B, Khalid F. (2026) · DOI: 10.7759/cureus.108182 ## 임상 시나리오 Clinical Guide: Recognizing & Managing Puerperal Hematoma A puerperal hematoma is an obstetric emergency resulting from a ruptured blood vessel in the vulvar, vaginal, or retroperitoneal tissues following traumatic delivery. Early recognition and immediate intervention prevent life-threatening hemorrhage. Key Assessment Findings - **Pain:** Severe, unrelenting perineal or rectal pain (often 8/10 or higher) not relieved by standard analgesics. This is the cardinal differentiating symptom. - **Inspection:** Significant perineal edema, purple or bluish discoloration of the skin, and visible asymmetry or a palpable mass at the vulva or vagina. - **Systemic Signs:** Tachycardia, hypotension, restlessness, and pallor may develop as blood loss accumulates. Monitor for signs of hypovolemic shock. - **Risk Factors:** Prolonged second stage of labor, operative vaginal delivery (forceps/vacuum), nulliparity, episiotomy, and multiple gestation. Immediate Nursing Actions - **Notify the Healthcare Provider Immediately:** Report the assessment findings (pain level, discoloration, asymmetry, vital signs) without delay. This is a medical emergency requiring surgical evaluation. - **Monitor Vital Signs Frequently:** Assess blood pressure, heart rate, respiratory rate, and oxygen saturation every 5-15 minutes to detect early hemodynamic instability. - **Estimate Blood Loss:** Weigh perineal pads and assess for expanding hematoma size by marking the border on the skin with a pen and noting the time. - **Prepare for Intervention:** Anticipate the need for incision and drainage, possible blood transfusion, IV fluid resuscitation, and surgical exploration. - **Provide Emotional Support:** Explain all procedures calmly, keep the client and family informed, and maintain a reassuring presence during this stressful event. Interventions to Avoid - **Ice Packs Alone:** While cold therapy reduces edema, it does not stop active arterial or venous bleeding and delays definitive surgical management. - **Kegel Exercises:** Contraindicated in the acute phase as increased intra-abdominal and pelvic pressure can worsen bleeding and hematoma expansion. - **Delayed Reassessment:** Waiting to re-evaluate pain after analgesia is dangerous; unrelieved severe pain is the primary red flag for a space-occupying bleed. ## 핵심 개념 - **puerperal hematoma** — A collection of blood within the connective tissues of the vulva or vagina resulting from a ruptured blood vessel after traumatic delivery, presenting as severe unrelieved pain, edema, purple discoloration, and asymmetry. - **prolonged second stage of labor** — A labor phase exceeding 2-3 hours in nulliparous women, increasing the risk for birth canal trauma, including hematoma formation due to sustained pressure on pelvic tissues. - **hallmark symptom of hematoma** — Severe, unrelenting perineal pain unrelieved by standard analgesics, distinguishing it from normal postpartum discomfort as the expanding blood mass exerts pressure on nerves. ## 같은 주제 문제 - [A nurse is assessing a postpartum client 24 hours after vaginal delivery. 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