Post-Normal Labor (SVD)
- Estimated blood loss (EBL): normal SVD <500 mL; PPH = >500 mL SVD / >1000 mL C/S; ถ้ามี PPH → active management
- Perineal repair: episiotomy หรือ tear degree (1st: mucosa; 2nd: muscle; 3rd: anal sphincter; 4th: rectal mucosa); ตรวจสอบหลังปิด
- Uterine tone — atony = most common cause PPH; bimanual massage + uterotonics
- Placenta complete? — inspect for missing cotyledon; retained placenta = manual removal
- Neonatal assessment: APGAR 1 min + 5 min; skin-to-skin + early breastfeeding initiation
🕐 One-Day Orders
🔬 Investigation
- Vital signs q15 min x 1h → q30 min x 1h → q1h x 2h (post-delivery monitoring)
- Uterine height + tone q15-30 min — atony detection
- Lochia amount (pad count/saturation)
- CBC ถ้า significant blood loss หรือ EBL >500 mL
- DTX ถ้า GDM
💊 Medication
- Syntocinon (oxytocin) 10 IU IM หลัง delivery anterior shoulder (3rd stage management) — standard of care
- Controlled cord traction + uterine massage
- Perineal wound care: NSS irrigation; iodine 10% dilute if needed
- Analgesia post-delivery:
- Paracetamol 500-1000 mg PO q6h PRN
- Ibuprofen 400 mg q8h (if no CI) — effective for perineal pain + uterine cramps
- Neonatal care: Vitamin K 1 mg IM, eye drops (Tetracycline/Erythromycin), footprint + ID band
- Breastfeeding initiation within 1h of birth — skin-to-skin
🔁 Continuous Orders
🔬 Investigation
- BP q4-6h จน stable และไม่มี pre-eclampsia
- CBC day 1 — post-delivery Hb; ถ้า Hb <9 + symptoms = transfuse
- VDRL, HIV result ถ้ายังไม่ทราบ
💊 Medication
- Iron supplement — Ferrous sulfate 200 mg PO BID x 3 เดือน ถ้า Hb <10 post-delivery
- Stool softener — Lactulose 15 mL OD ถ้ามี 3rd-4th degree tear (prevent straining)
- [PPH prophylaxis ถ้า high-risk — uterine atony,>3 children, big baby]: Misoprostol 600 mcg SL หรือ Ergometrine 0.2 mg IM (contraindicated if HTN)
- [Active PPH]: Syntocinon 40 IU + NSS 500 mL IV over 4h; Misoprostol 800-1000 mcg rectal; Carboprost IM; Bimanual compression; B-Lynch suture/uterine artery ligation if unresponsive
- Discharge: Day 2-3 if lochia normal, BP stable, voiding well, perineum healing