An unexpected pressure injury

11 May 2018 | Pressure Injury Prevention

Kate shares her story of getting an unexpected pressure injury following the birth of her baby.

On the day of her elective caesarean, Kate was focused on getting through the surgery safely with a healthy baby.

‘I arrived at 7 am and was prepped for surgery as my baby was breech, but I was left waiting for several hours due to other emergency presentations. By this time, I had started to go into labour and when the umbilical cord prolapsed I was whisked into theatre for an emergency caesarean.’

She delivered a beautiful healthy baby girl in 45 seconds but had to face other complications; a torn bladder meaning a catheter was put in place. The postnatal wards were full, so she was kept in the delivery suite overnight.

‘When I finally made it home, I noticed the skin over my tailbone was extremely tender and hot to touch. It took a couple of days but the skin turned hard, like the top of a large blister and eventually peeled off.’

‘I later discovered that this was a pressure injury and that it was totally preventable. In sharing my story I’m not attaching blame to the care I received. I was fortunate: this was a relatively minor injury and it healed quickly.

Kate now knows the injury occurred because she was immobile for many hours whilst recovering from the surgery, in a bed that wasn’t appropriate. The bed in the delivery suite was a plastic mattress covered by a thin sheet. It may have been appropriate for short term delivery but it was very uncomfortable for a long duration and this was not checked by staff at the time. Kate should have been given a more appropriate bed and also assisted to change her position at regular intervals so that pressure didn’t build in one place.

Kate says that the lesson she’d like to pass on is that ‘any time spent under similar circumstances puts anyone at risk, even a healthy, mobile person like I was, and needs to be monitored, and action taken to prevent and manage the injury.’

Pressure injuries are preventable and raising awareness of risk factors and simple steps to take to prevent them will minimise harm and discomfort for patients.

Gabrielle Nicholson, project manager for the Health Quality & Safety Commission’s pressure injury prevention programme says there are globally recognised ways to reduce the risk and impact of pressure injuries.

‘The SSKIN bundle, for example, provides a useful way to make sure all of the correct steps are taken to prevent pressure injuries from occurring.’

The SSKIN bundle includes the following steps:

  • Surface – provide a supportive and pressure-relieving surface
  • Skin inspection – undertake regular checks for discolouration and pain on bony areas (such as hips and heels) and under or around medical devices
  • Keep moving – change position often
  • Incontinence – keep skin dry and clean
  • Nutrition – eat healthily and drink plenty of fluids.

A great starting point for all health professionals, carers and people giving and receiving care is the Guiding principles for pressure injury prevention and management in New Zealand published in 2017 and available on the ACC website.

Last updated 11/05/2018