2 Wks Postpartum Bleed in ER - page 2
by flyingchange 8,533 Views | 13 Comments
Hi everyone, Just hoping I can pick your knowledgeable brains because we had a situation last night that I hadn't seen before, but we learned about it in L&D clinical, and all of the things I'd learned about were not done. So... Read More
- 0Jul 5, '11 by CEGI was thinking the same thing about retained products and milk supply.
The only other thing I would add would be a manual exploration of the uterus might be necessary if you were remote from being able to do a D & C. If nothing else you could explore the uterus and perform bimanual compression. Obviously this would be very painful for the patient.
- 0Jul 6, '11 by Esme12 Senior ModeratorQuote from AltraI've seen Methergine given in the ER in a similar situation, but that was with OB present. I can totally picture your ER MDs consulting with OB at the other hospital, and being given instructions to just get the patient to them as quickly as possible. You might also have considered starting 1-2 units of uncrossmatched blood prior to the transfer, if there was time.
If the patient was hemodynamically stable there would be no reason to transfuse her. The increased risk involved with uncrossed blood in a hemodynamically stable would be debateable and possibly contraindicated. Some EMS will not transport blood infusing unless it is accompanied by a nurse or the rig and a Mobile Intensive Care unit and just not an ALS unit. If she was unstable they would have to attempt to stablize her before she is transfered and transfusion prior to transfer would be considered. In order to be transfered there has to be an accepting MD on the other end to orchestrate care from that end and in of course in consultation with the sending MD....according to COBRA/EMTALA rules and regs.
As usual there are many case senarios that can be played out in caring for any patient. When there are inexperienced residents involved it is almost imperitive that the ED nurse can develop the plan of care......thank goodness in the ED there is always an attending ED MD.
- 0Jul 6, '11 by Mec_HappensQuote from LilyRoseRNI was thinking the same thing about retained placenta and breastfeeding. I wonder if the baby was gaining weight.I'm also wondering like the PP if it was a rare clotting disorder, because if she's able to breastfeed, it's probably not retained placenta. The removal of the placenta is what signals the brain's hormones to tell the breasts to make milk, right?
- 1Jul 7, '11 by flyingchangeQuote from ElvishOkay. Yes, I could understand this. She said her placenta was delivered intact but that's not really an exact science, is itEven when we have a hemorrhage from retained frags in the hospital immediately postpartum, we don't like to do pit until all the offending clots/frags are removed. Otherwise you're just spitting into the wind - a uterus contracting but it can't contract all the way because the clots etc. are impeding it.
Quote from Esme12The care provided was completely supportive until we got her transferred to the OB/GYN surgery unit at a neighboring hospital. I feel a lot better about it now, but at the time I felt like we were seriously doing nothing for her. This helped, thanks!The Emergency care of the patient is suppportive, IV, O2, labs, until a D/C is peformed as retained products are the usual cause of late PPH. It is optimal to have the patient transfered to a facility that has OB/GYN services as this is optimal care ans well within EMTALA to a higher level of care.
Quote from ElvishLearn something new every day - I had no idea retained placenta affected milk production...You're right but if it's a smallish piece, or if it's not attached to the uterine wall anymore, it might not impede BFing. Also, the body starts making colostrum as early as the second trimester, so it's not necessarily an all-or-nothing proposition.
Quote from CEGThis was what I expected to see happen. At the most they attempted a pelvic which was challenging because of all the clots, and they determined that the blood was coming from above the cervix... I was thinking "well, yeah"The only other thing I would add would be a manual exploration of the uterus might be necessary if you were remote from being able to do a D & C. If nothing else you could explore the uterus and perform bimanual compression.
Quote from Esme12This makes way more sense now. We did have crossmatched blood available but they decided to just keep her on IV, and this is after her BP bottomed out. I don't know if our EMS would transport w/ blood infusing but that would make it way more complicated. And I guess the same complexity exists for volume expanders like Dextran too. Faster to just keep her stable and ship her out.Some EMS will not transport blood infusing unless it is accompanied by a nurse or the rig and a Mobile Intensive Care unit and just not an ALS unit. If she was unstable they would have to attempt to stablize her before she is transfered and transfusion prior to transfer would be considered. In order to be transfered there has to be an accepting MD on the other end to orchestrate care from that end and in of course in consultation with the sending MD....according to COBRA/EMTALA rules and regs.
Thanks everyone for your replies. L&D nursing was not my strong point in clinical.... I learned a lot from this thread, thanks!!