2 Wks Postpartum Bleed in ER

[flyingchange]

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 I am looking to understand the "real world" a little bit better :)

We had a G1P1, 2-weeks-postpartum, breastfeeding mom present to triage passing fist-sized clots. Soaked 4 pads within the hour. HR ~170, BP 130/90. Got her back to a trauma room and in bed between all the clots. She denied any pain or cramping. Fundus was midline, 1" below umbilicus and boggy. Pt states she wasn't doing anything unusual when the bleeding started.

So what I'd *expected* to see in her management was something to promote uterine contractions (oxytocin or massages or something), but really what it looked like to my inexperienced eyes was symptom management until we could get her transferred out to the ob/gyn unit at another hospital.

We had some new residents in last night so I wondered if that was the reason, but they relied very heavily on RN advice (wrt stuff like inserting 18ga AC IVs, running NS at a bolus instead of at the ordered 100cc, and at one point she crashed to 70/50 and the RN went to put her on an NRB and the resident asked her why because she was satting 100%). Anyway the orders were very symptom focused (8 mg Zofran was the only drug we gave), blood type and screen, NS "at 100cc" which turned into 2L bolus. Then she was transferred.

So that's what happened last night in our small ER and I was wondering what this situation would have looked like if it was managed by L&D nurses and OB/gyn docs?

[Mec_Happens]

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?

I was thinking the same thing about retained placenta and breastfeeding. I wonder if the baby was gaining weight.

[flyingchange]

Even 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.

Okay. Yes, I could understand this. She said her placenta was delivered intact but that's not really an exact science, is it :)

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.

The 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!

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.

Learn something new every day - I had no idea retained placenta affected milk production...

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.

This 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"

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.

This 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.

Thanks everyone for your replies. L&D nursing was not my strong point in clinical.... I learned a lot from this thread, thanks!!