fundal checks

Specialties Ob/Gyn

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What is the protocol for fundal checks on c-section pts? As far as frequency goes?

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

You SHOULD palpate fundi on post op patients. It's not always apparent any other way but to check. I had a bad pp bleed on a c/s patient 3 hours out, the other day......and vigorous massage plus methergine/hemabate were all that saved her and me. Sometimes, post op C/S patients get boggy, too. I know this from experience. It's painful, but you have no choice sometimes.

Specializes in Community, OB, Nursery.

I usually tell my c/s moms to take a deep breath while I'm palpating. That at least distracts them while I'm doing that. I know it's not fun so I don't press any harder than I have to. If fundus is firm @u or below I stop. If it's boggy at all, I massage. To my mind there's really no other way to tell what the uterus is doing unless I palpate. And I'm NOT documenting that it's firm unless I've seen for myself.

Specializes in Midwifery.
You SHOULD palpate fundi on post op patients. It's not always apparent any other way but to check. I had a bad pp bleed on a c/s patient 3 hours out, the other day......and vigorous massage plus methergine/hemabate were all that saved her and me. Sometimes, post op C/S patients get boggy, too. I know this from experience. It's painful, but you have no choice sometimes.

I disagree! There are other ways of monitoring a womans condition. I'd be interested to see research that supports fundal checks on any postpartum woman ( after the intial post birth period) - as far as I know there is none. We've all had post section women bleed - and in that instance fundal massage is a must if the uterus is atonic!

If a post section woman has dodgy obs and lots of abdo pain check her fundus - she may have one up to her boobs full of clot - but routine poking of the uterine fundus on section women is overkill and painful.:heartbeat

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

We must agree to disagree. The reason I say this, is, the other ways you monitor, (change in vital signs or how a patient feels) may indicate bleeding that has been active already too long, and possibly becoming pathologic. You cannot wait until a person is symptomatic or her vital signs change before you do something. By then, she has lost too much blood already, and will likely need a transfusion. Why on earth not prevent this by a simple fundal check and massage PRN, is beyond me. If I had not been checking my patient the other day, she may have been in DEEP trouble by the time her vital signs or any other changes alerted me to the problem. As it was, she still needed blood to get back to normal. I shudder to think what may have happened if I had NOT checked her fundus. I stand by what I say.

We have had 3 women post-op bleed badly after their c/s in the last month alone. Two of them were due to poor contracting of their uteri post-op. Also, these two had to be transfused, one with 4 units of blood. This is enough personal anecdotal experience for me not to change practices. Pain is inherent in having a c/s. I had my fundus palpated and massaged after my own c/s, and know how painful it was, but I would rather have pain than bleed out.

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
I usually tell my c/s moms to take a deep breath while I'm palpating. That at least distracts them while I'm doing that. I know it's not fun so I don't press any harder than I have to. If fundus is firm @u or below I stop. If it's boggy at all, I massage. To my mind there's really no other way to tell what the uterus is doing unless I palpate. And I'm NOT documenting that it's firm unless I've seen for myself.

I could not agree more. Thank you.

We must agree to disagree. The reason I say this, is, the other ways you monitor, (change in vital signs or how a patient feels) may indicate bleeding that has been active already too long, and possibly becoming pathologic. You cannot wait until a person is symptomatic or her vital signs change before you do something. By then, she has lost too much blood already, and will likely need a transfusion. Why on earth not prevent this by a simple fundal check and massage PRN, is beyond me. If I had not been checking my patient the other day, she may have been in DEEP trouble by the time her vital signs or any other changes alerted me to the problem. As it was, she still needed blood to get back to normal. I shudder to think what may have happened if I had NOT checked her fundus. I stand by what I say.

We have had 3 women post-op bleed badly after their c/s in the last month alone. Two of them were due to poor contracting of their uteri post-op. Also, these two had to be transfused, one with 4 units of blood. This is enough personal anecdotal experience for me not to change practices. Pain is inherent in having a c/s. I had my fundus palpated and massaged after my own c/s, and know how painful it was, but I would rather have pain than bleed out.

THANK YOU! :bow: This is exactly what happened to me....I ended up needing 2 separate transfusions and went into shock. Two and one half days after my c-section, I had to have one nurse on each side of me hold my knees back to my ears while the OB on call was almost elbow deep inside of me pulling clots out (unmedicated, I might add--it was an emergency). I'll gladly take the pain of a fundal massage any day over what I went through. With my second baby, I was happy to have the nurses do the fundal checks, no matter how painful! Childbirth isn't easy and if I make the decision to have a baby, I'll go through what's necessary to make sure I'm healthy and alive to see him grow!!!!!!

Specializes in Midwifery.

We will have to disagree SMBEs - my "anecdotal" evidence is the opposite.

Your woman still had the PPH; still needed transfusing- so did the fundal check prevent it from being nasty or did the drugs and the uterine massage do that? To me they are two separate issues; my point is that regular palpation (to check for "bogginess") of the uterine fundus doesn't prevent PPH; some people obviously believe it can add to picking it up earlier, but I think that's debatable. Now massaging a boggy fundus that is bleeding is a different story!!

And i agree it is better to pick something up before it gets too bad - not sure how well fundal checks do that though!

Specializes in Community, OB, Nursery.
We will have to disagree SMBEs - my "anecdotal" evidence is the opposite.

Your woman still had the PPH; still needed transfusing- so did the fundal check prevent it from being nasty or did the drugs and the uterine massage do that? To me they are two separate issues; my point is that regular palpation (to check for "bogginess") of the uterine fundus doesn't prevent PPH; some people obviously believe it can add to picking it up earlier, but I think that's debatable. Now massaging a boggy fundus that is bleeding is a different story!!

And i agree it is better to pick something up before it gets too bad - not sure how well fundal checks do that though!

This is interesting to me. How do you pick something up before it gets bad if you're not checking the fundus? To me, fundus and lochia are two things I check at pretty much the same time. I'm not arguing w/ you, though, Oz. I just really want to know. We are, it seems, talking about different practice standards and I'm genuinely interested in what you assess if you're not assessing the fundus.

Specializes in Midwifery.

Yep different practices and can I say it's not just something I choose to do - no dr or midwife or nurse in our unit palpates fundus' on post section pts routinely; it seems to be something that is more common in Australia and the UK. And having said that I can only remember a handful of section women having trouble with PPH (once back on the ward that is) in many years.

Heres what we do as routine with our women post section:

They are recovered in OT for an hour or so post op

The come back to the ward with an oxytocic infusion going which we titrate to lochia amount

Obs are done 1/2 hrly by 2 hours then hrly by two (they usually have a pca so are done hrly for 24 hours).

We check pad, pain level, drain output (not many have drains), wound for ooze; the usual.

So I have no idea how different that is to what you guys do ?

So how often do you do fundal checks? See to me unless you have your hand on that fundus constantly; by the time you feel a boggy fundus its too late....the risk of PPH has already happened - I don't think I'm making sense....

Specializes in Midwifery.

And to add - not sure if this makes any difference. Most of our section babys come out to the ward with their mothers. So our women are encouraged to be fairly active from the word go. Not saying we expect them to get straight up of course! But they are often sitting up breasfeeding fairly soon so maybe that encourages the lochia to flow rather than pool??

Specializes in Community, OB, Nursery.

No, you're making sense. ;)

We get our c/s moms out to the floor generally 1-1.5 hrs post-op. What goes on back in recovery I don't know so much, but we do q30min x 3, then q4h x 48h, then q8h. Our scheduled c/s get duramorph, which we have to assess RR every hr x 12hr, then q2h x 12 more. Our standard IV infusion is D5LR or NS with 20u Pit going at 125ml/hr. Pit only goes in the first 2 bags. We don't titrate Pit out on the floor though. That's one difference but I'm not sure that that's the dealbreaker. I don't think I've ever seen a drain on a fresh c/s pt; you said y'all don't do it much either.

Honestly, I don't see many PPHs in c/s moms either. (Knock on wood. :)) I'm not sure whether I've just gotten lucky, in which case, please let's keep that going, or what. We have had pts (fortunately not MY pts) that have had massive clots blocking the cervical os and there's no way we would've known had we not been checking the fundus. Now, if you get a pt w/ absolutely zero bleeding on the pad, would that be an indication for you to check?

Again, I'm not trying to come across as snarky. I find this really interesting, and if your outcomes are not any worse than ours, then I think it's worth looking at. (Incidentally, I'd bet the c/s rate in Oz is much better than it is here.)

Specializes in Midwifery.

Honestly, I don't see many PPHs in c/s moms either. (Knock on wood. :)) I'm not sure whether I've just gotten lucky, in which case, please let's keep that going, or what. We have had pts (fortunately not MY pts) that have had massive clots blocking the cervical os and there's no way we would've known had we not been checking the fundus. Now, if you get a pt w/ absolutely zero bleeding on the pad, would that be an indication for you to check?

Again, I'm not trying to come across as snarky. I find this really interesting, and if your outcomes are not any worse than ours, then I think it's worth looking at. (Incidentally, I'd bet the c/s rate in Oz is much better than it is here.)

Yes definitely - gentle checking with no loss - but not that often. No I know your not being snarky - this is truly interesting and its good to reflect I think. Certainly has had me doing so. And unfortunately our section rates are yucko too - 25-30%! Although we do I think probably use less oxytocic generally. For augmentation that is.

Interestingly we used to go over board with fundal checking on SVDs - we now only do that once per shift - I suspect that will decrease as time goes on too in low risk women.:redpinkhe:redpinkhe

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