Fundal check

[Mary C, MSN, RN, APRN, CNM]

Came in to a patient 3 hours postpartum. Fundus 3/u, not rising, but not decreasing with fundal massage. No clots expressed with massage. Lochia moderate, bp 120s-130s/80s and stable; hr 80-100.

I checked the poor patient every hour, and did VS q 2 hours. Called to update provider at 0300 and 0700 (still 3/u, bleeding appropriate), no orders received except for Methergine during recovery (0200). Pt without IV.

Next shift aware (both provider and Nurse). Thoughts?

ETA: Obviously, I am concerned about retained placenta or clots, or even a hematoma. The abdomen was nontender and pt asymptomatic. Just very concerned... I need to sleep (I go back tonight!)

[TonieRN]

Whats her gravida and parity? Whats her bladder doing? How is she feeling?

[Mary C, MSN, RN, APRN, CNM]

G2P2. She was voiding well, her bladder was nondistended, and her fundus was midline. Her skin was pink, warm and dry. She denies dizziness, beyond slight nausea that went away when she ate something.

[NurseNora, BSN, RN]

Where was her fundus for the first 2 hours post partum? Was this a change or had she been high all the time?

Some women just have a big uterus. I've seen it most often with a grand multip or after a really big baby or multiples, but some times it's just an unusually big uterus. Once you've ruled out problems, as you did, it may just be that this patient is at the far end of the bell curve of normal.

[miss81, BSN, RN]

Over the next few shifts, keep an eye on weather she starts producing breast milk. That could be a clue that she has not expelled all the placental parts.

[Mary C, MSN, RN, APRN, CNM]

It was 5/u per the report I was given. She was straight cathed, received methergine because her bleeding was moderate to large and her fundus was boggy, to the right, and 5/u. After the methergine, cathing, and massage, it was 3/u and the bleeding moderate and firm as a rock.

[cnmbfa]

miss81: Great thinking on your part re: milk production. I personally think there are some large clots blocking the cervix. An easy way to sure she uis reasonably OK is to check her H&H. If her fundus is still that high after 24 hours, she might benefit from an ultrasound.

[klone, MSN, RN]

Over the next few shifts, keep an eye on weather she starts producing breast milk. That could be a clue that she has not expelled all the placental parts.

This is a good thought. However, IME, that's something that becomes more apparent over the next few weeks, rather than the next few days. Many women don't have lactogenesis 2 until after hospital discharge. And I see a lot of women with retained POC who still have adequate milk production.