H & H

[sandseaandstone]

I am five weeks into my orientation in labor and delivery. I have an ER background as well as cardiac stress testing and occupational health. I was able to witness a spontaneous lady partsl delivery yesterday with a hemorrhage afterwards the patient's hemoglobin was 11.6 prior to delivery. The next hemoglobin that was drawn around five hours after delivery was a nine. Today the patient passed the baseball size clot and her hemoglobin is 7.6. The patient denies dizziness but she is very pale she is very tachycardic at about 118 to 140. I feel like this patient should be receiving blood products. How old below does your obstetrical floor let the H&H get before transfusing!?

[sandseaandstone]

I forgot to mention that after delivery this patient did receive two bags of Patosa and she also received one dose of Methergine and she also received 200 µg of Cytotec.

[sandseaandstone]

*Pitocin

[Esme12, ASN, BSN, RN]

New guideline on healthy young people and even open hearts is 7 or under. If the patient is asymptomatic they leave them.

[sandseaandstone]

What about the related tachycardia?

[Esme12, ASN, BSN, RN]

it really depends....for an open heart they will transfuse....a post partum they probably won't. I am not OB savvy some who is will come along. New evidence suggests that transfusion at anything 8 and above isn't beneficial. I was 7.2 after delivery hemorrhage...they gave me the option but they didn't feel it was absolutely necessary. I took iron...forever. I was tachy for a few days but recovered quickly

[sandseaandstone]

She had a midline episiotomy....why is she still having clots of that size if she had all of that pit, methergine, and cytotec? Those size clots are normal? That hemoglobin was drawn this am, long before the baseball sized clot was passed this afternoon. (She was not my patient today)----if she was my patient, should it be reasonable to consider retained placenta, un approximated midline episiotomy or internal lady partsl lacerations?

[klone, MSN, RN]

She could have retained placenta. That would be The primary reason for clots that size. Generally healthy postpartum women don't get transfused unless they're symptomatic.

[sandseaandstone]

Thank you for helping me understand---And just to clarify by symptoms, you mean:: dizziness and what else?

[klone, MSN, RN]

Dizziness, lethargy, inability to get out of bed. That kind of thing. It's been my experience that OB docs have a much higher threshold for allowing low H&H, where in another department, they'd be freaking out. You have to remember that in most cases, you're seeing healthy young women who can easily bounce back from blood loss and/or low H&H. Plus, in most cases, you're already dealing with some dilutional anemia (which is why "anemia" is defined differently in pregnant women than in the rest of the population).

[klone, MSN, RN]

My biggest concern (and is something that is frequently overlooked by the OBs, because that's not where their mind goes) is that retained POC and/or very low crit can cause delayed lactogenesis II, which can really affect longterm breastfeeding outcomes. So if she does have retained POC, it's best to get it fixed ASAP, from a lactation standpoint.

Did they ever do a quick bedside U/S scan to look for placenta? That's what our docs would be doing with a woman who was continuing to have blood clots.

[sandseaandstone]

She did get 3 bags of LR the day prior, so I could see having dilution come into play. No, a bedside ultrasound was not done as of when I left yesterday. I think I understand a little bit better what I am to expect I terms of labs, symptoms and treatment. I am very glad for the responses....it is a fine line between waiting for a woman's body to respond to the low H&H and to be vigilant assessing for symptoms----I'm so glad this forum is here---I really appreciate you guys!