Is PP Hemorrhage usually pretty obvious???

Envy · May 23, 2007

You need to be aware of the pt. history--was it a preciptious or prolonged first or second stage of labor, or both. What drugs were used, oxytocin and mag.sulfate. Were forceps or vacuumn extractor used. Is the mother exhausted. If a large, boggy uterus, clots and right red blood may be due to uterine atony. If a firm uterus with bright red blood, steady stream or trickle of unclotted blood may be due to lacerations. If firm uterus with bright red blood, extreme perneal or pelvic pain, difficulty voiding, unexplained tachycardia due to hematoma. Check for decreased systolic blood pressure, reduced pulse pressue and delayed capillary filling time, cold, clammy skin. If the pt shows fear, anxiety or restlessness they may be having pp hemorrhage.

SmilingBluEyes · May 24, 2007

No, it's not always obvious nor immediate. That is why close and careful monitoring and observation by experienced nurses is so critical, and why increasing nurse-patient ratios are dangerous. I have seen people who were apparently "fine" bleed out hours after a delivery. I had a close friend nearly die of hemorrhage secondary to a missed diagnosis of placenta accreta hours after her 5th child was born uneventfully. So no, you can't say it's always or even necessarily usually obvious..... I have seen some pretty horrific cases in just my short 10 years in OB.....cases that that can get by even the most trained eyes, unless we are very vigilant. The above post is excellent in helping you be aware and recognize things quickly when they begin to turn. Experience is the very best teacher, as is the usual case in OB. GOOD question!

azzurra29 · May 24, 2007

Wow, thank you both for the helpful information/answers. Actually, I know from theory that PP hemorrhage can be insidious but I wanted to hear from more seasoned nurses. Wow, I'm still processing all that--especially what this means for new nurses on the unit. The good thing is that the experienced ones can certainly help them out to spot things. Thanks.

SmilingBluEyes · May 24, 2007

It means new nurses on the unit should always be unafraid to follow instincts and ask, ask, ask questions and if need be, drag the seasoned nurses into situations that for whatever reason, seem to be going badly. Nothing wrong with bending our ears or asking for help. That is what we are there to do: help.

shortstuff31117 · May 25, 2007

I'm pretty new to L&D so I feel like you do. In my first month of work I went to check a fundus and blood came spraying out of the patient. That was obvious to me and I got help.

Later on in my training, my preceptor and I had a more subtle hemorrhage. The pt. kind of trickled blood for awhile after her deliver but her vitals were stable. My preceptor and I both pushed on her uterus really hard trying to express clots but never got anything. We figured she probably had a tear that was missed, so we called the doctor. Her partner came and found that she did indeed have a small tear that was oozing but not enough to explain all the bleeding. Around this time the pt. dropped her blood pressure and began feeling dizzy. The doctor was finally able to express some clots and decided to call in her OB backup for a 2nd opinion (she was a family practice doc). The OB came and checked things out and was able to express some more clots, a lot of clots. (Why we werent getting any who knows). After she left the room, my preceptor pushed on the pts. fundus and out came a whole mess of clots...so we went off the the OR for a D&C.

To me this was a pretty subtle hemorrhage because her fundus was always firm...never had an issue with it being boggy.

Sorry this got so long. ALWAYS bring in a more experienced nurse if you are unsure about a pts. bleeding. I have done this a zillion times. It's how you learn. And don't be afraid to call a doctor and tell them that you are uncomfortable with a pts. bleeding and you think they should come check it out. Also remember it sometimes takes awhile for a pts. vital signs to show changes, so you cannot always rely on that.

Hope that helps a little!

azzurra29 · May 25, 2007

Thanks shortstuff. The descriptions really helped me to visualize things a bit more.

Question: when you say the pt trickled blood for awhile, what exactly do you mean? That is, what exactly are you seeing when you examine the pt? This is one thing I haven't really understood.

Another question: I read somewhere that pushing too hard on the uterus can cause uterine rupture... is that true..? or what exactly do you mean when you say you pushed hard?

Thanks.

shortstuff31117 · May 26, 2007

I guess when I say trickled I mean by looking at the pads you could tell she was trickling blood. It wasn't like blood was spraying out when we massaged her fundus or just running out of her in general, it was just slowly coming out over time. I think we ended up with 4-5 chux pads with a pretty good amount of blood on them. I imagine this is where it can get confusing because she was bleeding yet her fundus was always firm when we checked it. So in my mind I would think that the uterus was contracting and therefore clamping down over that placenta spot, but I guess it doesnt always work that way.

When I say pushed on the fundus I mean that in order to try and express any clots you have to push pretty hard on the top of the fundus to do this. This is what I was taught to do at least the first few times I'm checking a fundus after delivery. You always put your other hand down near the pubic bone to anchor the uterus while you push too. Maybe this is not standard practice? I dont know!

Maybe someone else has an answer about the uterine rupture thing???

NurseNora, BSN, RN · May 30, 2007

You are unlikely to rupture a post partum uterus with pressure, it's fundal pressure on an undelivered uterus that's likely to rupture it. Before delivery, the uterine wall is very thin and giving fundal pressure to help push the baby out can tear it. That's why no on gives fundal pressure anymore. But after delivery, the uterine walls are thick again and rupture is unlikely.

Giving superpubic pressure while doing fundal massage is standard practice. All the tissues have stretched with the delivery along with the ligaments that hold the uterus in place, so it's not difficult to push the uterus out of the lady parts. Not a good thing to happen!

If you have any thoughts that your patient is bleeding too much, be sure to start a pad count. Soaking more than one pad per hour is too much. You can also weigh pads and clots to get a better estimate of the actual blood loss.

MamaMadge, ADN, BSN · May 30, 2007

I was going to repeat what NurseNora said. When in doubt, start a pad count and weigh pads and chux. Chart this information carefully and you will have the clinical picture for the care provider.

I was told by a doc once that you cannot push hard enough on a post partum uterus to rupture it...but you must support the lower uterine segment just above the pubic bone while doing this.

Another good point to remember is that vital sign changes can sometimes be the LAST sign of hemorrhage! Don't be falsely reassured by stable vitals! Always get your shift lead or an experienced RN to double check anything questionable.

GOOD LUCK!

Elvish, BSN, DNP, RN, NP · May 30, 2007

The last PP hemorrhage I saw was a precip delivery (clue#1) on a multipara (clue #2) and our OBs are known to yank on the cord to get the placenta out:angryfire. (clue #3) Anyway.

Her first 3 checks were fine, fundus firm, VS good, got up to pee. About 10 minutes after the last check, they're on the call bell sounding panicky. I go in & there's blood flowing from this poor woman's lady parts. So needless to say I called for help & we got on the phone with the docs. So we're massaging & getting some big clots while waiting for MDs. We got some Pit going (standing orders for that) & OB comes in to do a manual extraction...lo and behold, out comes some more placenta & membrane, along with some more big honkin' clots.

It has been my experience that if pt is bleeding and at the same time complaining of really bad uterine cramping/contractions, it's usually bc the uterus is trying to expel a clot or fragment or something.

Never never never be afraid to ask someone to help, or even just have a second set of eyes take a look at the pad.

AfghaniPrinzess · Jun 8, 2007

Hi, I had a post op c-section the other day and she actually had no signs of a PP hem except that she felt very nauseated and kept vomiting. This can easily be overlooked because you would think post op c-section pts would have some nausea. however, I gave her several different nausea meds and she kept on vomiting...so i decided to keep her on our unit longer rather than take her over to post partum even tho the other nurses kept telling me to take her over... because something just didnt seem right....her fundus was firm...she had a normal amt of lochia...but the fact that her vomiting did not resolve and just the way she "looked".....told me to keep her longer....so then during one of my checks i lift up the blanket and there is clots and clots and blood EVERYWHERE...i had just checked her 15 mins prior and she had just a small amt of bleeding.....

so i guess what im trying to say is sometimes its just the feeling you get....and other times it may not be the obvious signs like a boggy uterus....in my case the pt being nauseated and vomiting despite being giving nausea meds signaled me to a possible hemorrhage waiting to happen...so you just have to be alert and if you suspect a patient may hemorrhage (if possible) try to keep the pt on L & D till whatever they are experiencing is resolved.

Hope that helps a bit... :)