Published May 23, 2007
You are reading page 2 of Is PP Hemorrhage usually pretty obvious???
I was recently called up to the M/B floor to help cath a patient. When I arrived the woman was totally pale and the chux underneath her had a moderate amount of blood. I asked the nurse for a brief report. She said the patient's uterus was well above the umbilicus to the right. They had tried to cath her twice but did not get any return of urine.
They were so focused on one thing (thinking her bladder was full) that they didn't look beyond that.
Being new to the scene I immediately noted the woman's color. I told one nurse to take a b/p (it was 70/50) while I did a fundal check. I expressed about 1000 cc of clots and blood from the uterus (always weigh chux and clots 1cc=1gm). We started two large bore IVs and called for OB and anesthesia. Unfortunately the woman ended up with a hyst after her second surgery.
WOW some seriously eye-opening stories. Thanks for sharing.
Good thread. Thanks everyone for sharing. I am mainly an L&D nurse but float to postpartum occ. I feel competent to proficient in PP, but I still drag in a very experienced person as a second eye--I do that in L&D as well. You should hopefully work in a unit where there is teamwork and a willingness to help each other. It is best for you and best for your patients.
Great thread! Any other tips?? I'm being oriented to PP (from nursery, we are working our way to mother/baby couplet care) and my orientation is pretty much over, with of course no serious complications during orientation! Isn't that the way it always works...at least for me I always have the best, healthiest patients when I'm on orientation:( Good for most of the time, but it would be nice to have some hands on learning too!
NurseNora, BSN, RN
No new suggestions, but I just had a PPH last night. Off going nurse told me the patient had had a very large amount of bleeding about an hour before with a clot 10-15 cm in size. When I went to meet her the first time, she was pale and nonresponsive to questions with lots of blood on the pad. I pushed out a large clot (she became very responsive at that point). I weighed the clot and the pads and she had put out almost 1000cc in that hour. I really wish that the previous nurse had seen the large amount of blood and thought to weigh her pads. From her description of things, I think her blood loss was even higher with that first bleed.
Some Methergine helped the bleeding, although she had a trickle of blood every time I touched her fundus for a while. Her H&H was 6.3 and 19.7. So I spent the rest of the night giving her four units of PRBC's. Her lack of responsiveness was more psychological than physical (she had a complex psycho social history). When I brought the first unit of blood into her room, she was sitting up in bed chatting and laughing with her mother. They don't usually respond to transfusions until after you hang the blood!
Anyway, weigh those pads if you have any question about your patient's bleeding. It's easier to get the MD's attention when you can say that your patient has lost 975 cc of blood by weight, rather than just saying she soaked the pad and had a really, really big clot.
Elvish, BSN, DNP, RN, NP
Very good suggestion!!!
Although I am only a pre-nursing student who aspires to work in L&D, I thought it may be helpful to share my own PP hemorage stories from a patients perspective...
1st hemmorage - First child, normal pregnancy, natural delivery, prolonged crowning (doc not there nurses refused to deliver), cord around neck, blue baby that required resussitation. Discharged from hospital after less than 24 hours (this was in 1994) with no problems. I knew something was not right the first week after delivery when my blood turned bright red and increased. Called doc and was told "your fine, its normal). One more week passes and again bright red and increased... called doc... again told "okay/normal" yet this time the doc is obviously annoyed. Third, forth and fifth week passes with on again - off again bright red flow. I grew so concerned that I just showed up at my ob's office and insisted he see me. He did a vaginal and uterine (pressure) check and said, "YOU ARE FINE" and that this would count as my "6-week check-up". Two days later after putting my daughter in her carseat and preparing to leave the house, I suddenly felt a huge gush come out of my vagina and looked down to find my jeans completely saturated with blood and pooling at my feet. I knew exactly what was happening and thought I was going to die. I calmly layed down next to my daughter's car seat on my bed, elavated my feet above my head and called my mother (less that 5 minutes away) so she could take me to the ER (almost 10 minutes away). I reclined in the passenger seat while sitting on a huge stack of towels on the way to the hospital. I cried and told my mom to tell my then boyfriend (now husband) that I love him and to make sure both of them tell my daughter how much I loved her.... I really thought I was going to die. I began to fade as we pulled up to the ER's curb. I remember them putting me in a wheel chair and seeing the blood-soaked towels I was sitting on. I remember the other patients sitting in the ER's waiting room gasping as the saw the trail of blood that was left behind me as they rushed me to a room. I blacked out as the cut off my jeans. When I came too, I found out that I had a portion of the placenta still inside me (which they got out) and had received a blood transfusion. I do not remember how much blood they said I lot, but they said I was lucky to be alive. The point to me telling this story in hope that any current/future OB's will tell their patients to seek medical attention immedciately if their discharge becomes bright-red and/or increases (which I know you already do) AND to also tell them to seek a second opinon or go to an emergency room if their OB brushes them off and says this is fine. I knew that this was not okay, but as a first-time (and young) mother, I felt like I "HAD" to believe my OB. Man do I know better now!!
As for my second PP hemmorage, it was immediately following the birth of my 3rd child in 2003. The prenancy was complicated after a loss and nearly 4 years of secondary infertility. Diagnosed with incompetent cervix at 22 wks gestation and underwent surgery for a cervical cerclage three days later. Contractions immediately followed surgery and continued... put on mag sul (and given steroids) to stop preterm labor. Send home to strict bedrest while on turb for the remainder of pregnancy. In and out of the hospital four more time (pre-term labor) before being induced (GO FIGURE!! LOL) at almost 39 weeks (large baby). Pitocin did nothing after almost a day and began to see fetal decells (spelling?). Received epi in prep for c/s THEN wham.... contractions came as did baby. Delivered almost 10 pound son who had no problems. Delivery was followed by a removal of a large labial cyst (not bartholins or ?? - can't remember) and external vag reconstruction. PP bleeding was heavy and of concern the entire time. OB left and two nurses continued to monitor me. They kept me in the delivery room out of concern and because I was considered unstable. Uterine pressure was given intermittently to remove clots, but none came out and bleeding continued. There was question as to where the sorce of the bleeding was - uterine, site of cyst, or reconstructed area. It felt like hours went by and I was kept comfortable (codine I believe) and unable to see my baby. I saturated pads continuously and remember it dripping on the floor. They gave me a shot to help clot my blood and it subsequently began to get under control. After a short time, they wanted me to void so they could clean me up, and move me to a PP room. I got really dizzy the second I got up and could not walk (not from epi). Half way to the restroom, blood began to gush out of me. They sat me on the toilet where I passed out. They broke out the smelling salt and put me back in bed while my doc was paged. It was difficult and EXTREMELY PAINFUL to examine me because of the vaginal incisions and stiches. The nurse agrued with the doc while I cried out... she begged him to allow her to give me morphine via shot. She won - THANK GOD! :) It turns out I had a pretty significant uterine tear than need repair and low and behold another transfusion due to blood loss. I later found out (from a nurse) that my nurses had been fighting to have my OB examine me for quite a while before it happened. They felt confident that I was bleeding out. Thank heaven for nurses!!
Sorry so long, but I hope my stories will help someone. I myself am very frightened of experiencing this with a patient once I become a L&D nurse. You can be your bottom dollar I will err on the side of caution and as for second/third opinons if something is abnormal.
MamaMadge, ADN, BSN
Thanks for sharing your stories! Your personal experiences will serve you well when you become an L & D nurse! I think once you have been doing this for a while, if you have to ask yourself "is this too much bleeding?" your instincts are telling you that it IS and you need to take action fast!
You are very welcome MamaMadge and thank YOU as well! In my own personal experience and in many of the post I have read, I have heard too many stories of physician "laziness" -- even when the nurses are CERTAIN there is a problem. Unfortunately for me, I had two OB's (out of four) whom fell in this category and put my life at risk. I cannot say enough for the work that nurses do and for advocating for their patients!!
No not always obvious. You will learn by what your patient does/doesn't do, what you see and gut instinct (and time). The obvious ones are easy, you see it coming with the gushing blood and boggy uterus. The ones I worry about are the ones that aren't obvious because they can go one longer without detection. Signs I find worrisome are NO bleeding and a very tender uterus that was not tender before. Everyone bleeds pp and if someone has no bleeding I am worried about retained clots that need to be expressed.
I had a case of a preciptous delivery, minmal bleeding who had a foley in place, draining well. She had a very tender uterus and immediately became unresponsive, with still no bleeding. This was also several hours post delivery. I called the doc in and he expressed several hundred ccs worth of clots. She got pit, stablized, and bleeding slowed. I went to check in on another pt, came back and asked how she felt. She was dizzy again, her color was terrible and her BP bottomed out. Called the doc back, expressed more clots and we ended up going for an emergency D&C. Several nits of blood later she stablized properly.
If you are ever in doubt about someone,ask a more experienced nurse or physician to check her over.
I think it's great that you are a little intimidated going into OB...my guess is that you will do just wonderfully!!! When new OB/L&D nurses start and are not scared (or know it all), that's when the rest of us get pretty concerned, because those are the ones who (in my experience anyway) don't listen or take the initiative (like you are) to learn and grow in their profession.
As far as PPH, just stay on top of your assessment. If color, level of orientation, fundus, or bleeding seems abnormal, there's a pretty good possibility something is going on. As with everything else in OB, there is no single tried-and-true way to determine if PPH is occuring or not.
Not to sound like a broken record, but you should always nab a more experienced nurse when in doubt. On my unit, all of us pick each other's brains...for opinions, etc...Best resource available, for sure!!!
with post partum hem...you usually get that gut feeling when looking at the patient...most patients will turn pale and one key sign is when doing fundal checks you wont get a lot of lochia back...check after check...and the fundus will be above the umbilicus...and at times...may continue to creep higher and higher up versus coming down....also make sure you know the hx of each pt...usually pts who have had a pp hem in the past will have it again...also those women who have very quick labors and deliver rapidly...as well as those pts who have very big babies....and also...red heads!!
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