Maybe you guys can answer this.... (Kind of long, sorry!)

[Christy1019, ASN, RN]

I've never worked as a nurse in Ob-Gyn (although as a student, I never imagined doing anything else lol), and have been an ER nurse for 4+ years. However, I had a patient in the ED not too long ago that left me with some questions that the ER doc couldn't seem to answer for me, and I can't remember enough from school to answer myself. I'm the type of person & nurse who loves to learn all about anything medical that I'm unfamiliar with, and even the smallest details will stick in my head if left unanswered lol.

Let me start by saying, patient was never unstable, and no specific patient identifying info (name, location etc) will be given. I'm only posting here to get an OBGYN nurses perspective and give me some insight on what I'm unsure of so that if presented with a similar situation in the future, I won't feel so helpless to answer a pt's questions or help them to understand.

I had a young, female pt come to the ED for c/o episode of vag bleeding described as gushing/squirting, bright red blood that saturated 2 pads in short time span just prior to coming, but had stopped upon arrival to ED. Also c/o mild nausea and light cramping, denied any s/s of orthostasis, VS all within normal limits, pt looked healthy, not pale, etc. IV placed, labs drawn for cbc, bHcg, lytes, & coags, and urine preg test done which was negative.

Pt gives hx of uncomplicated, pre-term lady partsl delivery at 21wks gestation due to incompetent cervix that occured 11wks prior and was this pt's first pregnancy. Pt has had multiple follow up appts with her OB since b/c of prolonged post partum bleeding that was described as heavy bleeding every few weeks with lighter bleeding inbetween, but hadn't ever completely stopped since she delivered. Also c/o "stringy, creamy discharge" (I've never heard of "stringy" discharge before), but states her OB said everything was okay & not to worry.

While starting her IV & talking to the pt, she tells me she's worried she has retained POC or something and that she happens to work in medical field as well & says a friend (radiology tech) had done an Ultrasound on her at work or something b/c she was upset her OB hadn't done one. She said her friend saw "something small, resembling tissue at the top of her cervix" (Trust me, I reminded her how techs were not trained to read the results or make a diagnosis as a radiologist would be). And after I spoke with the ER doc, we agreed it was probably a clot which she had been passing as well, and that it was highly unlikely to be any retained POC after 11wks without her being severely septic by now.

ER doc & myself initially thought she might've become pregnant since then and was now miscarrying, despite the negative Ucg, and were waiting for the BHcg results. I assist Doc to perform pelvic exam, he says cervix is closed, he doesn't see much bleeding at this time, and that if her bloodwork came back okay she would be d/c'ed home to follow up with her own OB. Bloodwork comes back, BHcg was negative (so much for my theory lol), hgb is over 12, lytes and coags are all normal. Pt is told this, and subsequently gets d/c'ed with instructions to follow up.

I know this probably seems like a simple enough presentation and likely run of the mill for some of you, but there are a few things that I don't understand...

First, isn't it abnormal to have post partum bleeding lasting 11wks, after a uncomplicated vag delivery? I thought it was supposed to stop around 6 wks or so, and definately not continue to be anything heavy after the first few weeks, or am I mistaken? The doc just shrugged his shoulders when I asked him the same question. Also, is the description of "stringy, creamy discharge" normal post partum? And if so, would it be lasting this long??

Second, I'm quite confident in what I told this patient regarding likelihood of retained POC this long after, w/out any indiciations of infection, but my experience in the ED is usually cases of retained POC found either very soon after a miscarriage/delivery where they have not become septic, OR the other end of the spectrum where they are severely septic because it wasn't caught in time and are now critical. However, have any of you EVER heard of seen anything to the contrary? And if the fetus and placenta are delivered intact, is there even anything besides uterine lining to be retained anyways?

Third, unless the pt's description of this episode of "hemmorhage-like bleeding" that brought her to the ED is completely inaccurate and blown out of proportion, (Which, for the record I don't think was the case, as pt was noted to have dried blood all down her legs & her fiance seemed panicked when I met them), what would cause a woman who has been having continuous bleeding for any prolonged time, to have an acute onset of bright red bleeding described as "squirting/gushing" in any situation other than acute miscarriage or hemorrhage? Especially to stop so abruptly without any intervention?

My personal theory (since the ER doc was no help to me), is that this is something related to a hormonal problem, but I can't explain where all of the blood is coming from, this long after delivery. I mean the uterine lining that was built up to maintain a pregnancy must have been completely shed by now, right? Also, why wouldn't her OB, or even the ED doc bother to do an ultrasound just to make sure there isn't something else going on? Or is that just my non-OBGyn experience assuming that they should? Although I do believe the history given by the patient, I was surprised by her completely normal Hgb. I mean, I personally become anemic during my periods and they never last more than a week! Could any of the bleeding be due to the incompetent cervix (which, by the way, I was completely unfamiliar with that term before this pt), even if the Doc says her cervix is now closed??

Sorry for the length of this post, I just wanted to make sure I didn't leave anything out that could help anyone to answer my questions. Luckily, I am pretty familiar with the majority of ob-gyn related cases that come to the ED, (STD, miscarriage etc), but I've found that anything more complicated than what we see daily, automatically gets consulted by OB who only spends a brief time with each patient, and in the meantime they are left with a bunch of ER staff that really doesn't know a whole lot about the subject, and can't really explain things so that they can really understand what is going on, the way you guys are so good at doing with your patients. And I hate that aspect of ED nursing... we can save a life, fix broken bones, etc without batting an eye, but our business is to "Treat and Street" the majority of patients, and are often so overcrowded & understaffed that we don't always have the luxury to sit and talk with our patients. However, I try to make it my personal practice to make sure each patient undestands what is going on, and won't leave the ED with a bunch of unanswered questions.

My personal satisfaction comes with a patient telling me "Thank you so much for explaining that to me, noone ever said it so I understood it before". Whether we see the results or not, it DOES make a difference when a patient fully understands what is wrong with them, because they are more likely to take care of it and be compliant with treatment when they do. Once, I had an elderly pt who we found to be extremely hyperglycemic (>700), and in the medical record I saw he had been dx'ed with diabetes the year prior... When asked why he wasn't taking his insulin or glipizide, the pt said to me "I took those meds that day like they told me to, and I thought the diabetes would be fixed!" Obviously, this pt had no proper diabetic teaching, which is scary considering they expected him to administer insulin to himself appropriately!

So although some of you might find it silly that a nurse who is not brand-new is asking about lady partsl bleeding, hopefully my explanation for why I come to you guys for some insight will cause some of you to take time out of your day to give your thoughts on this, which I can assure will be greatly appreciated! Thank you in advance, and for taking the time to read this! :bowingpur

[NJNursing, ASN, RN]

That is a pretty complicated case. I have seen the stringy discharge with some pts with std's. She may have a small bit of retained placenta but she would normally just have a steady, continual bleed, not the heavy/light cycle. If the cervix is closed, its not incompetent. She probably needs an exploratory d&c just to make sure, The thing seen at the top of the cervix on the ultrasound could of been a clot that needs to be expressed.

[Christy1019, ASN, RN]

Wouldn't any retained products have caused some sort of infection by now?

[PeepnBiscuitsRN]

After my son was born- stat section, none the less, I had retained POC and I bled for about two and a half months. No I'm not exaggerating, I'm dead serious. It would cycle, it would be heavy and red, can't recall if there was any tissue passed or not, and then it would pink up, and get real light...and then it would pick right up again red. My OB was skeptical, after all, I had had a section, they supposedly clean you right the heck out-unless perhaps a student was performing it (and there was) after about...I want to say 6 weeks they did an u/s, plus a pregnancy test which oddly still read positive, and saw something on the ultrasound. The doc on call suggested a D&C, (plus a couple of units of blood because my HGB was about 8, masked by dehydration from breastfeeding) but my regular OB said I could wait to see if I passed the tissue naturally. So, needless to say I went about a month and a half more before finally having the D&C. No infection, just pesky bleeding and anemia. I realize I'm lucky I didn't develop an infection, but I don't know that retained products from a normal vag 11 weeks ago would be that out there.

[Guest321574]

The stringy description could just have been from the blood mixed with the fertile cervical mucous, since it resembles egg whites, and "stretches." Perhaps she was having her period, and it caught her off guard. After my second child, my periods changed to the point that they are fast and furious, with the majority of the bleeding coming in about 8 hours, and the next 3 days or so are very light/spotting. But I guess that would not explain no active bleeding at the time of the examination...