postpartum hemorrage PPH

[livtek]

What the horrible night shift I had today, but gave me a lot experience for the future. I do not know if I did mistake or not.

Here is the story:

I got admission at 2300, she was G4P3 with light bleeding and firm fundus, she went to bathroom with me twice , had normal bleeding. At 0545 she went to restroom everything was fine, at 0720 she was screaming from room I went to the room with my manager and she opened here sheets and the pt. was in full of blood with big clots. I told here I went with her to the bathroom 1 hour ago and she was fine. We changed here I gave her IV fluids and Methergine I.V. push and she is stabilized. After we changed shifts and I went to manager office to apologize but she told me it is OK it can happened so fast, and gave me advice to never trust multiply mothers, and that I'm still learning, I'm New grad 5 months in the unit. Do you think I did something wrong? I checked her fundus around midnight it was firm, can this PPH happen so suddenly?

[judyblueeyes]

I don't see anything you did wrong.

I suspect her fundus was firm because it was full of blood. I would recommend asking the L&D nurse who delivers the pt to you where the fundus is/was and then checking that yourself while the other nurse is still present. Also, do a very good fundal check to see if you can express anything.

The only time I have had your experience happen to me was a pp twins pt. I thought the high fundus was due to the twin pregnancy (but it wasn't). I wasn't sure and asked for a second opinion from a more experienced nurse. Unfortunately, we were both wrong (but the pt did well).

My motto is "Never trust a pregnant (or recently pregnant) woman". LOL

[Ado Annie, ASN, RN]

I don't see anything you did wrong.

I suspect her fundus was firm because it was full of blood. I would recommend asking the L&D nurse who delivers the pt to you where the fundus is/was and then checking that yourself while the other nurse is still present. Also, do a very good fundal check to see if you can express anything.

The only time I have had your experience happen to me was a pp twins pt. I thought the high fundus was due to the twin pregnancy (but it wasn't). I wasn't sure and asked for a second opinion from a more experienced nurse. Unfortunately, we were both wrong (but the pt did well).

My motto is "Never trust a pregnant (or recently pregnant) woman". LOL

....and don't be too timid! When I was the twin mom bleeding to beat the band, a couple of nurses came and gingerly poked at my belly, but what finally got things under control was the one they brought in who man-handled my uterus. It HURT but got the job done.

[NurseNora, BSN, RN]

The first fundal check I do on a recently delivered patient HURTS. I tell her I'm going to push really hard, just once. If a clot comes out, then I'll do it again until no clot comes out. If no clot comes out, I won't have to push that hard again. Sometimes it just takes really firm pressure to be sure the uterus is empty.

Once you know where her fundus belongs, you don't have to push that hard again as long as she stays at that same level. The really important thing to remember is to be giving firm super pubic pressure at the same time as the fundal pressure so you don't invert the uterus along with the clot. Then you'll really have a PPH to worry about!!

[RNmommy]

Our policy is to do fundal checks immediately post void x3 voids. It's important to note the height AND position of the fundus, as well as lochial flow. If I pt is 4+ hours post delivery and has ANY trickling when I push on her fundus post-void (ESP if multip or large baby), I am concerned and will check her fundus more frequently. Also, a uterus filling with clots will rise above the U over time.

[unikuelady, RN]

I would also like to add that even if the patient states they are voiding ok, check for full bladder. Some patients have a hard time emptying their bladders. I agree with the previous posters advice on not being too gentle for the first assessment. This will come with experience. A good way to get experience is to spend some time with the L&D nurses and observe/practice fundal massage with them.

When you do have a questionable PP hemorrhage.......make sure the patient is in the bed! Its better to have them make a mess in the bed, than pass out on the floor! On Christmas day a few years ago I answered the call light of a patient who was assessed by her nurse just 30 min before I came into the room. Blood everywhere-pph that responded to methergine, IVF with Pitocin, good fundal massage to express the clots. Patient turned out ok. Then after she was taken care of....another new nurse asked me to check her patient...because she thought she was bleeding a little too much. I walked into the room and observed the patient slumped in the bedside chair-blood pouring on the floor-pt very weak/lethargic. Called for help, did the usual routine and this patient ended up needing 3 units of blood. PPH can be very very scary. ALWAYS get help with these patients and you will do fine.

Its also helpful to go over "what-to-do" scenarios in staff meetings to keep your skills current for these emergency situations.:icon_hug:

[RNnL&D]

I agree with the previous posters advice on not being too gentle for the first assessment. This will come with experience. A good way to get experience is to spend some time with the L&D nurses and observe/practice fundal massage with them.

Yes, PP nurses are much "nicer" with fundal assessments. Practice with a L&D nurse and you won't feel bad about "hurting" the pt with a neccessary intervention.

[SmilingBluEyes]

Good advice from the other posters. Fundal checks can't be "gentle" even for csections---you have to be sure fundi are firm, or you may well have a hemorrhage on your hands----even hours after delivery!