PP Hemorrhage (long)

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I responded to an earlier thread re: experiences in 1st year as an L&D nurse and this got me thinking about a PP Hemorrhage situation I was involved in a couple months ago that I still have some questions/concerns about ...

G2P1 comes in from ER complete/+1, SROM at home earlier with thick mec, I am the only nurse available at bedside with 1 OB tech, get pt in bed, cannot find FHTs (at all!), searching searching searchign for FHTs for about 3 mins(thinking of other things that need to be done), attempt to place ISE, FOB states "ummm yeah, we have a birth plan and we do not want any internal monitors", OH CRAP!, explain risks blah blah blah, they still refuse. I call for any doc availabe for delivery. (This was a midwife pt, she was not there yet).

Midwife walks in moments before delivery and takes over. I inform unable to find FHTS, thick mec, no IV access. Midwife says IV access not necessary. Ok .. whatever, no prob. SVD. FOB rips the mom's breast feeding bra off and demands we immediately put the baby to the breast. Um, can we make sure baby is alive first, suction mec, etc? Baby ends up in level II.

While midwife is repairing lacs and I notice increased bleeding I INSIST on placing an IV. Bleeding decreases. Everything appears fine, clean up room, etc. About 15 mins later, Mom is sitting up talking, bleeding minimal to moderate, firm and 1 below U. Mom ask for ice chips, "sure brb". Was not gone from room for 2 mins! Come back, mom is gray,blood pouring off bed, BP 27/12!

Many hours later ... mom is alive, THANK GOD! But FOB "refuses" to allow her to have a blood transfusion unless it is his blood (they are the same type). Mom seems to agree with everything although she is not as verbal as FOB.

The midwife told me later if I had not placed the IV when I did she probably would not have lived. I never ever ever want this experience to happen to me again.

Is it possible for a nurse to refuse to take care of a pt that refuses necessary medical interventions such as a heplock? I'm not talking about not taking any birthing plan pts, just extremes. I really felt very afraid for my license after this situation, even though I know I performed to the best of my ability.

Oh and after this was all said and done .. the mom says "yeah this happened with my first baby too!" :angryfire

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Specializes in OB.

It sounds like you had a very rough day. I am not very fond of taking care of pt's with strict birthplans. I like to go over all the plan with them and piont out things that could come up and discuss the possible interventions. Obviosly not possible in your case since she came in complete.

If the same thing happened with her first baby then her provider should have gone over the birth plan in the office and made it very clear that she will need IV access for labor. Anyone with a history of PPH needs IV access, no way around it!

It sounds like you did a great job! As for the nurse refusing to take care of a pt that refuses medical intervention, I don't think it is totally up to the one nurse. If there is time (not in this case) you sould get the provider to explain everything to them and if need be sign AMA forms. Now if the provider is not on your side and is ok with the pt refusing treatment then you need to get your charge nurse involved.

It is these few extreme cases of birth plans that make nurses hate birthplans because all you end up doing is sitting on pins and needles hoping nothing goes wrong. And if something like this happens there is not much time to discuss the interventions and why they are needed. I am not anti birthplan I think people should think about what kind of birth experience they want, but they need to be able to roll wiht things if they don't go as planned.

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Specializes in Maternal - Child Health.

You did a wonderful job of advocating for your patient, even if she and her SO do not realize it!

Had she not discussed her history of PP hemorrhage with her midwife during her pre-natal care? If not, then she is guilty of negligence herself. If she did, and the midwife chose to allow her to deliver without IV access, then I would direct my concerns to the midwife, nurse manager, and risk manager, as that would seem to be an unnecessary risk.

You did a great job, and will carry this terrifying experience with you throughout your professional career. It will enable you to save another mom's life someday!

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I don't know for sure whether the CNM knew about the first PP hemorrhage. The patient told me later that her first child was born in Africa while they were there on a mission trip. Considering no one mentioned it until after this experience was over, I would probably assume that she did not mention it to the midwife either.

I wanted to tell this mom that she should probably never get pregnant again and that she was lucky to be alive. I refrained however. Would this have been inappropriate?

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It probably would not be appropriate to actually tell her she shouldn't get pregnant again, however it would've been ok to tell her she is lucky she's alive!! PP hemorrhage actually happened to me 2 years ago after giving birth to my 1st daughter. VERY SCARY experience. Life changing for sure. It really scared me and made me think about having any more kids. I asked my physician what the chances were of that happening again and he said about 1 in 10. I almost didn't make it, and I can't say how scared I am that it could happen again. I am so surprised that this woman did not even mention it beforehand, I don't think she understood how serious the situation was!!! Probably just thought "whatever happens to me they will fix!". I don't know. I guess you got some good experience anyway. :) Sounds like you did a good job. Oh-just curious, but what interventions were done?? Did she ever receive a blood transfusion?

I don't know for sure whether the CNM knew about the first PP hemorrhage. The patient told me later that her first child was born in Africa while they were there on a mission trip. Considering no one mentioned it until after this experience was over, I would probably assume that she did not mention it to the midwife either.

I wanted to tell this mom that she should probably never get pregnant again and that she was lucky to be alive. I refrained however. Would this have been inappropriate?

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The interventions that were done were: fundal massage (obviously), trendelenberg, 2nd IV line started, fluid bolus, IM hemabate, IM methergine, IM hemabate again, (crash cart to bedside), O2, foley cath insertion. Thankfully these measures were enough to get the bleeding under control and "revive" the pt. It seemed like this took hours though, it was in actuality only about 15-20 mins.

She did end up receiving a blood transfusion, actually several but this did not take place until the 1st or 2nd postpartum day. Her H&H were extremely low, I can't remember exactly but I'm thinking was approx. 6 & 17 or so. I heard it got as low as 4 & 12 however.

I felt very unsure of myself during this situation, completely felt like I had no idea what to do. I can guarantee though when this situation occurs again I WILL know what to do.

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Specializes in Nurse Manager, Labor and Delivery.

The cynic in me wonders what the FOB would've done if the mom had died as a result of the PP events... or the baby had died subsequently to mec aspriation... I wonder if he would've sued? Where does accountablity lie when rigid birth plans end up adversely???? Just wondering what y'all think.

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Specializes in ER.

I think you did perfectly. The problem with planning is that sometimes there isn't time to discuss the pros and cons sanely- like when mom shows up fully with thick meconium. We end up being blunt and perhaps not customer friendly in a crisis. Like "breathing comes before breastfeeding- lets make sure he/she is OK first" or "she will die if I don't get that IV in NOW" Then people say "well nobody explained it to me.."

Nice job of getting that line by the way (27/12!!!)

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LOL .. I will not take credit for that 2nd line .. that was ALL anesthesia.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
The interventions that were done were: fundal massage (obviously), trendelenberg, 2nd IV line started, fluid bolus, IM hemabate, IM methergine, IM hemabate again, (crash cart to bedside), O2, foley cath insertion. Thankfully these measures were enough to get the bleeding under control and "revive" the pt. It seemed like this took hours though, it was in actuality only about 15-20 mins.

She did end up receiving a blood transfusion, actually several but this did not take place until the 1st or 2nd postpartum day. Her H&H were extremely low, I can't remember exactly but I'm thinking was approx. 6 & 17 or so. I heard it got as low as 4 & 12 however.

I felt very unsure of myself during this situation, completely felt like I had no idea what to do. I can guarantee though when this situation occurs again I WILL know what to do.

All of us facing such dire circumstances feel self doubt, anxiety, and worry---- and go over and over in our heads what we could have done better. I had a young girl nearly die on me my first year out of school due to hemorrhage after a grossly normal lady partsl delivery without so much as a tiny laceration. She just crashed so fast----I was beyond shocked. It was 2 hours or so after delivery, when I had (foolishly) already dc'd her IV. I remember how she begged me to help her live and worried what would happen to her baby when she "died"......yes she was dying. Thank God, she did not.

To this day, I go over the scenario in my head and replay how it would have gone if I had done things differently. It occurs to me, I could have done some things better. It also occurs to me, had I not been quick on my feet, she would be dead now, as the doctors were no where near and it happened fast. NO exaggeration.

My advice to you is NOT to beat yourself up about this. Or to go on in self-doubt. Take what you can and learn from it. DO NOT FORGET TO PRAISE YOURSELF for the things you did right. The things you feel you could have done better, learn from. And let the rest go. Don't let this stymie you. You did the best you could in a difficult situation. Learn whatever you can from it and move on! I think you did well, myself. I have been in situations like this many times, with difficult families etc. It's never easy. But never doubt your instincts when they tell you clearly what to do. You need them!

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Great job! I have had many moments of self-doubt and many run-ins w/ docs re. pts. over the years. You know what's right and you need to do it. You really stepped up to the plate for the pt. It is really hard to overcome intimidation by providers, pt's, and families. I wrestle w/ this a lot. I figure I'd rather stand up for what is right then and there rather than tell it to God or someone's lawyer later when the mom or baby are dead or grieviously injured.

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Wow, first of all congrats on the good nursing you provided this pt ( which I am sure she will never fully appreciate ), now, my pet peeve with these know-it-all people is that I don't understand why they don't just have their babies at home....Oh I know....they want someone to take responsability for them and they want to feel safe...BINGO...Well, let us do our darn job !!! They are also the first ones to sue if anything goes wrong....could we (staff/hospital ) not then countersuit for their obstructive behavior ?.... " Well, your honor they never told us my wife could die with a bp 27/12 !!!! "

Do husbands/family go into an OR for other procedures and start telling the surgeon what they want and don't want ?

Anyways, you did very well !

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