??? about PP Hemorrhage

[shortstuff31117]

I have seen 2 PP hemorrhages since I've been working L&D. The first one - the pts. fundus had to be massaged to be firm. and then we got a lot of clots out. Gave methergine and was fine after that.

The second one - 5th baby, fundus had to be massaged after placenta delivery but firmed up quickly. Stayed firm always after that, but pt. continued to bleed, not excessively but just a bit too much. Myself and 2 other nurses pushed and pushed on her fundus and never got any clots. Finally doctor comes in and pushes, and gets tons of clots. To OR for D&C.

So my question is -- what is the cause of the second pts. hemorrhage? I think I'm just a little unclear about the different causes of PP hemorrghage?

Thanks!

[Elvish, BSN, DNP, RN, NP]

If it's a 5th baby, the uterus might be atonic and might need a bit more frequent help getting back in shape. She might be ok by appearances, but in a grand multip uterus, she can be pooling and still might not have a ton of external bleeding.

Might have just been a matter of MD's technique -- NOT necessarily better, just different.

I have had hemorrhaging moms that very few clots come out of until they move or turn just a little bit one way or the other, then it's like the floodgates open up and there's so much you can't see straight. Really!

Sometimes with grand multips it's hard to tell.....

[LizzyL&DRN]

If she went back to OR for D&C it sounds like maybe the doc thought there may have been some placenta left in. If a chunk of placenta is stuck inside, you can very well have a firm fundus but have heavy bleeding.

[babyktchr, BSN, RN]

Even if the fundus is firm, the lower segment may not be, and that is where you get your clots. You really have to mash hard, and sometimes go up in the lady parts because they are stuck in the cervix. Agree with the above post also, retained placenta can cause heavy bleeding.