2 Wks Postpartum Bleed in ER

Elvish, BSN, DNP, RN, NP · Jul 5, 2011

It sounds like she may have had some retained placenta or membrane fragments keeping her uterus from contracting all the way. It's unusual for it to manifest that far out, but not unheard of. At that point, what she needs is either a manual extraction or a D&C. Even when we have a hemorrhage from retained frags in the hospital immediately postpartum, we don't like to do pit until all the offending clots/frags are removed. Otherwise you're just spitting into the wind - a uterus contracting but it can't contract all the way because the clots etc. are impeding it. For two weeks postpartum, a uterus should be way lower than u - 1.

I'm surprised she wasn't febrile at that point as well, but I guess it's not a given. Does this help any?

JenTheRN · Jul 5, 2011

The important thing is to get her bleeding under control. 1st thing to do is massage the heck out of her uterus. By two weeks pp the uterus should be quite far under the umbilicus. Yes, she will need some pitocin, methergine, or another drug to make her uterus contract, but if she has bleeding that far after delivery I would think she would need a D&C as the most likely culprit would be retained placenta.

I don't see that many cases of this, so maybe someone else could share some thoughts, but I think they were trying to stablize her so that she could go into surgery.

JeneraterRN · Jul 5, 2011

I agree with the first two respondents, though I am surprised by the length out from delivery, as well. It would be useful to know her WC, med and surgical history, and medications in case there is something in there to potentiate or worsen bleeding. I had a retained placenta myself, but bleeding was not the problem so much as infection. Was she septic from retained placenta? DIC comes to mind. I hope those thoughts help!

Esme12, ASN, BSN, RN · Jul 5, 2011

About one percent of postpartum women have what's called a late postpartum hemorrhage (also known as a delayed or secondary postpartum hemorrhage). This term is used to describe severe bleeding that occurs between 24 hours and 12 weeks after childbirth, though late postpartum hemorrhages typically occur one to two weeks postpartum.

Late postpartum hemorrhage may be caused by a uterus that doesn't contract normally, possibly as a result of fragments of the placenta or the amniotic sac that remain in the uterus after birth, an infection, or both. A late postpartum hemorrhage may also be caused by an inherited disorder that alters your blood's ability to clot, such as von Willebrand's disease. Sometimes, though, the cause is unknown.

The Emergency care of the patient is suppportive, IV, O2, labs, until a D/C is peformed as retained products are the usual cause of late PPH. It is optimal to have the patient transfered to a facility that has OB/GYN services as this is optimal care ans well within EMTALA to a higher level of care.

http://emedicine.medscape.com/article/260187-overview

http://emedicine.medscape.com/article/260187-overview#aw2aab6b4

http://gino-memoirofaschizo.blogspot.com/2010/08/nursing-care-plan-ncp-postpartum.html

I hope this helps....:)

**LibraSunCNM, BSN, MSN, CNM** · Jul 5, 2011

I'm also wondering like the PP if it was a rare clotting disorder, because if she's able to breastfeed, it's probably not retained placenta. The removal of the placenta is what signals the brain's hormones to tell the breasts to make milk, right?

Elvish, BSN, DNP, RN, NP · Jul 5, 2011

I'm also wondering like the PP if it was a rare clotting disorder, because if she's able to breastfeed, it's probably not retained placenta. The removal of the placenta is what signals the brain's hormones to tell the breasts to make milk, right?

You're right but if it's a smallish piece, or if it's not attached to the uterine wall anymore, it might not impede BFing. Also, the body starts making colostrum as early as the second trimester, so it's not necessarily an all-or-nothing proposition.

Altra, BSN, RN · Jul 5, 2011

I've seen Methergine given in the ER in a similar situation, but that was with OB present. I can totally picture your ER MDs consulting with OB at the other hospital, and being given instructions to just get the patient to them as quickly as possible. You might also have considered starting 1-2 units of uncrossmatched blood prior to the transfer, if there was time.

**LibraSunCNM, BSN, MSN, CNM** · Jul 5, 2011

You're right but if it's a smallish piece, or if it's not attached to the uterine wall anymore, it might not impede BFing. Also, the body starts making colostrum as early as the second trimester, so it's not necessarily an all-or-nothing proposition.

Gotcha, thanks for the info!

klone, MSN, RN · Jul 5, 2011

I'm also wondering like the PP if it was a rare clotting disorder, because if she's able to breastfeed, it's probably not retained placenta. The removal of the placenta is what signals the brain's hormones to tell the breasts to make milk, right?

Yes, but it's not uncommon for women with retained placenta to still undergo lactogenesis II. Supply is usually not where it should be, though.

CEG · Jul 6, 2011

I was thinking the same thing about retained products and milk supply.

The only other thing I would add would be a manual exploration of the uterus might be necessary if you were remote from being able to do a D & C. If nothing else you could explore the uterus and perform bimanual compression. Obviously this would be very painful for the patient.

Esme12, ASN, BSN, RN · Jul 6, 2011

I've seen Methergine given in the ER in a similar situation, but that was with OB present. I can totally picture your ER MDs consulting with OB at the other hospital, and being given instructions to just get the patient to them as quickly as possible. You might also have considered starting 1-2 units of uncrossmatched blood prior to the transfer, if there was time.

If the patient was hemodynamically stable there would be no reason to transfuse her. The increased risk involved with uncrossed blood in a hemodynamically stable would be debateable and possibly contraindicated. Some EMS will not transport blood infusing unless it is accompanied by a nurse or the rig and a Mobile Intensive Care unit and just not an ALS unit. If she was unstable they would have to attempt to stablize her before she is transfered and transfusion prior to transfer would be considered. In order to be transfered there has to be an accepting MD on the other end to orchestrate care from that end and in of course in consultation with the sending MD....according to COBRA/EMTALA rules and regs.

http://crashingpatient.com/wp-content/pdf/emtala-draft.pdf

http://emedicine.medscape.com/article/790053-overview

http://www.emtala.com/faq.htm

http://www.emtala.com/

As usual there are many case senarios that can be played out in caring for any patient. When there are inexperienced residents involved it is almost imperitive that the ED nurse can develop the plan of care......thank goodness in the ED there is always an attending ED MD.