Mothering Forum banner

1 - 6 of 6 Posts

·
Registered
Joined
·
242 Posts
Discussion Starter · #1 ·
About postpartum bleeding/clots ...<br>
I'm a new midwife and would love to hear the collective wisdom here about how you might have handled a situation I found myself in last night. Five months into practice, I often find myself wondering if I am being too conservative or too careless or something in between. I do have mentors who I can call upon when I wonder WTF to do, but it's also so helpful to read these boards and hear about how the rest of you might manage things. I have recently felt that my education and experience re: late PPH, retained products, clots etc is lacking ... this was reflected in my uncertainty about what to do with the following:<br><br>
I was paged last night at 3am by a mother whose birth I attended 10 days ago. She called to report that she stood up after BFing her baby and felt a gush onto her pad. She reported that she had soaked the pad completely with blood - front to back and side to side, knocked a 'pad-sized' clot into the toilet, and was continuing to trickle into the toilet. She changed her pad and paged me, saying that she felt the new pad filling up, and that she was feeling painful cramping.<br><br>
I had seen her 3 days previously (d7) and her lochia had been steadily decreasing. Her fundus had been midway between the umbilicus and symphysis.<br><br>
What would you say/do/ask/recommend in this situation?
 

·
Registered
Joined
·
2,671 Posts
How long did she continue to bleed? I wonder if she may have expelled some retained membrane. Those are usually not substantial enough to cause hemorrhage or interfere with involution but can be quite alarming when they are finally released.
 

·
Registered
Joined
·
6,956 Posts
Wait and see, get an ultrasound, and/or do some oral methergine.<br>
I'd probably stay on the phone with her for 20 minutes and see what happens over that time. A little fundal massage while we waited on the phone, nurse the baby.
 

·
Registered
Joined
·
3,473 Posts
You said that she got up after nursing the baby at 3am. I would want to know--was she sleeping for a few hours prior to waking to nurse? Did she nurse in bed lying down before getting up? Because from what you said, it sounds like while asleep, she had some blood pooling in her uterus--and if she'd been asleep 3-4hrs or more, it would have been a goodly amt of blood and some of it would have naturally clotted during that time. Then, she stands up and the pooled blood/clot falls out...it looks like a lot, but is not so alarming because it is the result of seeping slowly over time--not actually a rush of fresh bleeding. Does this make sense?<br><br>
The painful cramping was a good sign, IMO--that tells us that her uterus was working hard and fast to shrink again, and stop the bleeding. I always tell moms--yeah, afterpains really hurt for some of us! But we still have to welcome them because they're so important.<br><br>
Usually, by 10 days pp you don't see quite so much of this effect as uterine involution is well underway by then (much more common in first few days pp)--but it could happen. I would probably ask mom if she had exerted herself in some particular way in the last day or so (lifting too much weight, excess stairwalking...)--or just generally was on her feet more than before, or under more stress for any reason, or had had less sleep than before (fussy baby?nursing issues, family stuff?)-- anything that might have been energy draining and could lead to greater uterine bogginess than is typical at this stage. I do agree that this episode could have been the release of retained membrane--but also could have been the result of her overdoing it and/or excess stress.<br><br>
But as long as nursing/fundal massage brought the bleeding well under control fairly soon, and mom was feeling ok, I would not worry too much. I definitely would advise that she take it real easy for the next day or so: rest with feet up, make sure to eat/drink excellently, nurse often (or at least keep baby to bare breast a LOT, however much baby wants to suck). Would verify that she was getting enough help around the house, or with nursing or anything that might pose a strain for her right now--help her get such help together if needed. Some women, especially if they have a wonderful birth, just feel so good and don't realize that they still need recovery time anyway! Or alternatively, their dp/fam does not realize that recovery time is needed, and moms are handed too much work too soon whether they feel ready or not.<br><br>
I'd only be suggesting methergine, or u/s, if all was not well--but would certainly bring those things up if bleeding did not reduce and stay reduced over the next hours/days with rest and such.
 

·
Registered
Joined
·
242 Posts
Discussion Starter · #5 ·
Thanks for your responses!<br><br>
On the phone, I did ask about her physical activity the previous day (normal, pretty low-key) and asked her to do some fundal massage. She couldn't really tell me where her fundus was (I do routinely explain to women what I'm feeling at postpartum visits and show them where I feel their fundus). She sounded alert and chipper and was feeling well except for the cramps. I didn't ask her to nurse the baby - I guess because she'd just fed her - will remember this for next time. I always do explain the 'gush after sitting/lying' phenomenon but like you point out, MsBlack, I don't really expect that to happen as late as 10 days.<br><br>
I ended up going over to her place since it's not far from me and I wasn't feeling totally confident about my phone assessment. We recently had another woman in care with retained fragments who had several episodes of bleeding over a few weeks, ending in a d&c at 7weeks postpartum - I definitely think this influenced my management.<br><br>
The bleeding had slowed somewhat by the time I got there, about an hour after the first gush. She'd saved the pads and there was about 100cc - plus what she had reported losing into the toilet. Did her vital signs - all normal. Her fundus was high and boggy - a finger or two below the umbilicus - with some gentle massage it became well-contracted and lower.<br><br>
I showed her and her partner where her fundus should be and told them to massage there and nurse the baby if she had more heavy bleeding that night - also to page me and we would consider OB assessment at the hospital. I had our office assistant order an ultrasound for later in the week (it was actually today and I haven't seen the report yet).<br><br>
Some of this was probably overkill, but what can you do when you don't know what else to do? <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/smile.gif" style="border:0px solid;" title="smile"> At least we had a nice postpartum visit in the middle of the night - weighed the baby and chatted about the election before I left.
 

·
Registered
Joined
·
3,473 Posts
Overkill or not, I think I would have done the same as you. Clearly, something is/was going on to prompt all this--and I would have expected that an hour later, with all that cramping, that you'd have found a firm/low fundus by the time you arrived. Sounds as if maybe there is something retained....which may well pass/did pass, but it would be good to know for sure.
 
1 - 6 of 6 Posts
Top