#18 Hemorrhage Management & Case Study

Welcome back to this episode of Happy Hour with Bundle Birth Nurses. It’s funny we’re going to have this talk because literally two episodes ago, I believe, I was like, “Ugh, I’m so over postpartum hemorrhage.” And then yesterday… But-

Spoke too soon.

… that’s what’s nice about this podcast, right? Is that, yeah, we can witness something or be a part of something, and I’m like, “Ooh, we should talk about that on the podcast.” So today, we are going to talk a little bit about postpartum hemorrhage. I want to talk about something I learned yesterday because we are all still learning. And then I want to talk about some of the causes of postpartum hemorrhage and then some recommendations that the new CMQCC toolkit, the version three, has come out with, which is a medication recommendation that we’ve been talking about. And then we’ll just give some tips.

So, first off, we had an in-service yesterday at my hospital and an MD came and he was educating and doing a little sim for postpartum hemorrhage. And he asked, “Do you know why…” And he said, “Women,” in this story, so I’m going to say use women. “Do you know why women can hemorrhage 500 mls?” And we’re like, “All right.” Versus if someone in the ED, like a trauma came in and they were hemorrhaging 200, 300, they would be super concerned. In my mind, my original thought was like, “Yeah. We produce more RBCs.” Right? Don’t they say we had 30% pregnancy?

It’s more blood volume and more. Yeah.

And I think red blood cells. I didn’t know that actual plasma volume increases up to 45%.

Yeah. It’s total blood volume.

Yeah. Which dilutes our blood, so we make more diluted blood. So when we lose our blood, we’re not losing a bunch of oxygenated blood, we’re losing volume, which is a lot, but we’re not losing a ton of oxygenated volume. And our body has adapted-

Oxygenated meaning RBCs because RBCs carry the oxygen.

Yes. Yeah. So I thought that was really fascinating. I was like, “Wow, we’re so cool.” Our bodies are amazing.

Yeah. Our bodies are nuts.

So I just thought that was a fun little tidbit to learn. So Sarah, four T’s of hemorrhage.

So the four T’s are… let me just preface by saying, the four T’s we teach in mentorship and they are the four things we’re looking for the causes of postpartum hemorrhage. So if you’re like, “Ugh,” because obviously if someone’s bleeding too much, you want to identify, “What’s going on here, and how do we stop it?” And so let me see if I can go through them. They are uterine, tone, so we don’t want uterine acne that can cause postpartum bleeding. Trauma to surrounding our cervical lack, even like a uterine rupture, an undiagnosed uterine rupture that delivered vaginally. I’ve had that happen. Could be a tone, trauma, thrombin. Is it thrombin? So a clotting disorder, right? That you don’t have the necessary components to clot. And I truly don’t have my notes in front of me, which I am very impressed with myself right now, although I’m not going to be able to get the last one.

Yes you are.

Tone, trauma, thrombin. Give me a clue.

When you have to get something out.

Oh, a retained particle of conception.

It’s tissue. Holy moly. I’m like, I know it.

I know the reason.

So tissue meaning there is retained tissue inside. I feel like just retained anything, that’s preventing the uterus from clamping down, causing more bleeding or an invasive placenta. So an accreta, percreta undiagnosed in that case, because hopefully it’s been diagnosed ahead of time.

Right. So he also mentioned yesterday that sometimes you inspect the placenta and they’re like, “Yeah it looks great.” And then they get rid of the placenta and then she does have, or they have a retained placenta and why does that happen? And he taught about how we can have that extra lobe. And so you’ll have a placenta and then you’ll have membrane and then on the other side of that membrane you’ll have another lobe. And so we’re not expecting that extra lobe.

How often does that happen?

It’s a good question, but-

I’m going to find out.

… it’s just something to think about. So if you have… acne is not your issue and you’re… The fundus is firm but they’re still bleeding but that placenta looked okay, maybe some of that conversation with the doctor is like, “Is there any way she had an extra lobe?” To maybe just remind them too, like, “Oh yeah, that’s possible technically.” So just a little something there.

And the only way to know that would likely be by a bimanual.

Yes, or-

Or ultrasound.

Yeah, I was going to say. So they said that especially if you’re in the middle of a hemorrhage and you’ve given all the meds, it’s going to be really hard to get in there. And so the best thing would be an ultrasound, even though it is pretty hard to see that in an ultrasound.

I’ve seen them come in with an ultrasound a lot in hemorrhages.

Yeah. And so I was actually prompted, I keep that on my mind as the charge nurse on the unit to be like, “Oh, I’m going to make sure I get ultrasound into the room when we’re having a hemorrhage for my nurses and the provider,” just to have as an option. So I never thought about that before. We’re always learning.

Yeah. So rule out your four T’s. Tone, tissue, thrombin, trauma.

Trauma. And so another interesting fact was he was describing, and I would love if an OB or a midwife could chime in on this, DM me about this. But how after a patient has been laboring for a long time and pushing for a long time his words were the vagina wall and the vagina canal is like butter and can… is so susceptible to tears. And that’s why sometimes you’ll see when they’re pressing, you cease to…

Barely touch.

Yeah. And they’ll start bleeding. And so, maybe if you’ve been pushing with a patient, you’ve seen that too. And so that’s why if you’re using forceps, which I know are more rare these days, it could cause trauma. So if you have a forcep delivery, you should be thinking… trauma is on your mind. So that was a little-

Also one of the risk factors for postpartum hemorrhage.

Yeah.

What’s one of the highest risk factors for postpartum hemorrhage?

A previous hemorrhage.

There is a risk factor. That was the one I was going for.

What is the highest one? Would it be a cesarean? Now I’m looking at my notes because I want to cheat. I would think in my mind, I’m like, big baby, long induction.

You’re onto it, yes. It is long use of pitocin. The prolonged use of pitocin, so which is why we need to be paying attention to also if they’re there for an induction, go up. It’s not the dose of pitocin, it’s the length of use of pitocin.

Yeah. Those uteruses get tired.

Yep. Get them to adequate and then if it’s not working, give them a rest. And that’s not your decision to make, but it is something to have on your radar for your three day induction. And we all… If you’ve been in practice for a while, you naturally like, “Oh they’re a long induction. I need to be ready for a postpartum hemorrhage because the uterus is tired.” But it really is truly related to prolonged use of pitocin.

Yeah, I’m looking at the notes now because I’m cheating. But they’re classified prolonged use of pitocin to be over 24 hours and that’s common friends. So-

Unless you listen to our Speedy Inductions podcast.

Oh yes, listen to that. Use-

I haven’t had one of those in a long time.

Yeah. So you have your reason, so tone. So we’re always massaging that fundus, seeing if it’s firm. If you have a firm fundus and they’re still bleeding, move on to the next. So do they have risk factors for trauma? Did they have an operative birth? Was their cervix completely dilated when they pushed that baby out? Did they have a precipitous birth? And is there a hematoma? Things like that. If you’re ruling out that, and obviously it’s not just you ruling this out. Do they have retained placenta pieces? Sometimes with the retain and the clots, I’m thinking the fundus is moving up. You can get it to be firm, the blood will release and then all of a sudden it starts moving up again and they’re still bleeding, and-

By moving up, we’re talking at the umbilicus. So it’s higher above the umbilicus. Umbilicus, which one do you say?

Umbilicus.

My nursing prof would say umbilicus and it always… I chuckled. I still do. So you’ve assessed I’m two finger breadths below the umbilicus, the belly button. And now it’s at, now it’s one above, that you absolutely should be paying attention to.

Yeah, for sure. And then… Or there’s a steady trickle and it’s just not stopping could be a sign that there’s retain placenta. So you make that phone call, you get the doctor in the room to just assess if that’s something you’re worried about or the resident. And then next could be a thrombin issue. So really looking at their labs, is there something you missed? Do they have low fry fibrinogen? What could be there to indicate that, that’s a thrombin issue? But for the part, the highest percentage of our postpartum hemorrhages are uterine acne. And so medication wise, meds we’re going to give right away. I will say that at my facility we throw Cytotec at them right away, but that is not the recommended course. So on the topic of meds, CMQCC lays this out really nice for us in all the different stages.

And so you don’t quantify the blood loss stages, this might be a new topic for you. You have stage one where you should activate your hemorrhage protocol that you have in place at your hospital. So for this one, stage one’s a little iffy because newer research was going to… it needs to be a thousand standard, but we know that more than 500 in a vaginal birth is abnormal. And so you’ll see either a thousand total or 500 in a vaginal, a thousand in cesarean, or if they say a thousand total, they’ll have a disclaimer. But 500 is abnormal and you should be really assessing that. So we’ll just say for this podcast, over 500 in vaginal or over a thousand in cesarean with continued bleeding or there’s signs of abnormal vital signs, we would activate stage one hemorrhage protocol. So for this one, for meds, you are going to make sure that you’re giving your pitocin that that is activated. You’re doing that

Up to 40 units though. We really need to be paying attention. I reviewed a case in mentorship actually where somebody… she got the 20 and then the provider was like, “Give 10 IM.” And then two nurses gave it in the thigh or something and then they ended up at 60 and it was this whole drama. And in emergencies we know that when we’re giving medications, that closed loop of communication is so important, especially if you’re giving things with a verbal MD order and then putting them in later. It’s like, who’s doing each thing? That same thing goes for terb. I’ve seen terb given more than once too, of like, “I just gave it.” “Wait, you did?” That’s besides the point, but I’m definitely not giving terb here. But to pay attention to who’s doing what.

Yeah, that’s great. And then it’ll say in stage one to move on to those second level uterotonic, and what they consider second level uterotonic are going to be metrogyl, hemabate, and mansidotac. Only if the patient is hypertensive or asthmatic. So-

We’re moving away from Cytotech, the shift is away from Cytotech.

Yeah. And so in all of these two, they want you to have TXA on your mind to consider TXA. The thing about TXA is that it’s not for uterine ane, it doesn’t work that way. It’s for clotting. And so if you can fix the uterine ane you don’t necessarily need the TXA. But I did hear yesterday that our rates of maternal mortality with hemorrhaging has significantly decreased with the introduction of TXA in the OB world, so TXA is great. And so if your patient does not have hypertension, you want to do Metrogel, 0.2 milligrams Im, or if they do have hypertension, you want to do hemabate, 250 micrograms Im. what’s nice about hemabate and why a lot of physicians like hemabate is that you can give it every 15 minutes for eight doses, which is like if it’s not working, give it again. If it’s not working-

And some Imodium please.

Yes. And I was going to say, but it does give those side effects. So you want to, as a nurse, call out for Imodium because it will cause awful diarrhea for your patients. If you are giving side attack, they want to do side attack sublingual, it doesn’t have to go through the GI tract. If you do recklessly, you’re going through the GI track, so you have to go ORPO and it doesn’t have to get filtered through our organ systems. So, if you’re doing a sublingual, it’s going straight to the blood system. So put it under their tongue and it’s going to dissolve. I know that’s something that we don’t do on my unit, and we’re going to try to push to do sublingual more for our hemorrhages.

I think that with the meds too, it’s good to understand the workflow that PIT is our first line of treatment up to 40 units. Consider TXA early and then go through, do they have risk factors for any of the postpartum hemorrhage meds, high pretension or asthma? Decide accordingly. Go for one of those two meds. If they have both, then we go to Cytotec sublingual.

Yep. So besides these meds, our nursing intervention, so as we know are to, one facilitate all of… you’re going to call your team in, you’re going to make sure that-

Get some extra hands.

Yeah, you’re going to have some extra hands. You want your provider to know what’s happening. You want your charge nurse, you want your anesthesia team. If you have midwives, you can have your midwife in hand, but with the provider coming, the OB. And then you’re massaging a fundus, you’re making sure the vital signs are tracking, making sure their bladder is empty for any of these interventions. In the future, you want to make sure their bladder’s empty, that could be with street cloth or a foley.

I say leave it in if they give you permission, so you know that’s never becoming an issue.

Yeah, make sure your scrub tech, if you have them on the unit is there. You might need some supplies in the room. So if you know you can anticipate a DNC, there are some speculums you might need, you might need the… what am I thinking? The…

Ring.

The ring forceps. Every time they ask me I’m like, “Ooh, don’t know what those are.” And I’m like, “I need to learn what those ara, so I could get them myself.”

Slash call someone for them.

Right. You might need some sutures. There’s just activating. And then what’s the family doing in the room? Where’s the baby at? How informed is the patient? Are you updating them on what’s happening? Being honest and open with communication, letting them know we’re here for them is really good. I would say if you’re a unit that’s type in crosses, and so were you Sarah… did your units type in cross? I thought-

Not type in cross.

Oh. No. Did you type at a screen?

Screen. Everybody, yes.

Apparently not everyone does that. I didn’t know that. And so if you are a unit that type in screens, this might be the time to be like, “Hey, you want me to type in cross and hold two units?” If you’re not a unit-

This is the time to do it.

This is the time to type in screen.

Type in screen but throw it in as a cross. It is no harm having a crossmatch on hand when you already know their bleeding is more than normal, so that’s also second line. When you throw in the second line, a lot of times for a type and screen they need a double verification of the blood. So draw some labs and while you’re at it, to get… and not that they’re necessarily accurate, especially in H&H or whatever, but you get some labs, some more information and then they can type and cross at that point when you’re getting your second line in.

Yeah. And I’m actually looking for the blood bank part of the CMQCC algorithm, they want you to type in screen everyone that’s medium risk on your hemorrhage risk assessment, so instead of doing everyone. But we do everyone, and I’m really glad we do everybody because like you said, it takes a while for them to do the second verification.

I think too for nursing interventions, one of our best indicators of decompensation is our vital signs. And so often they’re cycling every 15, bump it up to every five, throw a pulse socks on them, so you have that regular data and you can watch the trends of what’s actually happening, because a patient who’s not tachycardic with a normal BP at 500, I’m less worried about than somebody who has a steady trickle but is mildly tachycardic and their blood pressure has dropped by 5%, 10%, 5 is probably expected.

You know what I mean? Those vital signs, especially in the PACU guys, this was something that as a preceptor I nailed in because I’d had so many subtle cases that were caught based on a slight tachycardia after surgery and that tacky especially… they’re on the ekg, so that’s really helpful. But a continuous pulse-ox is the same thing. And wait, they were 80 and now they’re 101 noted, might be something to throw in the chart and notify your MD about, “Hey blah blah blah, I’m seeing x, y, z,” because that slight tachycardia is one of those very early signs that if you catch it, you can stay ahead of the game, especially I’m thinking postop complications and hemorrhage.

We normalize abnormal vital signs all the time.

That is so true. That is so true of like, “Oh, well it’s a little blood pressure.”

She’s 110.

Yeah, she’s nervous.

No, totally. Or they low blood pressure for epidural.

What’s the first sign for low blood pressure in your head? Say post epidural, the patient’s going to run low. What’s the first thing you see clinically?

I think I start seeing D cells, or I see they’re nauseous.

Yes. It’s nausea. That was something, especially if you’re a newer nurse, you just got an epidural, you lay them down, they’re like, “Ooh, I feel nauseous.” Then nausea will likely hit before lightheadedness. So throw a blood pressure, start your blood pressure and open them up and just know it’s coming. So once you hit stage two, which remembers a thousand to 1500 mls qbl, you’re needing a lot of things, you better have that second IBN. You’re prepping the OR. You’re maybe giving oxygen by face mask, activating a rapid response at this point.

And this piece… I remember when we were filming mentorship and putting this curriculum together, being like, “Really?” It feels premature because we’re so used to, “Well, handle it,” or, “Oh it’ll fix itself,” or, “Oh it’s fine.” But this is that response to the morbidity mortality crisis in the United States. We have to be a smidgen more… and by a smidgen I mean that sarcastically, more on top of it. And I think we need to start taking this much more seriously. And what I love about these documents like CMQCC, like A1 standard is it gives us backing for, “No, based on the qbl, the OR needs to be opened. That second line needs to be in. We need to be giving meds and we’re activating a rapid response.”

So, we’ve been activating rapids more so at my facility and…

I don’t know what it is about a rapid that I’m like, “No, we don’t need them.”

I know and obviously we need them because the mortality rate in this nation is awful, right? So-

And more hands, more supplies, more awareness, more help. Especially at this point they’re postpartum, they’re not pregnant anymore. It’s a postpartum hemorrhage.

And we can-

The med-surg patient.

And I heard something yesterday too, my director was talking about this, “Get the team there and then release people you don’t need. You might not need this person but you need this person.” So you don’t have to have everyone there that comes for a rapid, but maybe you just need that one nurse or whatever. But we’ve been activating them to do… when we do our massive transfusion protocols and we’ll talk about that a little bit later, and they will run the level one rapid infuser and that’s what we do.

Really nice, rather than anesthesia. Interesting.

So that’s been really nice for us.

Well, in moral of the story is you have to have… these are the conversations you’re having at the nurses station when you have a moment, which we all have a moment, or even on your break, you’re in the nurse’s lounge and what do they do for that? Or who normally comes? At what point do we usually activate rapid response? When you have your manager there, what point do you want us to? Because CMQCC says… and that by the way is a California collaborative, but it is nationally recognized. So it comes out of California but it also applies to your state regardless where you’re at. But at a thousand they’re saying give RBCs a thousand. The number of hemorrhages. I’ve been a part of, were like, “Oops, we should’ve transfused.” And they feel better and you’re ahead of it, versus once you start getting behind, there comes a point with a hemorrhage where you cannot catch up. And that’s where our mortality comes in, and why hemorrhage really does need to be taken seriously.

Yeah. And you brought something up too, it’s mortality but it’s also morbidity. And so maybe that early transfusion helps perfuse their organs. At later now, we have patients that are on dialysis the rest of their life because of their postpartum hemorrhage, right? And they didn’t have enough blood infusion.

Yeah. We’re so afraid of like, “Oh they don’t need blood.” And what’s the resistance? That’s what I want to ask. Maybe we ask our anesthesiologist that stuff, because I feel like it’s anesthesia of like, “No, I’ll give plasma. No, I’ll give blah blah blah.” That’s like, there’s some pushback to transfusing and I know transfusion reaction. But if you’ve type in crossed and I guess a blood shortage, we’re trying to be careful with not overdoing it. But if we’ve seen the blood out, then give them some blood back in. Blood is life anyway.

Blood is life. I wanted to mention, I wanted to pop in here to talk to you a little bit about the vital signs because we talked about that a second ago. There is clinical signs of hypovolemia. So at a thousand mls, there’s a slight change in vital signs, but it’s not until 1500 mls that you’ll see more vital signs. That’s a lot of blood that you need.

That’s a lot of blood. And our estimations are terrible at this and we have to always also consider if they have vital sign changes, where is this blood going? Internally into a hematoma that… just because you don’t necessarily see it into their uterus, that their uterus is full, you express a thousand mls of clots covering the bed, that’s a lot.

And their number one sign is narrowed pulse pressure. So they mentioned that with the hemorrhage, the diastolic pressure will rise because it reflects vasoconstriction and then it narrows the pulse pressure. So you have less of a difference between your systolic and diastolic, your…

It is significantly narrowing tachycardia and then their diuretic sweating week. And then you have greater than 2,500 mls you are going to have. And then you get up to 2000, you’re going to have hypotension, the narrow pulse pressure, tachycardia, which is… they quantifies over 110 and then tachypnea, they define that as over 24 for our postpartum.

And then they’re going to be pale, they might be cool to the touch, they might start getting restless with some mental status changes. And then we’re looking at their urine output. That is important. So if you have a follia, that’s nice.

So let’s just say we have a patient, we’re in the PACU, they had a scheduled C-section, maybe it’s not scheduled. No, they had an unplanned. They labored and had a C-section. And you’re monitoring everything. You’re concerned about fundus rising. You’re not seeing a ton of blood loss out the vagina when you do your fundus pressures. They feel mostly firm. But you’re starting to see some vital sign changes. What do we do?

I would call my provider.

Provider says, “It’s fine. She seems stressed out.”

I would look at my other things. So what’s my urine output? How do they feel? What’s the… How are they acting? Are they acting the same? It’s nice when I’ve been in labor section and recovery with them because then I’ve known them this whole time. But if I don’t, I can ask the family member, do they seem like they’re acting themselves?

It feels a little out of it because of C-section meds, is what the anesthesiologist says. She’s like, there but just extra lethargic seeming.

What’s her urine output?

20.

In how long?

45 minutes.

And I feel uncomfy like I have a pit in my stomach. And what’s the… I can tell by vital signs. So I don’t see blood. The fundus is high.

Fundus is not high, high. It’s one above. And you’re massaging. It feels firm. Nothing’s coming out. It’s just like normal firm. No, let’s say firm. It feels firm. Not like a softball in the pelvis but… You’re like, it’s on the larger side but I don’t know, maybe she just had big anatomy. Big anatomy, like big uterus that would justify it. And then the blood pressure is used to be at 112 over 72 and now it’s 100 over 61 and the pulse is 101. Previous pulse 75.

Her belly is soft all around her fundus?

Yeah.

I feel like normally in real life, I’d be like, “Yeah. I feel fine.” But because we’re having this conversation, I feel like I’m on the spot. I would use my cuss words and I would say, “I’m concerned, I need you to come to the bedside.”

Okay. And the provider is like, “I don’t really want to.”

Okay then I’ll escalate to my charge and have her come to the bedside.

Charge comes, anesthesia comes, says they’ll give plasma and by this time they’re 110 and the patient is diaphoretic. Resident comes, evaluates charges there, everybody’s like, “I don’t know.” And she’s cognizant. She’s… level of consciousness, normal. She’s supporting her baby, but looks pale and tacky. Blood pressure is now, we’ll say a 100 over 78.

So the pulse pressure is narrowing.

You don’t see bleeding.

Is what you’re telling me.

Yeah. We just turned this into a case study.

Yeah, we did. So then I have my charge anesthesiologist resident. Is the resident talking to the attending, was the attending still not caring?

Yeah.

So at this point I’m going to get my hospitalist involved. So I called them and asked them to come to the bedside and tell my concerns. And what happens?

They say give her two units. So they gave her two units and she improves and say keep watching in the PACU.

What’s her urine output now and how long has it been?

Same. No more urine output.

Okay. So I would escalate this further and say, “I don’t agree with the plan because her urine output isn’t changing, something’s wrong.”

But sometimes postop, they’re… everything slows. And we just give her 500 mls more of fluid and just give her body a second. Just keep her in the PACU for continuing monitoring. And by the way, her pulse is now 97 after the PRBC’s two units and plasma, if I remember right. And now it’s 98 and you’re like, “Oh. Okay, I’m appease for now.” So you keep monitoring her in the PACU. An hour later, her pulse is back up to 106.

Her urine output’s the same, and I already gave the bullets.

Yeah. Maybe you have a little bit of urine, a little bit of urine. It’s dark, but there’s urine. It’s so interesting that you’re fixated on the urine output. I don’t know that, that would be my instinct.

It’s been my new thing.

Because just everything slows when you’re-

Because I’m thinking internal bleeding. And so…

But why would that slow urine output?

Because I’m thinking if she’s bleeding, she’s not profusing her organs. And it should not profusing to her kidneys and giving urine output. So…

So, you think she’s internally bleeding?

Yeah. She’s not bleeding outwards, but you’re making me worried. You’re just going to tell me at the end here like, she’s fine.

It was nothing.

So, okay.

But now she’s back up for tacky, fundus firm, at the same level. She’s now starting to feel a little bit dizzy, doesn’t feel good. Maybe a little just icky feeling. What do you do?

What is the rest of her belly feel like?

Fine. Normal. But post pregnant. So at this point you… in theory… Yes. Yes. There’s a second line for the blood already. And you sent labs with that. But your labs are normal C-section, it’s an hour and a half after C-section. How accurate are they? Something… It’s lowered but nothing critical.

Okay. I don’t know, because in my mind she’s got blood, right? Her fundus is firm. I’m normalizing her vital signs in my head. What’s her respiratory rate?

18.

All she has is 106, which technically tachycardia isn’t over 110 for this. So I’m going to wait.

So, what I want to note here is that you gave two units of RBCs and she improved, and now she’s not the same. She’s now less better. That’s not clinical.

So how long-

See what I mean? It’s real though.

So how long after-

This is real life.

… the two units did?

An hour and 15.

So an hour and 15 after the two units, she’s getting worse again.

Yeah. You see the pulse start creeping, okay?

So I guess I would mention that.

Okay, provider says, “Cool, keep watching. It’s not tachycardic.” Your gut says, “I don’t feel good about it.”

So she’s not tachycardic.

106. What did I say? 106.

Yeah, 106.

108. Now it’s 108.

And so how’s her-

We just got off the phone.

How’s her mood?

She’s real mellow, lethargic, looking pale. Something’s off, dry mouth.

I’m going to relay all those, and then anything else from that?

Diaphoretic. Anesthesia now. So you call anesthesia, you’re like, “Somebody’s got to be in here and look at this patient. I am done with this.” Anesthesia looks at them and says, “Something’s off. We got to escalate.” Anesthesia finally calls your doctor.

Finally.

Yes. I’m going to give you the end of this story. I exaggerated a few things, but I had two cases that I will never forget. One of which I was the primary and I was in the PACU and it was mostly this case. They gave plasma instead of RBCs. It just felt like the clinical course was weird. And I kept being like, “Something’s off. She’s not right,” whatever. They ended up taking her back and they found a retroperitoneal bleed and opened her up and had 2,500 mls in her abdomen. It was quite the case. So I’d had this case and then I was orienting a new nurse and we had the exact same clinical presentation. And this time I was much more diligent about being like, “No, you need to assess her. No, something’s off. No, I’m seeing this creep.” And I pulled up the graph of the vital signs and it was the pulse actually that got them paying attention to me other than now…

And I was like, “Her pulse is beginning to rise.” They gave blood, saw an improvement, pulse went back down. And then after a little bit of continued monitoring, pulse began to creep up. And I’m like, “There is a trend here. She recovered from the blood, something is not right.” And they ended up opening her back up and it was… they found like 800 in the abdomen and they went back hours before this time. And I remember talking to my orientee and her being like, “Oh no, the pulse…” And me being like, “It’s 106, but something is off,” because her baseline was seventies. This is not normal for her. And so this is where I learned from the first case where both of which survived, who knows what the morbidity turned out to be? Knock on wood. But our astute nursing care, why are we one on one in the PACU?

Because their post-op, and if you look up… just Google retroperitoneal bleed, so you can see where this is located. It’s like an internal bleed, right? And what happened was… and I’ve heard of cases where you open them back up and what’s tampon nodding the wound is the actual blood. And the moment you open them up, they code. So this is where… This issue is… We need a trigger warning on this episode for sure, because we have to be taking this seriously. And us as nurses, if you are not getting the response that you need from your providers, you got to push it up and you have to document this. I am pushing it up, charge nurse something is off. And this isn’t being hyper. You want to give tangible evidence that something is off. Pull up the trends. And I remember seeing the graph of the pulse and them being like, “Oh, yeah, we gave the blood, it recovered and now it’s creeping back up.” And there’s something going on here and it’s your job to figure it out.

I’m telling you, there’s something going on here I am seeing with my eyes. And luckily that orientee actually got oriented to what it means to be on top of your nursing care. And that first round, luckily there wasn’t a poor outcome, but I learned very quickly like, “Oh, what is this retroperitoneal bleed thing?” And post-op this is why our C-sections are actual risks. It’s like the risk of mortality in a C-section’s four times as much as a vaginal birth. So anyway, that’s my little tangent random case study.

It was great.

And we put you on the spot, but that’s real life, right? And they’re like, “Oh, it’s fine. Oh, it’s fine. Oh, we gave blood, bye.” No, and I don’t know something’s off or “Well, they’re sweaty and their pulse is a hundred.” What was it before? You have to be watching the trends and the moment it starts to get up, and you’re watching the response times, push it up your chain and make that response happen. We can’t be leaving these patients. Well… And it has to go beyond. I notified the doctor and I wrote it down. It’s not about documentation. They’re-

No new orders received.

… real lives. There are real lives on the line here. So I feel like I’ve been coming in hard and I act like I know what I’m doing, but this is hard stuff.

It is hard stuff.

And this is why we’re actual nurses and why they have a registered nurse involved in their care, because our job is to assess and notify of changes and status.

I think that’s a good reminder because you’re absolutely right. And then notify changes, give recommendations. But overall, what are the reasons? I was like, “Hemorrhages are lame,” in the last podcast.

Was… I don’t know, because I guess I’m sick of them, but they are happening. And what’s nice about hemorrhages is we do have a lot of steps that we can take and we have these, we keep talking about them and keep reading through these material. You will know the steps to take. There’s not that many meds, right? There’s a handful of meds, a handful of interventions and a handful of things we can do alone. And then we need to call the team. So we’re going to link the CMQCC toolkit on this episode so you can look through it.

And use it as backing for you. If there’s pushback on interventions, it’s like at this point we need to have a second line in guys, what’s our hemorrhage protocol? Who’s the extra in the room? What’s anesthesia doing? What meds are being given? What meds do I need to grab or have someone grab for me? It’s being on top of our nursing care. This is leveling up our nursing care and not being lazy nurses, which none of us want to be, especially when we end up having to deal with the consequence of what happens when we’re not paying attention.

Yep. And if you’re at a hospital that doesn’t have those kind of resources, you don’t have protocols, you don’t have massive transfusion procedures, you don’t have a hemorrhaged cart, then this handout will help you do that. Just like she said, use this as a guide, use this as a tool. It’s 279 pages.

And I will say that this episode’s going to come out before Black Friday, but stay tuned for Black Friday sale because we have a one page cheat sheet that will be available for digital download, that I just updated with the new recommendations from CMQCC that you can purchase on our site for like nothing. And if you wait for Black Friday, it’ll be practically free.

Thanks for spending your time with us today here on this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, right? Leave a rating review and share this episode with a friend. If you want more from us, head to bundlebirth.com or follow us on Instagram.

Now it’s your turn to take what you learned today, apply it to your life, assess your patients, be on top of your vital signs, and follow the steps in your hemorrhage protocols based on your units and or following CMQCC, and diligently assess their bleeding and respond appropriately. We’ll see you next time.