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Friday
May162008

When We Don't Know Why...

... it is imperative to find the answer.

Reader Comments (3)

but what about when we can't find the answer?

May 17, 2008 | Unregistered CommenterSarah Stewart

The answer is somewhere. Someone has it. If you can't find it, find the people that can.

There are ALWAYS those who are more skilled than us out there. Utilize them... even if our egos fall in the toilet.

The life of a woman and baby can depend on it.

May 17, 2008 | Unregistered CommenterNavelgazing Midwife

Hmmm, if you are referring to Morag - I'm not sure you are 100% right. Often the docs can't find the answer either. I'm in a tertiary unit. If a woman had 1 litre loss and it wasn't uterine in origin, then we'd look for tears/trauma. If the blood was coming quickly we'd be preparing to go to theatre and repair in theatre. But if it was by then a 'trickle', we would repair in the room - with possibly a tampon (rather than pack) in the vagina to be able to visualize and repair any tear. When we finished we'd take out the tampon (always count your swabs!) and if bleeding had by then stopped (i.e. everything seemed to be normal level of loss from the uterus) we would not be looking at the cervix (even if the cervix was suspected as the origin of the earlier bleed). An FBC (your CBC) would be done later to determine the effect of the blood loss, iron supplementation needed. Clotting disorders would be checked for as part of that, but the fact that the bleeding had stopped would be taken provisionally as a good sign. If she wasn't symptomatic, we wouldn't be overly concerned and we wouldn't be giving a blood transfusion to an asymptomatic woman. We would handover that the blood loss was significant (>500 mls) to the postnatal ward, and they would be alert to any changes in her obs. If the bloods came back and showed no clotting disorder, the tear repaired was minor, the uterus had been well-contracted at all times...well, then the loss would be unexplained, ?cervix. None of our docs would go looking for it at that point if the woman was asymptomatic - what would be the point? What they want to know is "is she currently at risk" and if not - well, her cervix can be looked at at a later date...

If we started jumping up and down in front of the docs and telling them "it is imperative to find the answer" they would roll on the floor laughing.

Granted, this is all in a tertiary hospital setting, and therefore you can afford to be a little more relaxed about a pph than in a home situation. But our (on site) birth unit guidelines (written with the main unit) don't demand transfer/obstetric-unit involvement for every pph-by-volume, it depends on whether the mother symptomatic and whether there is concern that the loss is not settling.

At home, I think we would pretty much always transfer in for a loss like that - not because of the loss itself, but because at the time of calling for transfer we would not know if it was going to settle or if she would remain asymptomatic. And because the level of observation needed of the mother would be a bit higher postnatally than if everything was normal.

One of the things that a really thorough training does is teach you what you ought to worry you, but it also tells you when you can afford to be a bit more relaxed.

May 18, 2008 | Unregistered CommenterYehudit

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