what this her first cesarean?
what was the reason for the cesarean?
sorry...I missed this info in the question.
this is her 3rd...accident in teens prevents natural delivery
do you need more info
was she closed with sutures under the skin or staples?
did she have retained placenta noted on the D&C?
was she placed on antibiotics?
sutures inside staples outside
now on keflex
as far as the bleeding goes...not terribly uncommon to see this happen.
this is because the more times the uterus is cut (repeat cesareans) the deeper the placent can grow into the muscle of the uterus.
two weeks later she is using several doubled 4x4 guaze pads that soak with fresh blood
ok...the first part was the vaginal bleeding.
the part with the incsion....
and her pain is not subsiding
now, sounds like she also had a small infection
she is pale and anemic
yes in incision and into the abdomen
when it comes to the bleeding...usually it is leaking of collected blood from under the skin
fresh blood suggests more active bleeding..and the way the abdomen is closed this is usually from the skin or the fat just beneath the skin.
there is a large "blister" looking thing on the outside that continues to fill with fresh red blood
probably due to infection.
she should be on an iron supplement by now...
should she stay with the same doctor of get a second opinion...she bounced right back without complications from her other sections
they were giving her liquid iron in hospital...she had a four day stay then went back for the d&c
Ok...honestly, sounds like her treatment has been appropriate this far..
how long should we expect this bleeding
these types of problems are a bit more common with subsequent cesareans...and that due to the amount of scar tissue.
I would give it the week of keflex...the infection and bleeding should clear by then.
she was in surgery for over one and a half hours taking out scar tissue and had her tubes tied
if not, I think it's completely reasonable to have her ask for a second opinion.
it's been four days on keflex without any results and her pain is a #7 or8 on the pain scale...this is not like her
what would happen if a piece of gauze or sponge was left in by accident...what would we see?
yes...that's a possiblity.
and usually it causes women to get ill...fever, chills..etc.
on day 7..if she isn't better ask to have an abdominal X-Ray done.
there are fibers in the sponges that can be seen with a simple X-Ray
so day 7 of keflex you mean?
I have heard of both pain and no pain...so I can't say pain would be a reliable predictor.
yes...day 7 of keflex.
might it cause blood to have to escape?
what is the likelyhood it could be a small bleed internally?
no..I wouldn't think so
right...so, it's unlikely to be deep inside..usually the skin or fat just beneath it
because the abdomen can hold a lot of blood...
a week after section her uterus was above her navel and that seemed strange to me
it came down after she dropped several fist sized clots
yes...that is unusual
and that's the reason...
when there are clost in the uterus it cannot contract and shrink down, which is what causes a woman to stop bleeding.
nobody in the hospital was checking her incision and nobody took off the dressing or felt or massaged her uterus...i thought that was very strange
personal preference I guess..
I remove the dressing at 24 hours and check the incsion myself daily.
the nurses are usually trained to evaluate the the uterus at least daily.
they were noting that the incision was clean and dry but nobody had looked at it and they didn't know the bandage was on until she left on the fourth day...i am a nurse so i stayed with her
Yes..that is unusual in my opinion.
but i havent worked ob in so many years i thought a lot must have changed
the staff is in trouble for all of the false documentation....but we have not formally complained
no...the basics of surgery are the same.
I would bring it up to someone...there seems to be a lack of training there.
so...keep taking the keflex, watch fever, watch her color and pain level and see if bleeding slows for hopefully stop...when would you think at the end of the keflex it's time for second opinion
and...make sure she it taking an iron supplement twice a day.
they d/c her iron after she had 3 bags of blood because her numbers looked good but she has always been anemic
we should ask for new blood work too i think
usually we don't transfuse to 'normal' because the RBCs don't live that long
we usually transfuse to low normal and then put a woman on iron.
well i mean after transfusing it was up to normal and then they stopped her liquid iron
if you transfuse to normal you can suppress the bone marrow from making more RBCs because everything seems normal, but it is transient.
so...iron is probably a good idea for her, but getting the blood test will confirm that
so you don't think it sounds like a slow abdominal bleed then?
no..not in my opinion.
the fascia is closed so any abdominal bleed would be confined in the abdomen
so when there is bleeding from the incsion it is usually from the layers above the fascia.
and what would we see from that? from the slow abd bleed? her belly is a little hard and much too sore to palpate
very rarely the fasical closure well separate, but if there were fresh blood and that were the cause she would be near death by now.
ok...or possibly an area can't heal up around a sponge?
before the bleeding she had pus with a foul odor
that sounds like a wound infection
so blood would automatically come next?
not uncommon...the inflammation makes the vessels more porus...I guess is how I would phrase it.
ok...how long should we expect it to bleed so heavily then?
it's approx 90cc a day now
I'd give it the next 3 days of keflex and if she is bleeding enough, that you as a nurse, is concerned about I would get the second opinion.
that's quite a bit.
i think so too
ok...thanks for letting me pick your brain...anything else you should tell me to watch for?
the ones you mentioned earlier...and
tachycardia, nausea/vomiting, near syncope, dizziness..etc...all the signs that she is profoundly anemic and needs to be seen in the ER.
ok...i did take her there when she had all these sign when she had the D&C....she is terribly pale and i am going to ask for new blood work tomorrow as well...
thank you...you've been helpful in that you said most everything that i was thinking about
have a good night