Contingency management

NewFNP deals with a lot of vaginal complaints. They generally run along the lines of itch, olfactory woes or a forgotten objet causing distress and/or one of the aforementioned concerns.

What is exceedingly uncommon (n=1 in five years) is for a woman, three days post-partum, to present to clinic with a chief complaint of "something is coming out of my vagina." NewFNP had two differentials: retained products or prolapsed uterus.

As newFNP and her patient assumed their respective positions, newFNP briefly thought, "Holy mother, is that an umbilical cord??" before coming to her senses. What she saw was a shiny, slimy, veiny mess with a decent sized clot in the middle of it, discovered only by digital exploration of said mess. NewFNP admits that she was surprised at the absolute lack of vaginal bleeding given the situation.

"Placenta," she thought. "Now what?"

NewFNP gave the protruding mass a gentle tug. Nothing moving and no pain on the patient's end. A slightly more forceful tug elicited movement but nothing spectacular. At this point, newFNP brought in Dr. Dual-Ivy-League-Degrees for assistance. While newFNP maneuvered the speculum around the protruding mass, Dr. Dual-Ivy-League-Degrees tugged with the ring forceps. Again, nothing. Not wanting to cause a hemorrhage and noting increased vaginal bleeding and that the patient's pulse was 120, newFNP and Dr. Dual-Ivy-League-Degrees stopped their efforts and called for an ambulance.

NewFNP probably could have handled the entire situation alone, but was just too uncertain. If the patient had been hemorrhaging and had something protruding from her vagina, that is an entirely different call: get whatever is causing the problem OUT. But this was different and newFNP just hasn't managed post-partum complications such as this in the past.

What a great learning experience for newFNP, both in learning about the actual care of this patient and of trusting her knowledge and feeling confident in her care.