Blood has always been my favorite body fluid but......

The other day I was at home, NOT in the OB ward.  I was actually supposed to be there but it was really quiet and I’d been working a ton and my house was a mess so I told the nursing assistant to just call me if anything exciting came in.  I lasted at home about 20 minutes before I got the call that a pregnant lady had come in.  I headed down.

When I arrived I saw them helping the woman from a motorbike.  That’s right…in labor, riding a motorcycle.  Oh dear.  We helped her back to the labor ward and I started asking the normal questions.  First being, what’s going on?  They said that she had started laboring the night before, but had started bleeding almost as soon as the labor started.  I got the Doppler to check for fetal heart tones.  I got a rate of 160 but when I checked it against the mothers pulse I found that it was really the mothers pulse. Good grief!!! (That’s really fast!)  I am not at ALL an ultrasound guru but I took her back to the ultrasound room to see if I could confirm that there were no fetal hearts on the ultrasound.  Because Jesus loves me, I got a really clear picture of the chest wall (really clear pictures of….. well, anything are rare with me) and could see that the baby’s heart wasn’t beating. 

Ok, now to figure out why this woman is bleeding.  There are a few options.  Number one, the placenta is down too low and is causing bleeding.  Number two, the placenta has prematurely separated from the uterine wall and she’s bleeding.  Number three (and number scariest!) is that her uterus has ruptured.  But how the heck do I tell!??!?!?!?!  

I did a vaginal exam and felt….something squishy.  I tried to see where the head was on the ultrasound (usually one of the things I can actually find) but was having trouble being sure.  The squishy thing I felt on exam didn’t feel like a head.  I called one of my friends (shout out most wise and excellent CHO!!!) to come help me. I needed to bounce some ideas off someone.  We did a speculum exam and sure enough…it didn’t look like a head. It was kind of blueish….yeah.  So I figured it must be the placenta that is covering the opening of the cervix, which is now causing her bleeding.  But now what to do?  This woman was still bleeding and I wanted it to stop! We checked her hemoglobin and it was already low enough to need a transfusion.  The other problem was that her blood type was extremely rare. She came with someone who had her blood type so we were able to get her one unit, but we knew that the likelihood of getting any more was extremely rare.  Any bleeding she was doing would most likely not be able to be replaced. That’s scary!

I hit the books. I knew that if the baby was alive, and the birth wasn’t imminent we would take her for a c-section.  However, the baby was already gone.  So do I need to make her undergo a c-section if the baby isn’t alive? I wasn’t sure. I started reading about bleeding during labor and started reading about placentae abruption (premature separation of the placenta from the uterus).  In this section it said that if the baby was already dead, you could try a vaginal delivery. I figured that if that was true for a separation of the placenta, it could be true for placenta previa as well.  Let’s try it.

Her contractions weren’t very strong so I have her some medicine to get things going.  I went back to reading while I waited for the medications to kick in.  It wasn’t too long after that I went back in and checked her and she was fully dilated. I decided to let her push.  (NOTE:  IT MIGHT GET A LITTLE GRAPHIC HERE.  YOU WERE WARNED!) 

Ok.  So as she was pushing, there was this bulge coming out, but it was like it just wouldn’t come out.  I let her push a couple times and….nothing.  Then I started looking at it closer.  Hmmmm.  That looks really fluid..y.  Could it be that instead of the placenta those are her bulging membranes?  (Remember, I have mentioned this many times:  OB is NOT my thing!)  By George I think it might be her membranes.  Since we don’t have any of the fancy tools to rupture membranes I used my fingernail and sure enough, a fountain of fluid came out.  Nice!  Oh sheesh. And there’s the head.  One push and out came the head.  One more push and the baby shot out of the woman.  And I mean SHOT out of her.  But it wasn’t only the baby, the placenta came out with her.  As well as more blood than I have ever seen in one place!  I’m serious. Giant clots, a river of blood…wow. 

As I pushed on her uterus to get all the clots out, it was like there was an artery bleed. Every time I pushed on her uterus, blood squirted out.  Oh my gosh.  Is this a ruptured uterus?? Is she going to bleed to death in front of me???  The OR team is at lunch. I have yet to see everyone gather, scrub and open a woman up in less than an hour. Does she have an hour?  I started to get that cold ball of fear in the pit of my stomach as the panic started to creep in.  There was just so much blood! And I knew that because she came in with such a low blood count, she didn’t have much reserve.  We had lost too many mothers lately.  I did NOT want her to be another one!!

I pulled out my phone and started calling my CHO friend, the one I’d consulted earlier. As I did that I went into the hall and because Jesus loves me, the hospital administrator was in the hall (he’s also been a nurse forever and has seen just about everything).  I calmly said “Excuse me, but can you please come in here?  NOW? “  He got the gist.  We decided to take her to the OR so we could get a better look and see if we could see where all the blood was coming from.  Did she rupture her uterus?  Did she tear her cervix as the baby was coming out? (I did mention that it SHOT out of her right?  Did I also mention that this was her 9^th pregnancy???  We couldn’t have kept that kid in there if we’d wanted to!)

We got her to the OR. We tried to do a speculum exam but there was just so much blood that it kept filling up the speculum and we couldn’t get a good view.  We decided to call the OR guy on call to see if he could come help us.  When he arrived he asked me about the placenta.  Was it intact? I told him that to be honest, I couldn’t really remember because it came out with the baby….and all the blood distracted me. I ran back to the delivery room to check.  I looked at the placenta.  Well, it looks like all the other placentas I’ve seen…..I guess it’s good?  I went back and told him it looked ok to me.  After digging around inside her uterus for a bit, he pulled out….pieces of placenta.  Jackpot!!

We figured that she had indeed had placenta abruption. That’s why her placenta had come out with the baby, instead of the 5-15 min. later that it usually comes out.  But part of the placenta had not detached, so was still attached to the uterus.  And that can make you bleed!!!  Yes, I checked her placenta but…..I didn’t do a very good job! I’ve never seen an incomplete placenta before and it looked like all the other ones I’d seen.  My bad.  Have I mentioned that OB IS NOT MY THING?!?!?! 

Once the OR guy removed the placenta, the bleeding slowed considerably!  She continued to bleed a little but not like before.  Thank you Lord!!  In addition, her family was able to find a second unit of blood for her…which was an absolute Christmas miracle!!  I’m just so thankful that in spite of all my inadequacies my God was so faithful and sent me people who could help!   A few days later the woman was ready to be discharged.  Yeah for happy endings!!