Sometimes the third stage of labor is more memorable than the birth of the infant. In the middle of the night, it is so easy to let down your guard after the crying infant is placed in its mother's arms, but there is much more to to birth than that. I've had some placentas give me more grey hairs than the babies who preceded them. Here's one story.
Graciela was a young second-time mother who was admitted to my residency hospital one evening before I arrived for my night float shift. At my residency program, interns ran Labor and Delivery when they were on call or night float, so my first responsibility was "running the board," or reviewing the progress of the laboring women whose names were written on a huge dry-erase board in the doctor's charting room. The outgoing intern told me about the six or so women who were hoping to have their babies before daybreak. One of them was Graciela. She'd been admitted at 4 centimeters of dilations and had progressed to 7 centimeters within a few hours, so her labor looked promising. She was very stoic and hadn't asked for any fentanyl for pain, but had an IV in so she could receive antibiotics for group beta streptococcus (GBS) positive status.
I had to run around to the other rooms, but by the time I went to check on Graciela she was already looking transitional. She had her eyes closed and made strange, keening noises that sounded grunty at the end. Her nurse and I looked at each other. She might be complete, the look said. This was her second birth, so things might move quickly from now on out. I pushed aside any thought of leaving the labor room to take care of the other hundred or so things that needed my attention and pulled out a few pairs of gloves in case I needed them.
I did. With her next contraction, Graciela bore down hard. Her vulva began bulging almost immediately. "Call Dr. Covarrubias," I told the nurse, thinking we'd need an attending there soon. Every resident delivery must be supervised by an attending physician, and all interns develop a pretty good sense of when to call.
I didn't even have time to put on my gown before Graciela's baby was crowning. The next push brought the head, and the body slipped out easily behind it. "Felicitaciones," I told the weary mother, and laid her baby girl on her chest.
Dr. Covarrubias hadn't arrived yet, but that was no big deal because the birth had gone so smoothly. I grabbed the plastic tub we used to catch the placenta and an extra Mayo clamp. There was a little gush of blood and the umbilical cord lengthened, two signs that the placenta was ready to be delivered. I gave the cord a little tug. Nothing. I waited a moment, then gave it another tug. The placenta slipped out easily.
Almost done, I thought. I was examining Graciela to see if she had any lacerations. This is a tender procedure in the minutes after a woman has given birth, when her vulva is sore from having stretched during crowning, so I was taking my time. Graciela and Juan, her husband, were cooing over the baby girl, and I was counting myself lucky that my night was starting with such a nice smooth birth, when suddenly there was a huge gush of blood.
"I think we need to start some Pit," I said to Graciela's nurse. Pitocin is used after delivery of the placenta to control uterine atony and staunch postpartum bleeding. Graciela's nurse, Bonnie, had the Pitocin ready and injected it into a bag of LR. The blood kept coming. I massaged Graciela's abdomen, which made her wince. The uterine fundus felt good and firm, although it seemed a bit lower than usual, but the blood kept coming. I looked up and saw the Pitocin was wide open.
Time to do some bimanual massage. This technique requires the operator to place one gloved hand in the vagina (sometimes two fingers is sufficient, other times the entire hand is necessary) and one hand on the abdomen, and compress the uterus between them. (This article in the American Family Physician discussed management of postpartum hemorrhage; Figure 2 shows an illustration of bimanual massage.) This helps a boggy, uncontracted uterus clamp down and close off all the bleeding vessels that remain open after delivery of the placenta if the uterus does not clamp down by itself. It is spectacularly unpleasant to the woman, so I was careful to explain what I was doing to Graciela.
Instead of the floppy uterus I was expecting to feel, instead I felt a meaty, rough, apple-sized mass in the vagina. Something was wrong here. Blood still poured from Graciela, despite appropriate management to this point. By this time, extra nurses had arrived to help with the unexpected crisis.
I had more than a bit of sweat on my brow by the time Dr. Covarrubias arrived. He took a look at the blood on the floor and my flushed face and still remained calm. "What's going on?" he asked.
I told him. I estimated there had already been 1200cc of blood loss already. "There's something weird about her uterus," I said, with classic intern's naivety. "It doesn't feel right. Will you check?" I stepped away from Graciela. She was moaning in discomfort and Juan had his arms wrapped around her shoulders.
Dr. Covarrubias got his gloves on while I asked the nurses to give Graciela some fentanyl and explained to her why Dr. Covarrubias was going to examine her and why we were worried about her bleeding. Dr. C examined her gravely.
"Her uterus is inverted," he said matter-of-factly. I'd never encountered this before, but I'd read about it. Occasionally as the placenta detaches from the inside of the uterus, it will pull on the fundus, or the upper portion of the uterus, which then turns inside out and can even be pulled all the way out of the introitus of the vagina. This site has good illustrations of the phenomenon. In Graciela's case, the inside-out fundus was still high in the vagina--I'd felt it as the rough-textured, meaty mass when I was examining her.
"OK, what do we do?" I asked.
"I'm going to try to reduce it here," he said. "Otherwise we'll have to take her to the OR to get it back into place." He paused and I knew he was thinking of the delay waiting for the OR team to arrive would mean for the patient, if the bleeding could not be controlled. Even as we bustled around Graciela, she had lost at least another 500cc of blood.
Reduction of uterine inversion. Image credit.
He replaced his examining hand in the vagina and instantly Graciela started climbing out of bed. "Never mind the fentanyl," I told the nurses. "Give her some morphine."
"How much?" one of them asked. Graciela was yelling now. The intensity of the exam was overwhelming her, and yet this was a true obstetrical emergency and we didn't have time to give her deeper anesthesia.
"Ten," I said. "And two of Ativan." I went around to Graciela's head and held her hand as Dr. C continued his attempts to replace the uterus. This brought me face to face with the IV pump.
"Dr. Covarrubias," I said, "Do you want the Pitocin on?"
He looked up. "It's on?" he asked.
"Yes. I started it when the bleeding began."
"Turn it off," he said--still calm but edgier than usual for him. "I need the uterus to relax."
Even with the Pitocin off, the uterus remained stubbornly inside-out. "Give her some terbutaline," said Dr. C. Terbutaline is a beta-agnoist which relaxes the uterine muscle. It is used to stop preterm contractions but here Dr. C was going to use it to relax the uterus entirely.
That did the trick. Once the terbutaline was in and the morphine was effective, Dr. C gently pushed the inverted uterus up into Graciela's pelvis. I could see her entire abdomen rise upward as the uterus settled back into place. Graciela was breathing rhythmically, using techniques which had served her so well in labor. I told her it was over, she was safe, and I believed it myself because I could see her bleeding had finally tapered down to a trickle.
Graciela did well. Her bleeding remained under control and even though she had a pretty good drop in hematocrit the next morning, no transfusion was necessary because she remained asymptomatic. For a long time I thought I'd made a mistake with that second tug on the umbilical cord, but since then I've been involved with a couple other cases of inversion in which the woman pushed the placenta out by herself, so there is no correlation between pulling on an umbilical cord and uterine inversion. One thing I did learn from Graciela's case is that you're not "done" with a birth until the woman is a few hours post-delivery, and there have even been a few cases in which I would have extended the period of surveillance to several days post-delivery, but I'll save those for future posts.
You're funny--why would I have balked at this? :) If you're referring to a Twitter comment, the context there was NOT immed. post-partum where a fist would not be considered out of the ordinary. This post is actually pretty awesome.
No ketamine (or etomidate?) onhand in L&D for situations like this? Just wondering if the fentanyl delay was due to C-II/not on unit -- I have no idea what is "normal" for L&D in a US hospital.
Great rookie story, though--I always appreciate good "learning moment" narratives.
P.S it's "felicidades" if you're saying it to someone as an interjection. "Felicitaciones" is simply the noun, eg. "Congratulations are in order!" vs. "Congratulations!!" (at least that's the way it is in Mexican Spanish) ;)
Posted by: enrico | July 17, 2008 at 03:32 PM
Excellent post. Inspires me.
Posted by: Rural Physician | July 17, 2008 at 09:46 PM