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Saturday
Sep302006

What's In a Scratch

I wrote humorously in Connect the Dots about my getting scratched as I was opening a vial of methergine.

Let's take this apart.

We suspected mom's previous postpartum hemorrhage (PPH) had been from terrible mismanagement of her third stage. Mom had to have some goodly amounts of pitocin, methergine and then hemabate (a medication I didn't know when I received her records) to stem the tide.

Hemabate is a prostaglandin F2 alpha oxytocic that is used in abortions, but is now used more in postpartum hemorrhages than cytotec seems to be. I've been reading comparisons and while cytotec was once the darling of PPH control, now it seems to be hemabate.

That I hadn't heard of the medication until reading through this woman's chart, I felt, was an interesting window into either the newness of the use of the medication or the lack of experience with PPH I have had. I suspected probably the latter.

During the pregnancy, we talked on and off about the PPH the first time and how to make sure it didn't happen again... being as hands-off with the placenta as possible, making sure mom was well-nourished, nursing the baby right after birth, keeping things quiet and warm (a la Odent), etc.

Heading into labor, contractions were sporatic and incoordinate. Days of starts and stops that didn't seem to be from any mal-positioned baby kept my brow furrowed in confusion. I merely waited to see what would happen once labor kicked in good and hard.

Once I was called and then labor was going, not long before the decision was made to move into the hospital, I palpated mom's abdomen, much to her extreme discomfort. I begged her to let me feel just for a moment... as quickly as I could... her uterus was soft as butter on one side and while hard, not as hard as it "should" have been (could have been?) on the other side; labor does not progress with a uterus making these moves. I heard the nurse was doing the same thing in the hospital - speaking of the incoordinate contractions - they remained so for most of the labor, apparently.

So, earlier in the labor, when the apprentice and assistant arrived and I'd already set up, I'd saved the meds for the apprentice to draw up so she could practice. Sitting on the floor in front of me, my red med box held the methergine, pitocin, Vitamin K, homeopathics, etc. I watched as the pitocin was drawn up and then when I wanted the methergine drawn up in the other syringe with 10 units of pitocin, we had a mini-discussion that made me kind of cranky. (I know I already covered this, but please indulge me.)

I do have experience putting pit and meth in one syringe when a woman is hemorrhaging... why waste time with two pokes? Just throw it in one, for goodness sake. The assistant had not heard of this and she seemed to be challenging me a tad more than I had patience for (unusual for me, actually). My apprentice opened a methergine and tipped it upside down and as she pushed the needle in, the methergine spilled out onto her lap.

The discussion continued and I was increasingly frustrated. I explained my point, again, and said, "I'll do it," because I felt if she had ethical issues with putting the two together, I would just do it myself and not make her do something she had issues with.

I got out a new vial of methergine and flicked it to make sure the liquid was down to the bottom and flicked it right into my apprentice's face. What was up with that? She should have had goal posts up.

I took it back and tried to open it. And I couldn't get the damn vial to open! I tried with my fingers about 4 or 5 times. I never have a problem opening those things. The assistant or apprentice handed me a paper towel that I should have been using in the first place (I actually had gauze sitting right there for the job) and I started trying to open it again. It was so hard to open! Never had I struggled to open a vial so hard.

And then it finally snapped open.

And as it did, it dragged across my thumb, forefinger, middle finger, and hand under where my wedding ring knuckle is.

I looked down and saw the blood and glass and methergine spilled on the slices and looked at my friends and think I said something like, "This can't be good."

I started sopping up the blood with the paper towel and then started opening gauze that was sitting there and using that. The assistant suggested I go wash it out when I said how terrible it was burning. Was it the methergine?

I got up and took some gauze and went and scrubbed it good and hard with kiddie soap and gauze before drying it with new gauze and pressing more new gauze on it to try and make the bleeding stop on the back of my hand.

As I said in the other post, I made a giant production about my hand... FAR out of proportion to the reality of the injury. Some of it was for comedic relief, but some of it was just bizarre in retrospect. We have pictures of my hand wrapped in rolls of tape and gauze and it was decidedly hysterical talking about going to the plastic surgeon or getting a skin graft - sitting here now, it was odd odd odd that I talked so much about my damn hand.

My assistant and apprentice lovingly and laughingly asked about my physical well-being, pretending to chart it. I was "excused" from left-handed duties because of the heavy weight of the bandaged hand.

At first, the whole hand was mummified, but gradually, digits were unfolded and bandaided with purple "active" bandaids. Once the birth seemed imminent, I took the last thick white strap of plastic and gauze off and replaced it with a brilliant blue bandaid. I looked like a guitar player who'd played a hard set one night - nothing more.

So, in the interest of trying to justify my bizarre behavior - or maybe to highlight a spiritual message being sent to me to PAY ATTENTION - I offer this explanation for my hand being sliced open.

I believe my hand being sliced by methergine was no accident. I believe that it's continuous bleeding far beyond what it should have was no accident. I believe I was being told to watch out... to look ahead... that methergine and pitocin together ain't gonna cut it. Literally.

I believe that when I bandaged my hand, and then unwrapped and re-wrapped and unwrapped and re-wrapped it again, I believe I was almost smacking myself in the head with PAY ATTENTION PAY ATTENTION PAY ATTENTION - LOOK LOOK LOOK - LOOK AT THIS - IT ISN'T WORKING - IT ISN'T STOPPING - IT'S STILL BLEEDING - THE PAIN IS STILL THERE. I kept holding my hand UP and waving... holding it up for pictures... showing people... asking for sympathy (not my laboring mama) - it really was a very strange moment in time, this hand thing.

"Can't you see me yet? Don't you see? Don't you see that the medication didn't work? It broke! It cut! It fell! It spilled!"

Messages from where (?) telling me/us this birth wasn't safe at home. I hated getting to the place when we faced the hospital decision... mother and I crying, she so sad about her lost homebirth experience; I for her dreams, also lost.

When the birth happened, a CNM caught the baby and there was no uterine manipulation at all. No one pulled a placenta out. No one pulled on a cord. No one did anything to cause the repeat of what occured during this woman's first postpartum hemorrhage.

I was told by my apprentice that it seemed as if a faucet of blood had been turned on.

Pitocin, methergine and hemabate were once again used to stem the tide of blood coming from my client's vagina.

She was told she bled 1800 cc. Anything over 500 cc is considered a PPH. 250-500 cc is pretty normal for a birth.

It's doubtful any serious manipulations had been done during the first delivery to cause this sort of PPH. Some, perhaps, but repeats this similar can't be done without exact circumstances - and the only exact circumstance was delivery.

I don't carry hemabate. As far as I know, I am not permitted to. I will be checking on that Monday. It's a pretty hefty medication. Many midwives use cytotec for PPH in homebirths (rectally).

(Doctors will love this, I'm sure.) It terrifies me what would have happened if she'd have delivered at home. She very likely could have died. There is no doubt in my mind. I can't imagine that bimanual compression would stop that kind of bleeding, but I could be wrong. I would certainly do it! I think, "What if she'd been a primip?" I know there's risk in everything. But, it scares the holy shit out of me.

I told mom when I saw her the day she got out of the hospital that I was sorry she didn't get her homebirth, but that she could have had a lovely homebirth and then her husband might have been home with two girls and a funeral to pay for. Instead, she had a hospital birth and was lying in her bed with her daughters and her husband was cooking in the kitchen.

Not such a bad trade off in my book.

Isn't that so un-midwife of me to say?

Reader Comments (17)

so for incoordinate contractions- cramp bark- viburnum Op. or viburnum prunifolium either one helps to stop this kind of contractions= or alteast support more coordinate ones- they are smooth muscle relaxants that can be used to a degree for high blood pressure as well.
maybe she has some fibroids or scar tissue, adhesions that are causing this kind of thing?
anyhow glad to hear your hand is ok. but I am hoping you get less painful messages in the future-- eve n sundancers limit the # of days of sacrifice and the kind of willing sacrifice-- KWIM take care dearheart

September 30, 2006 | Unregistered CommenterAnonymous

My thoughts...I wonder about how good an idea it is to presume, put in public detail and then tell a woman that she would have died if she hadn't gone to the hospital--to leave her with that sort of message when really, nobody knows. As much as you felt comfortable that her hospital birth was necessary, you have no real evidence that she "would have died." That's about as extreme as it comes, and maybe you could still have made yourself and her comfortable with the transport by telling yourself and her that a hemorrhage of that nature is usually best managed in the hospital. While you may think death is what COULD have happened, it isn't really the truth.

Some of the more recent literature suggests that a PPH may be better defined as a loss greater than 1000cc, or anything that causes signs and symptoms of hemodynamic instability. I tend to agree as many women lose more than 500cc in the normal postpartum period, but it still seems up for subjective definition.

October 1, 2006 | Unregistered CommenterAnonymous

Barb~It has been impressed upon me that women do not bleed to death quickly. It takes more than 2 hours (cite:physician midwifery instructor) to exanguinate from pph - as the blood pours out, the blood pressure drops and the bleeding slows.
If it makes you feel more prepared, take a look at the great recent articles about pph in low resource settings. Although cytotec is gettig the press, there are techniques, like the use of shock pants, totally external bimanual compression, compression the inferior vena cava, etc.
On the other hand, I totally understand the intuition and feeling that "oh my goodness, I am so glad we transferred" because the first thing to be really unusual was not the last.

October 1, 2006 | Unregistered CommenterJane

Very un-midwife of you? No...in fact, entirely, totally, and completely midwife-of-you to say such a thing. The failure of the medical mindset is the assumption that *every* birth must be medically managed. The beauty of the midwifery model is the understanding that most -- but not all -- births are normal. You would be derelict to ignore those exceptions, and, in fact, fall prey to the very same failure (in opposite terms) suffered by the medical model.

October 1, 2006 | Unregistered CommenterAnonymous

I think it makes you sound like the best kind of midwife-one that puts her clients and their baby's safety before all else. Women have to trust that you will know when to call it quits! You are too hard on yourself.

October 1, 2006 | Unregistered Commentersajmom

Wow. What an amazing discovery. I think it's fantastic that you have such insight to see what was being told to you. It's so hard for us to see and hear those things in the moment. Thank goodness for that mama. I hope your hand is feeling better!

October 1, 2006 | Unregistered CommenterRebekah

I changed my verbage to more ambiguous as it should have been at first. Writing it, I felt more emphatic. You are right, though... I should have been less emphatic.

Thank you for pointing it out.

October 1, 2006 | Unregistered CommenterNavelgazing Midwife

Always good to remember that hemorrhage doesn't always happen in a second's time, but when the faucet is on full blast, it is hard to gauge how long is too long, you know? And my concern, of course, is DIC.

So, if this mama was going to have another baby... how would midwives/student midwives prepare her prenatally herb-nutrition-wise and would they consider her a homebirth/vaginal birth candidate?

October 1, 2006 | Unregistered CommenterNavelgazing Midwife

Re: not sounding like a midwife...

When I spoke to my partner about being scared, she said she was THRILLED I was scared by some of the things that had come my way of late. She said that as a cop, she only liked working with cops that were scared; it was the cops that weren't scared that were dangerous. When people are scared (not immobilized or terrified), their senses are heightened, their awareness is on alert, they are paying utter attention to detail - and everyone, including the client and themselves, benefits.

This helped me a lot to relax about be afraid of the possibility of hemorrhage.

You who read know my skills are in shoulder dystocia. I rarely have hemorrhages, so they aren't as familiar to me. While I know what to do, I don't experience them as frequently, so they aren't on the tip of my tongue the way shoulder dystocias are.

As this client's birth came closer, I rehearsed the steps and read and re-read the appropriate skills and visualized how to tend to her and those around her if something occurred.

Writing this, my stomach is in knots. I still have work to do, obviously.

It is in my admitting fear, in my looking at my weaknesses and my desire to grow and change that I keep going when I thought this week I was going to just quit and be a birth photographer.

I was told by many that midwifery is in my blood and that I had to find a way to resolve the fear and balance it with my knowledge and intuition and my true belief in birth while acknowledging the realities that birth isn't always perfect, even when we beg it to be.

I do keep trying.

Thanks for walking with me. All of you.

October 1, 2006 | Unregistered CommenterNavelgazing Midwife

I would take her as a client again, if she wanted. I think my counseling would concentrate on her feelings after birth - some women are more or less symtomatic, even after large blood losses - the woman who is woozy after birth with a 300 cc loss contrasts well with the woman who feels great after a 1800 cc blood loss. I'd encourage the later woman, just because it is so much easier for a walking woman to take herself to the hospital than an unconsious/woozy one.
It would be nice is she could go into labor with an above average hematocrit, but not essential. I think I'd like to offer some blood work to make sure she has a normal clotting profile, but again, not essential.
I'd probably also ask her to consider an IV or heplock and also active management of third stage - again, not as a requirement of attending her, but as a true offer.
I don't attend births at home because I ignore/don't know the possibility for bad outcomes - as has been suggested to me. I have a family member that died in childbirth. I used to work in special education and see the little ones that were harmed due to bad luck, or illness or accident or drug use.

October 1, 2006 | Unregistered CommenterJane

Fascinating and rich with things that students love to read!!! As a side note I wanted to let you know that LM's in Washington State may (andI believe most do) carry Hemabate for PPH.

October 1, 2006 | Unregistered CommenterLouisa

Do you have access to something like the ALSO course? Thinking of your comment about trying to keep up with rarely-used skills.

The Ontario midwives have developed an emergency skills workshop that is specific to midwives and assumes that you'll need to be able to handle the unexpected in the home setting. I've seen some US midwives go through it and it doesn't always reflect their working circumstances (we have two midwives at every birth, for instance) but I think it's truer than a course intended for doctors.

Some of the facilitators will travel with the course. They've set it up to run in BC now, I believe.

October 1, 2006 | Unregistered CommenterLucina

what a bunch of crap-- how many women have you critics ever known to die of hemorrhage? not many in modern America but I have had long standing friends who have had women die as a result of hemorrhage in America -- 2 women had hemorrhage under 1 hr- and you know what else BP was fine until they were already into DIC-- now these women were transfered but unsuccessfully treated in hospital- one other woman was in the hospital and did take your "classic" 2+ hrs to bleed to death- I think that this is the slow bleed time- internal hemorrhage missed uterine tear- there is a brisk bleed time that includes DIC once fluids are reduced to a point DIC occurs in the collapsed circulatory system and they you have bleeding from everywhere---

October 3, 2006 | Unregistered CommenterAnonymous

we have a full quiver mom who had a hemorrhage last time that scared the crap out of us- though she was moving toward DIC had some very weird clotting that looked like small little bits but all her bleeding after a point looked like that until after we ran IV fluids in quickly- so something we are recommending to her to do before she might get pregnant again is to take some supportive and toning herbs- she has 8 children 12 pregnancies. we pretty much formulated it for her
partly for physical qualities and partly for what she will eat/drink/taste. so general things that most women will eat that help build connective tissue/and have vitamin C, berries,antioxidants fresh or frozen should include dark berries as well as raspberries and strawberries, and then there is Red raspberry leaf tea which has long been used as a uterine toner. have this woman eat green veggies everyday sure fine if she wants to eat corn or sweetpotatoes but for veggies at least 2 in a day that are green/vitamin K sources.
then other things to think about does she need some liver support? heat or cooling? other types of basic care? exercise? many old mother's cordials not only include uterine toners but some relaxants as well-- like viburnum or michella
look for and treat high BP, pelvic congestion...
for our gal when she is pregnant again we will be recommending belly banding last baby laid sideways most of the pregnancy- and I think that this added to her uterus being out of shape- uterine massage-

October 3, 2006 | Unregistered CommenterAnonymous

I have seen pph in the hospital. (Retained placenta) I was scared, the doctor was scared, the nurse was scared. The mom was passing out -- bp 60/35 (passing away?) It was a pretty quick bleed, the cord had come away from the placenta with little or no tugging by the doctor.

This was about 5 or more years ago. Hemabate was used to help the mom along with pit and methergine. I helped press fluid into the mom from an IV bag rolled up in my hands so that the nurse could do more technical things for the mom. I still sweat when I remember this birth and feel glad that I could do this thing to help this mom at least a little.

I just needed to tell this story, abbreviated though it is.

October 4, 2006 | Unregistered CommenterRose Marie

It is a good thing you listened to what the methergine/bandage was telling you...how did you come to the place where you knew you *had* to go to hospital? Was it the bandage incident, or the ctx?

December 3, 2006 | Unregistered CommenterCathi Cogle

It was the lack of progress and the back and forth of the cervical dilation that precipitated the trip to the hospital. I am not quite so superstitious as to base a transfer to the hospital on a scratch.

I have since heard from many other midwives that the incoordinate contrations were a serious red flag for the postpartum hemorrhage as well as the cervical dilation going back and forth. This is not something I had heard of before, but will surely be speaking about to students in the future!

December 3, 2006 | Unregistered CommenterNavelgazing Midwife

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