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Friday
Jan132012

Beth's Hemorrhagic Miscarriage

This is a re-post from several years ago, but the topic came up recently on Facebook, so was led to re-post it now. Plus, Beth, the woman in the story, is writing her view of the experience and when she has finished, I will add that to the end of this one. Check back in a few days.

Trigger Warning: Miscarriage discussed in detail as well as a photo of the Products of Conception (POC) at the end of the post. 

I got a call from the glamour sono place 3 days ago. My client, 16 weeks along, had gone in on a whim to see the baby's gender. She brought her best friend and all the kids as well. During the ultrasound, it was apparent there was no heartbeat and, of course, the sonographer couldn't say anything, so she mentioned that the baby actually measured 8 weeks... perhaps she was off on dates? As soon as my client left, the sonographer called me even though she didn't have a prescription from me or anything. I am very grateful for her caring. Immediately I called Beth (she was still driving home) and told her what she already knew. Beth is very calm and quiet, very matter-of-fact, so calling her while she was still on the road wasn't an odd thing to do. For another woman it might have been totally inappropriate. 

I was Beth's midwife for her last baby. She's had 2 hospital births, a UC and then the birth with me. She'd asked me to be her midwife this time, too, so I was very much looking forward to working with her again. 

For another reason, she had to go to the doctor, so sent her to a beautiful, gentle doctor we were just getting to know. Dr. G(entle). I had not done a prenatal on her at all, still, so technically, she was his patient. 

Because she had not had a spontaneous miscarriage and it had been so long since the fetus had died, it was important for her to consider inducing the miscarriage (technically, it is called an abortion, but doesn't mean it in the political sense, merely a medical sense... an SAB - spontaneous abortion). She went to see Dr. G and after another sono verified the demise, mom had labs drawn (to check her iron levels with a Hemoglobin and her HCG [pregnancy hormones], both as baselines) and then filled the prescription for Cytotec ("medically managed miscarriage"). Beth is very aware of the controversy around Cytotec, but for miscarriage, this is an absolutely correct usage for it. Even so, not everyone would prefer this, instead choosing a D&C. Weighing the risks and benefits is really important because D&Cs come with their own set of risks. 

On June 30 at about 7pm, she placed the Cytotec into the os of her cervix. (I didn't know she was putting it in so quickly; I would have recommended she wait until first thing in the morning after a good night's sleep. Note! Inductions of any kind are best done first thing in the morning!) She had no contractions and nothing really happened until about 1:30am on July 1. Then she started bleeding and didn’t seem to stop. Sitting on the toilet, she dropped clot after clot and dripped blood that sounded like she was peeing. She began going through more than a Poise an hour (extra large pad), but thought it was all normal (and very well would have been except it didn’t stop). 

I got a call at 5:17am with Beth saying she felt faint and was getting worried. I jumped out of bed and was out of the house in 11 minutes, the only make-up on was from the day before. I barely combed my hair and poured a Diet Coke in my Big Gulp cup and headed out the door. Being 45 minutes away, I talked to her once I was on the road, asking about the bleeding and she telling me about the clots she could hear plopping into the toilet and the large amount of blood that kept coming out. I asked her to please not get up without help and she said she was going to wait for me. I told her she might have to pee and if she did, please have help. She said, again, she would wait for me. 

Beth was at another client of mine’s home because she has 3 small girls in a little house and knew she would need some help as she began the letting go process. I am so, so glad she was at my other client’s home, a woman who’d caught Beth’s UC baby and was a wonderful and loving best friend. L has two beautiful girls and her husband R was home, too. In fact, when I got to the house, R opened the door, ushering me right to Beth who was on the couch in the living room. I arrived at 6:25am. 

I sat with Beth on the couch, listening to her tell me she felt so dizzy when she got up, but she needed to pee. After a few minutes, I walked with her to the bathroom and she sat, plops of clots and blood gushing into the toilet. The clot that I saw was twice as big as my fist, but it was quickly covered with blood, the toilet looking like only thick blood was in the bowl. Had she been doing this since early in the morning? She said she’d wanted to call me at 3:00am, but thought she should wait longer. I wish she’d have called me earlier! Don’t ever worry about waking a midwife! 

I learned at Casa de Nacimiento (a birth center I trained at in El Paso, Texas) that when women tend to faint, it is often after they pee. The fluid shift in the body might be one reason, but I don’t know the exact technical reasons; I just know that it happened at Casa a lot. My Anglo clients didn’t faint nearly as much as the Hispanic women… don’t know what’s up with that either. 

Beth felt very dizzy, so she rested her head on my thigh for a few minutes. She would pick her head up, then lower it again; we stayed there for about 15 minutes, blood dripping the whole time. Then she took a deep breath and said she could get back to the couch, so she cleaned up a little, pulled up her undies and pj pants and we left the bathroom. She stepped out first and I was sort of behind/beside her and knew I needed to get in front of her. As I was stepping to scoot around her (we were in a hallway), she went down. And went down fucking hard. 

Beth fell as if she were a Sequoia… straight forward, stiff… and right onto her face. Onto a tile floor. Horrified, I fell to her side, touching her gently as she twitched in the way women who faint do. R came to be with us, too. L and the kids were still asleep. I spoke softly to Beth, telling her she wasn’t alone (I know that many people who faint lift out of their bodies and can see and hear what is happening even though they can’t respond) and apologizing for not catching her as she fell to the floor. Today, Beth said that was the first thing she remembers after the bathroom, my telling her, “I’m so sorry I didn’t catch you!” As she got back into her body and could talk, she said her face hurt. Her lips swelled immediately, her top lip nearly touching her nose. Later we were able to joke that women could naturally plump their lips simply by falling on them each morning. Who needs those pesky bee sting injections? 

Beth fainted at 7:15am didn’t move from her exact same position for over 45 minutes. L woke up and we all sat on the floor next to her, talking with her about how she was feeling and what I felt we needed to do. Right after L woke up, I grabbed my phone and called Dr. G, relaying the events to him. I told him I thought we should come in and he shared with me what would happen if we went into the ER… fluids, a sono and if there were still POC, she would need the D&C. He said that he felt the worst was over and asked how much she was bleeding. We took her pants off, put a Chux under her and there was very little bleeding. He asked for her BP and I didn’t leave her to grab the cuff right when she fell, but took the few seconds to get it and took her BP… wrong. She was face down, upside down to my usual orientation, and I put the cuff on upside down. Rolling my eyes, I re-placed it, taking her BP and it was 80/40… a re-take a few minutes later was 90/50, so it was coming up. I asked Dr. G if he felt a shot of pit might be called for. He said the Cytotec worked in much the same way, but it couldn’t hurt. I had an instinct that it would help, but think that’s because of my limited ability to attend to hemorrhage in the home setting. The doctor said he still felt comfortable with her remaining home as long as I stayed with her and if there were changes, we would go in. After hanging up, I went and got a pit out of the car along with some homeopathics (after talking to another midwife who is far more skilled than I in homeopathy). I gave her the shot of pit in her left upper arm. L got Beth some arnica and gave that to her as soon as we thought of it. 

Beth loved lying on the cool floor. We also got ice packs and put them on her bare back, her neck and gave her ice chips as well as sips of water. After that first 45 minutes, we turned Beth over to her back (it was horrible see the whole damage of her lips and teeth!), getting her a pillow and then really encouraging her to drink water to increase her fluids. L also got her a Popsicle to suck on to help quell the swelling. Any thought of sitting up was squashed as she said she knew she would faint if she did. One of L’s daughters woke up and casually asked, “Why does Miss Beth have no pants on?” We said she wasn’t feeling well and was hot, so didn’t want any covers. 

Once Beth was on her back, she rested for quite awhile longer. I checked her uterus and it was very firm and easily felt. When I talked to Dr. G, he suggested that perhaps some tissue was still in the uterus or in the os of the cervix and uterine massage would be a great idea to move the tissue along. While initially, it didn’t seem there was any bleeding, slowly, I could see blood seeping through the Chux pad. The doctor also said some bimanual compression would be necessary if she started hemorrhaging badly, but we never got to that point. 

Beth began getting cold, so L found a Nemo towel (she asked for Scooby-Doo, but L and I scoffed… nothing but Disney; it really was the only choice) and we covered her with it. She really liked my massaging her uterus. When I had to step away, she did it herself. It seemed the uterus was always firm, but there was one side that got boggier and needed massage. We talked about my calling 911, but if the ambulance came to take her, they would take her to the only hospital in the county that all of us despise. This was the hospital where my client was abused and I turned them in to JCAHO – and ever since, they won’t let me past the front desk, even when transporting my own clients. Beth refused to go to this hospital, so we talked about how to get her to the hospital. She said she was feeling better, but still didn’t think she could get to the bed that was about 10 feet away. R said he would carry her there, so she put her arms around his neck and he lifted her, straight off the floor and carried her to the bed L had gotten ready with Chux and clean sheets. Beth melted into the bed. She said it was much more comfortable than the tile floor. 

I gave Beth some Nat Mur for the bleeding (I didn’t have anything else the midwife recommended) and Arnica 200 for her swelling. We did a couple three doses altogether. She had to go to the bathroom and getting up was out of the question, so I told her to just go on the Chux, but she couldn’t so B got her a Pull-Up and she easily peed into that. Beth was lying on L’s youngest daughter’s bed and L said it had great pee karma, so she shouldn’t have any trouble going; she didn’t. Maybe urinating would help keep the uterus firm? 

Beth felt so much better in the bed. Perhaps the bleeding really was done. Dr. G called again and said it can be so hard, the Cytotec/miscarriage experience, that sometimes it’s such a storm and he was sorry she’d been experiencing that aspect. Certainly the storm had blown itself out. 

With Beth resting, I told L I was going to sit in my car in the driveway and try to nap for a few minutes, but I would be back in shortly to check on her. L stayed with her. About five minutes after I got into the car, L came out and said Beth was sweating. I dashed in and knew then she was absolutely going into shock. I called Dr. G to let him know we were on our way in and he said he would call the ER to let them know we were heading in. 

R had left for work a few minutes earlier, so L called him back and while we waited, L got the van ready to hold Beth in the back row, still lying down. Any lifting of her head brought her complete dizziness and an urge to faint. R came in and lifted Beth easily and put her in the back of the van, feet raised and she was put in charge of massaging her own uterus, not only to keep it firm, but also to give her something to do, focus on something other than how poorly she was feeling. 

I followed L and instructed her that if Beth needed help, to pull over and I would call 911 immediately. Blessedly, even though it was 9:00am, the traffic heading south wasn’t bad at all. 

We got to the hospital Emergency Room parking lot and I calmly (but quickly) went in to get a gurney for Beth. I had to wait for the nurse fill out the paper wait for the nurse again tell her she can’t go in a wheelchair she can’t sit up she needs a gurney… “Let me go talk to my supervisor” oh, hello supervisor, oh, the gurney won’t fit here how about we move the van so the gurney can get next to the van where is everyone why don’t they frickin’ hurry UP already oh, move the van how clever of you. L moved the van to where the ambulances drive up and then Beth slid out of the van on her butt and rolled onto the gurney. I breathed a huge sigh of relief that we were at the hospital. Writing this, it brings tears to my eyes. The two hours of worry and concern… and heightened awareness… were over… at least with regards to my personal responsibility. 

Monitors were attached, the blood pressure cuff attached and the pulse oxymeter all attached within seconds of getting to the curtained off section we would be assigned to for the next 12 hours. Blood was drawn and the IV started, even before the nurse got orders to do so. Over and over, Beth, L and I would sigh deeply and say, “I’m so glad we’re here.” Sometimes the hospital is a wondrous place to be. 

Know that things were done very quickly –for an emergency room. Beth had a sono and a CT scan, the ER doc was an angel, asking me what I thought about a D&C, saying he didn’t want to counter her HCP. I was flabbergasted. Oh, and the nurse knew who I was… had looked over my website and wanted to be a CNM but didn’t know how to get there. I gave her my card and she promised to email me. 

Dr. G came in, cancelling his afternoon so he could spend it with Beth, looking at the sono results which showed something in the os of the cervix, so he was going to do an exam to see what he could find. The CT scan’s results came later and were normal. (She had the scan because she smacked her head so hard on the floor.) The blood work came back showing that her hemoglobin had gone from a 12.7 to a 10… not really horrid, actually. The doctor wanted to re-check her Hgb after the vaginal exam to see if it continued dropping. 

Dr. G came in with “drumsticks” – long, long cotton swabs, gloves and a nurse to assist. Within moments of the exam, it became apparent why Beth had been hemorrhaging. The POC had gotten trapped between the uterus and the vagina, lodging itself in the os, not allowing the uterus to clamp down on the “open wound” area the delivering placenta left inside. It didn’t take five minutes to relieve Beth’s body of the baby that seemed to linger inside. Whereas we thought her uterus had been clamping down before, after the POC was removed, it was a distinct difference, how low the uterus shifted and how firm it finally stayed. There still was some bleeding, but not anything like there had been, so the doctor talked about rectal Cytotec which made Beth shudder. We both explained that rectal Cytotec is used for hemorrhaging and since she’d had several babies, it might not be a bad idea to stop all the inappropriate bleeding. Beth very much wanted to avoid the Cytotec. Later, she began taking methergine, the other medication many midwives carry, along with Pitocin. We give methergine to women who might have retained membranes, so this seemed like a good idea. 

Another sono showed the uterus, os and vagina were empty. The miscarriage was complete. 

It became apparent that she was going to spend the night. They offered to let her go if her Hgb wasn’t much lower (it was lower), but Beth really felt she needed to stay. For a former UCer to say she needed to stay in the hospital, they best listen to her! 

All the major drama and work completed and the waiting for a bed begun, I excused myself about 2pm and went home to nap; I am on call for a term mama and definitely needed to rest up a little. It won’t surprise birth workers, but I wasn’t the least bit yawn-y when with Beth until things started to wind down. In the moment, I felt unlimited energy, no pain in my feet and completely present. As I drove home, however, I was groggy and couldn’t wait to climb inbetween my bamboo sheets. 

Beth got a bed about 12 hours after entering the ER. L stayed with her the whole time, feeding her ice chips and juices now that the possibility of surgery had vanished. I learned the next morning why she wasn’t eating food; her teeth’s re-positioning didn’t allow her to chew, her molars unable to meet because of the way her front teeth had moved around. I continue to feel just horrid about her falling face down. I wish I could re-play that moment (I would step out of the bathroom ahead of her) or fix her teeth as easily as I can measure dilation. 

I went to see Beth the morning after and her Hgb was now 6. She accepted the offer to receive two pints of blood (A Positive, just like me). Dr. G said she didn’t have to have the blood, but after L’s hemorrhage (after her last birth), she saw how it took three months for her to get back on her feet and knew she couldn’t take that long with three young girls. She said if she hadn’t seen L’s recovery without a blood transfusion, she would have refused. Seeing it, however, she knew it was the best choice for her. Each bag takes about three hours to drip in and I was there for ¾ of the first bag. When I walked into the room, she was the color of the sheets. By the time I left 2 hours later, she had some color in her cheeks and already felt much better. After both bags, she felt like a new woman. 

Walking in, there was a sono machine and tech next to Beth’s bed. She was getting a heart ultrasound to make sure there were no misfirings that caused her fainting. I yacked with Beth as we watched and listened to her heartbeat on the monitor. 

After the really long sono, she had to go to the bathroom and was doing that at a bedside toilet. She’d gotten up twice to sit on the toilet, always with someone present, and didn’t faint sitting up for a couple of minutes each time. 

While the sono tech was still there, another woman came in and stood to the side. She was a Physician’s Assistant (PA) for the cardiologist who ordered the ultrasound. I asked her to please wait until Beth went to the bathroom and she stepped out. 

Sitting the bed up a little, Beth slid out of the bed and sat on the toilet, peeing tons (the heck if she was going to get swollen from those IVs!). While she was on the toilet, I straightened her wrinkly, unruly sheets and blankets, including the ever-present Nemo towel. I needed more Chux and the PA brought me giant diapers instead, I putting her back in bed, tucking the Chux under her once they delivered them. 

I was only there two hours and 100 annoying things occurred. The sono tech dislodged Beth’s IV and I had to grab the nurse to fix it, but not before blood gooshed all over the blankets and sheets. The bed across from her was empty, but the phone rang as the person on the other end looked for the former occupant. A nurse asked her what she could do for her and when Beth asked for grape juice, the nurse said they didn’t have any… “We have apple juice…” “Um, they’ve been bringing me grape juice all morning.” A nurse’s tech went to get some for her and I followed with her pitcher to get her some ice and even more juice. The tech returned with two grape juices and a small cup of ice. I trumped him with two more juices and the pitcher of ice. Ha! She’d explained she needed a soft diet, but no one put that in to food services. I don’t know if it finally happened, but L was bringing in soft food for Beth to chew. A nurse came in to take vitals. 

And then the PA came in during the cacophony of medical visitors. She asked 100 questions about Beth’s medical history and then when we got to the part about her fainting, she asked me what it looked like. I told her how she fell (groan) and how she had those typical jerky movements of someone who faints. Her ears perked up and she said, “Like seizures?” Um… not really, but you could say it looked a little like that. She bit on that concept like a pit bull on a beef bone. I repeated that it wasn’t a seizure, per se and finally settled on the word “twitching.” She matter-of-factly said, “We’re going to move you up to the cardiac floor so we can put a heart monitor on you until you leave and then we’ll send you home with a holter monitor that you’ll wear for twenty days and then come back so we can determine if your heart was the reason for fainting. Beth kind of sat there for a second and I said, way too loud, “Um… how do you FEEL about that Beth?” and she said, “I think it’s stupid.” (I think she really said, “I think that’s overkill,” but she really meant the stupid comment.) The PA was taken aback. In her gentle way, Beth refused the visit to the Cardiologist and even the move up to the Cardiology wing. The PA wished her well and left. Beth and I laughed our heads off about that until her (new) nurse came cheerfully in saying, “Okay! We’re going to move you now up to Cardiology…” and Beth said, “I’m not going.” The nurse was totally taken aback and a back and forth, “But you have to,” “But I don’t want to” went between the two. The nurse saying, “We need the bed” as if that was going to convince her. Beth pointed to the empty bed across the room and said, “They can have that one.” I said, “Maybe you want to talk to the Nursing Supervisor?” and the nurse kind of huffed out. Again, we laughed, but were a bit peeved that she ignored the supervisor comment. About 15 minutes later, she came in and said the Nursing Supervisor said she didn’t have to move. Beth said, “I wasn’t going.” 

During all of this we talked about all the meds she was on and I chuckled saying she’s probably taken more meds in the last two days than she has combined in the last 15 years! She said that was surely the truth. She also had a running list of firsts for her: fainting, blood transfusion, IV antibiotics and more. 

During the day, she finally stood and walked, walking around the whole floor before she left. About 7pm last night, 36 hours after entering the hospital, Beth was released, but only after Dr. G called the Cardiologist who wasn’t going to release her because she was being non-compliant! He finally did and she left, going to L and R’s house again to recuperate and be taken care of. I got the greatest text that said, “I‘m gonna make you proud at how much nothing I will be doing.” 

So, amidst all this drama and trauma, we’d barely touched the issue of losing the baby. Every once in awhile I would ask how she was doing and she would always say, “Okay.” Last night, I texted her that as things got quieter, she would probably find herself feeling more and to let the emotions wash over her, for the miscarriage and the hospital stay… and reminded her that women who hemorrhage have a tendency to be sadder than usual as the hormones of un-pregnancy find their balance. She said she would be gentle on herself and would call me anytime she needed to talk. 

I’m glad she’s resting and being lovingly taken care of… she deserves it at this challenging time. 

Twice during the experience, I was told, “You saved her.” I didn’t really think about that, but if I did, I’m glad and also know it is all a part of my calling as a midwife. It didn’t feel heroic, but apparently it was a really good thing, my going to help and getting her more help. I’m just glad my friend is still here.