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Entries in postpartum hemorrhage (5)

Tuesday
May012012

Cesarean Scar: Anonymous 4

On the morning of December 15th I went into labor on my own, at my house. By the time I got to the hospital, I was 4cm dilated. About half an hour after I was admitted and in my room, they checked me and I was 5cm- so they broke my water. Within 45 minutes after they broke my water, I was fully dilated. All of a sudden, my son's heart rate plummeted to the 40's. They had me lie on one side, then the other, then get on all fours. His heart rate was still low, so before I could even process what was happening they were running me down the hall and into surgery. I had an emergency c-section because my baby's cord was wrapped around his neck three times. I was awake long enough to hear him cry for the first time, and my husband say "He's perfect!"... that's all I remember. I was later told I had a postpartum hemorrhage on the table, and ruined some poor nurse's shoes with my blood. My son had a short stay in the NICU after he was born- he became lethargic and as a result wouldn't nurse, and his blood sugar levels became low and they feared meningitis. Thankfully, he is fine.

When I woke up from surgery and remembered what had happened, I was terrified to look under my gown. I was afraid to see the incision, and afraid that since my c-section was an emergency, that I would be cut vertically. I can't lie, I was relieved to see that it wasn't. I had a low transverse incision.

In the weeks following his birth, I was concerned about the dreaded c-section "shelf"- afraid of how my scar would heal... all that stuff.

It's been four months and my feelings towards my scar have radically changed. I'm damned proud of that scar. I wear it like a badge of honor. It wasn't my birth plan to have a Cesarean birth- but coming home with a baby was my ultimate birth plan, and the c-section allowed me to do this. When I feel my scar, it's still pretty numb, and hard as it is still healing. But what I see and feel when I look at or touch my scar is simply gratitude. I am beyond thankful to live in an age when this operation is a possibility- what if I had been born 100 years ago? Would my son and I have lived? I don't think so.

When I look at my scar, I thank God for blessing me with a beautiful, healthy son.

When I look at my scar, I'm reminded that my little boy is a fighter- and so am I.

 

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.

Friday
Mar182011

LifeWrap

I came across this article, "Cinematographer and Midwife Travel World But Return to Marin" and in there, we learn the midwife, Suellen Anderson-Miller, travels the globe teaching health care professionals in developing nations how to use the LifeWraps... a neoprene full-body wrap that can stop life-taking hemorrhages after childbirth.

The LifeWrap costs about $175 and can be used up to 50 times.

Question: Why don't homebirth midwives have these? How come I've never heard of them before? Is this something midwives are interested in carrying?

I sure would be. 

Sunday
Mar062011

Exposition Trail: Intro

It's true. I have real concerns about the level of education and training of many non-nurse midwives. I first confessed my beliefs in a 2008 post called "Midwifery Education." That post was so reviled and I was smacked so hard by the midwifery community, I pulled, then edited the piece, now called "Midwifery Education (Lite)." In that post, I said:

"I like that nurses all go through the same courses. They don’t all have the same experiences, of course, but all have the concrete base. All that “boring” stuff I mentioned above lays a foundation of commonality that continues into the Master’s Program a nurse enters to get her midwifery degree.

LMs and CPMs come from a wide variety of backgrounds and that can be great and not-so-great. Some, like me, tried the apprenticeship route, but found working with many different midwives was a better fit. I also didn’t have the foundation of a MEAC-accredited school, something I think is imperative today and something I definitely missed out on. I know there are non-MEAC schools and they might be phenomenal, but the way our society leans is towards accreditation and having the MEAC approval means the schools went through some pretty tight hoops to get where they are. I’ve considered going through one of the three-year schools even now, but know I want a different type of experience than what MEAC-schools have to offer."

I ended the post enrolled back in school, wanting to become an RN and then possibly CNM. I just knew I needed and wanted more education.

A lot has happened since then. To me and to others. I've kept my eyes open and have seen some rather harsh experiences in birth, too many at the hands of non-nurse midwives.

Below, I share a part of the birth story from Natural Birth Goddess' blog... the January 23, 2011 Homebirth of the Twins. Even though I've been formulating this series for some time now... and it's certainly picked up momentum since I've left homebirth midwifery behind... this birth story is the perfect springboard to emphasize the crucial importance of education and skill in a homebirth midwife. While this birth took place in a midwife-illegal state and many have equated that aspect as an excuse for the midwife's actions, I know (because I've heard it several times) the same sort of actions happen in midwife-legal states.

I'm sure to piss off a whole lot of folks by my trip down Exposition Trail, but so be it. I know my thoughts are the thoughts of others, women who spend time in my email and on the phone, not knowing who to go to or who to report their midwives to. And I have similar thoughts as other midwives who also think formalized education can transform homebirth midwifery. But that story will unfold with time.

For now, sit as I did, in disbelief at what I was reading.

"I got about 5 minutes to nurse both babies and cuddle them before the second placenta (Ariana's) was birthed.  I noticed, immediately, however, that there were some large blood clots that came with the placenta (the first placenta had not been birthed, yet).  That concerned me greatly...and although the midwife reassured me that all was fine (I mentioned it repeatedly that I was concerned about the blood clots) but she immediately started giving me herbal tinctures to help with contractions and stop bleeding.  I didn't think much of it at the time.  I was just focused on getting the first placenta delivered (and worrying about the blood clots). 

However, as I pushed, I would feel gushes of blood.  Since I had hemorrhaged before with the birth of my second child (Adrian), I knew the signs all too well.  I had mentioned the bleeding to the midwife and she was still reassuring me that all was fine.  She had me changing positions (standing, squatting, sitting, etc) and pushing.  Nothing was happening.  Nursing the babies didn't help, nipple stimulation didn't help.  I asked several times about the clotting and the bleeding and stated, "I'm hemorrhaging" and she reassured me that all was going along fine.  I got to the point where I felt like I needed to lay down (I was still in the bathroom).  My husband helped me to the bed where I laid down and pushed a few more times.  I remember feeling like my energy was slipping away.  I felt weak, I felt cold and I wanted to say something and I couldn't say a word.  I looked over in to the bathroom and was shocked at the amount of blood that was on the floor, the towels and the chux pads.  I tried to say something to the midwife about the blood, but I couldn't get the words out (I knew this was bad)...at that point, she put the oxygen mask on me. 

I remember my mom asking the midwife if she was going to call the ambulance.  I remember the midwife was sitting at the end of the bed and said, "I haven't decided, yet."  At that point, my husband grabbed his cell phone and called the paramedics.  My husband called for the ambulance at 7:05am.  Almost 35 minutes after I first noticed the blood clots.  As soon as the paramedics were called, the midwife and her assistant grabbed all of the bloody towels and put them in a garbage bag, mopped up the floor quickly, and threw away all of the chux pads.  The midwife even changed the chux pad that was under me, and full of blood. 

When the EMTs arrived, I had a little blood on the chux pad.  My husband had told them I had hemorrhaged and was losing a lot of blood.  I remember seeing 2 of the paramedics look at me (and the not very bloody chux pad under me) and look in the bathroom and not move any faster.  There was no urgency. 

After what felt like an eternity (they asked me if I was having problems with the last placenta, and the midwife mentioned I had been up for 30 hours--which was a total lie) they took my blood pressure (which was very high) and strapped me to the gurney, got me into a (very) cold ambulance.  The last thing I really remember in the ambulance is getting the IV inserted...and the one female EMT saying, "I think she lost a lot more blood than we saw..." 

When I was finally on the Labor and Delivery floor, we waited for the doctor to arrive.  Once she got there, I was given Cytotec (to increase the contractions--and it did this very effectively) and some pain killers (the contractions were that bad--and I could not imagine being induced with Cytotec, which is dangerous, anyways).  The placenta was delivered within a few pushes and I laid down on the bed.  After an hour or so, I wanted to get up to go to the bathroom (couldn't stand the thought of a bedpan) so the nurses helped me--reluctantly because they wanted me to use the bedpan--and I almost immediately passed out.  That is the last thing I remember until several hours later. 

Just after I passed out, I was started on blood transfusions.  I got 3 units of blood that day.  The doctor (who was absolutely great) wanted to keep me overnight for a 4th transfusion, but gave me the choice to go home since I  was eating, looked good (all my color was back and I was coherent).  I chose to go home that day because I wanted to get home to the girls since I had spent the first 14 hours of the girls' life in the hospital without them.  My blood count was in a "safe" range and the doctor was ok with me leaving. 

While I was in the hospital, I had 2 really good friends drop everything that they were doing to wet nurse the babies since I really wanted to avoid formula feeding them.  I cannot tell you how reassuring that was for me.  To know that the babies were being well cared for and fed while I could not be there just took so much stress and worry off of me and gave me the relief I needed to get well enough to get home to them. 

The next few days were a bit of a haze (as it is for any new parent).  The twins started out on very different sleep and nursing schedules that I was only getting about 45 minutes of sleep at a time.  I did have friends and family over all day long that helped with my other kids so I could spend all my time in bed resting and taking care of the babies.  It took about 2 1/2 weeks for me to really get used to having twins.  But I found, despite most other advice, that keeping them on their opposite schedules actually suited me (and my family) very well.  With not having to nurse, burp, and change 2 babies at the same time all the time, I have the time to really spend with each girl. I can nurse, change, and burp each individually and then cuddle with each one by themselves.  I really love the one on one time I spend with them. 

Overall, my homebirth was very good.  Excellent, even.  I did learn, though, that if there is any apprehension or concern about anything that is going on during the birth, you have to put your foot down and make the decision for yourself.  You are in charge of your birth, every aspect of it.  I should have told the midwife that I wanted to go to the hospital immediately when I saw those blood clots.  I don't, completely, blame the midwife for not transferring me sooner, but I do think she waited too long."

Mom wanted me to share the story. At first, the midwives she'd shared the story with told her everything was fine, to just move on. It wasn't until I read and commented on the story, followed by other midwives reiterating her midwife's egregious inaction that she began to believe she had a right to be angry. She has not seen or spoken to her midwife since the birth. I've counseled her to wait awhile, until she's somewhat healed from the anemia and twin birth before scheduling a sit-down meeting with her.

Mom also wants it known that she consciously chose to homebirth, that she felt her options were more dangerous in the hospital, a vaginal birth in the operating room or a scheduled cesarean, but she had discussed, at length, the seriousness of her hemorrhage history and how the midwife would handle a PPH if it happened again. She convinced the mom of her skill and experience in this area; she obviously lied.

I was shaking with fury for over an hour after reading this story. Part of my anger is the increasing frequency of these stories. Something has to be done. And the only people to do something is us... if we don't want to watch homebirth midwifery be illegalized everywhere in this country.

My writing is so we can talk, openly and transparently, about the changes we must make to homebirth midwifery... changes that, literally, saves the lives of mothers and babies.

Wednesday
Feb272008

Long Note to Students/Apprentices & Homebirth Advocates

In the comments section, you will see that the person in question is NOT an apprentice or student, but a lay person. The assumption was definitely mine as she made it sound as if she knew what she was talking about, spoke about how many midwives attended births, said things that only a midwife or apprentice would typically know. But, my assumption was wrong! Sorry for the incorrect finger-pointing.

So, I'll need to change the post around to say what I still want to say, but from a different slant.

Thanks, non-student, midwifery advocate for clarifying.

I will say, however, that anyone "defending" homebirth sure as crap should know what they are saying before putting their foot in the entire homebirth community. It really does make us look bad.

---------------

If you are going to argue on other websites or with midwifery/medical folks, please get your facts straight so you don't look foolish or make the whole of the homebirth community appear ignorant!!

A homebirth advocate (HBA) made a comment in another blog that leaves me shaking my head in utter confusion and not a little bit of concern. She cavalierly say that midwives at home can do everything short of hysterectomy for a woman who is hemorrhaging.

deep breath

Let's begin, shall we?

A discussion of a hemorrhage in the hospital was being had. The woman bled immediately postpartum and it was obviously frighting and extremely serious. It took 4 people and many steps to stop the bleeding. The steps were not outlined at this early point in the conversation.

A HBA poked her head in and said:

This makes me curious. OB nurse, can you specify what it was that stopped the hemmorhage? What steps were taken? In my state there (to my knowledge) isn't anything a home birth midwife couldn't do to stop a hemmorhage that a hospital does, short of a hysterectomy. Could you elaborate?

To say the midwife can't do anything less than a hospital does BUT a hysterectomy speaks volumes about what a midwife cannot do. Hemorrhaging women sometimes need hysterectomies! FAST!

For crying in a bucket, women wanting to birth at home should know every detail of what happens in whatever setting so they can give TRUE informed consent!

The discussion unfolds like this; my questions/comments are in black:

The OB Nurse asks and the HBA replies:

1) Do they have 4 trained people there?

There are 4 or more people present at births my midwifery practice attends. While it's standard, I doubt it's a requirement. I bet 2 is closer to the requirement.

HBA, if you are going to support homebirth and consider yourself active in midwifery legislation, it really would behoove you to know what the law mandates as well as what the standard of care is. There is no "betting" in midwifery. You either know or you keep your mouth shut or you say you don't know and go find out the answer.

2) Can they give all these Meds? Pitocin, cytotec, methergine, hemabate.

Of Course.

I would really like to know where you live that the midwives all carry cytotec and hemabate.

This is the "Adverse Warning" from the Hemabate Website. Would YOU want to use this medication outside of a hospital? I've asked before, but haven't gotten an answer - do any homebirth midwives carry hemabate? What are the standards of care of usage if you do have to use it? How symptomatic is the mom? How much blood does she need to have lost? Do you try cytotec first?

BEGIN WARNING:

The adverse effects of Hemabate Sterile Solution are generally transient and reversible when therapy ends. The most frequent adverse reactions observed are related to its contractile effect on smooth muscle.

In patients studied, approximately two-thirds experienced vomiting and diarrhea, approximately one-third had nausea, one-eighth had a temperature increase greater than 2° F, and one-fourteenth experienced flushing.

The pretreatment or concurrent administration of antiemetic and antidiarrheal drugs decreases considerably the very high incidence of gastrointestinal effects common with all prostaglandins used for abortion. Their use should be considered an integral part of the management of patients undergoing abortion with Hemabate.

Of those patients experiencing a temperature elevation, approximately one-sixteenth had a clinical diagnosis of endometritis. The remaining temperature elevations returned to normal within several hours after the last injection.

Adverse effects observed during the use of Hemabate for abortion and for hemorrhage, not all of which are clearly drug related, in decreasing order of frequency include:

Vomiting
Diarrhea
Nausea
Flushing or hot flashes
Chills or shivering
Coughing
Headaches
Endometritis
Hiccough
Dysmenorrhea - like pain
Paresthesia
Backache
Muscular pain
Breast tenderness
Eye pain
Drowsiness
Dystonia
AsthmaInjection site pain
Tinnitus
Vertigo
Vaso-vagal syndrome
Dryness of mouth
Hyperventilation
Respiratory distress
Hematemesis
Taste alterations
Urinary tract infection
Septic shock
Torticollis
Lethargy
Hypertension
Tachycardia
Pulmonary edema
Endometritis from IUCD
Nervousness
Nosebleed
Sleep disorders
Dyspnea
Tightness in chest
Wheezing
Posterior cervical perforation
Weakness
Diaphoresis
Dizziness
Blurred vision
Epigastric pain
Excessive thirst
Twitching eyelids
Gagging, retching
Dry throat
Sensation of choking
Thyroid storm
Syncope
Palpitations
Rash
Upper respiratory infection
Leg cramps
Perforated uterus
Anxiety
Chest pain
Retained placental fragment
Shortness of breath
Fullness of throat
Uterine sacculation
Faintness, light- headedness
Uterine rupture

3)Are some of the folks able to start another IV line well? Be really proficient at it?
Even apprentices have passed Phlebotomy and IV training. Obviously proficiency is subjective.

It just makes me angry that you would say "obviously proficiency is subjective." OBVIOUSLY to the rest of us, profiency is NOT subjective! And I also encourage you to find out if all the apprentices have had IV training - ours certainly have not.

Being taught how to do an IV and practicing on giggling friends and fellow students is NOTHING like inserting an IV to save a woman's life. Blood vessels are nearly non-existent when a massive hemorrhage is happening. Do homebirth midwives know how to do a "Cut Down?" I know I don't and unless a midwife has done medical care in the war or worked in high risk places, she won't know how to do one either. But, there are people who know how to do them in the hospital.
4) Can they place a ballon (sic) tamponade at home?

I don't know what this is, so I have no idea if they can or can't.

No, they/we cannot. If you don't know what something is, ask or look it up! There are about 80,000 websites that explain balloon tamponade when used for postpartum hemorrhage.

Look here

and

here. This site has an amazingly detailed description of what to do for a postpartum hemorrhage in the hospital. It is untrue that homebirth midwives are able to do what can be done in the hospital. If we used addition and subtraction, I am willing to bet homebirth midwives can do a fraction of what can be done in the hospital.

Read this article for a great description of using a sterile condom as a tamponade inside the uterus. (No, we can't do this either in a homebirth setting!)

5) Do they have blood that is typed and screened for the mother who has lost most of her circulation?

No, they do not carry blood products. They would place IV and transport for this. (and after any of the above treatments, unless the blood loss was mild)

Yes we do. RhoGam/Anti-D is a blood product. BE CLEAR in what you say. If you think I am being picky, you bet I am. We are being JUDGED by what we are saying. People read things like what has been posted and roll their eyes at how uneducated homebirth midwives are. We cannot afford to make foolish, careless remarks.

In another post, OB Nurse says:

What did we do for our PPH?

Started 2 large bore IV's

Gave oxytocin, cytotec, hemabate

Fundal Massage

Foley Catheter

Took her Vital Signs, monitored blood loss, and at no time did the OB stop massaging her fundus.

Also, we *could have* given her blood, which we *almost* had to do, as well as an emergency hysterectomy almost immediately if it came down to it.

I want to say right off that I was making assumptions in suggesting that the woman would have died at home. Sorry. I don't know what would have happened, because I don't know how many skilled birth attendants are normally around. In my area, one midwife attends home births without any other assistance. I do know that it took 4 of us to get her IV's started, run around getting the meds, the foley, one to massage her fundus, one to monitor her vital signs, weigh the pads, phone the blood bank, etc.

Thanks for the reply ob nurse. I wasn’t being snarky either, just curious. All the above can be easily done at home in case of a PPH. None of this requires specialized equipment, only the hands and skill of the providers. (?!?!?! Oh, really? Do the midwives you work for carry 14 gauge IV catheters? I am also distressed at the word "easily," as if these things are a hair toss backwards in difficulty level.) The difference is time to blood products and hysterectomy, which thankfully your patient didn’t need. It bears mention that my city has a couple OB squads which respond to homebirths if called. Still doesn't get a hysterectomy any faster though.

Another important site gives yet another detailed outline of what steps need to be done in a hospital hemorrhage.

Including answering this baffling question:

May I ask why the Foley?

One of the easiest ways to try and end uterine atony is by emptying the bladder! A full bladder can interfere with a uterus' attempts at clamping down. Plus, any manipulations done to the uterus for PPH care can damage the bladder if it is distended with urine. Also, a Foley is used to measure input and output - crucial in a number of ways including getting an idea of the body's system's inner workings; if urine output doesn't equal input, then something is wrong and needs to be explored immediately.

Do the midwives in your area carry Foley's? Most midwives I know do not (myself included). We/They/I carry straight caths.

“I want to say right off that I was making assumptions in suggesting that the woman would have died at home. Sorry. I don't know what would have happened, because I don't know how many skilled birth attendants are normally around. In my area, one midwife attends home births without any other assistance.”

I think that is something that varys with location. As I mentioned above, 4 providers are the standard number to attend homebirths in my area. But I don’t think that is a rule.

Doing births for over 2 decades, I haven't ever heard of taking 4 providers to a birth unless you were bringing along students/spectators/journalists/etc. Oh, except when we had twins - we had 3 LMs, 1 CNM and a highly trained apprentice, so I can see piling on the care providers in unusual circumstances, but to have 4 trained midwives/apprentices is amazingly odd, even in a city as large as the one I am in that has over a dozen Licensed Midwives working.

“What does happen in the home if mother is bleeding to death and the baby requires resus as well? That is my question. Genuinely curious, not trying to be snarky at all...”

In my area the same steps would be taken, only with fewer people as one or more would be attending to the baby.

We do say that we bring one attendant for the mom and one for the baby where I am. Not every midwife might choose to have another set of hands, but around here, it is the standard of care.

So, knowing what I know about PPH, why would I still be a midwife in a homebirth setting? Because women do weigh the risks and benefits. They, in many cases, understand the reasons for postpartum hemorrhage (distended uterus, previous history of bleeding, long labor, large baby, etc.) including the catch-all that sometimes there IS no reason that can be discovered either earlier or later. And still, they choose a homebirth because they feel the interventions that happen in hospitals might also be precipitating factors, including using oxytocin (that tires out the uterus once the baby is born), manipulation of the uterus including an aggressive third stage management and having adrenalin coursing through her system because of the fear or anger that occurs while in the hospital.

I am a homebirth midwife who also weighs the risks to my life and that of the mothers' and babies'. When a woman begins to step towards a hemorrhage late in pregnancy or during labor, transferring to the hospital is a better idea than staying at home and waiting it out. Blessedly, I've made the right decisions (for the most part) so far. Once, I should have transported sooner, but the end result was positive after the clients were very angry and disbelieving that the woman (who'd had a large HBAC) needed to be hospitalized and given blood. It took almost a year for them to accept that she was hemorrhaging and did need to be transported. I knew I'd made the right decision. This mom went on to have a fantastic hospital VBAC a couple of years later.

My main reason for writing this post is to really speak to students, apprentices and HBAs. I want them/you to really understand what you are getting into as a homebirth care provider and someone who's speaking with authority about homebirths. If YOU don't know, how iare your clients or friends going to make informed decisions? And, with this discussion being played out on the Internet, it really is important to get the facts right and to be able to argue intelligently and sanely. Giving misinformation and boasting makes ALL homebirth advocates look like asses. And we all aren't asses.

All HBAs should become hyper-vigilant in their self-education. Don't know something you read about here? Then learn about it, for goodness' sake! Don't just ask someone else to tell you what it is - get moving and learn about it yourself.

deep breath

And so, I shall finish my post about "Midwifery Education" in the next day or so and post it. Right along these lines, blurry sometimes - the knowledge, information and skills of a homebirth midwife; I'm examining myself most intently.