Uterine infection

[Wendy HS]

I've had two normal pregnancy's and two normal delivery's, but my first baby ended up in NICU for a week for reasons we still don't know why. I attribute it possibly to the interventions used (drugs), that I felt were somewhat forced on me unneccesarily. My second was a drug free, natural hospital delivery where they checked me for dialation, and gave me an IV (I am assuming because my water broke before I went into labor and she came at 37 weeks and my doc had not done the GBS test yet so we don't know if I was positive or not). Other than that I would say they checked me vaginally about 5 to 10 times in a 14 hour period to check on progress. When I did get to a 9 or 10? I had a small lip and instead of waiting for me to progress on my own the doctor decided to go up in there and move the lip (he was tired of running back and forth from his office across the street). It was pretty painful as I had no meds, but I got through it and she pretty much slid right down and crowned, two pushes and she was born. A student doc pulled the placenta out within minutes of delivery and I would say it was a little painful, but not bad. Right after that she seemed scared and nervous and I heard her say to the doctor that she couldn't get the bleeding to stop. They gave me a shot of pitocin in my thigh and I guess that must have taken care of it. I did notice with this baby I bled more and passed some clots, but they didn't seem concerned so neither was I. Everything was great and they released us. After I got home the cramping was getting very painful to the point that I called the doctor and made sure that was normal. They said it was and I left it at that until a few hours later the pain got so bad I couldn't take it. I looked at myself in the mirror and I looked like a ghost. I was so white I couldn't believe it. I could hardly walk, everything hurt so bad. I went into the doctors office and he checked me and immediately put me in the hospital saying he thought I had a uterine infection. He pulled my husband aside later and thanked him for bringing me in saying they just lost a woman to the same thing a few weeks earlier and that I was in danger of dying. That was a shocker!!! I was in the hospital for about a week on strong IV antibiotics and I recovered and was told later it was a strep infection. My question is how did this happen? What are the things that could be done differently to avoid an infection like this? Should I insist that my midwife not check me vaginally (especially if my water breaks), should I insist that they leave the placenta alone as long as possible? Should I insist that they not shove the cervix back but wait for my body to do it's job? I can't help but think that all of this could have been prevented. It is miserable to spend your babies first weeks of life in a hospital, and being so sick and in pain that you can't enjoy them. I am seeing a midwife this time in hopes of a chance to have more say in what is done to me and my baby. I know there are risks no matter what, but it seems like in both hospital births that they robbed me of time with my babies that I will not get back. I am okay with that because that can't be undone, but if I can prevent this same thing with this little one I would sure like to. When I asked my doctor what causes an infection like this he said, "I don't know". I just want to lower the risks if I can. I am getting a little concerned about my midwife now doing too much. I know I have a full say, but I need to let her know up front what I expect, cause we all know when you are in the throws of labor you really can't talk or resist much. Is there really any benefit to being checked so often for dialation?

[thenaturefreak]

Should I insist that my midwife not check me vaginally (especially if my water breaks), should I insist that they leave the placenta alone as long as possible? Should I insist that they not shove the cervix back but wait for my body to do it's job?

My understanding is the less done to make things happen faster the better. Same with sticking anything up into the birthing canal. I would think that having less cervical exams would make it less likely for you to develop an infection.

If the 3rd stage of labor is progressing normally, it is usually better to allow the placenta to detach on it's own and let you birth it without assistance.

But.... please do not blame yourself for any of what happened. There is always a chance that you can have complications after/during birth even if everything is done with minimal interventions.

It sounds like you are doing your best to make this next birth the one you want and the questions you have are great. I would do some research and use that to back up your choices. It sounds like you will get to put some new stuff on your birth plan this time around to prevent a traumatic birth/postpartum experience.

[terra-pip]

I agree the less done the better. For instance no need to be constantly checking in your last weeks to see if you're dilated before labor (maybe after the due date), also no need for stripping of membranes (I know you didn't mention that but it's a practice even the most natural minded midwife sometimes does), also breaking waters is not really helpful if done too early. I had artificial breaking of the membranes with my first two and I waited until 7-8 cms before letting it be done. It does feel really good and helps contractions build but too soon and you've started the "clock" countdown to baby coming out...and that's too much pressure.

While in labor it does help to know how much you're dilated. When you are admitted to the hospital and the closer you are to pushing...but certainly not every single time someone walks in the room. I wouldn't want anyone trying to manually help any part of my cervix dilate. And I definitely would be sure to make it clear in your birthing plan how you want the placenta delivered. There should be no tugging or pulling or reaching inside (it should be assumed it will deliver naturally and intact unless problems obviously are apparent)...putting your baby to the breast right away really helps to jump start stronger contractions to get that placenta moving along as well, I also ask that the cord cut be delayed until it stops pulsating.

Also bleeding can happen even in a very normal natural birth. I bled a bit and passed a very large and scary clot with my 2nd and my placenta was intact and allowed to come naturally...it was slow in coming and then when it did it came out very fast. Not sure if that had anything to do with it. I also felt pretty shaky. I would ask for a Methegrin pill instead of a Pitocin shot in case you should bleed. Pitocin has been known to inhibit milk production. My OB at my second birth didn't even bat an eye at my request that no Pitocin be given. So when I passed the clot (a few hours after birth) they were ready with the Methegrin.

I'm not sure if anything that happened to you caused your infection..but the placenta is suspect. I also do not allow students in my prenatal care or birth. I know they got to learn somehow, but I rather it not be on me. Since I bled with my second I plan on just asking for the Methegrin this time regardless.

Make sure your midwife has access to meds to stop bleeding.(A good MW, homebirth or otherwise should have both Methegrin and Pitocin with her at your labor) If she doesn't and wants to use any kind of herbs etc to stop bleeding...I wouldn't trust it. That's just me though. One thing that does help with the natural amount of blood that is lost is to drink a drink of OJ mixed with steeped rose hips tea. You could take this to the hospital with you if you're delivering there. It doesn't stop bleeding but really helps with the normal fatigue that comes with the normal blood loss.

[MsBlack]

If they 'just lost a woman to the same thing' recently, then I'd say that there's a pretty good chance that you got a hospital-borne infection. Another piece of 'supporting evidence' to this idea is that so many internal exams/manipulations were done: as others have noted, vag insertions of any kind can push germs up your vagina, and when the water is broken that means those germs have easy access to your uterus (and the baby, too). Possibly you were heavily colonized with group b strep, which lives near the outer/lower end of the vagina--which means that during exams, that was being pushed upward. So the infection could have originated from you. However, it seems just as likely to me that the pathogen originated in the hospital, as I first noted. Meaning that the germ was airborne, was on surfaces in the room including clothing, etc--and that your care providers introduced it themselves.

Either way, an important element of infection-prevention is reducing the number of vag exams/insertions! You can also request that nurses/docs use a solution of hibiclense when they plan to do a vag exam...to immerse their gloved hand into a .2% solution of hibiclense prior to exam, every time. This is especially important once water is broken. They can also sponge off your vulva/perineum with the hibiclense prior to exam, to help reduce/eliminate the number of germs that you either came in with, or simply picked up while you were there.

Was the infection cultured? You may want to find out. You might never know now (since you missed the gbs test last time) where the infection originated--but if they cultured the infection then there is some chance of finding out. Knowing the specific type AND strain of the infection can give clues; you might want to get a copy of your records to find out. Some pathogens are known to be hospital borne, others are just as likely to be 'mom-borne' as hospital borne.

But again--it's hard for me to imagine a need for a minimum of 5 vag exams in 14hrs! I don't know as I've ever done that many checks--even in far longer labors. There are lots of other ways to discover progress via external observations. Something else you might want to discover is just how many vag exams were performed, which should also be on your med record.

In any event, if you are planning another hospital birth, then I'd say, stay home a lot longer. Get a good doula to help you figure out when you are far enough along in labor that you won't be in the hospital long prior to birth--can be hard to be exact, but still--if you're not in the hospital, then you're not available for all that messing around.

Hopsital borne infections are on the rise--you may want to try to do some digging on the hospital, to see if it seems it is a safe enough place to give birth with respect to this issue. I'm just glad to know that your baby didn't get sick, since a neonate is so much more likely to die, or experience lingering/permanent harm from such a virulent infection as you had.

[Wittyone]

I recently had a client who developed a uterine infection just a few days pp - it was caught quickly and she did not get as sick as you, but it's hard to say how it originated. She was gbs negative, her first cervical exam was at 7 cm with bag of water still intact, bag broke on its own, and then had one more exam when she started pushing, quick labor, spontaneous placenta without pulling - by all accounts she should not have gotten infected yet she did.

The thing that jumps out at me from your story are the number of exams after your water was broken!! We make it a policy not to check someone once their water breaks until we reach a decision making point - entering the tub, requesting pain meds, requesting an epidural, etc. Even then, we use a sterile speculum for a visual exam and try to hold off on a digital exam until we see lots of hair. If it's not going to change what you are doing there's not really a need to be up in there!

[Wendy HS]

My thought was they did way to many exams too. I just didn't know enough to ask them not too. I really didn't like appreciate the whole pushing the cervix back, but the doctor didn't even ask about that, he just did it, and I was, lets say in a real vunerable position. I don't think I had the GBS strep. They did culture the infection and the doctor did say it was strep, but he did not say it was from me or GBS. I don't know how many streps there are that you can get, but I don't think it was that one. I will know now to make even more details in my birthing plan than before. Hopefully since this isn't a hospital birth things will be a little easier. Thanks for all your suggestions.

[MsBlack]

Wittyone--

I too developed a pp infection--after my 2nd baby, UC, short labor, NO vag exams or placenta pulling/extracting of any sort. No idea if I was GBS positive, or what the infection was specifically. It was moderately severe--but I treated myself at home w/herbs for a couple weeks (it was way better w/in a couple days tho). Probably something in the environment at the time, and I was not as aware then as now, about postpartum vulnerability to infection and possible vectors. Never experienced that again (thanks be, because it really kicked my butt, hurt!)

While pp infection is rare enough when good rules are followed (as already mentioned), it can happen.

Wendy--again, really sounds like a hospital borne infection. Even gbs of the same variety as some women 'typically' carry, can be present in any environment, such as your home. It's just that in hospitals, you have the probability of more virulent strains of any 'typical germ' (typically carried by regular, non-hospital people, and *usually* unlikely to cause infection). These can be various forms of strep, staph, other--antibiotic-, antiseptic- and disinfectant-resistant varieties-- that evolve specifically in the hospital/nursing home setting.

But in general, there are many varieties of strep--you have your strep A, strep B, and D-- some strep families I'm familiar with--and each 'family' has various 'members'. So--you could well have had a 'strep' infection, but saying 'strep' does not actually say all that much! It would still be worth discovering just what they found; you may want to test to see if you still carry it. Carrying a low number of colonies in your bloodstream wouldn't necessarily make you feel sick, isn't necessarily a 'worry', but it can tell you where you *may be* vulnerable.

For instance, I know a mom who picked up a form of strep D during her years of hospital work; it lay around in her bloodstream unnoticed (she never knew of it) until after her first baby...where it found it's way to her breasts and caused repetitive infective mastitis, pretty severe. After dealing with a couple rounds of it, we decided it bore deeper investigation (decided it couldn't be 'typical non-infective, simple-plugged-duct-type' of mastitis). Milk culture showed the type of germ--red-flagged as 'nosocomial (hospital borne), and antibiotic resistant' in the med literature--which led to making the right choice of antibiotics for treatment.

So in your case, due to the higher-than-average chance (not that we know for sure) that your pp infection was hospital borne, it's worth knowing 'just in case'. You might never see another sign of this again...but you'll know where to begin if you do have any issues w/uterine or breast (or even general) infection following birth.

[Wendy HS]

Thanks, I will call the doctor this week to see if I can get some of my records. I would like to know if they tested me for GBS and also for sure what my daughters blood type is, it isn't really clear on the release papers. Thanks again.

[limette]

I had one with dd2 and I'm sure it's because there was a hand up there pretty much through the entire 2 hours of pushing. The OB also pulled out the placenta immediately after the birth. I guess she couldn't wait for it to come on it's own.

It didn't hit until day 9 pp. I had a lot of pain and felt like I had the flu. I didn't go in until the next morning and by then was really sick. I was pushed to the top of the triage list at the ER. I absolutely refused to stay in the hospital for meds. So they agreed to give me a high dose in advance of receiving test results confirming the diagnosis (it was pretty obvious that I had a uterine infection) and they released me later that day with more meds. It cleared up fairly quickly after that.

This time if I see anyone coming near me with gloved hands, they are getting a swift kick in the head.

[Wendy HS]

I had to laugh about the swift kick in the head. Wouldn't that be a surprise to anyone down there. Bet they would back away. ha ha No seriously, thanks for all the advice. My plan is to write all this down in even more detail than the last time, which I am sure my midwife will read, but to be honest I don't think the hospital doctor ever even looked at my birth plan, I think the nurses did though. I am also going to make sure that my DH and my mom know all of my requests by memory so that if they start doing something to me they can help put a stop to it!!!!

[HeatherB]

I would definitely think it was hospital-borne. Your chances of picking up infections like that are much lower at home, simply because there are fewer people and fewer SICK people.

Strep is extremely common in its various forms, and most strep isn't going to cause a problem - strep throat, perhaps. But, when it gets into an open wound (i.e., placenta wound) it can cause very serious problems. It tends to be very fast moving, as well, so prompt action is required.

I'm glad you got the care you needed, and I would certainly think it highly unlikely that you'd run into trouble again! It's pretty rare, all together, and certainly being at home with an experienced (and more hands-off) midwife will be a great asset.