[homemademomma]

went to a wonderful birth last night. when she first came in she went to pee, and called me in to show me a clot that had come out, maybe the size of a peach pit. her membranes had ruptured earlier, and it was very blood tinged. when i saw the clot and the water, my heart jumped out of my throat. just the night before i had been reading about intrapartal bleeding, and what is normal/abnormal, and how to differentiate fetal and maternal bleeding. so i listened to the baby for maybe 5 minutes, and the heart reate was variable (our doppler has a little readout winder) and reactive, with no tachycardia or bradycardia, so i felt a lot better. moms vs were stable too. she has been hypertensive throughout the pg, but not horribly so. she was 8cm dilated when she got here, and never had anymore bleeding/bloody fluid after the clot. so she started pushing spontaneosly, and pretty much stayed on her side because of her bp. eventually she pulled herself into a squat, and stayed there the rest of the time. at the very very end she asked for a birth stool to rest on. anyway, she birthed the baby, no problem. baby goes to moms chest and is kind of slow to start- definitely aware but very dusky and floppy. baby had had been a little bradycardic, with some decels at the end of pushing, but reacted well to scalp stimulation so we werent too worried. anyway baby came around fine, with just a little back rubbing and talking to her. i noticed as i checked for tears that her cervix was right there at the entrance to her vagina.

and then a fountain of blood squirts out of her. for some reason my biggest block has always been pph with the placenta still inside. it has never happened to me before. after maybe 0.002 seconds of freakout, i grabbed her uterus and rubbed it down while i grabbed the cord and felt inside to see is it was coming out. the assistant was drawing pit while this is going on. i kept a hand on the cord and felt forher uterus, and it was rising in her abdomen and was hard, like a balloon. her uterus was filling with blood. after about 45 seconds of massage, it came out duncan. the pit finally gets administered, but she is still bleeding and her uterus is totally floppy, so i use one hand to push the cervix/uterus back up and the other to massage it. and i felt on the very inside of her cervix what felt like a piece of placenta, and i was like oh sh*t, but then i felt a little more and it was the placenta attachment site. her uterus firmed up shortly after that. we ended giving shepherds purse a little later and then IM methergine because it wasnt staying firm.

the placenta was totally attached right next to the os. the clot must have been from a slight separation caused by being so far dilated. and then when the baby came out and the cervix/uterus changed shape so quickly, the edge must have detached, causing the geyser of blood.

i just wanted to share this story, because i have never been confronted with this problem before. partially detached placentas with hem. are seriously my biggest block- whenever i am thinking about what to do in that situation, i kind of blank and have to really think it through. im glad her placenta came on its own. i didnt want to manually remove it. do you think her high bd could have contributed to the bleeding, or was it just becuase the placenta was so low? has anyone else dealt with this issue before, or similar issues? what did you do?

i was glad this happened to me while i am still a student. even though i did it myself, and i think i handled it well, knowing my rpeceptor was there to back me up was nice. it was scary for me. she lost easily 900cc in the first hour pp. after that her bleeding was minimal

 

[Artisan]

Wow... she was lucky to have a caregiver like you. I'm glad she had a good birth!

 

[sevenkids]

I've had a few like that, yes the high bp could have caused the seperation, also because it was so low. Anytime I see a Duncan placenta I look for pph. Placentas come out duncan only when they are low lying. Usually with a partial seperation you'll see some frank bleeding, and then as the baby's head comes down, it slow or stops as the head puts pressure on the seperated edge, and then you'll get a scary gush after, or if it had flopped over the os, the uterus will fill with blood.
Had a complete abruption during second stage a few months ago too. talk about scary! Baby came out with APGAR of maybe 1, (more like 0, if you ask me. ) and the placenta flopped out right behind him. Low risk mama, too, great bp, non-smoker, good nutrition. Quick transport by fire rescue, a transfusion, and he's doing wonderful now.
few questions, because I'm always interested in how other midwives do their thang.
did she have an ultrasound? Were the FHTs harder to find prenatally? Did you hear the placenta when listening for the baby? Was the baby harder to palpate? Did the baby stay high for a long time?

 

[homemademomma]

Quote:

Originally Posted by sevenkids Had a complete abruption during second stage a few months ago too. talk about scary! Baby came out with APGAR of maybe 1, (more like 0, if you ask me. ) and the placenta flopped out right behind him.

i had that once too- when i was in colombia (SA) we had someone come in who was being induced at 34 wks (this is a high risk hospital where the women who come in are poor and generally have not been seen prenatally- the judge gestational age- and fetal size- by fundal height.) for oligohydramnios. and they were using cytotec. anyway they rush ehr into delivery and put her on the table and out comes t he tiniest crowning head i have ever seen, then a white baby with a placenta on top of her. they only have stethoscopes to hear fht, so i had no idea (except for knowing about the cyttoce/oligo/prematurity) that the baby was in trouble. everyone in the room- doctors, nurses, students- backed to the wall, and my partner grabbed the baby (she is an l&d nurse here). the O2 mask was deflated and we couldnt get the tank to turn on. amazingly baby came around with just a little stim, but it was scary. that baby would have died if my partner hadnt been there. i had no idea what to do (i thought the baby was dead) and everyone in the room just backed away.

Quote:

Originally Posted by sevenkids did she have an ultrasound?

no- we heard placenta sounds down low and anterior prenatally, however.

Quote:

Originally Posted by sevenkids Were the FHTs harder to find prenatally?

no, very easy to hear prenatally and in labor, even during pushing when the head was really low

Quote:

Originally Posted by sevenkids Did you hear the placenta when listening for the baby?

yes- it was low

Quote:

Originally Posted by sevenkids Was the baby harder to palpate?

no, it was really clear

Quote:

Originally Posted by sevenkids Did the baby stay high for a long time?

baby was engaged around 36 weeks, i think. she was easily +2 when she came in to the birth center in labor