Stop the Bleeding

My friend and fellow blogger Stephanie gave me sage advice about this rotation from her dad, an ob/gyn. "Stop the bleeding," he says. Unfortunately, I learned this well on my last call night when one patient's peripartum plight became more and more worrisome.

This woman had a prior C-section and was attempting a vaginal birth after C-section ("VBAC" or TOLAC = trial of labor after cesarean). Attempting a normal vaginal delivery with a previous surgery on the uterus carries a risk of uterine rupture, a life-threatening condition for mother and fetus when the womb tears open from the forces of contractions. Some institutions including UCSF support women choosing VBAC by offering in house anesthesia, close monitoring, and experienced staff. Our patient had a constellation of poor risk factors. She was post-term (41 weeks+6 days). Although she had broken her bag of water, she was not in labor (premature rupture of membranes), and as a result, was at risk for infection (chorioamnionitis). After reviewing risks with her, we decided to augment her labor with pitocin. While benign and standard for a regular laboring patient, pitocin for her carried further risk of uterine rupture (1-2% rather than 0.8%).

Even with gentle pitocin augmentation, she wasn't progressing; the cervix was minimally dilated and effaced, the baby was at a high station. But we kept going until about 9 at night when a nurse called for a doctor. The patient had a large episode of painless vaginal bleeding, about 500mL (the same volume as a bottle of water). We were worried; the whole team rushed in, two attendings and the anesthesiologist were at the bedside, and we were evaluating for fetal distress and uterine rupture. But the baby was doing fine and the patient's vitals were stable. A cervical exam by the resident was "weird"; the cervix did not feel normal, and the baby's head could not be palpated. A bedside ultrasound confirmed the diagnosis; this was a previously unknown placenta previa (the patient's care had been transferred from an outside hospital and they did not know this).

We then decided to C-section the patient; she and her husband agreed to the plan. She lost another liter of blood during the spinal anesthesia. We had two IVs but one stopped working. Her blood pressure dropped to 60/30mmHg before we managed to transfuse two units. When we crash sectioned her, she lost another liter of blood. Baby was out and doing fine. But the placenta took a lot of negotiation; part of it may have been overlying the previous C-section scar and grown into the tissue of the uterus (previously unknown placenta accreta). We worked hard to stop the bleeding, managing to evacuate all placental tissue. We typed and crossed her for a few more units.

A few hours later, a nurse called us from the recovery room where the patient passed two "baseball sized clots" per vagina. She was still bleeding. The resident and the attending did several attempts at manual evacuation of clot. The uterus was pretty "boggy", the word we use when it doesn't clamp down to prevent bleeding. While the rest of our body clots to stop bleeding, the uterus, a muscle, needs to contract. If stuff is in the uterine cavity, whether placenta or clot, the uterus cannot contract effectively. So the resident and attending manually scraped out clots. We gave some methergine and hemabate but she bled liter after liter of blood.

Normally after every surgery and delivery we estimate blood loss. A normal blood loss in a vaginal delivery might be 350mL; in a C-section, maybe 800mL. Above 500mL in a regular delivery and 1L in a C-section, we consider a hemorrhage. The proverbial 70kg man has 5L of blood. Here, our patient lost 500mL before reaching the OR, another 2L in the OR, and now 2L post operatively.

The resident initiated a massive transfusion protocol, treating this patient as if she were a victim of a car crash or had a heavy gastrointestinal bleed. We called the blood bank to get more blood and fresh frozen plasma (containing coagulation factors). We were afraid she would go into DIC - dissminated intravascular coagulation - due to depletion of coagulation factors. The anesthesiologist toyed with the idea of inserting an arterial line and transferring to ICU. We finally stopped the bleeding with a Bakri tamponade balloon, exerting intrauterine pressure.

In the end, the patient remained stable, and the baby was healthy. After transfusion of five units of blood, we normalized her lab values. But throughout the night, her course was tenuous and prompted us to think of many critical care issues that we normally do not deal with on labor and delivery. Always stop the bleeding.