Postpartum hemorrhage and the case of the peculiar placenta

This Thursday I was about to go for a walk around 5pm in an effort catch the last few hours of sunlight and fresh air after a busy day of meetings and prenatal consults.  As I opened the door to leave a woman walked into ACAM accompanied by her Mother and sister, who were supporting her on both sides.   Her face was strained and she was clearly trying to hold her legs together as she walked.

“Tiene dolores?”  I asked them (Is she having contractions?).

Emphatic nods from all 3 women.

“I’ll go get the midwives.”  I told them.  I ran up the stairs to get Nancy and Imelda, the midwives on call.   I quickly forgot about the plans for my walk.

We took the patient into one of the labor rooms and the family explained in Mam that her water had just broken less than an hour before and the contractions were strong.  This was her 4th baby.  I’ll call the patient by an alternate name, Celia, for privacy’s sake.  She laid down on the bed and I checked her cervix- 4cm dilated and thin, with the baby’s head nicely in position.  This being her 4th baby, I figured things would progress rapidly.  I palpated her belly to get an idea of the size of the baby.  It felt really large by Guatemalan standards, like an 8 or 8.5 pounder.  Most of the babies here are around 5.5-6.5 pounds, so I silently hoped to myself that this baby wouldn’t have any trouble getting out.  I asked the Mother how much her last baby weighed and she replied 7lbs 11oz.  I breathed a sigh of relief that she had already pushed out a decent sized baby.

She continued to lay flat on the bed and was in too much pain to get up and move around.  I decided to save myself the effort of trying to convince her to get up and change positions as I’ve already learned in my short time here that trying to get a Maya woman to do something in labor that she doesn’t want to is like trying to move a volcano.

Her contractions intensified quickly and she moaned softly as she breathed through them.  These women are tough and are generally stoic throughout labor with the occasional “Ay!” of pain with a particularly strong contraction.   She gripped the headboard of the bed and writhed a little.  After about 30 minutes she felt a lot more pressure and asked to be checked again.  She was 7cm.

The midwives and I began preparing for the birth.  Once a multip (a woman with previous babies) is 7cm things can move very quickly to 10cm and time to push.  I did a quick check through all our supplies in the room, with particular attention to making sure we had all our medications for postpartum hemorrhage.  The more babies a woman has had, the higher her risk for hemorrhage.  Our hemorrhage pack had lots of vials of injectable oxytocin and 10 little pills of misoprostol, the first lines of defense as far as medications go.  IV supplies were also ready and waiting.  We don’t typically start IVs at ACAM unless women request them or they are a “grand multip” meaning they are on their 5th baby or beyond. The ambu bag was also sitting there ready in case the baby needed any extra help breathing.  We were ready.

Celia started pushing.  Nancy the midwife was sitting on the bed ready to deliver the baby.  The baby was moving down, but slowly for a 4th baby.  She pushed and pushed and the head came down lower, but then was sucked back up between pushes.  I began running through scenarios in my mind based on what I was seeing.  Shoulder dystocia.  Cord tightly wrapped around the baby’s neck.  Just relax.  Breathe.  It’ll probably be fine.

Delivering babies in rural Guatemala at a birth center is worlds apart from my previous work experience.  In some ways it is infinitely more challenging.   In others, it feels simpler and easier.  Nonetheless, here at ACAM I am the most seasoned provider and in case of emergencies I am the last line of defense.  I can’t call in my OB or the pediatric team.  I don’t have someone to easily run things by.  It’s stressful but I am also finding that my skills are solid and even life-saving.  I was lucky to attend this birth with the two most highly trained midwives in ACAM because I needed their excellent skills and quick responses to handle what came next.

After about 30 minutes of pushing, the baby’s head delivered.  “I’m here if you need any help”, I said softly to Nancy.  She was protecting the patient’s perineum and delivering the head slowly with skill.  The head delivered and sat there for a while.  It was facing downward and Nancy checked for the cord.  No cord.  The head didn’t rotate and the shoulders didn’t come easily.  This is quite unusual here because as I said, most babies are small and come shooting out in one push.  I moved into Nancy’s place on the bed and put my hands on the baby’s head.  I could feel the baby had room and I didn’t think that we had a real shoulder dystocia.  “Push!”  I told Celia.  With a little help, the baby’s head slowly rotated and the anterior shoulder popped out, but the fit was snug.  If you’ve ever worked in obstetrics, you will know what a welcome sight that little shoulder is.   A true shoulder dystocia occurs when the baby’s head delivers, but the shoulder is stuck behind the Mother’s pubic bone.  This is an obstetric emergency and requires various maneuvers that must be done quickly because the baby is deprived of oxygen during the time the head is out and the body is not.

I happily delivered the baby, a chunky 8+ pound girl completely covered in vernix.  She was a little stunned, but was breathing (with some effort) and had good color.  Thank you, thank you, I thought to myself.   I cut the cord more quickly than usual because it was abnormally short and extremely thick.  The baby could barely be laid down on the bed because of how short the cord was.

Next step; placenta.  Nancy and I traded places again and she began putting some tension on the cord.  She thought the placenta hadn’t detached yet, so waited a little longer.   I could see some bleeding from the separation so I helped her to put a little more traction on the cord and asked Celia to push to help deliver the placenta.  It was coming, but very slowly.  Celia had to push at least 3-4 times until it came.  The placenta was enormous and when it was fully out I looked down to examine it to make sure it was intact and nothing was left in the uterus.

When I looked down I saw an enormous growth on the placenta, unlike anything I had seen before.  No wonder it had been a little hard to deliver the placenta, it was like delivering another (smaller) baby!   It looked like either an extra giant lobe, another placenta, as if there had been a twin, or a big tumor.  The strange part was that the umbilical cord inserted right into the growth, so the area was very vascular and the blood had to go through that part to get to the baby.   If we had delivered that back home, it would have been sent straight to pathology.   Since that was not an option, I took pictures of it and sent them along to my OB colleagues back home for ideas.  Our most likely explanation is something called a placental chorangioma, a usually benign vascular tumor.  It can be associated with pregnancy complications and is more often seen in places with high elevation, which would make sense here.

The family’s eyes got wide as they looked at the placenta.  Even they could tell that something was wrong with it.   Then, in Mam, the grandmother began to explain that a few days ago, Celia had felt very sick with chest pain and shortness of breath and severe headache.  When the headache and chest pain got really strong, she began convulsing and passed out.   They never took her to the hospital.  Could this placental growth have caused this??

Jesus.   Maybe they could have mentioned that before?  Maybe it’s best I didn’t know.

I didn’t get the full translation of that conversation until after we had finished the delivery.  It sounds like the patient may have had an eclamptic seizure several days prior to delivery, but I have no way of knowing if that indeed happened.  Her blood pressures were normal in labor and thankfully her baby was fine.

Once the placenta was out and my shock at how strange it looked was subsidizing, the patient began to hemorrhage.  Imelda was massaging the uterus when it began pumping blood.  “Hemorragia!”  she exclaimed.  Nancy drew up 2 vials of oxytocin and I grabbed the misoprostol and we rapidly injected her and inserted the pills.  The midwives were doing uterine massage, but a little too gently, and I took over and began mashing on the uterus until giant blood clots came shooting out.  The uterus started firming up, but then would get soft and boggy again.  More vigorous compression- the patient was wincing and writhing but we had to keep going to save her from bleeding out.  Nancy skillfully started an IV and we opened the line as quickly as possible.  More and more clots were coming and I was relentlessly massaging the uterus despite how much pain the patient was in.

After about 30 minutes (which felt more like hours) the patient’s bleeding subsided.  We had a bucket full of blood clots and uterine blood probably measuring at least 1000mLs.  I sat by the patient and checked her pulse and blood pressure every few minutes, which thankfully stayed stable.  After the first bottle of IV fluids went in, the patient refused another one since she said it “gave her chills”.  People here feel very strongly about how being cold is NOT good for you.   I talked to Celia and her Mother at length about how much fluid she had lost and how strongly I recommended that we continue to give her IV fluids.   She smiled at me and said “No thanks, I’m fine” about three times.  I decided to appeal to the husband since I wasn’t getting anywhere with the patient.  Sadly but truly, I knew that if he said we were doing it, she wouldn’t have much choice.   I wouldn’t normally cater to the machismo ways, but in this case the situation was dire enough that I decided to use it in my favor.   Besides, I could tell the husband was genuinely concerned about her blood loss, which I found reassuring.

This phenomenon of women refusing treatment when its needed is a big challenge for me.  You can expend a lot of energy explaining why something is medically necessary, but if she doesn’t want it then no amount of logical medical explanation will suffice.  I talked through this with Nikki, one of the North American midwives who helped to found ACAM many years ago.  She is deeply familiar with this phenomenon too and called Maya women experts in “passive resistance”.  They have been oppressed, brutalized, and ordered around by light-skinned people for many many years.  So when you tell them what is best for them, they don’t get upset, but simply smile at you politely and either don’t say anything or tell you they’re fine.  But they certainly don’t do what you want them to.   It’s a powerful tactic and it’s been necessary for this population in a myriad of ways.

What this polite passive statement is really saying is- don’t tell me what to do white lady, I don’t have much reason to trust you.   And truthfully they don’t.  That’s why we are so lucky to have indigenous Maya midwives running ACAM.  They can explain things in Mam in a culturally sensitive way and there is an inherent trust there that could not exist with a Caucasian or Latino healthcare provider.

This birth was my first real obstetric emergency outside of a hospital.   I felt so thankful that this woman came to ACAM for her delivery.  Had she decided to have her baby at home, she would likely be dead.  Postpartum hemorrhage is the leading cause of maternal death in the developing world and it’s highly preventable with the right medications and interventions.  I’m also finding that the more deliveries I attend with the ACAM midwives, the more I can see which skills they have and which ones can be strengthened.  Showing them how to do more effective uterine massage or how to safely deliver a placenta is practical and makes me feel like my time here will leave a sustainable impact since the midwives can continue using these crucial skills.

Never a dull moment here at ACAM!  In July alone we have already had about 15 deliveries,  including one this morning at 5:30am, which was MUCH smoother and thankfully less exciting than Thursday’s.   This weekend I took a much-needed day of relaxation and went to the hot springs called Las Fuentes Georginas (outside of Xela) with a friend.

Until next time, thanks for reading!

5 thoughts on “Postpartum hemorrhage and the case of the peculiar placenta

  1. Oh! I was getting tense just reading this…first at the idea of a shoulder dystocia, thinking about McRoberts and suprapubic pressure and holding your breath til that baby delivers…then wanting to climb through the page and mash on that fundus for you. So glad/relieved to read all was well in the end. Would love to see the placenta picture. Well done you, the other Midwives and Mama!

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  2. Wow Mal! They are so lucky to have you there. So did you convince the husband that she needed another bottle of IV fluids?!

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