This is a birth story written from my perspective as midwife. The names and identifying details have been altered to respect the privacy of the family, but the story is true. If you have read my paper High Risk, you may recognize this as a case that I brought before peer review.
Annie was the picture of sweetness and innocence. Her big blue eyes, bright under perpetually raised eyebrows, looked at me with absolute trust. If I told her to eat a certain food, she’d buy it that very day. If I asked her to drink more water, she didn’t even wait until the appointment was over. Her husband John, dressed in cargo pants and a plaid shirt and sporting a couple Christian-themed tattoos, seemed equally eager to please. He would sit, knees apart and leaning forward, his arms resting on his thighs, hanging on my words. They were a devoted couple, devoted to each other, their faith, and to this baby, their first. To them, giving this baby the best start meant doing whatever I said.
The day Annie turned 39 weeks I received a phone call from John. “Annie just woke up from a nap and now she’s on her hands and knees and moaning.” I felt a little rush of excitement. “I’ll be right there. Just try to keep her calm and comfortable.” I phoned my apprentice Erin and we were both on the road within five minutes. A previous exam had revealed that Annie’s baby’s head was already very low in her pelvis; I had hoped that this would mean a short labor, and it seemed things had come on quickly, especially for a first baby.
I rolled my suitcase and oxygen tank into the apartment and washed my hands. Annie was now lying on her side in bed, breathing heavily. “Can I check you, please?” No resistance. She parted her knees as I donned a sterile glove and lubricated my fingers. My apprentice placed an absorbent pad under her bottom, and I conducted an exam.
“You’re completely dilated and the baby’s head is right here. There is a tight bag of water in front of the baby’s head.” I removed my fingers, smiled, and peered into her luminous face. “Your body has done an amazing thing. Most of the work is already done.”
Lying beside her, John’s face broke into a grin. He petted his wife’s pink face, tenderly brushing wisps of blond hair away from her eyes, and kissed her cheek. “You’re amazing, baby. I love you so much.” Annie floated in another world, nothing seeming to register. “Laborland,” I explained to John.
For the next two hours our team of three helped Annie into different positions. We pressed on her back as she rocked on her hands and knees. We held her hands as she sat on the toilet. I encouraged her to bear down if it felt good, but she felt no urge to do so. Finally I offered to break her water, and she consented.
The bag was under so much pressure I was able to pop it easily, even without a contraction. Clear fluid spilled out onto the pad. Erin listened for heart tones, strong as ever. The baby’s head was so low, I figured Annie would start to feel the urge to push any time now. We waited. She breathed. Soft words of encouragement surrounded her. Cool wet cloths dabbed at her face. I took her hand in mine and gave her the hand massage I learned in doula class. John followed our lead, caressing her and speaking words of love. Annie drifted through space and time, seemingly oblivious. Each contraction brought moans and movement; each rest in between brought sighs and stillness. Two hours ticked by, and still Annie felt no urge to bear down.
Finally I took charge. “Annie, some women don’t feel the urge to bear down until they start pushing. You’ve been complete for a long while, let’s try some strong pushes.” Annie consciousness was hovering just out of reach. Another contraction came and went, and Annie made only a small effort at pushing. “You’re going to have to be strong now. It’s time to get down to business,” I instructed. A change of position, a pep talk, and a drink of juice, and she was ready to get things done.
It didn’t take long. A few really strong pushes, and I could see the baby’s head. “You’re doing great, Annie! Your baby is almost here!” The encouragement seemed to lend her extra strength. Squatting, she pushed with all her might, and with every push we saw a bit more head, a bit more blond baby hair. Her perineum started to bulge.
Knowing the baby would be born soon, I asked Annie to change positions, believing that squatting might cause a tear. “I’d like you to lie on your side now,” I insisted, and helped her start to move. She only got halfway onto her side, twisted in an awkward pose, when the next contraction hit. Her body bore down with an automatic effort, and suddenly the baby’s head emerged completely. It was a big head. John’s eyes bugged out. I wiped the baby’s nose with a receiving blanket. No meconium, pink baby. Everything looked good.
“Good work Annie, your baby will be on your chest in just a minute!” I glanced at my watch’s second hand. One doesn’t want too much time to elapse between the head’s birth and the rest of the baby. When the next contraction came, I was happy when the baby’s shoulders released easily, and a large baby tumbled out onto the pad.
When a first-time mom sees her baby for the first time, the look on her face is priceless. However, this time I would not savor that look, as I usually did. The very moment I hoisted the hefty girl onto her mother, the blood started pouring out of Annie’s body as if someone had turned on a faucet.
“Get me the pit,” I said to Erin as I instantly followed the cord into the woman’s vagina. I could feel the placenta, and I knew it had to come out immediately. This hemorrhage was torrential, and leaving the placenta alone for any amount of time was out of the question. The pad was overcome and I knew the beige carpet was going to be in trouble. “Pray,” I instructed the couple, and “I’m sorry, I know, this hurts” I said to Annie as I scooped the large placenta out of her body. It came out in one piece. Erin quickly administered two doses of pitocin while I massaged the uterus. Erin replaced pads. The blood kept coming. “Call 911,” I instructed Erin while I applied pressure to her uterus from the outside.
“I need you to stop bleeding now, will you do that for me?” I remembered a story I read in a midwifery book. A couple who spoke Spanish were able to stop the woman’s hemorrhage simply by repeating “No mas sangre.” Surely between John’s prayers, all that pitocin, the pressure I was applying, and my insistence that she will herself to stop bleeding, surely this blood would slow down. I repeated, “I need you to stop bleeding, Annie.” “I’m trying, I don’t know how,” the poor girl responded. She was getting pale. She stopped replying to my commands.
“Talk to me Annie,” I said. “Where are you from?”
“Who was your best friend when you were a kid?”
“Annie! What is your husband’s name?”
“John,” she whispered.
“Look at your baby. We need you to stay here with us.”
Where was that damn ambulance?
“John, you need to pray for her now, pray for the bleeding to stop.”
The bleeding slowed. We changed the pads. Annie was able to drink a little juice. We all started to catch our breath a little bit. When we heard the ambulance arrive, Erin jumped up to show the EMTs in.
A brown-haired young woman and two middle-aged men, all wearing dark blue scrubs, walked in and took in the scene. Annie was lying in the middle of the living room floor. She wore an oversized t-shirt pulled up to her waist. We had covered her lower half with a baby blanket to preserve some modesty, but I was still massaging her uterus and monitoring for bleeding. John was shirtless and holding the naked baby, still attached to the placenta, which was sitting in a metal bowl. Erin was scribbling notes in Annie’s chart. The absurdity of the scene suddenly hit me as I imagined what the EMTs must have been thinking.
The woman donned some gloves and asked us some routine questions. She looked at the pad underneath Annie and said, “Well, this looks pretty normal to me.” I corrected her, “Actually, we’ve changed this pad four times. She’s bled a lot.” I indicated toward a trash bag, where scarlet saturated pads ghosted through the translucent plastic. The EMT’s eyes widened. “OK,” she said, “Let’s get you to the hospital.”
The EMTs loaded Annie onto a gurney and into the ambulance. I promised I’d meet her at the hospital. Erin and I returned to the apartment where John still sat on the floor, tears spilling down his cheeks, holding his naked new baby girl. I reassured him, “We’ll be there with her in no time. She’s in good hands, they won’t let anything happen to her.” I clamped the baby’s cord and John cut it. I cleaned the baby up a bit and we got her dressed and in the car seat. Erin made sure it was installed well, and John was off to the hospital.
Erin grabbed my shoulders. “Tell me that home birth is safe,” she dramatically demanded. There was no smile on her face. She needed reassurance. “Well, that one sure as hell wasn’t,” I heard myself say.
The doctors at the hospital provided us with some answers. Annie had suffered a 4th degree tear during the birth of her daughter. Fairly unusual, this kind of severe tearing can cause hemorrhage as well as permanent damage to the pelvic floor. When people would ask me in class about tearing, they were usually worried about pain, not dying. I would explain that severe tears are usually caused by episiotomies, which led them to believe that if they didn’t get an episiotomy (which they already didn’t want) they wouldn’t have to worry about tearing. Unfortunately, this logic did not help Annie.
For months I thought of little else. Why was life so unfair, that someone as innocent and sweet and beautiful as Annie, who had done “everything right” to get a beautiful birth, should have such a nasty injury? What had I done that was so wrong, or was this truly an arbitrary event that could have happened to anyone, with any midwife?
I still have flashbacks when I drive past their old neighborhood.
9 thoughts on “Birth Story: Annie Does Everything Right”
What would you have done differently?
I don’t think there’s anything that I could have reasonably been expected to do differently in this case. This is a case where the complication was totally unpredictable and there’s nothing that could have made this birth safe at home. When you or your client or loved one is suddenly bleeding out, all of a sudden the hospital is the only place you want to be, no matter how much you didn’t want to be there in the first place.
The only thing that would concern me is no urge to push for so long. After our training and my hospital experiences, I have never encouraged a mom to push at home, only wait until she must. So far in my practice, this has always happened, so I’ve been fortunate. I guess what I’ve learned from your story is that if there’s no urge, then something’s off and you could have trouble. Recommend transfer.
How about checking for bleeding from a tear when pitocin and bimanual compression weren’t working? (ie, remember the four T’s — tone, tissue, TRAUMA, thrombin — and don’t assume all postpartum bleeding must be from the uterus.) How about packing the vagina? Getting an IV started? All of those things could (and should) have been done at home while waiting for transport.
Sora, thanks for the comment. I agree that it was a mistake that I assumed she was bleeding from her uterus. I remember being genuinely shocked to hear she had such a severe tear. In South Carolina licensed midwives are not permitted to start IVs and we generally do not carry such equipment.
Understandable. I know that IV skills are very, very rarely needed in a homebirth setting. I also realize on re-reading that my original comment was a bit terse — I’m sure you were doing the best you knew to do at the time and certainly were not the only midwife to ever make that mistake. It certainly doesn’t sound like the tear itself could have been prevented. Because severe bleeding from a tear is fairly rare in the homebirth (and birth center) setting it’s easy to forget that it’s a possibility and default to more familiar uterine atony protocols. For the sake of other readers who may be attending births out of hospital I thought it important to point out that there *are* other steps that could have been taken prior to the arrival of the EMTs, even without the ability to start an IV — packing the vagina (with sterile absorbent wound packing material or a large quantity of sterile gauze squares) might have prevented a significant amount of blood loss while waiting for transport and en route to the hospital.
And applying pressure manually with sterile gauze to laceration. Can even use hemostats to clamp the tissue for hemostasis, but it hurts if you don’t use lidocaine. Could even take a few temporary stitches for hemostasis, which can be removed at hospital during the real repair. Lac bleeds tend to pump and gush. Sulcus tears especially bleed a lot. Cervical tears bleed like stink, pump and pump and don’t stop. Yes, definitely make it a habit to look for lacerations with heavy bleeds. Did you use any meds other than pit? And did you empty her bladder, and start an IV?
Thanks for your comment Karen!
I don’t think I had any meds other than pit with me at the time. I thereafter carried Cytotec. I did not start an IV because it’s not legal and I didn’t have the equipment. I didn’t use a catheter but she had very recently emptied her bladder on her own, if I remember correctly. (The chart is not in front of me.)
I was shocked to learn that the bleeding was from a tear. I saw nothing that indicated to me that it was from a tear as opposed to uterine. If I had known, I might have tried at least putting pressure if not clamping the tissue. This speaks more to my lack of experience than it does to this being an unusual medical case.