This blog post contains graphic descriptions of obstetric surgery which you may find upsetting.
Thursday was, hands down, the roughest day here so far.
It started off with a patient who had a placenta previa, a placenta that covered the cervix which made it impossible to have the baby without hemorrhaging. A C-section is the only safe way to have a baby when a woman has a placenta previa. This patient had had nine previous pregnancies and had six living children. She presented with heavy bleeding and the ultrasound showed the placenta covering the entire lower part of the uterus and the entire cervix.
We explained the significance, recommended a C-section, and she even agreed to a tubal ligation. She lost more than an average amount of blood during the surgery but seemed to do well. It was only when we got back to the maternity area that she started bleeding heavily. The uterus felt firm but she continued to bleed, passing large clots every few minutes. For a while it seemed to slow down but after an hour it seemed to be getting worse.
All of the things we had done, the medications and the massage of the uterus, hadn’t been successful so, after her consent, we ended up taking her back to the operating room (OR) and removing her uterus. I think she had oozing from the placental implantation site over the cervix, an area that really isn’t meant to be used for placentas. It can’t contract down and control the blood loss the way the upper part of the uterus can.
I had just removed the uterus and was still inspecting all of the areas we had sutured when I got a phone call from Labor and Delivery that another patient had come in with a dead baby and what looked like a ruptured uterus. By then it was about 10:30 pm and I was hungry and tired. The last thing in the world I wanted to look forward to was another two or three hours in surgery. I told the medical assistant who had assessed the patient that I would be over as soon as I finished the surgery I was doing and convinced myself that he had to be mistaken. He wasn’t, of course, and not only was her uterus ruptured but it was the worst uterine rupture I’ve seen so far.
The patient actually looked very stable when I walked in to see her but I could see what looked like a hand almost poking through the skin on her abdomen. The ultrasound confirmed that the baby was dead. She was so tender in that one area that I was immediately worried and when I looked at her urinary catheter I knew we were going to the OR. Instead of urine it was draining blood.
We got the consents we needed and had her in the OR within 30 minutes. Her hemoglobin was low so we had blood cooking in the blood bank. The first thing I saw upon entering her abdominal cavity was a Foley catheter floating in a pool of blood. That’s never a good sign. It means that the bladder is no longer intact. The second thing I saw was a small foot floating in that same pool of blood. The baby was outside of the uterus along with the placenta. After removing them I inspected what was left of the uterus but there wasn’t a lot that was recognizable. The uterus had ruptured in a star shaped fashion from the lower part. The rupture included the bladder which was filleted into about four big pieces.
The hysterectomy took a while. I had to put the cervix back together just so I’d have some landmarks to use as a reference. She ended up getting three units of blood during the operation, half of it to replace blood she’d already lost and half to replace blood she lost during the operation.
The hardest part of the operation was putting her bladder back together. It was like solving a puzzle, finding pieces that fit together and trying to put the back the way they used to be. It seems to have worked. I pulled her abdominal drain after two days when it quit putting out old blood and her catheter is actually putting out clear urine today for the first time in three days.
She is the perfect patient on top of all that. She gets up and walks, never complains about pain, and seems perfectly okay with the idea of not having a tenth pregnancy. She never had a C-section, the operation that increases the risk of a rupture. I think her uterus was just worn out from the other nine pregnancies.