As a gynecologic oncologist, I am rarely called to the labor and delivery suite, but I do serve as a surgical consultant for difficult cases: The skills needed to direct the dissection of a cancer from pelvic organs are the same as those needed to ligate uterine vessels that won’t stop bleeding. So when a medical student paged me to a delivery room recently, I ran to change into operating scrubs, my mind reviewing what must have occurred.
The problem was an everted uterus—a rare, life-threatening condition in which the uterus is delivered along with the baby. It can happen when the placenta comes out, pulling the uterus inside out until it flops onto the table, pouring blood onto the drapes, the towels, and the delivery room floor. The only question then is whether the bleeding can be stopped before the mother dies.
On television, labor and delivery end when the baby’s out, but there are three stages to the process: labor, when contractions pull the cervix open to allow the baby out; delivery, when dramatic pushing expels the baby; and the third stage, when the placenta passes. Normally, the placenta flops out of the birth canal because the muscles of the emptied uterus contract vigorously after the baby is delivered, clamping down on open blood vessels. Because the placenta has no muscle and can’t contract, it is sheared off the uterine wall during contractions and squeezed out.
This last stage of delivery can take a half hour or more, but if there’s no bleeding, there’s no rush. Still, the mother is uncomfortable in the stirrups, the father is curious, and the obstetrician bored, if not frustrated. Sometimes a doctor will check on the separation process by gently tugging on the umbilical cord. But that can lead to catastrophe, as it did for one tired intern that predawn morning.
When I reached the delivery room, all was chaos. There were three residents, an obstetrical attending physician, two anesthesiologists, and four nurses. All of them seemed to be shouting. The patient, with no family in sight, was under a mask, her face invisible. Someone was working to start an intravenous line in one arm, another in her neck. The paper drapes were crumpled. Bloody gauze littered the floor; clots seemed to be everywhere. The senior obstetrician explained the situation.
“She’s only 26,” he said, “but she’s been in labor for two days. The baby’s fine, just big. I was doing a cesarean in another room when this happened, but the residents tell me that the delivery was unremarkable—at least till the uterus everted.”
The obstetrics team had tried all the usual measures. After making sure that the bleeding wasn’t compounded by tears in the vagina or from retained bits of placenta stuck on the uterine wall, they had succeeded in replacing the uterus in the abdomen—no small success. Sometimes the cervix continues to contract after eversion, trapping the body of the uterus inside it. When this happens, blood cannot return to the heart because of the cervix’s tightening pressure on uterine veins. Yet blood continues to pour into the uterus through the arteries. Blood is being pumped into the trapped uterus, but it can’t flow back out. If that goes on for more than half an hour, the patient will bleed to death.
In this case, however, replacing the uterus in the abdomen failed to stop the bleeding. The uterus is a muscle, and like any muscle, it grows exhausted when forced to work for days without rest. After this delivery, it simply failed to contract. The obstetrics team had tried to stimulate contraction with massage and a variety of medical treatments, but the uterus failed to respond. A flaccid uterus has no way to stop blood from flowing through the torn channels where the placenta was attached. During a delivery, blood flow through the uterus can be almost a quart a minute, so a woman theoretically could bleed to death in a matter of minutes. In this case, almost an hour had passed since delivery.
The anesthesiologist came over, looking grave. “The hemoglobin’s down to 2,” he said. “We’ve been giving her fluids, and she’s not in shock yet. But somebody’s got to do something.”
“So transfuse her,” I suggested.
The obstetrician winced. “She won’t accept blood of any kind,” he said.
That was a frightening twist: A normal hemoglobin count is 12 to 14. Our patient had lost more than three-fourths of her blood volume. In the modern era of medicine, hemorrhage is one of the few remaining causes of maternal death, but surgery can usually stop it. In some cases, however, the blood loss is so profound that blood pressure falls to an impossible level. With no blood in the veins, flow to the brain, heart, liver, and kidneys drops off, causing irreparable damage. In some cases, components that regulate coagulation are so depleted that the remaining blood cannot clot, so suturing bleeding points to stem blood loss only causes more bleeding where the needle punctures tissue.
Transfusion can correct the blood loss, but the patient was a Honduran immigrant and a devout Pentecostalist who refused to accept blood in any form. When she came in for labor, she’d told her care team that she’d prefer death in this life to damnation in the next. The anesthesiologists had managed to stave off complications by administering intravenous salt and water. At this point, she had no reserve.
I looked at the anxious resident. She was trying to hold back the bleeding with one hand on the woman’s abdomen and another inside the vagina in order to compress the uterus and stop the flow of blood. The maneuver wasn’t working: The blood that seeped around the resident’s gloves was as thin as water.
“You have to open her,” I told the obstetrician. “If her uterus won’t clamp down, you have to take it out.”
“She’s only 26,” he objected. “She’s had four children, but she’s so young, and she hasn’t consented to surgery.”
“She can’t,” the anesthesiologist pointed out. “She’s arousable, but she slips in and out of consciousness. She wouldn’t understand anything you explain. You’ve got to do something.”
The obstetrician looked at me. “You have nothing to lose,” I pointed out. “If we operate, she might die. If we don’t operate, she will die.”
So the anesthesiology team put her to sleep. Then we splashed a sterilizing iodine solution on her abdomen and went in. The uterus was as soft as an underinflated water balloon. I pulled it out of the pelvis and held it in my fists, squeezing on the blood supply like a tourniquet while the obstetrician injected agents directly into the muscle to promote contraction. While I held the uterus, the anesthesiology team stabilized the woman’s blood pressure, which had dropped. Meanwhile, I laid out the options.
“We can try to tie off the arteries that flow into the uterus in an effort to save it,” I said. “But the uterus isn’t contracting, and unless it contracts, ligation will only slow the bleeding, not stop it. If she goes into shock while we’re doing that, she may never come back. I think we have to go ahead with hysterectomy.”
The obstetrician nodded. “And if anything goes wrong with the hysterectomy,” he said, “she’ll die.”
Cesarean hysterectomy is a dreaded operation, because the vessels to the recently pregnant uterus are engorged. Any slipped clamp or slight tear can result in torrential bleeding.
We did it anyway. Every vessel had to be tied twice; every knot had to hold. They did. She survived.
Actually, she did better than that. Within two days, she was walking. We watched her for signs of brain injury from prolonged blood loss, but aside from a little postpartum crankiness, she was fine. When we told her we’d removed her uterus, she was grateful: She said she had four children at home, another in the bassinet beside her, and she didn’t want more. When she came back for her six-week checkup, iron supplements had nearly boosted her hemoglobin level to normal. Meanwhile, the resident who had pulled on the placenta is graduating in June. She is now the epitome of patience in deliveries and aware of the place of surgery when the natural processes of delivery go awry.
Stewart Massad is chief of the gynecologic oncology division at the Southern Illinois University School of Medicine in Springfield. The cases described in Vital Signs are true stories, but the authors have changed some details about the patients to protect their privacy.