I have been meaning to write this blog for some time…a client of mine had a VBAC in March which was relatively straight forward, but there was some frank vaginal bleeding throughout labour which I was concerned about so I’ve decided to write a blog about bleeding in labour or Intrapartum hemorrhoage and the appropriate management.
My client had had a previous caesarean section two years (approx) earlier for a breech presenting baby after slow progress in labour (yes, she was actually given the chance to labour). This pregnancy was completely uncomplicated apart from the previous caesarean section. My client was planning a hospital birth…a VBAC, and planned to spend early labour at home then transfer to hospital once labour was established. Her ultrasounds had shown no complications with her baby or the placenta.
In the early hours of the morning, I received a call to come to my client who was having regular painful contractions…on arrival contractions were actually 4-6 mins apart, but when they were 6 mins apart they were very ‘strong’. All was well with Mother and baby until my client said she could feel something ‘coming out’. She was in the birth pool at home and under torch light I could see what appeared to be frank blood loss, just a small amount but it was frank. My instructions were to get out of the bath so I could assess the situation closer, and to see how much blood there was and possibly why. Fetal heart rate (FHR) was completely normal and so was maternal pulse.
Once my client was out of the bath she had several further ‘drips’ of blood. My thinking as an experienced Midwife was one of a few things…rapid progress in labour would be the most obvious, and it is not unusual to see some frank vaginal bleeding when labour progresses rapidly. The more sinister reasons crossed my mind too…that of the beginning of a uterine rupture, or even a revealed abruption of the placenta…but in the absence of any variation in FHR, this was unlikely.
I decided to do a vaginal examination…a very gentle one as an undiagnosed placenta previa or even more rarely an undiagnosed vasa previa could not be excluded either (this would mean than the ultrasounds had not diagnosed these issues…and this has happened before where ultrasonography does not pick up abnormalities of the fetus and the placenta). On vaginal examination my client was 6cm dilated with a firmly applied cervix. No placenta or vessels could be palpated and membranes could be felt in front of the baby’s head. I recommended going into the hospital now as I was concerned about the bleeding.
On arrival at the hospital Cardiotocograph (CTG – or baby monitoring) was all reassuring. Labour progressed relatively quickly however in the second stage there were profound variable decelerations with a slow recovery in between contractions and sometimes no recovery of the FHR. Sometimes the FHR stayed as low as 70-80bpm in between contractions. It was decided to place a ventouse (vacuum cup) on the baby’s head to encourage birth of the baby as quickly as possible. A baby girl was born in excellent condition without any compromise at all.
My client spent some time thinking about whether the ventouse was really necessary, considering her baby was well. My thinking is that the ventouse was necessary as we never really know where the bleeding is coming from, and how the baby is coping with labour until after birth. My client had lost on estimate 100mls of frank blood during labour and despite a reassuring CTG this type of blood loss isn’t normal, even with rapid progress in labour. Also when examining the research surrounding complications associated with VBAC, bleeding, placental abruption and uterine rupture, although rare, are real complications, and usually have profound implications for both Mother and baby. I think as Midwives our role is to protect normal birth as much as we possibly can, and because we are surrounded by normal labour and birth, it is unsettling when something happens outside the normal process. It is at these times, even when intuitively we feel something is ‘not quite right’ with labour and birth that we need to discuss, consult and refer women to appropriate care providers to keep Mothers and babies safe.