The calm before the storm

So I’m going out on a limb here to make a huge generalisation that ambulance officers dread being called to a birth. They either turn up to an emergency, or hate the mess they have to clean up when a multip shoots out a baby en route. They find the whole thing understandably stressful - so will do what they can to avoid it. To the point where they have superstitions about touching their birth kit in case it brings on a maternity job that shift!

But they do love stabbing people to put IV leurs in them. Which is how this story came about. I’m currently on holiday in the South Island and just have to get this one written so I can put it out of my mind. It’s a biggy.

I was at a normal first time mum’s birth, it was a long haul, progressing at a normal pace but she was getting tired and was unable to eat much despite lots of encouragement. Her contractions were starting to space apart. A bag of fluids can work wonders in this situation. It gives the uterus more power - so it contracts stronger and more often, as well as gives an all over energy boost for mum. Fluids can make the difference in avoiding a transfer to hospital for an assisted delivery. So after a short sleep, acupuncture, homeopathy and some good pushing hadn’t given me a peep of baby’s head I decided fluids would be the trick.

I’m usually pretty good at putting a leur in and don’t tend to miss that often. But not today, I failed everywhere I tried. The staff midwife was the next line of attack but she deemed it impossible. The next step is the anaesthetist at the hospital. That would require an ambo transfer. So the thinking was, if they have to come anyway why not get the ambos to put the leur in? They do them all the time. Hubby is always boasting about his leur skills. And who should turn up when I called, but the boaster himself!

It’s always good to see his smiley face at work - although I don’t see him there often - he was happy to put the leur in (yes he also found it hard 😉) and then I planned to send them on their merry way.

But my very generous client was happy for my hubby and his sidekick (a young Aussie bloke on placement over here) to stay and watch. How lucky was that! They would get to see a normal birth and hopefully that would help them stay chilled in future situations.

And it was wonderful! The fluids did their trick. A peep of head to a baby out in only 15 minutes. Beautiful slow crowning of the head with mum lying on her left side, we even convinced the dad to have a quick peek. Then once the head was out baby waited until the next contraction and with a little bit of pressure in the right places the shoulders came and he was handed up to meet his mum.

Meanwhile the sidekick had loads of good questions. He thought the baby should have been looking up, not down when it came and both he and hubby thought the process took too long. Ah no. This was fast for a first timer! They said they would have been worrying about how long it was taking, so what a gift my wonderful client gave them - showing them what was normal. That gift will get paid forward to their colleagues and other birthing women in hundreds of ways.

All smug and happy we were.

Then there was a placenta.

Now if ambos think babies are scary it’s the placenta that I have issues with. It’s not over till it’s over. And high alert continues until after the placenta is born and the blood loss is controlled.

So would they like to stay and watch this too? Definitely! They could see the learning opportunity and didn’t want to miss out.

So the placenta came away normally twenty minutes after baby, but behind it there were a whole lot of blood clots. This is relatively common and every midwife knows what to do next. But just to explain to the non midwives, a placenta is about the size of a bread and butter plate. When it comes away that ‘plate’ is the size of the wound that a women bleeds from. So the uterus needs to contract down to make the wound site loads smaller. A very tired uterus struggles to stay contracted, it also can’t contract if anything is still inside it. Like a little piece of the placenta or any clots. The normal amount of blood loss is up to 500mls. Any more than that and it is deemed a post partum haemorrhage (PPH). A pregnant woman carries around 5.5 litres of blood and she can usually cope well with losing 500ml. Any more than that and every women copes differently, but around the world a PPH is a leading cause of maternal death.

So with those clots appearing the theory is you massage the fundus (top of uterus) through the abdomen. This makes the uterus contract and push any more clots out. Usually this is enough to stop the bleeding. In this case it caused her to lose around 600mls in a huge gush. So while my student gave her an injection designed to make the uterus contract I reached inside to clear out any clots that might still be in there. Another 600ml gush. I’m thinking we are at about 1800mls now. That’s a lot in the space of about a minute. So this time I stayed with one hand inside on the uterus and one outside on the fundus - pushing the two hands together in order to put pressure on the wound and slow the bleeding down.

This move is called (the dreaded) Bimanual Compression - something we talk about in training but that thankfully most midwives never have to do. It’s rare that all our other steps and drugs won’t work. It’s the last resort. And we were there already. But to our extreme relief it was working. However, once you start this you can’t stop. Now I was stuck there. Luckily it put me in the position to have a helicopter view of what was happening around me. I could also talk to the woman and explain things to the dad from there. The sidekick was told how to ring the emergency bell for the staff midwife. Hubby was helping my student draw up the next drugs we needed. Then I got him to try to put another iv leur in - as in this situation you really want two. But he had no luck this time.

So it’s all hands on deck. Organised chaos. Adrenaline is high. Other midwives were at the unit seeing their own clients, so being the wonderful women they are, they were helping too. One colleague got very close and personal with my armpit to put a urinary catheter in - as a full bladder can also stop a uterus contracting. Another was in charge of dressing the baby as we needed to leave for the hospital FAST. Someone also had to ring the hospital. Sidekick was sent to get the stretcher and we were off! My student who had been amazing throughout those fifteen minutes would drive my car behind the ambulance. Dad and baby would come in their car.

But getting me into the ambulance proved to be a conundrum for the sidekick. The stretcher has an auto lift on it - too high for my short legs. And too hard for me to kneel on the side of the bed. Hubby was pushing the stretcher while sidekick stood behind me wondering how to lift me up without getting too personal. Hubby saved him, swapped positions and hurled me up and inside by the arse. Very graceful I’m sure!

Once inside it was a 25 min ride with all the bells and whistles. My poor client was also vomiting from the drugs we had given her that make everything contract, including the tummy. That catching job was left to hubby as I was standing bent over, legs wide, bracing myself to not fall over. Meanwhile my outside hand had gone completely numb. They always say bimanual compression is hard work. They aren’t wrong, it was a very long hour in that position.

On arrival I was lifted out with a bit more gentleness (there was an audience after all😬) and we were greeted by the docs at the door. Hubby and I were then both secretly stoked that the anaesthetist needed to use an ultrasound machine to help her put that second leur in.

But if I hadn’t called for help with that first leur... if the woman hadn’t been so generous about the ambos staying to watch... then we wouldn’t have had such fast transport out of there and the extra bodies to help. Bright side for sure.

However, that nice normal birth, that birth that would give those ambos faith in the normal process - turned so fast into an emergency I didn’t quite get the result I was after. But hey, as hubby pointed out, now they understand how fast things can change with births. They won’t wonder why they weren’t called earlier in an emergency and he also promises not to forget how cool it was watching the baby come out!

So at the hospital when I unwound my hands and slowly stood up it turns out all our drugs and the compression had worked. That uterus decided it would now stay contracted. Blood loss was weighed and it was 1830mls. That amazing, staunch woman was going to be ok. Never, ever do I want to see blood ‘hosing’ like that again. No one does. Usually blood loss mounts up as a steady trickle and you have more time to work through the steps needed.

It took a while for my body to recover. My left shoulder was so sore from pushing on the abdomen for days afterward. But what caught me by surprise was my sore arse! Bending over for an hour in that position and steadying myself in the ambulance made it feel like I was recovering from the first game of squash for the season. Mentally it will take much longer to come right, I’ve spent a lot of time talking it through with my client and her man and they are really enjoying parenthood. Both the hubby and I kept reliving it for a while, but at least we have each other to talk to. My student is getting her head around it all but should be reassured by how well she did!

By three days after I felt less fragile and relatively normal again but FML that day when I thought I was pretty bouncy I was leaving the birthcentre and this fulla asked me if I had a new grandchild. There is no coming back from that 😬👵🏻. I must have still looked pretty buggered 😂.

So hopefully this is written now and I can let it go and focus on this bloody freezing but beautiful view of the Marlborough sounds.

I‘ve had my once in a career turn of bimanual compression. I’m done surely.

And thank you to everyone that helped! 💕 You are all absolute rock stars.