Abruptio Placenta, Part 1

Sunday morning just after 3am I received a call from my client's mother (this client is 39 weeks pregnant, normally goes 2 weeks over-due with each pregnancy, and is having her 7th baby). Client's mother told me that the woman thought her water broke, walked to the bathroom in the dark, and once she turned on the light, realized that big "gush" was blood. Lots and lots of blood. "I'll be right there!" I said. Hung up, dressed and drove there praying and driving like a mad woman. There in 20 minutes.

We had known already that the placenta was completely anterior. She had had an ultrasound around 20 weeks, so we knew it wasn't low-lying. I couldn't hear any heart tones with the fetoscope through the entire pregnancy because of that placenta. Which is frustrating, because I do prefer the fetoscope to the doppler during prenatals, it's my second pair of hands when visualizing the baby's position.

At any rate, I arrived, put down my bag and listened for heart tones immediately. Baby was right there, in the 140s, chugging along. I palpated for abdominal pain (if there's a lot of blood with an abrupted placenta, the abdomen can feel constantly hard and paninful). No pain. No contractions. The client and her mother both cried tears of relief hearing the baby's heart tones.
Next I needed to see the blood. They had cleaned it up already. Shit! The mom told me I could see the towels they wiped it up with. Fine. She presented me with two large beach towels full of blood. Way too much blood. My client was wearing a pad and said she could feel more blood gushing out.
I (calmly as I could) told her I thought we needed to go to the hospital and now. That I thought the placenta had come away from the uterine wall and that both she and the baby could be at serious risk.
This particular client HATES HATES HATES hospitals. She immediately started crying tears of anger and frustration.
Here's a little background: She had her first three vaginally at the hospital. All of her kids have been big. Number 3 though, was a hair over 10 pounds and a shoulder dystocia (of course she was made to push flat on her back, feet in stirrups, scared doctors pulling on baby's head and not trying to free the shoulders~this retold to me by client's mother who witnessed the birth). The baby was born and was fine.
With baby #4, the baby was transverse in the last few weeks of pregnancy. They were also telling her the baby was huge. They scheduled a cesarean because the baby was sideways. Client showed up for her early morning c-section and ultrasound had found that the baby had turned head down. Client said great, she would go home and wait to go into labor. Wow-ho! They told her this baby is HUGE. They could tell by ultrasound. It was at least 10 1/2 to 11 pounds and they didn't want to risk another shoulder dystocia! Scared and confused, she consented to a cesarean. The baby was born fine. It took the staff two hours to tell her his weight, despite her asking over and over. When it came down to it, they finally had to tell her he was a whopping 8 pounds. Yet another unnecessary section done with scare tactics.

Needless to say, when pregnant with #5, she sought out midwives and planned a homebirth. That's when I met her as an apprentice. That birth went fine, except that she bled a lot immediately after birth. That was managed and controlled well and quickly and she did great. Baby close to 9 pounds.
#6 was also a homebirth with the same midwives. Baby was born with mec right at birth, but otherwise fine. Baby 9 pounds.

So back to Sunday morning and baby #7. We went to a local, small community hospital. I would've loved to go to the U of M hospital, but had no idea of how much bleeding was coming up and didn't want to risk the longer drive.
I called labor and delivery ahead of time to tell them we were coming, but we still had to be processed through ER. Which seemed to take forever. I told the woman receiving us that we needed to get an ultrasound NOW. My client, despite wearing a pad, had blood streaming down her thighs.
It still took nearly 10 minutes before they would stop with the bullshit paperwork and the printer that wouldn't work confusion before they had a security guard walk us back to L&D.
We were met there by a lovely nurse (and the nicest person we were going to encounter in that shitty little hospital that looked like it was plucked straight out of some impoverished eastern European country~ with it's taped together machines, hot stuffy rooms with dirty fans circulating stale air, and general filth along walls and floors). She was respectful to both of us and understood the planned homebirth and how hard it was to be somewhere we didn't want to be. She showed empathy and compassion throughout.
Next comes a young 20-something intern with deer-in-headlights eyes. She stammering questions and hopping from one foot to the other. My client introduces me as her midwife. The intern asks a few minutes later why my client chose not to have any prenatal care. I explained to her that I am the midwife. I've been giving my client routine prenatal care since the second month of the pregnancy. Everything has been fine until now. There's a lot of blood and I suspect her placenta has pulled away. We're here because we need an ultrasound.
The intern says, "Yeah, okay. But first I need to do a vaginal exam."
"With speculum," I say. Not to be a shit, but because the intern looks so afraid and if the placenta happens to be over the cervical os and she pokes fingers into it, we could have even more serious problems on our hands.
"Yeah, with a speculum," she says. And flits away.
She comes back with a speculum and bright light, and is followed by a bleach blond woman who looks like she was just woken from a qualude-induced slumber. I smile and say hello and she ignores me. The intern announces the blond as the floor doctor for the night. Then she inserts the speculum (and actually says what she's about to do before doing it~nice) and out comes a huge gush of blood, all over the floor and all over their shoes. The baby's heart tones have been fine through all of this.
Client is dilated to 2cm, water intact, no placenta over os that they can see.
Next they bring in an ancient, clunky, taped-together ultrasound device. We see the placenta from top to bottom. And near the top, but not on the margins, there is a silver-dollar size spot that has come away and the blood is just gushing past there with each pump of the mother's heart.
The blond doctor tells us in this flat, monotone voice (thin Ben Stein): "Your placenta has come away here. You could potentially lose a lot of blood and the baby could die. You can stay here or you can go home and have your home birth. My advice is to stay here and have a cesarean."
My client looks at me, hopeful at the prospect of going home. I tell her loud enough for all to hear: "Sweetie, this is serious. We can't have a home birth. The placenta could continue to pull away, and even if this was the only spot that abrupted, you are losing a lot of blood and you're not even in labor yet. I know you hate hospitals. But we come here when we need emergency care. We need to keep you and your baby safe and they have what we need. I'm not going anywhere. I'll be right here with you whatever happens."
My client begins to cry silently, and growl a bit in anger and frustration. The nice nurse apologizes for the situation and tells her she will make this go as smoothly as she can. The seemingly stoned doctor rolls her eyes and orders and IV and a foley catheter while walking away. No smiles, no sorry you've got shit luck. Nothing.
I wanted to smack her smug, mean face.