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.
