Help me come to terms with birth trauma and prepare for debrief

[louloutheshamed]

I had quite a traumatic birth experience 12 days ago with ds2, and would like mnetters thoughts on it. (I had a normal delivery with ds1 2.5 yrs ago). This is likely to be long!!

I was told at 20 wks that I had a low lying placenta- I went back for scans at 32, 34 and 36 weeks and it was still low. At 36 weeks I was admitted to the antenatal ward and told I would be there for 2 weeks until they delivered by elcs at 38 weeks. I had a date booked for cs, went through consent forms and everything. I was upset about being stuck in hospital and about needed I a cs, as I had a normal vaginal delivery with ds1, but when they talked me through the risks of bleeding and going into labour with a low placenta i realised it was the safest course of action.

Then, after 4 days on the antenatal ward, they said that I should have a transvaginal scan to see exactly how far the placenta was from internal os. It measured 2.9cm and safe limit is 2.5cm so I was allowed to go home. I should add that I had not had any bleeding at all (the main symptom if placenta praevia) throughout my whole pregnancy at this stage.

I went back at 39 weeks for another transvaginal scan. The consultant said she couldn't even see the placenta on the scan, just the cervix and the baby's head, and that the placenta was at least 4cm away. We left the hospital at about 6pm that night as we'd had a long wait. At 1am the following morning I woke up feeling wet. I stood up and huge clots of blood were falling out of me, the room was like a crime scene. I was also having mild contraction like pains. We went to the mau and the quickly transferred me to the delivery suite, after putting continuos monitors on (baby fine) doing my obs (fine) and inserting a canula and taking blood.

The first dr I saw examined me with a speculum but then said it was pointless as there was so much blood, he was scooping out clots of it. Then he did a VE and said I was 2cm dilated and that he wanted to do an ARM. The midwife seemed alarmed by this- she said wasn't it normal to be 2cm dilated with dc2? But he said I was in the early stages of labour and that it was best to get me going. I was terrified because I had been told that with the low lying placenta I should not go into labour as the risk of bleeding was too high. I asked about this and he said 'but the placenta is not low, it has moved.'

Then another registrar came in and did an abdominal scan. He said he placenta was low even though 'the experts in foetal medicine' (sarcastic tone) said otherwise. My impression was that the two drs didn't know what to do with me. They left the room.

The bleeding by this point had settled. They came back with a plan, which was to do a cs at 8am (it was now about 4am) unless I had any more bleeding in which case they would do it immediately.

I asked why the wait and he basically said it was a high risk procedure and they needed the 'right people' to be there- which then made me worry about who would do it if I was to have more bleeding!

They took me through the consent forms and all the risks- hysterectomy, paralysis from the spinal (!). I know his is standard but the atmosphere was awful, there seemed to be tension between the drs and the midwife. The midwife asked about the contractions I was experiencing and the 2nd dr waved his hand dismissing them, but I didn't know what this meant.

At 8am a new Consultant and surgeon arrived and calmly and confidently explained the procedure. They were very reassuring. I was taken into theatre. The spinal was a bit scary as it took a few
Goes, but then the actual op seemed fine. My son was delivered after 10 mins and then they inserted
A cooks catheter and did b-lynch stitches to stop the bleeding from the uterus. I didn't need a blood transfusion.

The care in recovery and in the postnatal ward was great. All the midwives seemed horrified at my story and recommended that i go
For a debrief to go through the notes etc.

The main thing is that the exact scenario that we were at pains to avoid (bleeding and emcs) was what Happened in the end. This is what I am struggling to accept.

The questions I have are:

What caused the bleeding?
Could the tv scan have caused the bleeding?
Had the 1st dr performed an ARM, what would have happened to me??
How accurate was the tv scan really? Is it part of a drive to reduce cs rates?

What are The implications for men for future Pregnancies and births if I decide On dc3? I have heard conflicting things about the likelihood of a low Placenta recurring esp after a Cs?

Some drs mentioned that other things could have caused the bleeding eg abruption and it could have been a coincidence and nothing to do with the placenta??

What are mnetters thoughts on my experience? Can you think if anything else I should Ask at the debrief?

Labour ward MW here. You've had a lot of contradicting information there so I'll try to unravel/explain some but your postnatal MW's were right - you need a debrief to go through the notes so all the relevant information is together.
Placental position is not always easy to define and the changing position of your baby can make a difference to the view that they can see. If I was the MW looking after you when you came in bleeding I would be reviewing the most recent scan and that would be the one from the Consultant in fetal medicine showing a low lying placenta but not a dangerously close to cervix one. In view of your heavy bleeding your MW was correct to question the wisdom of ARM without a repeat scan and so it's good that happened. If the placenta had been lower than previously thought it would have been a really bad idea to go poking around but the doctor who examined you must have thought he could feel membranes rather than placenta if he was considering ARM. You don't say if the contractions continued? Bleeding such as yours can cause uterine irritability and cause contractions so they may not have been labour contractions if you see what I mean - difficult to say without all the info/being there.

The decision to wait until "business" hours is also the correct one. It means the most senior Consultants are there in case of major bleeding and complications. That includes Obstetricians, Anaesthetists, Radiographers sometimes and Haematologists in the lab. If you had started bleeding again and they had to proceed during the night then those people would have been called in but much better to do it under calm controlled circumstances if possible.

The Obs/Surgeon who did your CS should have noted where the placenta was and if it was obvious if there had been any abruption or separation. However, it's not always possible to say categorically if there has been a small abruption (even if there appeared to be a lot of bleeding). Also, if you needed the uterine catheter and B-Lynch sutures there must have been significant bleeding during the op - these are not routine measures. I would be asking what your estimated blood loss was.

Did the trans vaginal scan cause the bleed? - unlikely since it wasn't immediate.
Are they accurate? - in well trained hands, yes. You say it was a Consultant so I would hope her documentation is exemplary.
Are tv scans part of a CS reducing drive? - No. They are a tool to give the best information in order to make the best decision for mode of birth and having the appropriate personnel caring for you.
What are the implications for a future pregnancy? There are differing risk factors depending on whether it was a placenta praevia (low lying) or an abruption. The Consultant who debriefs you will have the statistics which I don't have at hand.

It sounds very scary and you seem very composed. It's a good idea to talk about it if you have people you trust to just listen. Get all the information from your debrief and see how you feel then. You may want or feel you need some counseling or you may be happy with the answers you get from your debrief. People react differently and however you feel is normal. I hope you get the opportunity to debrief as soon as you are ready.

Thank you trafficwarden for such a detailed response. The placental abrupt ion is something I feel I need to find out about. I have rang to arrange the debrief so hopefully will get that opportunity soon.

Oh I felt the contractions until the spinal but they didn't seem to increase in frequency or intensity. The obstetrician said the same as you- that they were probably caused
By the bleeding, and he said it was a good thing as it meant that the uterus was Responsive and therefore more likely to contract to help stop bleeding after the operation?

When are you having the debrief? I had a very traumatic emcs, followed by further emergency surgery five months ago. I was very keen to get a debrief asap but was advised to wait a few months and I'm very glad that I did.

It was a difficult first couple of months trying to piece together what had happened and why. However, by giving myself some time to process things myself and understand what I was feeling about the whole thing, as well as recover physically and get over the shock of actually having a baby, I was able to approach the debrief in a very calm and objective way. I think if I'd gone sooner I would have been quite emotional and perhaps not taken as much in.

As it is, I now feel I can put the whole thing behind me and move on. I know everyone's different but I felt that waiting until about three months post-birth was really good advice.

I hope you get the answers you're looking for and congratulations on your DS!

That's a good point rallytog1, as you say everyone is different.

In an ideal world you would have had the facts explained to you at the time and again after the birth. Poor communication is such a major factor when there has been an adverse event/outcome. However, sometimes it's impossible to give a clear cut answer. Given the diversity of people's experiences on here it's clear the human body has many quirks and doesn't always follow any rule books!

I think knowing the facts is important - then you can start to process. It's easy to get things jumbled up and having all the information is much better than focusing on "what if's" and "Why not's". Good debrief services offer return visits to clarify anything you are not clear on and how to access further help.

Important points to remember:

Take your account of events with you as a reminder.
Write your questions down and leave space to write down the response.
Take someone sensible with you, maybe someone less emotionally involved and able to ask questions in case you forget something. Being assertive is good, being aggressive is not.
If you don't understand something, ask for a clearer explanation.
Find out who will be there from the hospital. The Consultant may be present, sometimes a specialized MW/Supervisor of MW's.

Best of luck and enjoy your new baby.

It's a good point about waiting. I know I'm only 12 days in but physically i am recovering well and I can talk through events without crying now!

I have rang and left a message with the debriefing service and they said they would get back to me within a week, so it is likely to be another few weeks at least before I get an appointment.

Just to update I ha e an appointment for next week.

I'm still feeling very jittery about the whole experience. I don't think I realised at the time how serious it was. A couple of midwives asked if we called 999 when I woke up bleeding, but we actually waited half an hour for my mum and dad to arrive to look after ds1.

I felt a bit freaked out when in googled b lynch sutures and read that they are a 'life saving measure' to prevent Pph. And last night on The Midwives there was a woman heammoraging and it made my blood run cold.

Think it's going to take me a while to get over.

I just wanted to update this and perhaps ask for further advice.

I had my debrief yesterday. It was useful and cathartic and helpful to see the notes. I learned, for example, that I lost. 1200ml of blood during the op itself, in addition to what I would have lost earlier due to the bleed. In Many ways I did not realise the seriousness of what I was going through until afterwards.

There were some things however that the senior midwife who did it could not answer and she has
Advised me to write to the consultant who performed the transvaginal scan to ask for clarification of a number of
Points- mainly as it was the information from the tv scan that resulted in the confusion and indecision which I found so traumatic.

Do mns think this would be a reasonable or useful thing to do?

Hi Lou, I am not an expert or even someone with any experience of this kind of thing, but to hopefully bump this for someone else, I'd say that if it's been recommended by a mw she obviously thinks its reasonable, and so long as your letter is fairly succinct and respectful then I can see no reason why it would be unreasonable. The worst outcome is that the consultant doesn't reply, but given that you're bound to want answers for both your own peace of mind and to inform any future pregnancy decisions that would be pretty unreasonable of him / her.

All the best.

Hi loulou, I'm glad you got some answers and feel it was useful to go back. I'm surprised the MW said for you to write to the Consultant - I would have thought she would follow it up herself. Perhaps that's just the way their system works.
If you do decide to write and ask, I would make a few suggestions:

Include your hospital number, the date of the scan and the date of your CS. She needs to be able to access the same information as you did with the MW.

Try to be as clear and unemotional as possible with your questions. You are looking for clarification but she may interpret it as a prelude to a complaint. That obviously depends on you having all the correct information. Explain you would like to return for a further debrief and would appreciate all the information being available within a reasonable time frame. The debrief MW might suggest a suitable time frame to accommodate busy schedules, holidays, etc.

Ask if there's anything else I can help with. I hope you are recovering well and enjoying your baby.

Reviving this thread...

Ok so in now 4 m post partum with ds2 who is wonderful.

Yesterday i attended a meeting with the consultant who did the tv scan and I thought this was my chance to put everything to bed.,,in actual fact I left with even more questions.

I feel looking back that I should never have been discharged when I was admitted antenatally and should have had the planned cs at 38 weeks, rathe than bleed and have emcs.

However, what the consultant said surprised me. She said I should have had a tv scan before being admitted and as a result if that I would never have been admitted as the placenta was almost 3cm from os. She maintains that I didn't actually have a low placenta by 39 weeks as it was 4cm away according to her scan.

She said the bleeding was coincidental and not caused by the placenta being low, and the reason why the drs were debating what to do was because both were valid options and I could have had a vaginal birth.

This confuses and saddens me. It's hard to conceive that having had a condition, the main symptom of which was bleeding, and then having bled, I'm now told it was nothing to do with that condition.

Also, I hate the thought that I might have had a cs unnecessarily. It would be easier to stomach if I knew it had had to be done.

Also, in terms if future dcs she has said the (perhaps unnecessary cs) means I am more likely to get placenta accreta next time which sounds hideous and life threatening and often requires hysterectomy!

She did say that was unlikely I'd get that after only one cs but the fact that she has mentioned it is terrifying and makes me sad as I really feel like I don't want to rule out having more dcs.

So...things still unresolved in my head. She is going to write to me d f is going to speak to the drs on duty that night.

Any thoughts? Dont know how to feel...

Hello again! I'm sorry you are still in this situation although delighted to hear you are enjoying your baby. It sounds like the Consultant you saw is firmly of the opinion that you did not have a low lying placenta. As I said before, it's not always easy to see exactly with an abdominal ultrasound and she should be the expert. However, she wasn't there the night you bled and did not do your CS. The decision for delivery by CS seems to have been made on the basis of you having had a large bleed and the uncertainty regarding your placental site. The Consultant who made that decision/did the op seems to be the one holding all the information you need and hopefully you will get that and perhaps be able to meet him. It is entirely possible that you had an abruption and nobody would have been able to predict that. The decision to admit you to the antenatal ward and plan CS seems to have been made without a thorough investigation first but there may be more to it. Some Consultant's are more risk averse than others but that's no excuse for lack of communication with you and between colleagues.
Regarding the risk of placenta accreta - the risk of placenta praevia in someone who has had one CS is 0.6% to 1.3%. Of those women, 11 to 14 % will have a morbidly adherent placenta, so overall a very small number. Yes, it does happen and it can be dangerous if you are one of the unlucky ones but it is not that common and can be managed appropriately. You have to consider it in relation to every other risk in childbirth. Think of all the women who have had one CS and go on to have a completely uneventful VBAC or repeat CS - they had the same statistical risk as you. If you want to do your own research, go to the NICE.org website, loads of information there.

I really hope they get their act together and provide you with the detail you need to reconcile yourself to the situation. It would be so much better if you could see both the US Consultant and the operating Consultant together and it might be worth requesting that from the debrief MW. Good luck.

Thank you trafficwarden your detailed replies have been so helpful in clarifying things.

I think I will see what her follow up letter says and go from there.

Something I'm not sure about is whether I'm more at risk of praevia because if the cs or because I've had a low placenta before. But according to her I didn't have a low placenta! So confusing!!

I had to look this up and the information is from 2009 - I couldn't find more recent stats:

Risk of placenta praevia - occurs in 0.5% of all births broken down into 0.38% after a single vaginal birth, 0.63% after a single CS and 0.72% after 2 consecutive CS. The way I would look at it is like this - if you did have a placenta praevia before, you would automatically have had a CS anyway so the statistics wouldn't change.

In the meantime, I would accept that in her expert opinion you did not have a placenta praevia. Unless the operating surgeon contradicts this then I would trust her diagnosis by TV scan over that of a LW registrar (who may or may not be experienced in scanning) using an abdominal US of a likely inferior standard. He felt the placenta was low but the diagnosis should be made on pretty exacting figures which is her specific area of expertise.

From the on call doctor's point of view - it's the middle of the night, a woman comes in bleeding heavily with mild contractions. This is a clinical picture more indicative of placenta praevia then abruption because abruption is usually (not always) associated with more pain. So he gets a second opinion and the Registrar thinks the placenta is low lying so he doesn't want to mess about unless the situation changes. He is making a personal clinical decision based on the current clinical situation. Even with the TV scan findings in the notes, he has to decide if he feels safe and confident to deal with the consequences as there has been doubt raised previously. As your condition is stable he lets an even more senior Consultant make the decision to deliver by CS under controlled circumstances in the morning. Did that Consultant not tell you what he thought it was?

It is quite possible that the placenta was on the low side of normal but not easy to view by US. In ideal conditions you might have been able to have a vaginal birth. But you had significant bleeding and the Consultant on the day decided it was safer to go for CS than allow labour to progress and risk further bleeding and the associated risks to you and the baby. Did they try to estimate how much you had lost before coming in to hospital? It could have been a partial abruption and the Consultant/surgeon may have been able to see that. Although 1200mls at CS is a lot, it's not life threatening. It sounds like you were managed very conservatively and the bleeding was well managed and controlled by the measures they took - as I said before, these are not routine. Given that your uterus appears not to have contracted well after the baby was born, being right there may have prevented a catastrophic bleed.

I'm sorry I can't put your mind at rest as I don't have all the information. But maybe by considering a different point of view you can see that it was not necessarily a bad decision or made lightly. I hope I'm not rambling - I do my best to communicate effectively at work but it's much easier face to face!

Thank you again. Yes that does make sense as to why the cs was performed.

One thing it said in my notes from the op was that my uterus was 'boggy' with 'low contractility' and that is why they did the catheter and stitches, as you suggest. I was told that these measures were likely before the op during my time as an inpatient when they believed I had a low placenta-- as the lower part of the womb is less muscular and contracts less well?? So the fact that I needed them would suggest that my placenta was low, wouldn't it?

No, not necessarily. It can and does happen unexpectedly. It's more likely in women who have had a prolonged labour, especially if they have had syntocinon to increase contractions. It also happens more often if you have a multiple pregnancy or polyhydramnios (excess fluid) as the uterus has to work harder. And it is more likely when someone has had an irritated uterus as you had after the initial bleed because the uterus again is working hard to contract and the muscles relax and don't have such a good blood supply to do the job.

Ok thanks again traffic warden. It's do good to have your expertise and I should really stop all this second guessing!!

No problem. I don't post that often, more of a browser but I hate it when someone is left worrying. The second guessing is normal but can cause more anxiety if you are not getting any answers so I hope getting an alternative point of view is useful. The human body is such a complex, fickle machine it's often not possible to give straight answers, even with the benefit of hindsight.

Sorry if I go over what has been said but I haven't read any answers.

I had a very similar experience with my first OP.

So I had placenta previa then a very grumpy sonographer told me at 34 weeks the placenta was far enough away from the OS for a natural delivery. During the scan I had became so familiar with it I thought I had seen something covering the OS and she bit my head off.

2 and a bit week my waters break middle of the night and I go to hospital, get checked and sent home to rest. 6am secondary waters go followed by the crime scene you describe. Blood and clots galore.

Rush back and by then the blood had subsided and im shoved into a low risk labour room!!

I keep trying to get someone to check me and nobody comes. I bleed on and off for an hour. New Midwife comes on, takes one look at the bathroom floor covered in blood and an emergency team are round me. They bring in a portable scanner and the minute the consultant look in, she was pointing at the Placenta over the OS. I told her about the sonographer and she rolls her eyes. I had the whole hysterectomy etc chat and was terrified. When she leaves the midwife say's the sonographers are notoriously like this and very unhelpful.

I was rushed to theater and my boy was delivered.

I felt very scared and unnerved with the way I was treated with various things throughout the pregnancy.

I went on to have two further healthy pregnancy's and natural births since so don't be put off.

Sorry my keyboard is sticking. Some dodgy text!

Had a quick scan at a few others. Please don't worry about future PG. I had my DS followed by my DD 2.5 years later then another 2.5 years later I had DS2 who is now 16 months.

I worried so much in my subsequent PG and wish I hadn't.

What did help was hypnobirthing. I highly recommend this OP. It calmed me down and made me much more confident and positive.

OK, I was never going to be allowed near the birthing pool but there is nothing wrong with a little high risk monitoring if need be.

I felt with my 2nd they were ultra keen to have me shipped off for a C Section as my waters broke and it was nearly 70 hours before she arrived. I had learned a lot through hypnobirthing and I was confident in myself.
Baby was not distressed, I was on IV antibiotics and I was being constantly monitored so I held my ground. Don't get me wrong, 1 mention of actual danger to my baby or me and I would have given in but there wasn't.

My 3rd was so fast he was nearly born in an ambulance.

No birth is like the last. I too looked up stats of getting previa or even acreta and was terrified. I couldn't relax until the 20 week scan but by #3 I accepted how different each PG and birth is.

I will let you into a little secret, come closer.... I wish I had had 3 CS now. Id be able to jump on the trampoline with the kids without peeing myself!!

Everything stays the same after a CS. Nothing stays the same after birth.....just saying!

Thank you Princesspants that is so encouraging.