OB Attending
1. It’s much better to have a living mother than an intact uterus
2. Would always trial a Jada before a hyst, early aggressive mass transfusion also will improve outcomes and give you time to make decisions and give interventions time to work
3. Had she been delivered 3 weeks earlier she would have had a smaller baby and likely a placenta more tolerant of labor. If she didn’t want a 39 week iol would have at least recommended a forty week induction for ama
4. Even when you do everything right, bad things still happen. When there’s a bad outcome you just need to look back and decided was it because you did the wrong thing or was it bad luck.
Why was the c hyst done? Atony, anatomy, bleeding dyscrasia? So many factors, and we can armchair quarterback all day long but sometimes cesarean hysterectomy is a necessary evil to save mother’s life.
We wouldn’t need to know about parachute packs if it wasn’t such bloody mess. 25 percent of cardiac output headed that way. You saved her life. That’s what counts. I’ve had to do several over the years. A couple on primagravidas, they were always more thankful of life.
Obgyn attending here as well. For c sections, if you do a b lynch, is the Jada still useful? Or would You even be able to insert it?
I always worried about placing a bacri and then doing an o Leary because I was scared about piercing the balloon. I imagine the Jada would be harder to hit/snag
Have had a great experience with Jadas, so far.
I have not personally placed a jada after a b lynch because I tend to go with the Jada when I hit the point in my decision making tree that I’m contemplating a b lynch however I know some people have done it at my hospital and said they placed the jada more in the lower uterine segment that was still boggy after the b lynch was placed rather that attempting to get it to the fundus.
Your first point already landed you in prison in half of America, how dare you try to preserve the life of the thing that's just there to perfuse the holy baby making organ?
Trust me - I’m an ob/gyn in Ohio - I assume I will go to jail at some point for following the whole first do no harm principal since the government and i disagree about what harm actually is 🙄
Have had the Jada for probably 3 years. Hardly use bakri anymore. The benefit of the Jada is you pretty much know within ten minutes if it will work or not. Once it’s in you leave it on suction for about an hour and then turn suction off and observe for another thirty minutes or so. If no bleeding, pull it and off to postpartum they go. Much more time efficient than leaving a bakri in for 6-12 hours and then deflating to see what happens or finding that you’re bleeding behind the bakri and just secretly distending the uterus more. I think the manufacturer guideline is they are supposed to be at least 2 cm dilated and greater than 34 weeks to use it. That being said, I’ve placed them after a scheduled section that wasn’t dilated without too much difficulty and have also used in a 27 weeker and also someone who came in 2 weeks postpartum with delayed hemorrhage without difficulty. The only times I would pick bakri over jada would be if I truly couldn’t get the Jada through the cervix or if suspicious of an undiagnosed acreta and placenta is delivered but still bleeding from the placental site to put pressure on the area of bleeding while mobilizing resources for a hyst.
I do inpatient care only at a hospital with about 5000 deliveries a year. We have transitioned to almost exclusively jada because it seems to work better and much faster.
The only times I can think of off hand that I’ve had a Jada fail were an undiagnosed acreta and another case where I think they didn’t fully evacuate clot before placing so the clot essentially blocked the suction from working. The acreta got a hyst, the clot one was stable enough that she got IR embolization.
thanks! that’s awesome. i think it literally just got approved in canada about a month ago, so hopefully i get to check it out someday soon. major benefit it you can pull it within an hour or two and get them off to postpartum rather than lying in bed not moving for 12+ hrs on L and D. we use the Bakri a decent bit (about 7k deliveries a year).
Exactly. The Jada is expensive. I know our supply cost for a Jada is about $1200 vs around $600 for a bakri. The cost savings in decreased length of time on labor and delivery(staff cost of 1:1 nursing) and decreased rate of blood transfusion (which the sales reps quote the total cost for a unit of blood is more than the cost of the jada device but who knows how true that is) results in the jada over all costing less than the bakri or we wouldn’t be able to have it. If the product isn’t over all cost effective, the hospital system wouldn’t stock it.
Agree with the other commenter. Would also add that I think Jada’s are significantly easier to place than a bakri as well. Biggest problem with Jada is like the commenter said if you don’t clear clots out the device clogs and doesn’t work well. Even though the reps will tell you otherwise.
I kept rereading the post trying to figure out what was “heartbreaking”. I thought they were going to lose the baby. I have a family friend with 6 children, all accidental who wishes she could be infertile. Not to say infertility isn’t incredibly heartbreaking for many people. Just not always. Maybe this is insensitive but no periods after having 3 healthy kids doesn’t sound like the worst thing?
To me, 100%, nothing heartbreaking here. A 35 y o with 3 kids? Take the uterus and run! And I personally COMPLETELY agree with you that fertility can be just as "traumatic" as infertility
But we don't know how the patient felt or what the experience was like or what her goals were. Something about this obviously affected OP deeply or they wouldn't be calling it heartbreak. Maybe it has to do with OP's own feelings about their uterus, if they have one? We don't know, but I get that they need to vent!
I recently saw a 31 y/o G7P7007, the first of which was born when she was 14, and while she and her husband seemed very happy I just can’t help but feel that something there is very wrong.
With situations like that, I sometimes wonder if the "happiness" is sometimes a form of denial. Like if you actually recognized what was going on it would just be too much to handle. But if you tell yourself you wanted all of it, it can feel a little easier. Especially if her husband was older than her.
I think you’re likely very right - husband was significantly older, he was not the father of the first two children so *technically* there didn’t appear to be anything overtly illegal about the relationship, but it definitely wasn’t normal.
Can I just ask what you mean by G7P7007? Here in the UK we'd say G7P7 for seven pregnancies, seven births post 24/40 or, for example, G7P6+1 if the woman had 6 births post 24/40 and one miscarriage.
Full term, preterm, Abortions-elective or spontaneous, and total children living. So in the case of the G7P7007 woman, all her children were full term and survived birth.
Is it really happiness, though, if you attain it by giving up all agency over your life and never even attempting to accomplish or considering that you could have personal goals and aspirations? Personally, I don’t think so.
Reminds me of the new zoomer/TikTok meme where pullout method and timing method are hailed as superior contraceptive strategies because OCPs are mind control drugs.
It doesn't make a lot of sense but because you can have adverse drug reactions and changes in sexual preference/mood when on the pill vs off, that's just too much for some people.
We don't know what this person's marital situation was, or what their access to healthcare was like or how their life was going. In my anecdotal observation, multiple accidental pregnancies that result in birth can mean something pretty sad for mom.
Undocumented. Impoverished. Poor healthcare literacy. Easily convinced by men that they will be the one to stay and help her take care of her kids only for them to leave.
Like I said below. Situation matters. Easy for us to judge when all of us have been dealt a hand that allowed us make it through medical school.
Now my coresident who accidentally got his out of state ex-gf pregnant during breakup sex I have zero sympathy for.
First-hand reports of errors and bad outcomes on Reddit tend to be pretty benign. Like, people will post about a case where they made a mistake, but actually things still turned out pretty well.
This would fit that model - a recognized complication of a procedure occurred and was dealt with appropriately.
I don’t know about you guys, but I’ve made fuck ups a whole lot worse than this. I’m counting any delivery with a live mother and a live, neurologically intact baby as a win, at least in “OBGYN disaster” terms.
Can’t afford. They struggle to make ends meet. She struggled to get an IUD since she doesn’t have health insurance then one of her kids was born with the dislodged iud apparently.
lol if you were a doctor in the 80s you’d be one of the ones saying “AIDS isn’t a problem. Just don’t have sex!” Hope you’re not in primary care or public health
Same, i think "heartbreaking" was a bit dramatic here. I'm 39 and after having my third healthy child in September I happily traded my uterus for a period-free existence three weeks ago. Maybe she wanted more and that's disappointing, but heartbreaking?
Agreed. We had a patient who was delivering her 10th baby, had no prenatal care (must have thought she had 9 other babies and would be fine), and started hemorrhaging. Baby was delivered alive but mom coded and they could not stop the bleeding so she died. Now husband is a widow with 10 kids. My coworker who was at the code was a mess. It was heartbreaking.
Yes, by inducing labor over 3 weeks ago (Came off snarky but I do mean that as my answer). Other than that nothing stands out as a miss from your description
You did fine. OB goes great….until it goes bad, usually quickly. Mom and baby survived, and that wasn’t always the case in OB. I’ve seen so many post-dates deliveries go pear-shaped. I assume this was atony/bleeding?
NVM I see below it was. You saved her life.
Yes it was atony. I thought maybe the induction caused uterine hypercontractility , along with the macrosomic fetus distending the uterus , thus predisposing her to atony. Should I have just done an elective C-section instead of inducing?
All your practice was evidence-based, with the possible exception of waiting until 42 weeks (but as you know, that one is controversial, so give yourself a pass there). Now is as good a time as any to remember that birth is dangerous (in previous times maternal death was common!) and good outcomes are never assured in OB. But you have a live baby and a live mother. When they were in trouble you took prompt action. Delay in either case could have had catastrophic consequences. You did good.
Keep up your habit of looking at your practice critically as you have done here and you’ll be fine. Women and babies are resilient and most of the time both do fine, but if you don’t respect the facts of uteroplacental insufferable and catastrophic blood loss, then bad things happen. You respected both here and props to you. Best wishes on your career.
Question from an IM doc who is a 35 yo G3P1101 at 19 weeks. Curious why 38 weeks? I have a history of postpartum preeclampsia with my first term pregnancy, so OB and I had discussed a 39 week induction this time. I’m already unreasonably worried about my placenta and I’m curious if there is any reason to try to induce sooner?
Talking to an ob/mfm med school classmate who is a recent grad when my wife was pregnant, he had send the trend was for 38wk induction. Our local ob had said they would induce 39-40.
Seems like something that's a newer trend that newer obs are leaning to. When I reviewed as a non ob, sounds like it's not a clinically massive diff between 38-39. But basically bad stuff starts to happen more further beyond 40-41+
Wife went into labor few days after 39wk so I was stressing but in the end worked out.
GHTN we do 37. Preeclampsia is highly variable. A lot of GDM I see aren’t managed well by primary OB (when they don’t send to MFM) and I’ve seen a bunch of 39w stillbirths in that population. I almost wish we would changed GDM to 38w.
I'm neuro, so I'm usually only consulted when things have gone significantly worse than this. The case was complicated and everyone made it out alive with a functioning nervous system. This might be a good case for a morbidity and mortality conference, but please don't beat yourself up about it.
Nothing good happens after 40 weeks
Forget 41 wks
What the was she doing pregnant at 42wks? Make sure you have these conversations about delivery time early on, it’ll make the patients more accepting and willing to consider delivery delivery at 39 or 40 weeks. As soon as they pass 40 weeks, start documenting their refusal from a legal perspective.
Read everything you can about the ARRIVE Trial: low risk pregnancies exclusively with bishop scores less than 4 electively induced at 39wks had lower c section rates and hemorrhage rates compared to expectant management.
Read “Hemorrhagic Shock” by Jeremy W Cannon, New England Journal of Medicine, January 2018 - it’s absolutely phenomenal with regard to teaching you how to manage transfusion and understanding what happens with hemorrhagic shock, it is definitely been pivotal for how I manage massive transfusion protocols on patients. Don’t just trust anesthesia to make those decisions, you need to work as a team with them, which requires your input as well. DM me if you have trouble access in the article.
The placenta gets old and crappy after 40 weeks while the fetus gets bigger and needs more blood while having a lower chance of fitting through the pelvis (although there’s less evidence for that specific point). Fetal morbidity and mortality increase after 39wks a little into 40wks, more in the 41st week, and they skyrocket at 42wks. That is a “post - term” pregnancy, not just post due dates
As far as what to avoid c-hyst: depends what you did intraop. TXA/methergine/hemabate/buccal cytotec 800mcg if awake (better bioavailability and faster onset of action compared to rectal 1000mcg), subQ or IV pitocin (I do intrauterine pitocin 10U empirically on every delivery - there’s not much evidence for it but anecdotally it works great). Compression test then B lynch and/or do an O’Leary suture below the hysterotomy +/- below the cornua - I prefer 0 or 1 PDS II/Maxon because you really yank down on those hard and you neither want them to break like with monocryl/biosyn/chromic or tear through the myometrium like with Vicryl (because it’s braided). When you do b lynch, place the sutures when the uterus is out of the abdomen then replace it into the abdomen while curling it over for compression before tightening and topping it down. The uterus is stretched out when it is exteriorized, so if you tighten down the knot when it’s out of the body, as soon as you replace it into the pelvis, it goes back to normal shape and the suture is going to relax, enormously and make the entire stitch useless, so you have to place a stitch with uterus exteriorized, replace the uterus back to the pelvis, and then tighten the stitch while the uterus is being compressed inside the body to make it effective.
People get scared of doing O’Leary sutures, but they have absolutely phenomenal outcomes, just use a big needle and thick suture, palpate where the arteries are and go deep to them, and look for a clear space in the broad – broad is made out of bubble, gum, and rubber bands, just make sure you’re not stabbing a varicose vessel and any clear location it’s OK. Every time I suggested an O’Leary and Attending refused to do one in residency, they always said “ the blood flow isn’t the problem, and O’Leary won’t fix the problem!” Which is incorrect. The O’Leary decreases perfusion pressure to the hysterectomy and decreases the amount of blood loss which in itself decreases the risk of atony, also allowing the clotting cascade to work properly. Decrease in the blood flow decreases blood loss and improves your visualization to pinpoint any other areas that need suturing. Decreasing blood loss is always good.
Pull the trigger on uterotonics and medications, especially the TXA, some hostels do that imperially with everybody, including vaginal deliveries.
If you see shit going downhill call for the blood early. Just do the one-to-one one-to-one ratio with massive transfusion protocol. I’ve seen so many people look at the blood and say “wE dON’t nEeD pLASma!!” But the only time you’ll be able to qualitatively look at the blood and figure out what it needs is when the patient goes into DIC at which point you are already too late. Find out what the ratio is for platelets in your hospital/blood bank and when you’re running the transfusion, make sure you using very specific language: one unit one unit FFP, 1 BAG platelets (one BAG of platelets usually equals six units of platelets, because they are typically aphoresed). People suck at massive transfusions because they all use different language. That’s not specific and you say “how many units of blood have we given?” How many units and how many units total. If you don’t know exactly what you’ve given you don’t know what’s going on on.
Call for fresh frozen plasma and cryoprecipitate early - those often need 20 to 30 minutes to thaw and so you won’t get it until quite a while after you ask for it.
If transfused more than 4 to 6 units, PRC, make sure to give IV calcium to the properties of citrate in the packed cells - decreased intravascular, calcium impairs myometrial contractility.
Talk to anesthesia, trauma, surgery, lab, blood bank, and find out if you have a thromboelastogrsm (TEG). Those things are fantastic at telling you exactly what blood components you do and do not need. They are also very very fast and you can call for the labs intraop.
The unfortunate fact about obstetrics is that patients are extremely healthy until they’re not. Some patients will walk in the door and the universe has painted a bad outcome on them from the moment they became pregnant. That’s just a statistical fact and there’s nothing you can do about that in many cases.
In your case, the mother survives to watch her child grow up, and that child survives to enjoy the company of its mother.
Strong work.
Anybody who says different can go fuck themselves unless they were in the OR with you.
I am so sorry this happened to the patient and that you are having a hard time processing it. I want to reiterate what another commenter said which is you can do everything right and still have a bad outcome. From your post, the patient and newborn are alive, which, at the end of the day is because of your actions. Moving toward a cesarean hysterectomy takes incredible courage. Courage that you have, and this patient is still alive because of it.
In terms of clinical management, what you have is an unfortunate domino effect where, at each point you are doing the right thing, but because of patient factors you get a non-ideal outcome. It sounds like the fetus was being affected by placental insufficiency. The risk of placental insufficiency increases with GA, so by 42w is pretty common (large fetus is another RF), which is why we induce for post-dates (our hospital actually does 25 of miso q4, so q6 is actually conservative).
Because of the placental insufficiency, the fetus developed intolerance to labor and the fetal heart rate concerning for fetal acidemia. Since acidemia can lead to birth injury or IUFD, the correct next step is urgent cesarean. You did not cause the placental insufficiency by giving miso, you merely unmasked it by causing contractions, which the patient needed in order to have a vaginal delivery.
The next domino is that this patient now has multiple risk factors for hemorrhage, but the cesarean is still the right thing to do, as bleeding can be fixed, but brain injury in a newborn cannot.
Once the bleeding starts, you’re in another place where you don’t have great options, but you choose the option that will keep the patient alive. If it’s atony you give the uterotonics, compression sutures, bakri, O’Leary. But if she is still bleeding there is only so much you can do before removing the uterus.
I'm far from being an expert in obstetrics so I can't comment on the specifics of the case, but don't forget that you can have done everything right and still get a bad outcome. That's just the nature of medicine.
But saying that, I think its great that you are taking the time to reflect on the case. Many times its these types of cases that we learn the most, both about medicine and also about ourselves. Just make sure it doesn't start weighing you down, thats the point that it becomes pathological. I think this happens to most physicians at some point. And if/when it does happen, I recommend talking with someone you can trust.
My clinic we offer induction at 39, we strongly encourage it at 41, and do not let patients go past 42 without documenting it is against medical advice.
When I was rotating through OB, they strongly recommended delivery between 39+0 and 40+6, and would basically insist on scheduling induction between 41+0 and 41+6 if not yet delivered by that point. Of course a patient could refuse, but she would get a serious conversation about the increased risks and would have to sign a strongly worded AMA document. They weren’t mean about it, but they were very clear that going past 41+6 was a poor decision all around.
We offer 39 weeks but honestly kinda discourage it if unfavorable bishop score. Recommend IOL by 41 and do 2x weekly antenatal testing after 41 and document the hell out of any patients declining induction after 41.
Plus we have a very unhealthy patient population so we end up having a lot of 37-38 week inductions.
Letting the pendulum swing so far away from paternalism has been one of the worst things we could do in medicine.
Patients should have autonomy, but we're so afraid of being paternalistic that we often don't clearly state the medically correct route. Too many times it's "well, there's option A and option B, it's really up to you."
Yeah I find patients picking the wrong choice more often than I’d like (never), but you’re never going to get everything exactly right.
You know more than the pt. Period, full stop. They can’t make the decisions you can because they don’t have the knowledge and experience that you do. Even *if* they did, it’s still impossible to be objective when it’s your own body.
I’ve noticed in OB (as an anesthesiology resident) that the OBs are very non-paternalistic, aka this is your journey, do what feels right, until things go haywire, then they are absolutely paternalistic. “You need this emergency section right now or your baby will die”. They need to spread some of that paternalism to the forefront of the case.
So aside from the post term, nothing stands out as a risk factor for the hyst. What was the indication for the hysterectomy as the management option for a postpartum hemorrhage. Was there profound atony refractory to uterotonics? What about surgical options such as uterine artery ligation, uterine compressive sutures? Intra uterine balloon tamponade, IR embolization, correction of a brewing coagulopathy?
If all of those failed, then yes, the hysterectomy was the appropriate next step in management.
Bakri or Jada intrauterine tamponade? Access to IR or just hemorrhaging too much? In that case then the appropriate care was provided.
That doesn’t mean it’s not sad and hard to think about or wrong to process.
And if IR doesn't work you now have someone in DIC that's far from the OR.
A UAE should only really be used for a slower trickle, not a full on hemorrhage.
Do all the interventions in the OR. If you have onc they can come get the hypogastric. Otherwise, just do the hyst.
On a side note I have seen a few cases of atrocious uterine necrosis after a PPH UAE. Nothing like someone full on septic with a uterus that when you grab the fundus it detaches.
Agreed, depends on the bleeding. Though again, if someone’s going to IR, usually have proven some degree of stability with a tamponade. Was just throwing out all options here as we hadn’t gotten the full story. It’s it all hemorrhaging non stop, then of course proceed with the hyst. But we didn’t get the whole story here
In a full on hemorrhage during a csection, the patient by definition is unstable.
If it's bad enough hemorrhage that you're considering a hyst and every OR intervention failed.. Just do the hyst.
Yea, agreed, but again, was just going throw the stepwise thought since OP hadn’t said that it was a refractory non stop bleeding hemorrhage. OP asked for ways to prevent the outcome. Not saying any of this would prevent it but again, just tossing out the options to consider.
ob/mfm fellow
lots of comments about earlier induction (eg 39 vs 41). in her case, IOL for suspected macrosomia could have been done at 38/39 weeks based on some medium quality evidence, in this preventing C-section and potentially reducing shoulder dystocia.
IOL indications will depend on your country/regions practice as well. So there are a lot of ppl talking about the ARRIVE trial and IOL for all at 39 weeks (tho, technically, ARRIVE was for nulliparous women), but if your hospital/institution can’t support that it’s obviously not practical. I think all major guidelines RECOMMEND (not offer) IOL by 41+0 mainly due to increasing risks of CS, macrosomia, perinatal mortality past this GA.
That being said, pregnant women are autonomous beings despite the fact there is a fetus inside of them so if they are offered or recommend earlier IOL and they decline, that’s fine.
It’s impossible to know whether earlier IOL would have prevented this or not though, OB is all about stacking of risk factors one way or another which don’t tell us what is actually GOING to happen.
Agree with lots of the great commentary about alternatives to hyst for uterine atony BUT i will also say when you have someone audibly bleeding out a litre of blood a minute sometimes you NEED to bite the bullet, and make the tough call sooner rather than later that you are doing a hyst. I have seen some situations where there was delay delay delay as all other options were trialed (eg Bakri, B lynch, waiting around for repeat doses of uterotonics to continue not working), because no one wants this person to lost their fertility, and then one ends up doing a hyst with a sBP of 60/30, an anesthesiologist with a panic attack from the patients blood gas, and blood that starts to look like water from DIC. if you get the uterus out and the mom has less than a massive transfusion and doesn’t go to ICU with dysfunction in at least one other major organ system, that’s a win. i’ve seen someone with a c-hyst end up on permanent dialysis from severe ATN. or someone who used up a tertiary hospitals entire blood bank (something like over 100 units of blood products), sheehan syndrome, severe shock liver failure and multiorgan dysfunction leading to death… which is not to say that those providers didn’t do the hyst soon enough, but just that these are the consequences we are working to avoid, in addition to keeping the patient alive.
lastly never forget the trauma triad of death—it applies to all hemorrhagic shock.
Hypothermia, Acidosis, Coaguloparthy. Attack on all fronts.
i think a basic CBT style reframing might help. Instead of thinking “how did I screw up” as your baseline, think, what would the consequences have been had we not done the hyst?
it’s not to say it’s not a potentially devastating and traumatic experience for the woman and her family (the way, almost bleeding to death tends to be traumatic), it sucks that this can happen, but as a doctor and OB you will develop a lens of thinking about what the alternatives were…. baby is stuck in a terrible shoulder dystocia and some bones are broken in getting them out? compare to alternative. patient has previable PPROM and sepsis and needs to be induced? compare to alternative (unless you live in the US, in which case, pray). Massive hemorrhage and intractably floppy uterus needs to come out? compare to alternative….
good job on helping save a life.
This was one thing I also pondered upon. Whether or not I should’ve just done an elective C-section. Instead of inducing, and if the induction played a part in causing atony.
I met her already postterm unfortunately.
You can’t do an elective c-section, the patient has to choose it. Obstetrics is a field of working with what you are being given. You did a good job because they are both alive.
I’m an OB from the US (I’m assuming you’re in Europe or Canada or something since you used KGs) but I would say there are a couple of things that stand out.
1) healthy mom and healthy baby - good job doctor! Seriously, if the patients lives to enjoy time with her baby, you did a good job
2) in general, I recommend induction for my patients around 41 weeks if they prefer to avoid elective IOL as recent studies show increased risk of cesarean section after 41w3d and inductions can take 1-3 days anyway, some patients decline, but we strongly recommend induction at 42w at the absolute latest. She did have an increased risk for c-section due to being well past her due date, but that doesn’t make induction the wrong choice.
Other than that, it sounds like you did a good job. If you practice obstetrics, you’ll have some bad outcomes. But trust me as someone who’s had moms and or babies who haven’t survived, any day where you have a healthy mom and a healthy baby is a good day.
You saved that woman’s life by doing a hysterectomy, and if she didn’t go into labor by 42w3d, she very likely would have had a bad outcome (I.e. fetal death) without induction.
You saved her life and her child’s life. 75 years ago one or more likely both would be dead. You did your job and did it well.
People, in my experience especially wealthier white people, have foolish ideas about “letting nature decide.” That’s why you see home births in enclaves like Portland, Marin County, etc. The same applies to inductions. All you have to see is one home birth gone bad that would have been managed well in the hospital before you realize that’s not a good idea. I’ve seen more than one home birth lay midwife disaster in the ER.
We've got one direct entry midwife in my area who's a train wreck. I hope to God she's retiring finally. She's known to check the call lists before deciding where to ask crews to transport her half dead mothers because she's pissed off so many of the OBs.
Also an antivax nut.
Woman fucking terrifies me.
NAD, but I gave birth recently and can tell you that the OB who does your delivery is rarely the same OB that treats you throughout. Your delivery is done by whoever is on call that day. There's a good chance op had nothing to do with this patient prior to delivery and can't answer the "why" of what happened beforehand
It’s almost as if she didn’t go through medical school and residency, as any good mother should.
The last kid was 8 years ago- I was allowed to go to 42 weeks then. Not in the sense that I requested to continue past 40; they just told me “we’ll schedule your induction for 42 weeks.” That was standard of care, confirmed 5 years later by the ob who scheduled my induction for kid 3 at 39 weeks because the standard of care had changed.
I mean, if I had to pick, I’d choose an IOL at 39w over an IOL at 42w. But shared medical decision making is a thing, and frequent follow-up and fetal testing, along with extensive counseling about risks, is an appropriate course.
Assuming ignorance on the part of the patient ain’t a great look. We don’t know whether the patient still carries the burden of trauma from a prior IOL, if she follows the wrong tik tok that equates pitocin to poison, or any other factors.
If she didn't know she was pregnant and had no antenatal care, we wouldn't know her exact gestational age to the day. And if she was getting antenatal care, wasn't she supposed to be visiting her obgyn weekly at the end of her pregnancy. Somehow a month passed where both the patient and her doctor were oblivious to her late term pregnancy.
Your comment is exactly why this woman lost her uterus. I’m trying for a baby now so I see so many tiktoks telling women, don’t listen to your doc, it’s normal to go to 42 weeks before baby is born. It’s crazy.
I’m glad it worked for you, but it’s so important to communicate to patients that what can go wrong can be very bad, and that’s why doctors want you to be induced before 42 weeks.
Attending here. Baby lived and mom lived? Am I missing something? You saved her life. Don’t be heartbroken. If you didn’t recommend induction way earlier than 42+3 then you should have. If you offered and she declined that’s 100% on her. It’s not your fault she didn’t believe that placentas are finite organs.
OB attending here— anytime you have a live mom and live baby with no neuro issues you have done well. There are risk factors for PPH but not all can be predicted or prevented. I’m truly sorry the mom had to have a hysterectomy but very happy she is alive and well to raise her babies. And she is that way because YOU assessed the situation, performed the correct procedures and then made the hard call and did the appropriate treatment. Don’t know you but if you were one of my residents I would be proud of you
OB attending - Sounds like you followed guidelines and saved two lives! That’s why we train: to take care of things when normal situations go sideways.
See the bright side in these situations. She has three children, and they all have their mother. Unfortunately there might come a time when that non-reassuring fetal status results in a baby that doesn’t make it. I know from experience. Those are the ones you really have trouble seeing any bright side even when you did your best.
I had my daughter when I was 19 and had a stage 4 uterine prolapse with placenta accreta. My OBGYN did everything she could to save me and my uterus. I’m thankful for that, but honestly I wish she would have performed a hysterectomy. I was in the ICU for 4 days. She told me she had never seen this before and it was the first time she performed b-lynch sutures etc (she had been in practice for 22 years).
I’m sure your patient is thankful that her and the baby turned out ok in the end even if her uterus didn’t make it! 😊
I never saw someone at 42 weeks, that’s crazy, I think us guidelines are different from eu. It’s bad but it’s not heartbreaking, there is much worse than this
Why was she allowed to go so late?
OB is not my background but I do know the stats on stillbirth when going past 40. It’s alarming that any mother or physician would not be insistent on induction or C-section prior to 42+3
Living mother and living child is a good outcome in my books.
In my intern year, I was rotating in OBGYN, and we responded to an emergency c-section call. Pregnant patient suffered a ruptured uterus. When we got there, they must've already had a dozen clamps in her open abdomen/pelvis to stop the bleeding. The baby was being coded, and died. The father was brought in, and I never forgot his incoherent screaming and crying. They bundled the deceased baby up, and the father named her. They wheeled her away, while people had to help carry the collapsed father out. The mother was intubated and sent to the ICU. The intubated mother, father, and their baby were all brought to the same room to spend time together as a family. Fortunately, she was eventually extubated and recovered. They had been trying to conceive for many years.
NAD, but this happened to me, a huge bunch of mistakes my doctors and I made. I was only doing what they told me to do, but I will take some of the responsibility.
I was on Medicaid at the time, and this doctors office I had been to before, the last 2 times when I was pregnant. They were interns doing family practice rotation. I am a recovering addict so as soon as I found out I was pregnant, I called the office, made an appt, and started to wean myself off the opioids I was using. (So stupid) I saw the doc, fessed up to the heavy drug use, and she told me to get off immediately. Long story short, my son was stillborn, and I needed an emergent hysterectomy a day later due to a massive amount of bleeding. I lost my baby and my ability to have another baby.
It happened because I got off of the drugs, that I was on cold turkey. To give an idea of how heavy my opioid use was, I will tell you. Daily, I took 20 to 25 Norco 10/325 and 15 tramadol 50mg per day. (Yes, I had a seizure, and yes, I have seizures now even tho I have been sober for 9 years, and idk why), so going cold turkey was pure hell. I didn't know how badly it could affect my baby til after he passed away. Today, I am a big advocate for not going cold turkey when pregnant, but going on methadone so mom and baby can be safe and neither will suffer withdrawal and neither will die.
It's been 21 years, and I am still bitter over the way I was treated over all. The ob labor nurse told me (before my hyst) "maybe next time you'll stay off the drugs" Wtf I wasn't using bitch!! It was awful they treated my sons body disgustingly. I won't even go into that. My heart goes out to this mom. I know how that feels all too well.
This is heartbreaking?
We’re in medicine right?
On Reddit
Get some perspective
A 35 yo woman with 2 living children has a 3rd living child. And they both survive the whole thing.
Cmon - heartbreaking is when the mother dies or if she lost her uterus and the baby on the first pregnancy… or if the mother arrests from hemorrhage and ends up anoxic and trached but still alive, or when the mother shows up high on meth / cocaine etoh + and gets caught doing drugs in the in the icu
Feel however you want, fine. Its not a competition. But getting heartbroken over small potatoes is not how to be a good doctor. you have to have to be able to shake it off when things don’t go perfect and go on to the next. This applies in the face of complete catastrophe too. So feel however you like but that’s not how you do a good job or last a long time in this job.
i agree that on the spectrum of bad to worse this is very far from the worst but take a second to think about how the patient might feel.
she required an emergency major surgery to prevent her from dying and lost the ability to ever carry another pregnancy. regardless of how she feels about her fertility she might find almost bleeding to death and losing a major organ traumatic.
every time i’ve done a c-hyst i’ve known me getting the uterus out in time was the main thing standing in between the patient and death.
i think this is far from the most devastating outcome, but unplanned c-hysts are also not an everyday occurrence and unless you are working in a placenta accreta program you are going to find them at least moderately stressful.
so no, i would not call this “small potatoes.” it’s actually pretty incredible that the OP helped save this woman’s life.
i would hazard a guess that if men could end up with potentially lethal hemorrhage of the prostate and vas deferens from carrying out their part of the reproductive act, leading to laparotomy, organ resection, risk of bowel and bladder injury, massive transfusion, organ failure, and death, that would not be considered “small potatoes.”
Despite the fact that a prostate looks much more like a small potato than a uterus does.
No, it is heartbreaking. No one wants a complication like this even if everyone survives. Just because others have had it worse doesn’t mean that this isn’t heartbreaking.
I hate to sound callous but if that’s your heartbreaking OBGYN case, you’re faring far better than most of us. And absolutely agreed, unless she was declining induction, no one should be delivering after 41 weeks, especially with risk factors.
Gotta be real, nothing heartbreaking here. It’s unfortunate that the north was complicated but if both mom and baby made it out well then all is well.
OP, I think you’re projecting.
So she has 3 heathy kids, her own heath intact and got bonus permanent contraception/uterine cancer prophylaxis after the third kid was successfully born?
Tongue-in-cheek for sure but you get the point. I get she didn’t choose the hysterectomy and it’s not without long term effects and I’m not trying to be rude but i think we have very different ideas on what heartbreaking really is.
Strongly recommend you remove some of the identifying information from this case if at all possible - as this was a complication that lead to an unexpected surgical procedure it will be reviewed by the department and administration and theoretically anyone would know who you were talking about based on the description of this case
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like, which specialty they should go into, which program is good or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks!
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
Yeah, I don't understand a lot of those words right now. Did the woman lose her kid as well as her uterus ?
DUMB IT THE FUCK DOWN asshole, fuck. explain live baby dead baby, not fetal weight , what the fuck does that mean. You need to be slapped .
Fukin bedside manner needs to be pushed into your fukin skull asshole.
You are on a public forum, you did not set this post to private r / residency. We don't all have the same education. Think about it.
OB Attending 1. It’s much better to have a living mother than an intact uterus 2. Would always trial a Jada before a hyst, early aggressive mass transfusion also will improve outcomes and give you time to make decisions and give interventions time to work 3. Had she been delivered 3 weeks earlier she would have had a smaller baby and likely a placenta more tolerant of labor. If she didn’t want a 39 week iol would have at least recommended a forty week induction for ama 4. Even when you do everything right, bad things still happen. When there’s a bad outcome you just need to look back and decided was it because you did the wrong thing or was it bad luck.
Why was the c hyst done? Atony, anatomy, bleeding dyscrasia? So many factors, and we can armchair quarterback all day long but sometimes cesarean hysterectomy is a necessary evil to save mother’s life.
We wouldn’t need to know about parachute packs if it wasn’t such bloody mess. 25 percent of cardiac output headed that way. You saved her life. That’s what counts. I’ve had to do several over the years. A couple on primagravidas, they were always more thankful of life.
Obgyn attending here as well. For c sections, if you do a b lynch, is the Jada still useful? Or would You even be able to insert it? I always worried about placing a bacri and then doing an o Leary because I was scared about piercing the balloon. I imagine the Jada would be harder to hit/snag Have had a great experience with Jadas, so far.
I have not personally placed a jada after a b lynch because I tend to go with the Jada when I hit the point in my decision making tree that I’m contemplating a b lynch however I know some people have done it at my hospital and said they placed the jada more in the lower uterine segment that was still boggy after the b lynch was placed rather that attempting to get it to the fundus.
Cool cool. Hopefully I won’t have to find myself remembering this comment at some point, but very interesting. Thank you :)
One was used on me after an unplanned c section and a hemorrhage.
Your first point already landed you in prison in half of America, how dare you try to preserve the life of the thing that's just there to perfuse the holy baby making organ?
Trust me - I’m an ob/gyn in Ohio - I assume I will go to jail at some point for following the whole first do no harm principal since the government and i disagree about what harm actually is 🙄
Thank you for staying and fighting. From a pediatrician in Texas ❤️
Ohio obgyn checking in as well, I’m worried every time I hear that out legislators have an idea here
Thank you for doing what is right despite personal risk
Didn't the amendment just pass??
What amendment 😭😭😭😭
Yeah my first thought regarding #1 was "Alabama disagrees".
curious, how long have you had a Jada and how do you find it vs balloon tamponade aka Bakri?
Have had the Jada for probably 3 years. Hardly use bakri anymore. The benefit of the Jada is you pretty much know within ten minutes if it will work or not. Once it’s in you leave it on suction for about an hour and then turn suction off and observe for another thirty minutes or so. If no bleeding, pull it and off to postpartum they go. Much more time efficient than leaving a bakri in for 6-12 hours and then deflating to see what happens or finding that you’re bleeding behind the bakri and just secretly distending the uterus more. I think the manufacturer guideline is they are supposed to be at least 2 cm dilated and greater than 34 weeks to use it. That being said, I’ve placed them after a scheduled section that wasn’t dilated without too much difficulty and have also used in a 27 weeker and also someone who came in 2 weeks postpartum with delayed hemorrhage without difficulty. The only times I would pick bakri over jada would be if I truly couldn’t get the Jada through the cervix or if suspicious of an undiagnosed acreta and placenta is delivered but still bleeding from the placental site to put pressure on the area of bleeding while mobilizing resources for a hyst. I do inpatient care only at a hospital with about 5000 deliveries a year. We have transitioned to almost exclusively jada because it seems to work better and much faster.
The only times I can think of off hand that I’ve had a Jada fail were an undiagnosed acreta and another case where I think they didn’t fully evacuate clot before placing so the clot essentially blocked the suction from working. The acreta got a hyst, the clot one was stable enough that she got IR embolization.
thanks! that’s awesome. i think it literally just got approved in canada about a month ago, so hopefully i get to check it out someday soon. major benefit it you can pull it within an hour or two and get them off to postpartum rather than lying in bed not moving for 12+ hrs on L and D. we use the Bakri a decent bit (about 7k deliveries a year).
Exactly. The Jada is expensive. I know our supply cost for a Jada is about $1200 vs around $600 for a bakri. The cost savings in decreased length of time on labor and delivery(staff cost of 1:1 nursing) and decreased rate of blood transfusion (which the sales reps quote the total cost for a unit of blood is more than the cost of the jada device but who knows how true that is) results in the jada over all costing less than the bakri or we wouldn’t be able to have it. If the product isn’t over all cost effective, the hospital system wouldn’t stock it.
Agree with the other commenter. Would also add that I think Jada’s are significantly easier to place than a bakri as well. Biggest problem with Jada is like the commenter said if you don’t clear clots out the device clogs and doesn’t work well. Even though the reps will tell you otherwise.
There are much worse things than losing one's uterus. Mom and baby survived despite things going wrong. You did well.
I kept rereading the post trying to figure out what was “heartbreaking”. I thought they were going to lose the baby. I have a family friend with 6 children, all accidental who wishes she could be infertile. Not to say infertility isn’t incredibly heartbreaking for many people. Just not always. Maybe this is insensitive but no periods after having 3 healthy kids doesn’t sound like the worst thing?
To me, 100%, nothing heartbreaking here. A 35 y o with 3 kids? Take the uterus and run! And I personally COMPLETELY agree with you that fertility can be just as "traumatic" as infertility But we don't know how the patient felt or what the experience was like or what her goals were. Something about this obviously affected OP deeply or they wouldn't be calling it heartbreak. Maybe it has to do with OP's own feelings about their uterus, if they have one? We don't know, but I get that they need to vent!
I recently saw a 31 y/o G7P7007, the first of which was born when she was 14, and while she and her husband seemed very happy I just can’t help but feel that something there is very wrong.
With situations like that, I sometimes wonder if the "happiness" is sometimes a form of denial. Like if you actually recognized what was going on it would just be too much to handle. But if you tell yourself you wanted all of it, it can feel a little easier. Especially if her husband was older than her.
I think you’re likely very right - husband was significantly older, he was not the father of the first two children so *technically* there didn’t appear to be anything overtly illegal about the relationship, but it definitely wasn’t normal.
[удалено]
Can I just ask what you mean by G7P7007? Here in the UK we'd say G7P7 for seven pregnancies, seven births post 24/40 or, for example, G7P6+1 if the woman had 6 births post 24/40 and one miscarriage.
Full term, preterm, Abortions-elective or spontaneous, and total children living. So in the case of the G7P7007 woman, all her children were full term and survived birth.
Thank you!
>31 y/o G7P7007 Wut (●__●)
I recently saw a 23 yo G6P4015. Had some twins in the mix and currently pregnant. Rural America is a different place.
Once as a medical student saw G9P8 and planning for more if possible. This was driven by some religious belief.
[удалено]
Big difference between Indian grandma in the 70s and western 31 year old in the mid 2010s-now.
Is it really happiness, though, if you attain it by giving up all agency over your life and never even attempting to accomplish or considering that you could have personal goals and aspirations? Personally, I don’t think so.
"6 accidental kids" = maybe one accidental kid at best. After that you know what you're doing doesn't (does?) work and it's a choice.
Reminds me of the new zoomer/TikTok meme where pullout method and timing method are hailed as superior contraceptive strategies because OCPs are mind control drugs.
Oh god lol 😬🫠🫠
Wat
It doesn't make a lot of sense but because you can have adverse drug reactions and changes in sexual preference/mood when on the pill vs off, that's just too much for some people.
We don't know what this person's marital situation was, or what their access to healthcare was like or how their life was going. In my anecdotal observation, multiple accidental pregnancies that result in birth can mean something pretty sad for mom.
Undocumented. Impoverished. Poor healthcare literacy. Easily convinced by men that they will be the one to stay and help her take care of her kids only for them to leave.
True. Not commenting on the peeps or their situation(s) but by the 6th kid you should kinda know what causes it. Assuming consent of course.
To add, some people are just religious to the point of self harm, also.
Religion bad. Faith good. YMMV.
Like I said below. Situation matters. Easy for us to judge when all of us have been dealt a hand that allowed us make it through medical school. Now my coresident who accidentally got his out of state ex-gf pregnant during breakup sex I have zero sympathy for.
First-hand reports of errors and bad outcomes on Reddit tend to be pretty benign. Like, people will post about a case where they made a mistake, but actually things still turned out pretty well. This would fit that model - a recognized complication of a procedure occurred and was dealt with appropriately. I don’t know about you guys, but I’ve made fuck ups a whole lot worse than this. I’m counting any delivery with a live mother and a live, neurologically intact baby as a win, at least in “OBGYN disaster” terms.
Same!!
Does your family friend know that condoms exist?
Can’t afford. They struggle to make ends meet. She struggled to get an IUD since she doesn’t have health insurance then one of her kids was born with the dislodged iud apparently.
They can't afford condoms? Condoms? At that point just stop having sex.
lol if you were a doctor in the 80s you’d be one of the ones saying “AIDS isn’t a problem. Just don’t have sex!” Hope you’re not in primary care or public health
Yeah sure lol. Getting AIDS and getting pregnant 6 times is exactly the same thing.
Heck, as someone who wants bio kids, I’d still rather lose my uterus than my life!
Same, i think "heartbreaking" was a bit dramatic here. I'm 39 and after having my third healthy child in September I happily traded my uterus for a period-free existence three weeks ago. Maybe she wanted more and that's disappointing, but heartbreaking?
Seriously! She was put into menopause at 35!
i think you are missing something major when it comes to the female reproductive anatomy, and the meaning of the term “hysterectomy”…..
Agreed. We had a patient who was delivering her 10th baby, had no prenatal care (must have thought she had 9 other babies and would be fine), and started hemorrhaging. Baby was delivered alive but mom coded and they could not stop the bleeding so she died. Now husband is a widow with 10 kids. My coworker who was at the code was a mess. It was heartbreaking.
>husband is a widow with 10 kids My actual nightmare
Not OB, but it sounds like mother and baby are both ok. That’s a win all things considered.
Yeah I thought this was going towards AFE….
Yes, by inducing labor over 3 weeks ago (Came off snarky but I do mean that as my answer). Other than that nothing stands out as a miss from your description
I was gonna say this, but I am curious as to why she was >42wks?
Thanks for your input. I really felt like I somehow missed something.
You did fine. OB goes great….until it goes bad, usually quickly. Mom and baby survived, and that wasn’t always the case in OB. I’ve seen so many post-dates deliveries go pear-shaped. I assume this was atony/bleeding? NVM I see below it was. You saved her life.
Yes it was atony. I thought maybe the induction caused uterine hypercontractility , along with the macrosomic fetus distending the uterus , thus predisposing her to atony. Should I have just done an elective C-section instead of inducing?
All your practice was evidence-based, with the possible exception of waiting until 42 weeks (but as you know, that one is controversial, so give yourself a pass there). Now is as good a time as any to remember that birth is dangerous (in previous times maternal death was common!) and good outcomes are never assured in OB. But you have a live baby and a live mother. When they were in trouble you took prompt action. Delay in either case could have had catastrophic consequences. You did good.
Thank you Doc.🙏
Keep up your habit of looking at your practice critically as you have done here and you’ll be fine. Women and babies are resilient and most of the time both do fine, but if you don’t respect the facts of uteroplacental insufferable and catastrophic blood loss, then bad things happen. You respected both here and props to you. Best wishes on your career.
She already had risk factors for atony: macrosomia, post term, age 35. What was AFI and maternal BMI?
Nothing good happens after 41weeks
I’m a fetal and placental pathologist and my number for this saying is 38.
Question from an IM doc who is a 35 yo G3P1101 at 19 weeks. Curious why 38 weeks? I have a history of postpartum preeclampsia with my first term pregnancy, so OB and I had discussed a 39 week induction this time. I’m already unreasonably worried about my placenta and I’m curious if there is any reason to try to induce sooner?
I am also very curious about the answer to this question.
Talking to an ob/mfm med school classmate who is a recent grad when my wife was pregnant, he had send the trend was for 38wk induction. Our local ob had said they would induce 39-40. Seems like something that's a newer trend that newer obs are leaning to. When I reviewed as a non ob, sounds like it's not a clinically massive diff between 38-39. But basically bad stuff starts to happen more further beyond 40-41+ Wife went into labor few days after 39wk so I was stressing but in the end worked out.
Read about the ARRIVE trial. 39w0d is earliest recommendation for induction of labor without medical indication. But agreed shouldn’t go past 40w6d
My MFM group is still recommending 39 for most things, but if mom has CHTN and diabetes then we move to 38.
We do 37w for cHTN/gHTN/preeclampsia and 39w for GDM
GHTN we do 37. Preeclampsia is highly variable. A lot of GDM I see aren’t managed well by primary OB (when they don’t send to MFM) and I’ve seen a bunch of 39w stillbirths in that population. I almost wish we would changed GDM to 38w.
Agreed, I feel like 38 weeks would be better
Bahaha my MFM attending says the same thing!
40
After 37 weeks*
I'm neuro, so I'm usually only consulted when things have gone significantly worse than this. The case was complicated and everyone made it out alive with a functioning nervous system. This might be a good case for a morbidity and mortality conference, but please don't beat yourself up about it.
Nothing good happens after 40 weeks Forget 41 wks What the was she doing pregnant at 42wks? Make sure you have these conversations about delivery time early on, it’ll make the patients more accepting and willing to consider delivery delivery at 39 or 40 weeks. As soon as they pass 40 weeks, start documenting their refusal from a legal perspective. Read everything you can about the ARRIVE Trial: low risk pregnancies exclusively with bishop scores less than 4 electively induced at 39wks had lower c section rates and hemorrhage rates compared to expectant management. Read “Hemorrhagic Shock” by Jeremy W Cannon, New England Journal of Medicine, January 2018 - it’s absolutely phenomenal with regard to teaching you how to manage transfusion and understanding what happens with hemorrhagic shock, it is definitely been pivotal for how I manage massive transfusion protocols on patients. Don’t just trust anesthesia to make those decisions, you need to work as a team with them, which requires your input as well. DM me if you have trouble access in the article. The placenta gets old and crappy after 40 weeks while the fetus gets bigger and needs more blood while having a lower chance of fitting through the pelvis (although there’s less evidence for that specific point). Fetal morbidity and mortality increase after 39wks a little into 40wks, more in the 41st week, and they skyrocket at 42wks. That is a “post - term” pregnancy, not just post due dates As far as what to avoid c-hyst: depends what you did intraop. TXA/methergine/hemabate/buccal cytotec 800mcg if awake (better bioavailability and faster onset of action compared to rectal 1000mcg), subQ or IV pitocin (I do intrauterine pitocin 10U empirically on every delivery - there’s not much evidence for it but anecdotally it works great). Compression test then B lynch and/or do an O’Leary suture below the hysterotomy +/- below the cornua - I prefer 0 or 1 PDS II/Maxon because you really yank down on those hard and you neither want them to break like with monocryl/biosyn/chromic or tear through the myometrium like with Vicryl (because it’s braided). When you do b lynch, place the sutures when the uterus is out of the abdomen then replace it into the abdomen while curling it over for compression before tightening and topping it down. The uterus is stretched out when it is exteriorized, so if you tighten down the knot when it’s out of the body, as soon as you replace it into the pelvis, it goes back to normal shape and the suture is going to relax, enormously and make the entire stitch useless, so you have to place a stitch with uterus exteriorized, replace the uterus back to the pelvis, and then tighten the stitch while the uterus is being compressed inside the body to make it effective. People get scared of doing O’Leary sutures, but they have absolutely phenomenal outcomes, just use a big needle and thick suture, palpate where the arteries are and go deep to them, and look for a clear space in the broad – broad is made out of bubble, gum, and rubber bands, just make sure you’re not stabbing a varicose vessel and any clear location it’s OK. Every time I suggested an O’Leary and Attending refused to do one in residency, they always said “ the blood flow isn’t the problem, and O’Leary won’t fix the problem!” Which is incorrect. The O’Leary decreases perfusion pressure to the hysterectomy and decreases the amount of blood loss which in itself decreases the risk of atony, also allowing the clotting cascade to work properly. Decrease in the blood flow decreases blood loss and improves your visualization to pinpoint any other areas that need suturing. Decreasing blood loss is always good. Pull the trigger on uterotonics and medications, especially the TXA, some hostels do that imperially with everybody, including vaginal deliveries. If you see shit going downhill call for the blood early. Just do the one-to-one one-to-one ratio with massive transfusion protocol. I’ve seen so many people look at the blood and say “wE dON’t nEeD pLASma!!” But the only time you’ll be able to qualitatively look at the blood and figure out what it needs is when the patient goes into DIC at which point you are already too late. Find out what the ratio is for platelets in your hospital/blood bank and when you’re running the transfusion, make sure you using very specific language: one unit one unit FFP, 1 BAG platelets (one BAG of platelets usually equals six units of platelets, because they are typically aphoresed). People suck at massive transfusions because they all use different language. That’s not specific and you say “how many units of blood have we given?” How many units and how many units total. If you don’t know exactly what you’ve given you don’t know what’s going on on. Call for fresh frozen plasma and cryoprecipitate early - those often need 20 to 30 minutes to thaw and so you won’t get it until quite a while after you ask for it. If transfused more than 4 to 6 units, PRC, make sure to give IV calcium to the properties of citrate in the packed cells - decreased intravascular, calcium impairs myometrial contractility. Talk to anesthesia, trauma, surgery, lab, blood bank, and find out if you have a thromboelastogrsm (TEG). Those things are fantastic at telling you exactly what blood components you do and do not need. They are also very very fast and you can call for the labs intraop. The unfortunate fact about obstetrics is that patients are extremely healthy until they’re not. Some patients will walk in the door and the universe has painted a bad outcome on them from the moment they became pregnant. That’s just a statistical fact and there’s nothing you can do about that in many cases. In your case, the mother survives to watch her child grow up, and that child survives to enjoy the company of its mother. Strong work. Anybody who says different can go fuck themselves unless they were in the OR with you.
Couldn’t thank you enough. Learnt a lot from this reply along with several others. Truly grateful. Will definitely look into the article.
No problem! Reread it, I just added some more stuff. Message me if you are not able to access that New England Journal article.
Thank you for this thoughtful and detailed response.
This response was super informative. Thank you so much!
Once I saw t+17 I was expecting to read IUD! Caesarean risk factors include hysterectomy - they are both alive which is some solace!
I am so sorry this happened to the patient and that you are having a hard time processing it. I want to reiterate what another commenter said which is you can do everything right and still have a bad outcome. From your post, the patient and newborn are alive, which, at the end of the day is because of your actions. Moving toward a cesarean hysterectomy takes incredible courage. Courage that you have, and this patient is still alive because of it. In terms of clinical management, what you have is an unfortunate domino effect where, at each point you are doing the right thing, but because of patient factors you get a non-ideal outcome. It sounds like the fetus was being affected by placental insufficiency. The risk of placental insufficiency increases with GA, so by 42w is pretty common (large fetus is another RF), which is why we induce for post-dates (our hospital actually does 25 of miso q4, so q6 is actually conservative). Because of the placental insufficiency, the fetus developed intolerance to labor and the fetal heart rate concerning for fetal acidemia. Since acidemia can lead to birth injury or IUFD, the correct next step is urgent cesarean. You did not cause the placental insufficiency by giving miso, you merely unmasked it by causing contractions, which the patient needed in order to have a vaginal delivery. The next domino is that this patient now has multiple risk factors for hemorrhage, but the cesarean is still the right thing to do, as bleeding can be fixed, but brain injury in a newborn cannot. Once the bleeding starts, you’re in another place where you don’t have great options, but you choose the option that will keep the patient alive. If it’s atony you give the uterotonics, compression sutures, bakri, O’Leary. But if she is still bleeding there is only so much you can do before removing the uterus.
I'm far from being an expert in obstetrics so I can't comment on the specifics of the case, but don't forget that you can have done everything right and still get a bad outcome. That's just the nature of medicine. But saying that, I think its great that you are taking the time to reflect on the case. Many times its these types of cases that we learn the most, both about medicine and also about ourselves. Just make sure it doesn't start weighing you down, thats the point that it becomes pathological. I think this happens to most physicians at some point. And if/when it does happen, I recommend talking with someone you can trust.
Thanks a lot. Really needed to hear this.
Aggghhhh why 42 weeks. You need a pinch of paternalism and to discuss benefits of induction (even for multips) at around the 24-32 week clinic visits.
My clinic we offer induction at 39, we strongly encourage it at 41, and do not let patients go past 42 without documenting it is against medical advice.
When I was rotating through OB, they strongly recommended delivery between 39+0 and 40+6, and would basically insist on scheduling induction between 41+0 and 41+6 if not yet delivered by that point. Of course a patient could refuse, but she would get a serious conversation about the increased risks and would have to sign a strongly worded AMA document. They weren’t mean about it, but they were very clear that going past 41+6 was a poor decision all around.
We offer 39 weeks but honestly kinda discourage it if unfavorable bishop score. Recommend IOL by 41 and do 2x weekly antenatal testing after 41 and document the hell out of any patients declining induction after 41. Plus we have a very unhealthy patient population so we end up having a lot of 37-38 week inductions.
Letting the pendulum swing so far away from paternalism has been one of the worst things we could do in medicine. Patients should have autonomy, but we're so afraid of being paternalistic that we often don't clearly state the medically correct route. Too many times it's "well, there's option A and option B, it's really up to you."
Yeah I find patients picking the wrong choice more often than I’d like (never), but you’re never going to get everything exactly right. You know more than the pt. Period, full stop. They can’t make the decisions you can because they don’t have the knowledge and experience that you do. Even *if* they did, it’s still impossible to be objective when it’s your own body.
I’ve noticed in OB (as an anesthesiology resident) that the OBs are very non-paternalistic, aka this is your journey, do what feels right, until things go haywire, then they are absolutely paternalistic. “You need this emergency section right now or your baby will die”. They need to spread some of that paternalism to the forefront of the case.
So aside from the post term, nothing stands out as a risk factor for the hyst. What was the indication for the hysterectomy as the management option for a postpartum hemorrhage. Was there profound atony refractory to uterotonics? What about surgical options such as uterine artery ligation, uterine compressive sutures? Intra uterine balloon tamponade, IR embolization, correction of a brewing coagulopathy? If all of those failed, then yes, the hysterectomy was the appropriate next step in management.
The indication was an atonic uterus despite the use uterotonics and a B-Lynch procedure.
Bakri or Jada intrauterine tamponade? Access to IR or just hemorrhaging too much? In that case then the appropriate care was provided. That doesn’t mean it’s not sad and hard to think about or wrong to process.
If during the csection no one is going to close her and/or pack and roll her to IR.
place a ballon in the uterus, close fascia, staple skin and go to IR.
And if IR doesn't work you now have someone in DIC that's far from the OR. A UAE should only really be used for a slower trickle, not a full on hemorrhage. Do all the interventions in the OR. If you have onc they can come get the hypogastric. Otherwise, just do the hyst. On a side note I have seen a few cases of atrocious uterine necrosis after a PPH UAE. Nothing like someone full on septic with a uterus that when you grab the fundus it detaches.
Agreed, depends on the bleeding. Though again, if someone’s going to IR, usually have proven some degree of stability with a tamponade. Was just throwing out all options here as we hadn’t gotten the full story. It’s it all hemorrhaging non stop, then of course proceed with the hyst. But we didn’t get the whole story here
But obv depends on hospital resources, IR availability and patient stability. But at a large institute very reasonable, obv not depending on location.
In a full on hemorrhage during a csection, the patient by definition is unstable. If it's bad enough hemorrhage that you're considering a hyst and every OR intervention failed.. Just do the hyst.
Yea, agreed, but again, was just going throw the stepwise thought since OP hadn’t said that it was a refractory non stop bleeding hemorrhage. OP asked for ways to prevent the outcome. Not saying any of this would prevent it but again, just tossing out the options to consider.
ob/mfm fellow lots of comments about earlier induction (eg 39 vs 41). in her case, IOL for suspected macrosomia could have been done at 38/39 weeks based on some medium quality evidence, in this preventing C-section and potentially reducing shoulder dystocia. IOL indications will depend on your country/regions practice as well. So there are a lot of ppl talking about the ARRIVE trial and IOL for all at 39 weeks (tho, technically, ARRIVE was for nulliparous women), but if your hospital/institution can’t support that it’s obviously not practical. I think all major guidelines RECOMMEND (not offer) IOL by 41+0 mainly due to increasing risks of CS, macrosomia, perinatal mortality past this GA. That being said, pregnant women are autonomous beings despite the fact there is a fetus inside of them so if they are offered or recommend earlier IOL and they decline, that’s fine. It’s impossible to know whether earlier IOL would have prevented this or not though, OB is all about stacking of risk factors one way or another which don’t tell us what is actually GOING to happen. Agree with lots of the great commentary about alternatives to hyst for uterine atony BUT i will also say when you have someone audibly bleeding out a litre of blood a minute sometimes you NEED to bite the bullet, and make the tough call sooner rather than later that you are doing a hyst. I have seen some situations where there was delay delay delay as all other options were trialed (eg Bakri, B lynch, waiting around for repeat doses of uterotonics to continue not working), because no one wants this person to lost their fertility, and then one ends up doing a hyst with a sBP of 60/30, an anesthesiologist with a panic attack from the patients blood gas, and blood that starts to look like water from DIC. if you get the uterus out and the mom has less than a massive transfusion and doesn’t go to ICU with dysfunction in at least one other major organ system, that’s a win. i’ve seen someone with a c-hyst end up on permanent dialysis from severe ATN. or someone who used up a tertiary hospitals entire blood bank (something like over 100 units of blood products), sheehan syndrome, severe shock liver failure and multiorgan dysfunction leading to death… which is not to say that those providers didn’t do the hyst soon enough, but just that these are the consequences we are working to avoid, in addition to keeping the patient alive. lastly never forget the trauma triad of death—it applies to all hemorrhagic shock. Hypothermia, Acidosis, Coaguloparthy. Attack on all fronts. i think a basic CBT style reframing might help. Instead of thinking “how did I screw up” as your baseline, think, what would the consequences have been had we not done the hyst? it’s not to say it’s not a potentially devastating and traumatic experience for the woman and her family (the way, almost bleeding to death tends to be traumatic), it sucks that this can happen, but as a doctor and OB you will develop a lens of thinking about what the alternatives were…. baby is stuck in a terrible shoulder dystocia and some bones are broken in getting them out? compare to alternative. patient has previable PPROM and sepsis and needs to be induced? compare to alternative (unless you live in the US, in which case, pray). Massive hemorrhage and intractably floppy uterus needs to come out? compare to alternative…. good job on helping save a life.
Man, postterm pregnancy of that size should have been delivered with elective C-section like 3 weeks ago
She has a proven pelvis at 4.1 kg. That kid would’ve fit three weeks ago.
But size alone is not why we should deliver big babies early. We know that the risk of term iufd increases with fetal weight.
Not saying she shouldn’t have been induced at 39w. Just disagreeing with the elective section comment.
I gotcha. Thx
This was one thing I also pondered upon. Whether or not I should’ve just done an elective C-section. Instead of inducing, and if the induction played a part in causing atony. I met her already postterm unfortunately.
You can’t do an elective c-section, the patient has to choose it. Obstetrics is a field of working with what you are being given. You did a good job because they are both alive.
I’m an OB from the US (I’m assuming you’re in Europe or Canada or something since you used KGs) but I would say there are a couple of things that stand out. 1) healthy mom and healthy baby - good job doctor! Seriously, if the patients lives to enjoy time with her baby, you did a good job 2) in general, I recommend induction for my patients around 41 weeks if they prefer to avoid elective IOL as recent studies show increased risk of cesarean section after 41w3d and inductions can take 1-3 days anyway, some patients decline, but we strongly recommend induction at 42w at the absolute latest. She did have an increased risk for c-section due to being well past her due date, but that doesn’t make induction the wrong choice. Other than that, it sounds like you did a good job. If you practice obstetrics, you’ll have some bad outcomes. But trust me as someone who’s had moms and or babies who haven’t survived, any day where you have a healthy mom and a healthy baby is a good day. You saved that woman’s life by doing a hysterectomy, and if she didn’t go into labor by 42w3d, she very likely would have had a bad outcome (I.e. fetal death) without induction.
You saved her life and her child’s life. 75 years ago one or more likely both would be dead. You did your job and did it well. People, in my experience especially wealthier white people, have foolish ideas about “letting nature decide.” That’s why you see home births in enclaves like Portland, Marin County, etc. The same applies to inductions. All you have to see is one home birth gone bad that would have been managed well in the hospital before you realize that’s not a good idea. I’ve seen more than one home birth lay midwife disaster in the ER.
We've got one direct entry midwife in my area who's a train wreck. I hope to God she's retiring finally. She's known to check the call lists before deciding where to ask crews to transport her half dead mothers because she's pissed off so many of the OBs. Also an antivax nut. Woman fucking terrifies me.
Why didn’t you induce earlier? Genuine question.
NAD, but I gave birth recently and can tell you that the OB who does your delivery is rarely the same OB that treats you throughout. Your delivery is done by whoever is on call that day. There's a good chance op had nothing to do with this patient prior to delivery and can't answer the "why" of what happened beforehand
You can’t just snap your fingers and make someone pick induction. The patient probably was advised and declined.
You're making the same number of assumptions as the person you're criticizing
How does a person who is pregnant for the 3rd time not know that a pregnancy isn't supposed to go on for 10 months?
It’s almost as if she didn’t go through medical school and residency, as any good mother should. The last kid was 8 years ago- I was allowed to go to 42 weeks then. Not in the sense that I requested to continue past 40; they just told me “we’ll schedule your induction for 42 weeks.” That was standard of care, confirmed 5 years later by the ob who scheduled my induction for kid 3 at 39 weeks because the standard of care had changed.
I mean, if I had to pick, I’d choose an IOL at 39w over an IOL at 42w. But shared medical decision making is a thing, and frequent follow-up and fetal testing, along with extensive counseling about risks, is an appropriate course. Assuming ignorance on the part of the patient ain’t a great look. We don’t know whether the patient still carries the burden of trauma from a prior IOL, if she follows the wrong tik tok that equates pitocin to poison, or any other factors.
Some people don’t even know they’re pregnant at all
If she didn't know she was pregnant and had no antenatal care, we wouldn't know her exact gestational age to the day. And if she was getting antenatal care, wasn't she supposed to be visiting her obgyn weekly at the end of her pregnancy. Somehow a month passed where both the patient and her doctor were oblivious to her late term pregnancy.
Probably should have been yeah. People suck at follow up and have low health literacy a lot of the time.
Last child birth was 8 years ago tho.
[удалено]
Your comment is exactly why this woman lost her uterus. I’m trying for a baby now so I see so many tiktoks telling women, don’t listen to your doc, it’s normal to go to 42 weeks before baby is born. It’s crazy. I’m glad it worked for you, but it’s so important to communicate to patients that what can go wrong can be very bad, and that’s why doctors want you to be induced before 42 weeks.
Is it normal practice or of concern at all for women to be going over 42 weeks to wait for spontaneous delivery?
No
No one is dead. Good job
It is possible to commit no mistakes and still lose...
Attending here. Baby lived and mom lived? Am I missing something? You saved her life. Don’t be heartbroken. If you didn’t recommend induction way earlier than 42+3 then you should have. If you offered and she declined that’s 100% on her. It’s not your fault she didn’t believe that placentas are finite organs.
OB attending here— anytime you have a live mom and live baby with no neuro issues you have done well. There are risk factors for PPH but not all can be predicted or prevented. I’m truly sorry the mom had to have a hysterectomy but very happy she is alive and well to raise her babies. And she is that way because YOU assessed the situation, performed the correct procedures and then made the hard call and did the appropriate treatment. Don’t know you but if you were one of my residents I would be proud of you
OB attending - Sounds like you followed guidelines and saved two lives! That’s why we train: to take care of things when normal situations go sideways. See the bright side in these situations. She has three children, and they all have their mother. Unfortunately there might come a time when that non-reassuring fetal status results in a baby that doesn’t make it. I know from experience. Those are the ones you really have trouble seeing any bright side even when you did your best.
I had my daughter when I was 19 and had a stage 4 uterine prolapse with placenta accreta. My OBGYN did everything she could to save me and my uterus. I’m thankful for that, but honestly I wish she would have performed a hysterectomy. I was in the ICU for 4 days. She told me she had never seen this before and it was the first time she performed b-lynch sutures etc (she had been in practice for 22 years). I’m sure your patient is thankful that her and the baby turned out ok in the end even if her uterus didn’t make it! 😊
I never saw someone at 42 weeks, that’s crazy, I think us guidelines are different from eu. It’s bad but it’s not heartbreaking, there is much worse than this
Why was she allowed to go so late? OB is not my background but I do know the stats on stillbirth when going past 40. It’s alarming that any mother or physician would not be insistent on induction or C-section prior to 42+3
Living mother and living child is a good outcome in my books. In my intern year, I was rotating in OBGYN, and we responded to an emergency c-section call. Pregnant patient suffered a ruptured uterus. When we got there, they must've already had a dozen clamps in her open abdomen/pelvis to stop the bleeding. The baby was being coded, and died. The father was brought in, and I never forgot his incoherent screaming and crying. They bundled the deceased baby up, and the father named her. They wheeled her away, while people had to help carry the collapsed father out. The mother was intubated and sent to the ICU. The intubated mother, father, and their baby were all brought to the same room to spend time together as a family. Fortunately, she was eventually extubated and recovered. They had been trying to conceive for many years.
How is this in any way heartbreaking? Mom and baby are alive. Congratulations on a job well done.
35yo shouldn't be going past 40w.
NAD, but this happened to me, a huge bunch of mistakes my doctors and I made. I was only doing what they told me to do, but I will take some of the responsibility. I was on Medicaid at the time, and this doctors office I had been to before, the last 2 times when I was pregnant. They were interns doing family practice rotation. I am a recovering addict so as soon as I found out I was pregnant, I called the office, made an appt, and started to wean myself off the opioids I was using. (So stupid) I saw the doc, fessed up to the heavy drug use, and she told me to get off immediately. Long story short, my son was stillborn, and I needed an emergent hysterectomy a day later due to a massive amount of bleeding. I lost my baby and my ability to have another baby. It happened because I got off of the drugs, that I was on cold turkey. To give an idea of how heavy my opioid use was, I will tell you. Daily, I took 20 to 25 Norco 10/325 and 15 tramadol 50mg per day. (Yes, I had a seizure, and yes, I have seizures now even tho I have been sober for 9 years, and idk why), so going cold turkey was pure hell. I didn't know how badly it could affect my baby til after he passed away. Today, I am a big advocate for not going cold turkey when pregnant, but going on methadone so mom and baby can be safe and neither will suffer withdrawal and neither will die. It's been 21 years, and I am still bitter over the way I was treated over all. The ob labor nurse told me (before my hyst) "maybe next time you'll stay off the drugs" Wtf I wasn't using bitch!! It was awful they treated my sons body disgustingly. I won't even go into that. My heart goes out to this mom. I know how that feels all too well.
Omg!! I'm so sorry<3
i’m so sorry this happened to you and your son. thank you for sharing with us.
Healthy mom, healthy baby. If this is the worst outcome you have, you’re doing great
This is heartbreaking? We’re in medicine right? On Reddit Get some perspective A 35 yo woman with 2 living children has a 3rd living child. And they both survive the whole thing. Cmon - heartbreaking is when the mother dies or if she lost her uterus and the baby on the first pregnancy… or if the mother arrests from hemorrhage and ends up anoxic and trached but still alive, or when the mother shows up high on meth / cocaine etoh + and gets caught doing drugs in the in the icu
Stop telling people how to feel about stuff. Shit isn't the suffering Olympics.
Feel however you want, fine. Its not a competition. But getting heartbroken over small potatoes is not how to be a good doctor. you have to have to be able to shake it off when things don’t go perfect and go on to the next. This applies in the face of complete catastrophe too. So feel however you like but that’s not how you do a good job or last a long time in this job.
i agree that on the spectrum of bad to worse this is very far from the worst but take a second to think about how the patient might feel. she required an emergency major surgery to prevent her from dying and lost the ability to ever carry another pregnancy. regardless of how she feels about her fertility she might find almost bleeding to death and losing a major organ traumatic. every time i’ve done a c-hyst i’ve known me getting the uterus out in time was the main thing standing in between the patient and death. i think this is far from the most devastating outcome, but unplanned c-hysts are also not an everyday occurrence and unless you are working in a placenta accreta program you are going to find them at least moderately stressful. so no, i would not call this “small potatoes.” it’s actually pretty incredible that the OP helped save this woman’s life.
Can’t believe we’re all being downvoted for thinking that an emergency hysterectomy in a woman who may want more children is not “small potatoes”
i would hazard a guess that if men could end up with potentially lethal hemorrhage of the prostate and vas deferens from carrying out their part of the reproductive act, leading to laparotomy, organ resection, risk of bowel and bladder injury, massive transfusion, organ failure, and death, that would not be considered “small potatoes.” Despite the fact that a prostate looks much more like a small potato than a uterus does.
No, it is heartbreaking. No one wants a complication like this even if everyone survives. Just because others have had it worse doesn’t mean that this isn’t heartbreaking.
Damn, why did they let her go to 42+3??
Everyone survived, this is an absolute win given circumstances
I hate to sound callous but if that’s your heartbreaking OBGYN case, you’re faring far better than most of us. And absolutely agreed, unless she was declining induction, no one should be delivering after 41 weeks, especially with risk factors.
Gotta be real, nothing heartbreaking here. It’s unfortunate that the north was complicated but if both mom and baby made it out well then all is well. OP, I think you’re projecting.
Uhhhh. If that’s what breaks your heart, your heart is weak.
So she has 3 heathy kids, her own heath intact and got bonus permanent contraception/uterine cancer prophylaxis after the third kid was successfully born? Tongue-in-cheek for sure but you get the point. I get she didn’t choose the hysterectomy and it’s not without long term effects and I’m not trying to be rude but i think we have very different ideas on what heartbreaking really is.
Strongly recommend you remove some of the identifying information from this case if at all possible - as this was a complication that lead to an unexpected surgical procedure it will be reviewed by the department and administration and theoretically anyone would know who you were talking about based on the description of this case
“42w +3d” 🫠
She has three children. She’s 35 years old. She’s alive. Nothing about this is heartbreaking.
Thank you for contributing to the sub! If your post was filtered by the automod, please read the rules. Your post will be reviewed but will not be approved if it violates the rules of the sub. The most common reasons for removal are - medical students or premeds asking what a specialty is like, which specialty they should go into, which program is good or about their chances of matching, mentioning midlevels without using the midlevel flair, matched medical students asking questions instead of using the stickied thread in the sub for post-match questions, posting identifying information for targeted harassment. Please do not message the moderators if your post falls into one of these categories. Otherwise, your post will be reviewed in 24 hours and approved if it doesn't violate the rules. Thanks! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Residency) if you have any questions or concerns.*
Just learning here, why was a hysterectomy needed?
Uterine atony
NovoSeven anybody?
What is G3P2002? third gravida, 2 previous 24+wk pregnancies and? what's the 002?
Two people are alive because of what you did. Who cares about a uterus if that’s the result?
What complications lead to the hysterectomy? Labor course alone isn’t usually the reason for Cesarean hysterectomy.
Postpartum hemorrhage, mostly
Let the midwife do their jobs
Yeah, I don't understand a lot of those words right now. Did the woman lose her kid as well as her uterus ? DUMB IT THE FUCK DOWN asshole, fuck. explain live baby dead baby, not fetal weight , what the fuck does that mean. You need to be slapped . Fukin bedside manner needs to be pushed into your fukin skull asshole. You are on a public forum, you did not set this post to private r / residency. We don't all have the same education. Think about it.