I attended a birth of a G 10 P6 this week. Uneventful prenatal care. Mom opted for no US, and there were no indications to obtain one. Labor onset with SROM, with what was described as "pink fluid." I went to assess, and indeed, the fluid was pink. Could have been bloody AF, or cervical change show; it was difficult to assess. I listened carefully to FHT's, and re-assessed for placental sounds over suprapubic area. No placental sounds, and baby was fabulous at 130-140's and reactive, even with UC's. Labor progressed normally, and fairly quickly (as one would expect with higher parity), and mom gave birth kneeling, to a 9 lb 8 oz girl over an intact perineum. As the shoulders were delivering, approx 100 cc clot slithered out. Ah-ha....probable marginal sinus abruption.
Baby was perfect, apgars 9-10, nursing within 15 minutes of birth. Passed first meconium plug at 18 minutes of age. Now....it gets odd. Baby started passing copious amounts of bloody meconium. And over the next hour, the stools got thinner, less meconium and more blood. Placenta birthed at 40 minutes, approx 300 cc clot and trailing membranes that were easily teased out. No obvious signs of abruption on placenta. At 90 minutes of age, after baby passed approx 250 cc of fresh, bloody meconium, we transported. Baby was nursing intermittently during that time, vitals were perfect. But I could not assess where blood loss was coming from. I guessed that this was an older abruption, and baby swallowed AF, and passed this in stools. But....the blood was very fresh-looking, red, no clots. I dosed baby with 1 drop of oral Vit K before transport (am not permitted to give IM vit K).
Arrived at Children's Hosp in my area, parents were received as well as I can expect for my political climate. Took two hours to get an abdominal x-ray, and another hour to get a CBC, which clotted. Repeat CBC revealed perfectly normal panel; in fact, 1 point elevated HGB. An Apt test was discussed, but never done, because it had been over 20 years since there had been an indication for one at this facility (grrr). They observed baby for 18 hours, then discharged with normal meconium stools finally passing, and a repeat normal x-ray and CBC. Baby stayed perfectly normal, nursing and stable vitals throughout.
My questions....could swallowing blood-tinged AF REALLY have caused that much bloody meconium? Wouldn't the blood have had an older, brown, coffee-ground appearance? Wouldn't baby have been more likely to be vomiting blood, because it is such a gastric irritant? Any thoughts on what else I might have assessed/done in this situation?
All opinions are welcomed and appreciated...thanks :)