miraculous

Finally, the longed-for moment: I left clinic early this morning to go over to the hospital for the Csection. This lady had far too many reasons for having a Csection: it would be her fifth delivery; she had a bicornuate uterus; and the baby was breech. She kept reminding us, in clinic and in the pre-op area, that she wanted her tubes tied. She didn’t mind being pregnant, she said, but she was tired of having surgery to get the baby out, and the stress that her recovery put on her family.

As she lay down after the spinal was put in, she remarked, “I’m feeling really nervous. I never felt this way the other times.” Everyone hastily tried to reassure her. I wonder whether the fact that, as we’d progressed down the hall to the operating room, three separate nurses had inquired of Dr. X (European-born chairman) whether he had a resident coming, whether he wanted them to call a resident, whether he was sure he didn’t need a resident. . . And he cheerfully said, “I’ve got Alice. No, I don’t need a resident. No, we’ll do just fine.” I had asked, outside, whether he would let me do some. I seem to have a knack for picking the wrong cases on which to verbalize my desire to participate. He gave me a gentle lecture on how complicated repeat Csections are, and wordlessly implied that I was lucky he wasn’t asking for a resident.

So for the entire case, I was swinging wildly between greed – “skin incision right through the old scar, I could have done that” – and repentance – “ooh, look how close that bladder was to the rectus muscle, and how stuck it is to everything, good thing I haven’t touched anything sharp yet” – and resentment of the scrub tech – “you could let me dab with the lap sponge, I know how to do that” – to gratitude for her presence – when she started suctioning the blue baby, as I was too astonished and clumsy to do anything (will I ever get over that reaction? you would think by this time I would be used to seeing a baby appear and start moving).

It was after the rectus muscles were divided that things got interesting. As I retracted (barehanded; Dr. X doesn’t go in for either bovies or retractors; he likes scissors and hands), Dr. X started snipping away at the mass of fibrous tissue which seemed to reveal pockets of fluid underneath. The bladder seemed to be extending far into the abdominal cavity. At length, he had exposed two apparently separate watery pockets. Then it clicked for both of us: we weren’t looking at the bladder, we were looking at the amniotic sac. There was, in fact, no uterus between the amniotic sac and the peritoneum. Dr. X and the scrub nurse exclaimed, and we had some difficulty to assure the mother at one and the same time that it was a miracle she was still alive, but there was nothing to be concerned about at the moment.

Her uterus had a huge anterior window. After the last Csection, it never healed, and was left with a hole in the middle. This fetus somehow implanted, and grew, without floating far enough out the window to hurt itself. The really miraculous part is that she was 37 weeks along: almost full-term. It’s amazing that her uterus held together that well. But if she had gone into labor, her uterus could very well have ruptured on the spot, without warning. None of her doctors realized that she had this window, so they had no reason to hurry the Csection along. After it was all over, I started wondering how many weeks earlier they would have wanted to section her if they’d known that was there.

After we stopped exclaiming, Dr. X incised the sac – largely ceremonial, since after all this manipulation it had started spurting out one side. He reached in and extracted the baby’s breech (=bottom) while I exerted as much fundal pressure as I could. Voila, large blue baby boy, who immediately started crying and kicking.

Then we went to work sewing up the uterus. Besides the fact that we hadn’t made an incision, and there didn’t seem to be any tissue in the lower uterine segment to sew to, and the fact that the cervix got torn, it wasn’t too bad. At least, with no uterine incision, we didn’t have much bleeding. Dr. X even let me put in a few stitches on the least complicated section, and then finished up himself with some very fancy footwork around the cervix and a couple bleeding spots. Then, we tied and cut the tubes. I’m not much in favor of permanent sterilization, but this was one lady in whom I felt that it was completely and totally indicated. Plus, it was simple enough that I got to do most of it. I am always in favor of those procedures.

Fascial closure, Dr. X let me do all but the very middle segment right over the bladder. I don’t know if he himself was sure where it was. I couldn’t tell where the bladder was in all that mass of fibrotic scar tissue. The general principle seemed to be to stay far away from anywhere it could even potentially be. For the skin closure, Dr. X produced a straight needle, like a huge fabric sewing needle with a cutting tip, and proposed that we should sew the skin with that. I saw that needle (Phillips, I think it’s called) once before in my brief surgical career. I don’t think it was on the skin then. He started it off on one end, creating a huge dog-ear, and then had me sew across. Of course I managed a blatant buttonhole almost immediately, and generally made a very raggedy closure. I was disgusted with myself, and with him for using that needle. I, myself, incredibly limited as I am, have done much neater, prettier closures with a plain vicryl and curved needle. Tsk. And then he tried to fix it by redoing and redoing the steri-strips. Straight needles have their place – in fabric. Humans need curved needles. I need to get back to the real surgery. . .

Overall, an exciting operation, good outcome (baby went to the nursery with a little tachypnea and retractions, but was expected to do fine), I got to sew on the uterus, which was a first, and I certainly learned about straight needles. Also, Dr. X forced me not to touch the curved needle with my fingers, but to adjust it in the needledriver with the forceps; which was good; because I needed an attending to give me permission to take the extra time to not use my fingers. Next, I need someone to make me take the time to palm instruments, and I’ll be all set.