At 5:30am, while the students were downstairs rounding on postpartum patients, a lady came in to triage, apparently progressing well in normal labor. The fetal heart tones on the monitor in triage were completely fine. They got her back in a room, and the heart rate dropped to the 70s, then the 30s. The intern had her back in the OR so fast, she didn’t even have an IV running, which was very comforting to the anesthesiologist, who had to put her under general anesthesia (no time to start an epidural) without any way to push bolus iv medications. The baby’s Apgars (a score from 0-10, evaluating baby’s movements, breathing, color, etc) at birth and five minutes were 0 and 2, and the last I heard it’s on a respirator in the NICU.

So that was just barely in time, if that much. I admire the idea of a birthing center, where women can have babies naturally, without a lot of medical intervention. But that also means no fetal monitor. Even most OBs agree that continuous fetal heart monitoring is not the wonder laypeople think it is. But if this lady had gone to a natural birthing center, even the one that’s a self-contained unit inside of this hospital (which would have been natural, as she was multiparous, at term, and progressing normally), the baby would have had no chance. Even if they had noticed the baby’s heart rate dropping, the added hundreds of yards from the midwives’ area to the OR could have meant the baby couldn’t be resuscitated.

As the night team came into rounds to hand off to the day team, the main discussion was about a fifteen-year-old girl, having her first baby. She had come in early yesterday evening to see if her water had broken, and been sent home. She came back around 2am, in labor, and dilating slowly. Just before we began rounds, her baby’s heart rate started dropping into the 90s, although it was coming back up. Two of the doctors kept an eye on the monitor in the corner, and halfway through rounds they suddenly ran out of the room. I barely waited to get permission, and ran after them.

We went back to her room, which was filled with three generations of female relatives, and two young men, one of whom, by the way he held her hand, seemed to be responsible for the situation. She was 9cm dilated, which is almost complete, but not quite. The nurse and the senior resident told her if she would push hard enough, she could get the baby past the little bit of cervix that was remaining. But she was young and scared. Even with an epidural in, she was screaming in the contractions, and could barely add any force through voluntary pushing. After five or ten minutes of trying to encourage her, while the baby’s heart rate kept dropping, they gave up, and started piling the IV equipment on the bed and shooing the family out of the way in order to rush back to the OR.

We ran through the small OR (I heard two of the nurses wondering why they never hear about stat Csections till they’re crashing through the door!) and rushed to set her up. Her mother and grandmother had to be left behind, and with the medical people shouting and running around, the girl was understandably upset. I didn’t scrub, but sat at the head of the bed, where the support person should usually sit, to hold her hand. And it was needed! Although she was completely numb, she was still feeling some contractions, though not the clamps or knife. But she was so scared, she was screaming and fighting anyway, even trying to grab at her belly while the two chief residents were cutting as fast as they could. They did not appreciate the interruption! The anesthesiologists and I had to hold her down while they got the baby out. After the baby was clear of her circulation, the anesthesiologists could use stronger iv sedatives, which they don’t want to do before the delivery, for fear of cutting down the baby’s respiratory drive right when it’s needed.

She was a little bit relieved to hear that the baby was out, and wriggling, but she kept struggling, so they had to give her ketamine, which is a dissociative anesthetic. That means the conscious part of the brain ignores whatever the body is feeling. She finally went to sleep and started snoring.

That baby’s Apgars were 8 and 9, which would be normal after even a vaginal delivery. In other words, for all that excitement, the baby was just fine. But with the current state of litigation, there was no way the doctors could distinguish between the baby that would have died without a stat Csection, and the one that could have waited another hour for a vaginal delivery. And now we have a fifteen-year-old girl, scared to death (hopefully, with all the drugs, she won’t remember much about that ten minutes in the OR), and with a scar on uterus that will put her at risk for the rest of her reproductive life – which will be pretty long. The only good thing is she’ll hopefully be scared enough to use good contraception for a couple of years; and maybe the two young girls who were in her room watching the commotion will wait a while before they get pregnant.

I want to be able to do Csections. A regular delivery is heady, and a stat section is a rush of adrenaline like no other. First, I think I need to learn how to control the adrenaline, though. The last couple of deliveries, when they looked tricky, I think I start praying under my breath. Which is no doubt a good thing, but apparently not reassuring to whoever’s in earshot; so I need to learn to pray quietly. Other than that, I think any panicked behavior I was doing would go away if I knew what to do, like what things to move from the IV pole so we could go back, what things in the OR I could have picked up to help with the setup, and eventually what to do to get the baby out. But whatever I have to go through to get here, if it’s four years of these hours, and a life with surgeon-types, I’ll do it to learn this.

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