Shortly after that last post we had two really great patients. In the morning I had met one of them, a 30-something primigravida, transferred from the military base for preterm labor. She had been in the hospital for more than a week, and we were planning to send her back to the base in a few days when she reached 36 weeks. Then her water broke, and her labor started up again. So all day I had been checking in on her with residents. The chief had chewed us out early in the day for checking the cervix after a preterm rupture of membrance (PROM), so after that we simply said hello, and waited for the baby to become visible or palpable.

The other lady was also a transfer, from the upscale suburban hospital I haven’t ever rotated at, for very preterm labor. She was only 25 weeks along, and had already lost two or three pregnancies. She was in her late 30s, and had expressed that she wasn’t going to try to get pregnant after this one, no matter how it turned out. We had also been checking on her throughout the day, as her cervix continued to progress, though without many contractions. At one point the residents did an amniocentesis, afraid that she had developed chorioamnionitis. The survival of babies at this age is about 50%, 30% without severe neurological deficits; if she was infected, that last number would be 2%. So we were all glad when the lab said there were no white cells and no bacteria in the fluid.

Around 10pm, however, she suddenly began to have regular contractions. The baby was breech, so she was rushed back to the OR for a Csection; the baby had also begun to have severe decels, although we weren’t sure how much those meant in such a young baby. Fortunately the CRNA was able to get a spinal in quickly so her husband could come back. While they were setting up the spinal and I was helping to hold her, I asked her if she would like to pray (mindful of my friend’s advice that patients should get used to doctors praying). She smiled and said she had plenty of prayer, since her husband was a minister and several of his fellow ministers were at that minute praying in the waiting room. I was impressed by how calm and cheerful she was, compared to the panic of other ladies during stat Csections.

They did a classical Csection (vertical incision because the lower part of the uterus isn’t thin enough this early in pregnancy to cut through) and got the baby out very easily. It was tiny, covered with hair all over, and its eyes were still sealed shut, but it was breathing. They didn’t even hold it up for the mother to see, just rushed it to the other room where the NICU team were waiting. Later on when we were leaving the OR the parents were allowed to look through the door, where they could just barely make out the baby, covered with respiratory equipment and all kinds of lines. The lady was so nice as we were sewing up, and then removing the cerclage that had been placed. She was saying thank you to everything that was said to her, which made all of us try to give her frequent updates about what we were doing. But it was heartbreaking for her and her husband to be saying thank you, and the baby in such a precarious situation.

We got out of the OR to find that the other transferred patient was complete. After about half an hour of pushing she delivered a baby girl, well-developed for her age. When they heard the baby cry, the parents both started sobbing for joy, and the father kept crying and smiling simultaneously for the next ten minutes. We were all delighted to be there for a birth so much desired. I frankly started crying too, although my cold was contributing some. I don’t care what the residents thought. The parents were so happy. Of course, this is about the only way the residents get such stable patients, is by almost-tragic transfers like these two; the whole team, doctors and nurses, very much enjoyed having grateful patients. Let me tell you, that’s one sure way to get lots of attention from healthcare providers.

Afterwards we went back to triage, and admitted two or three ladies who had been smoking, ignoring their diabetes or hypothyroidism, not coming to check on the baby, and full of STDs. It seemed very ironic that with such apathy they would deliver at term, fairly healthy babies, over and over, and these other ladies who so desperately want just one normal baby can’t have one. I’m sure God in his providence arranged it all; but humanly it’s very ironic.

After that I got about four hours of sleep, and then started on the gynecology service. I was paired with the second-year resident, Dr. M, who looks like the older sister I don’t have (to the amusement of all the nurses). She assisted at a bladder taping, a vaginal hysterectomy, and an exploratory laparoscopy. I got to hold things and pull retractors (the scrub nurse saying how much she like having medical students to stand in awkward positions and pull on things so she didn’t have to!), but it got me close enough to see a good deal, so I was fairly happy. Dr. M showed me how to sew up the skin incisions, and she was happy with my knots (yeah!). At one point the surgeon, nice older man, made a dirty joke, and was beginning to be offended when I didn’t laugh, but Dr. M and the scrub nurse (who had only met me half an hour before!) quickly told him that I was too innocent to even know what he was talking about. Which was not quite accurate, but I didn’t correct them! The humor in the OR, especially GYN OR, is awful; I was glad to have a mask. I was happier when the nurses stuck to gossiping about the character and competency of all the nurses and surgeons not actually in the room.

The worst part of the day was in the last surgery, the exploratory lap, which showed nothing abnormal at all. Which meant all the normal anatomy was right there. It was beautiful, all the delicate pink blood vessels, and the organs sliding together just right. Unfortunately, I had not had time on Sunday to review pelvic anatomy. Thus I remembered the names of about three ligaments, and guessed them randomly one after the other for everything I was asked. Not satisfactory. The attending didn’t say much, but the resident took me aside afterwards, drew out all the ligaments, and strongly implied that I’d better know them all, and all the blood vessels, by the next morning. I rushed to the library to check out Netter’s Anatomy. I think I have now memorized the branches of the iliac arteries, and am considering narrating for the next laparoscopy, just to be sure she knows I studied: “That’s the uterine suspensory ligament, also known as the infundiblo-pelvic ligament, which contains the ovarian artery, which is a branch of the renal artery, because that’s where the ovaries started during embryological development. And there we see the uterine artery, which is the second branch off of the anterior internal iliac artery, and gives off a branch to the superior vagina. . . “

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