Back at the nurses’ station, Dr. A was holding her purse. “I think I’ll go over to my office in the other building to do some paperwork,” she said. “Maybe my being farther out of reach will make these twins come along.” But first she took me back to introduce me to the mother. The room was crowded with husband, two cute little blonde girls, and three grandparents. The mother looked pale and small, more like a girl than a 30-something wife and mother, somewhat incongruous with her husband, a solid man with graying hair who was watching her with concerned eyes. Grandfather was fiddling with a video camera, and the patient’s mother asked if it would be ok for both her and the husband to be there for the delivery. At this hospital, when the baby is under 36wks, the delivery routinely is moved to the operating room, even if expected to be uneventful, so that the NICU can be right through the door, handy. Dr. A agreed that two people can come back, when the time comes, as long as nothing more complicated than a vaginal delivery is happening.

She went to her office, and I spent half an hour sitting in the nurses’ station, listening to their chat and trying to check up on the latest Middle East developments. (I’m hopelessly out of touch. I depend now on one-line updates from my family: “No ceasefire yet.” “Israel is trapping Hezbollah.” “Hezbollah killed more civilians.”) Then the nurse got up to check on her patient, and I tagged along. “Do you want to the cervical check before me?” she offered. (This is so different from last year. Then, I begged to do checks, and couldn’t get any; now, the nurses are handing everything to me. Fourth year is magic.) I pulled the glove on and checked cautiously. I knew that 30 minutes ago she was about 8cm, so I couldn’t quite believe what I felt. “I think she’s complete, station maybe +2,” I told the nurse. She raised her eyebrows, and checked herself. “You’re right,” she said, and pulled out her phone to start calling all the help she needed. I was left to explain to the family: “It’s time, we need to go back to the OR right now. I can take the two of you and show you where to change.” The grandmother hastily picked up the video camera, and she and dad followed me over to the OR, as the nurse told the mother, “Don’t push, okay? Just hold it till we get over there.” And the mother nodded a little: “I’m really not doing anything.”

Both the family members and I were almost shaking with excitement as I showed them to the little closet with shelves of paper scrubs. They looked a little puzzled by the blue gauzy objects, so I helped them sort out shirts and pants (so called by courtesy only). The grandmother was happily recalling how much more the family members are allowed to be present now than they were when she had her children. As dad finished dressing, his wife came rolling by, surrounded by nurses. We got back to the OR, stopping for paper hats.

Dr. A and her resident arrived, and got out the ultrasound machine to check on the twins again. They were now 29 weeks along. At 21 weeks, mom dilated to 2.5cm, and had a cerclage placed. At 23 weeks, twin A’s bag ruptured, and mom has been on bedrest in the hospital ever since. This morning she went into active labor, and the decision was made to remove the cerclage and let her go, since she had been ruptured for so long, and the twins are now old enough to have a good chance at life. The ultrasound was just to check again that twin A is still head down; they’re small enough that they could move without much trouble. It was only three days ago that twin A turned from transverse to vertex.

Once Dr. A and the resident were gowned, they told mom she could start pushing. She had had an epidural since this morning, so she needed the nurses to tell her when to push. Twin A crowned quickly, her head a strange pale yellow, with more lanugo than real hair (lanugo is the thin hair which covers a fetus’s entire body until close to maturity). Being small, she came out easily. The resident held her up for mom to see, as Dr. A clamped the cord and dad cut it. Then she was whisked off through the sliding door to NICU; but already she was screaming, loud and reassuring.

I wasn’t sure what to expect of a 29weeker; I had seen 33 and 34 week babies, and one 23 week baby, but nothing in between. I was glad to see how solid they looked (unlike the 23weeker, who was so fragile and tiny I expected him to fall apart as he was being delivered). Now I understood why the doctors were serious, but not too tense about this delivery. These babies are much bigger than the really tiny preemies that they see too often here.

Now, five minutes later, Dr. A looked worried again. Baby B’s heart rate was dropping, although only briefly. She checked inside, and found the placenta bulging a little in front of the baby’s head. Mom gave a little push, and the cord of the first baby slid further down, and there was bright red blood dripping out. Dr. A picked up the ultrasound probe again, concerned that baby B’s head might have moved away. It was still down, but very high up. “I don’t think this is working,” she told the parents. “The second twin doesn’t look like she’s going to come down, and the way her heart is looking I don’t want to wait too long.” Mom was of course very upset, partly at the danger to her baby, and partly at the prospect of having to have a Csection after all. Dr. A agreed to wait a few minutes longer. I was praying under my breath, and I could tell from the way dad and grandma bowed their heads that they were doing the same.

Ten minutes later, no change. The resident checked again, and said the placenta seemed even further forward. With the next contraction, we saw even more blood coming out. “That’s enough,” Dr. A said. “We need to do a Csection.” Mom nodded softly. “Whatever’s best for the baby.” The two relatives were shooed out of the room, and an anesthesiologist materialized (fortunately the epidural was already in place; Dr. A was able to take her time, because she knew she wouldn’t have to wait for that when she did make a decision). A scrub nurse appeared, and whip, snap, had an instrument table out and open. They can set up for a Csection fast back here. They may not be masters of surgical, or even sterile, technique; but the maternity OR knows speed.

Mom was quickly transferred to an operating table. “You scrub in,” Dr. A told me. The scrub nurse, Dolly, had already got my gown, and guessed my glove size. She’s one of those special nurses who manage everything quickly, and keep their team happy and smooth. While one nurse put a Foley in, the three of us scrubbed in, with Dolly dancing around, getting us dressed quickly, and passing drapes around us. Minutes after the initial decision, the theater was completely set up, the resident had scalpel in hand, and the husband had been brought back in to sit behind the little screen with his wife.

The patient was fortunately very thin, and the initial incision wasn’t difficult. The resident was a little hesitant about the uterine incision, and Dr. A had to make it. They pulled the uterus open, and chunks of placenta spilled out. The resident reached in, looking for the baby’s head. She couldn’t find it. A period of frantic activity ensued. It seemed to last five minutes, but it was probably much shorter. Dr. A reached in, pressing ruthlessly with her other hand on the patient’s abdomen. She pulled on the uterus farther, and farther. Some more chunks of placenta came out separately. Most of this was happening silently, because the only things they felt like saying – where on earth is this baby’s head? I can’t reach it; pull harder; what just tore? we have to get it out already – couldn’t be said with the patient conscious and the husband sitting attentively by. We managed by silently pulling out of Dr. A’s way as she wrestled with the now-deadly uterus as it refused to give up its treasure. Finally, the pale lanugo-coated head was visible, and the resident delivered the baby. It seemed puny compared to the first one, just barely managing a weak cry as it disappeared into NICU.

Now we had time to look at the uterus. It was cut from side to side; the doctors were obviously concerned that the uterine arteries (which run along the side edges of the uterus) had been torn. Even worse, somewhere in the struggle, the incision acquired a Tshape; I think Dr. A did it on purpose, from necessity, because she didn’t have time to do the proper J-shaped extension. A Tshaped incision is even worse than the classical up-and-down incision, since it heals even more weakly, and has a higher risk of rupture with future pregnancy. Dr. A and the resident whipped the T closed, then oversewed the edges, and finally had to ligate one uterine artery because it was oozing persistently.

Once the uterus seemed to have stopped bleeding, Dr. A suggested that the resident could get back to her regular duties, and I could help close. (That made the night worthwhile.) At this point nurses start bouncing in and out, because a mother at 34 weeks had arrived, complete – and her baby was transverse. Stat Csection in order. They were dashing around to find the OB doctors (since the proper supervisor was here, occupied), the anesthesia, and a scrub nurse. The new little scrub nurse begged to be let finish this case, and the clever, experienced scrub nurse could go handle the demanding doctor in the other room. While this was being settled, Dr. A let me close half the fascia, which is the usual division of labor, and I managed to move pretty quickly for only my second try at this job, and only had to be corrected in my needle placement about five times. Functioning as a private doctor rather than the OB staff, she closed with subcuticular stitches instead of staples, which she also let me do. This I’m getting to be almost confident at, and put them in neatly with only a little correction. The scrub nurse claimed to be impressed (I would be more excited if it had been Dolly; but I’ll settle for impressing little new scrub techs, too).

This morning my first patient was feeling well, and the Csection patient was awake and conversant. The first twin is good on its own, and the second one is only on CPAP. I understand they have a 90% survival rate at this age. I love OB call; if only I could do this, and never any clinic.

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