This afternoon I arrived to find, again, a new patient on the list in the midwives’ unit, of whom this was my first notice. Oh well. I went in, and found Dr. Knight about to break her water. I said hello briefly, then left to finish rounding on the other patients. I figured, since she was a primipara (first pregnancy), there would be plenty of time, and I could go to the office, and come back to check on her at lunch.

Around 11am Dr. A, whom I was with in clinic, called the hospital to check on her. She was told that the patient was very discouraged, only 4-5cm along, and distressed to hear that the midwife was stuck in the office all day. So, I went along over to see how well I could substitute for the midwife. I found two friends in the room with the couple. They introduced themselves as pastors. In fact, they said, the couple were in seminary together with them. Ooookayyyyyyy. I have real difficulty with three women informing me that they are pastors. And one of them used to be a massage therapist before she “became a pastor,” and was now massaging the mother. That part was great. I have got to say, for a bunch of modern people, of a theological persuasion which I would ordinarily detest, I was impressed throughout the day with how well they worked together. The husband was amazing, helping his wife, foreseeing what she would want next, holding her, helping her move, sitting in the tub with her. And the two friends were touching her, helping her, and had such a good way of using words to encourage her. I myself have a very limited stock of encouraging phrases, mostly limited to, “you’re doing great,” “good job,” repeat ad nauseam.

Today I learned a lot more. Partly from imitating the other two women, and wanting to be as supportive as they were. Partly because I was trying to stand in for the midwife, and for some insane reason, not only the patient and friends, but the nurse regarded me as some kind of medical authority! It was crazy. The nurse said, “I was just about to check her. Maybe you. . .?” With a meaningful look. So, being a student, and delighted to do vaginal exams on the slightest excuse (arg), I started getting on a glove. I whispered over my shoulder, “You are going to check behind me, right? Because I’m not really good at this yet.” The nurse gave a little giggle. “I’m not really that great at it either.” So our diagnosis of the vaginal exam was a mutual, “Maybe 5cm?” “Yes, it could be 5; or maybe 6, what do you think?” “If you think it’s 6, it could be 6.” . . . We were both relieved when the attending materialized a few minutes later, to confirm that it was 6.

Then, two hours later, time for another check (which the patient wanted, because she really wanted reassurance that she was progressing), the nurse said, “You want to do the check?” I said, “You should check after me, because I really wouldn’t make management decisions based on my results.” She just shrugged. So I checked, and said 7cm. The patient wasn’t thrilled with that result. An hour later, she wanted us to check again. The nurse’s response to me was, “You better do it, cause you did the last one.” So I felt around for a while, and finally concluded that, since an hour ago she was 7, she must be 8 now. I showed my finger measurement to the nurse and she said, “Yes, looks like 8, I guess.” That didn’t sound solid to me. So I dug a handy ruler out of my coat pocket, and looked at it. She was actually 9cm.

And more along the same lines. Should we go to the tub? Should we keep running iv fluids, or turn them off? Should we stand up, turn over, walk around? The nurse seemed to regard me as at least an equal in these discussions, if not a superior. And the patient would look at me every few minutes, with this really pathetic expression. I finally figured out that she wasn’t wishing I would leave, she was looking for affirmation. So as I said, I learned a lot more ways to express encouragement.

Around 3pm she started pushing (which she had been wanting to do ever since 11am, when she was only 4cm, to my great puzzlement; I thought women weren’t supposed to want to push till they were close to complete), and went on till close to 6. At one point, the attending being absent, the husband pointed out that the head was almost visible, and he could touch it. I was startled. I thought she must be about to deliver, and very calmly panicked. Remembering the other girl who tore so badly through me not being ready, I put on my gloves and sat down handy. The nurse came over and wanted to know what I thought was happening. I wanted to ask her! She said, “Do you think I should call the attending? Or NICU?” (There had been light meconium when Dr. Knight broke her water, so NICU staff were going to attend the birth.) I temporized: “Call the attending, I think, that won’t hurt anything, but wait and ask him if he wants to call NICU.”

As you can tell, I was rather off. It was two and a half hours before she delivered, in which time the attending walked in and out several more times. Finally, the head really crowned, and stayed crowned – for a long time. The attending raised the possibility of a vacuum, which the patient thought sounded good, but with the next push she moved the head so far, he decided to cut an episiotomy instead. Whereupon the head popped out – looking purple. They suctioned it, and the attending helped me get shoulders and legs out. And I knew there was trouble. A huge gush of thick brown mec came with the body, which was purplish and floppy. Not moving. The attending, moving like lightning, clamped and cut the cord, and handed the baby to the two NICU nurses. The parents, friends, and grandmother were laughing and crying. They didn’t know what was happening. The doctor and I just worked on the placenta, silently, letting them be happy as long as they could. Of course, before long they started looking towards the warmer, where the baby was breathing spontaneously, but moving weakly, and not crying. He didn’t cry the whole time he was in the room.

So the attending was sewing up his episiotomy, and the NICU doctor was talking to her about how the baby’s breathing was concerning, and he would need to be observed for a few hours. I knew that couldn’t be it. That baby did not look good enough to be kicking and screaming in just a few hours. As we sat in the cubbyhole writing things down afterwards, the head nurse came through and said, they thought the baby (now in transitional nursery) had been posturing: either severe hypoxic injury, or ongoing seizures. No no no no. That’s not supposed to happen. I hate this, I hate this, I want to unwind time to two weeks ago, and do a Csection, and get the baby. Their first baby, and he’s brain-damaged, and sooner or later they’re going to think, maybe if they’d been on an electronic monitor, instead of frequent doppler checks, ie in the regular L&D, instead of the midwives’ unit, things would have been different. And think the same thing right now, I can’t tell, the attending can’t tell. Maybe things were lost this morning, when there was light mec, and nothing bad enough to change our decision. Maybe the damage was done two weeks ago, at the due date. Maybe it happened in the last two hours of pushing, although I know that’s statistically unlikely.

As I was walking out of the hospital after that, lamenting the perfect baby that didn’t happen, I realized that I missed my appointment this afternoon to talk to the surgical residency director. I can’t quite care, although that’s disastrous. The baby, the baby, something happened to the baby; I don’t care what happens to my career. (I”m sure I’ll care more about this tomorrow.)

But the parents don’t know all this yet. They were thanking me, and saying I did a good job, and for once in my life I found the right words, and told her she’d done an amazing job. She was in labor from 10pm till 6pm the next day, and she never gave up, or asked to be moved and given an epidural.

Very bad outcome; sad story. But I still savor that feeling of being wanted and trusted by the patient and family. They weren’t just tolerating me, they liked having me there, and I did help her get through the labor. But boy, is it scary when the nurse doesn’t know more than you!

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