Yesterday afternoon Dr. A and I circumcised the twin boys. I’m getting almost good at Dr. A’s complicated method. There are so many instruments to juggle, though, I still can’t get through one procedure without having to repeat some step three times, because by the time I get to the next piece, I’ve dropped the previous one. Tsk. And she keeps telling me things after I’ve irretrievably done it the other way. After I inject the local: “That was 1%, wasn’t it? I myself usually like to use 2%; I just think it works better, you know?” Then ma’am, you could tell me that before I do five of them with 1%! After I do a ring block: “Hmm. I know some people like that method. I think the dorsal block works really well. See, you have to put the needle like this. . .” Then say that, rather than nodding when I propose to do a ring block! I’m starting to realize that I have a good five years ahead of keeping my mouth shut and putting up with the idiosyncracies of the attendings. . .

Last night I stayed till 8:30pm keeping an eye on a multip who’d started early in the morning. She should have been done in the afternoon, counting from her previous labors. In the end, she required vacuum assistance. So the attending delivered most of the baby. She had a laceration, which the attending said “oh yes, you can sew up,” and then did half of it before trusting me to finish the most superficial bits. Dr. Knight is such a wonderful doctor, so loyal to his patients, so obsessed with providing good care, that he barely lets his partners deliver his patients – let alone the medical student. I felt very disappointed, staying so late and then getting to do so little, but I can’t really complain, because it was his private patient, and it was just because he’s so careful of them.

Dr. A had a young teenage primip come to triage yesterday for a totally innocuous complaint, but it was noticed that her blood pressure was high, some 150s/90s. No symptoms, no proteinuria. So not pre-eclampsia by the definitions, just pregnancy-induced hypertension. Dr. A felt that, being only two weeks from her due date, with this sudden development of hypertension, it would be better to induce her. I didn’t completely follow the reasoning, and I suspect that some other doctors might have let her go home with close follow-up. It’s complicated because this girl literally jumps off the bed if you attempt a vaginal exam. And needles – let’s just say that it took me and a nurse holding her while the other nurse started the iv, after about half an hour of anguished discussion and multiple family members yelling at her to hold still. She was Group B beta strep positive (causes meningitis in neonates if untreated), so even if she went into labor naturally she would have had to have an iv, but I hated to wrestle with a pregnant patient. Her female “support persons” yelling at her didn’t help; I did manage to stop them. I got to put the cervidil in, with some difficulty.

The nurses, understandably, declined to check her again, except once in the morning, until she had an epidural. They guessed that she was somewhere around 4cm, and called anesthesia. The next I saw of her, she was lying comfortably in bed, remarking in a puzzled tone that she couldn’t feel her legs. She couldn’t feel the contractions either, so we persuaded her that she didn’t mind her legs. It must have been the magic CRNA who saw her, because she said the epidural didn’t hurt at all, and worked perfectly at once. What luck that she didn’t have to get stabbed three times. . . When I left, she was barely progressing, so we left her water intact. I certainly hope I get called tonight, because it would really not be nice for her to have to be three days in the hospital in labor.

Yesterday evening Dr. Knight took me to see in the NICU that baby whom I helped deliver in the midwives’ unit last Friday, with such a poor outcome. It was one of the few patients he had not managed to deliver himself. The parents were happily attempting to get the baby to latch on and suck at the same time. He seemed content to latch on, and then just stare at his father’s face. It was hard to tell in that posture, of course, but he seemed to be moving fairly  normally. He’s not seizing any more, being on phenobarb. No one has come up with a reason for his seizures, other than to call it hypoxemic encephalopathy, based on the very acidic cord gases. Dr. Knight and I discussed him at some length – away from the NICU. He looked up the ACOG guidelines on intrapartum fetal monitoring (which I did know by heart) to assure me that intermittent monitoring, as practiced in the midwives’ unit, is just as good as continuous. There seems to have been nothing we could have done differently. With his cord gas as acidic as it was, it seems likely that he had had some event a while back, and the exact method of delivery didn’t make a difference one way or the other.

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