This Week's Lesson: Be Prepared for Anything!

     This is mostly for my own selfish journaling. You are all welcome to read, though I don’t know if everyone will find it interesting. It may not be great reading for the faint of heart. And forgive me for committing the blog-o-sphere faux pas of publishing a post this long without a single picture. Nothing seemed appropriate.

     If you ever want to remember how small and inadequate you are, stand in a room where someone’s life is on shaky ground, and realize you have absolutely no idea what to do. This happened to me TWICE in the last week.

     The first time was early Tuesday morning, in the final few hours of a 24 hours shift. I happened to be standing next to the intern when his phone rang. “Yes, I’ll be right there. … I ‘ll call her immediately.” I followed as he headed down the hall as a brisk pace, while calling the senior resident, who happened to meet us on the way, so that we all entered the room together. There lay a woman. Well, she was lying, technically speaking, but there was nothing still or relaxing about the scene. The woman was writhing in the bed, screaming out frequently while her mother tried to comfort her.

     The senior resident approached the bed to attempt to question the patient, but almost immediately the woman called out “My water! I think my water broke!” It was clear she was right, as there was now a puddle of fluid joining her on the bed. The senior resident grabbed a glove and assumed the position for a cervical check. The woman nearly came off the bed and slung some colorful language toward the resident, who simply said: “That is not a head. That is not a head!  We are going to the OR!”

     She stood up, but before she could remove her gloves, the woman called out that she had to push, and it was clear that despite everyone’s protests, she was going to do so. The resident went right back to work, and soon we could all see two little feet. Then hips and pelvis. Then abdomen and torso. And then it was as if time stopped, and the baby did, too. The body stayed there, supported by the resident, but the head did not want to descend. We all waited in silence while the resident continued to work, verbally trying to remember how to help a “footling breech” finish the delivery process. After what seemed like an eternity, she cleared a posterior arm and was able to guide the head through the remainder of the journey.

     The Intensive Care Nursery team was standing by, going immediately to work on this poor little body, born six weeks too soon. The room remained quiet, save the woman’s cries, until the baby followed his mother’s example and made a few sputtering cries of his own. After a brief stop to see his mother, he was whisked away to the ICN (known more commonly as the NICU) where he began his recovery.

     Throughout the experience, I stood with empty hands at the end of the bed. Nurses rushed in and rushed out, each seemingly knowing exactly what they could do to help. I knew nothing. The world seemed to be spinning without me – independently of me. A thick frustration assailed me, as I felt myself a powerless observer. I wanted to help. I couldn’t help.

     We compared times following the experience, and found the call was placed to the resident’s phone at 5:25 a.m. and the time of delivery was 5:35 a.m. Ten minutes. It all happened in ten minutes. Ten very long minutes that I will not soon forget. Mom has been released from the hospital, and baby has done well as well.

     The second experience developed more slowly, but ended nearly as quickly. This baby was at term, but was also known to be lined up “breech.” Mother was scheduled to report to the labor and delivery unit for an “external version.” This is where the doctor attempts to push the baby into the proper position in order to allow the mother to deliver normally.

     Unfortunately, on the morning of the scheduled version, she, too, felt a gush of fluid. A visit to “OB Triage” confirmed that she had lost her amniotic fluid. A quick ultrasound showed the baby was still breech. This complicated things. External version is less successful without fluid. The mother expressed a desire to avoid cesarean delivery if possible, and we conferred with the attending physician. After some lengthy discussion, he decided to try attempt the version despite the loss of fluid, but encouraged her to get an epidural prior to the procedure, because it could be quite painful.

     After the epidural took effect, we entered her room (which happened to be the same room as the previous story) to attempt the version. I don’t think anyone had high expectations, though the attending said “50/50.” After 10 or 20 minutes of pushing on her stomach, he did succeed in getting the baby head down, though he could not quite get the baby to line up in the pelvis just right. After more discussion, we decided to get a small dose, what is slangly referred to as a “whiff”, of pitocin to firm up the uterus in the hope of helping the little one finish his descent onto the cervix and prepare for delivery.

     We took leave from the room and went to watch the monitor for contraction pattern and to monitor the baby’s heart rate. It took some time before the contraction pattern seemed acceptable, and the attending returned to the room to assess the situation. He came out grinning, saying he had checked by ultrasound and the baby was now properly positioned. The resident, somewhat unbelieving, and I then went into the room, assigned with the task of verifying fetal position and performing a cervical exam to assess dilation as we prepared for her labor stage. Turned out the baby seemed to be in the proper position. The resident gloved up and began to perform the cervical check, and as he did so, the baby’s heart rate took a nauseating dive. The nurse, standing in front of the monitor, said, somewhat lightheartedly, “There is no cord, right?” To which the resident responded: “No, there is no cord. Oh, wait. I have cord.”

     Once again, I found myself at the foot of the bed, moving in slow motion while the rest of the world seemed to be in fast forward. “Having cord” as he had stated meant that the umbilical cord has prolapsed, or beaten the head to the cervix. This is an emergency. If the baby’s head descends and compresses the cord, the baby will not get the blood and oxygen it needs. In a body so small, even relatively short periods without oxygen can cause very serious consequences, and mortality rates from this condition are very high. I had been taught previously, more than once, that “if you feel cord, do not move your hand.” It then becomes your job to try to hold back the head and protect the cord while the mother is prepared for cesarean delivery.

     So there we were, the resident awkwardly half sitting, half lying at the end of the bed, trying desperately to “protect the cord” while we rolled the patient straight back to the OR. It takes time for the level of epidural to reach “surgical levels” and time was not in our favor. The baby’s heart rate fell to critical levels when we entered the OR, and the doctor prepped the patient and made his first incision before the anesthesia was sufficient. She cried out, and the anesthesiologist made the decision to put her completely to sleep. In minutes, the baby was out, a girl, looking relatively pink (which is good) and with a heart rate, but making no efforts to breathe on her own. She was intubated and taken to the ICN (NICU), where she stabilized and began supporting her own respiration. Mother did well, as good as could be expected post-operatively.

     That same, overwhelming feeling of helplessness accompanied me through this experience as well. Both have served to motivate me to avoid a similar feeling in the future, which will require diligence in studying and in training – though I hope to not face many similar situations in the future!

    For this rotation, I am on the labor and delivery unit full time. There have been many lessons, like those mentioned here already. But one stands in stunning clarity, above all others. When working with obstetric patients, those pregnant and nearing delivery, you cannot expect anything. Complications arise in the most routine deliveries, and others that seem to be headed in the wrong direction work themselves out regardless of what you do. The best you can do is be prepared for anything. Literally, anything.