Saturday, September 30, 2006

On Call

It is finally fall here. The air is crisp and the colors are starting to deepen into bright reds, oranges, and yellows. I cannot believe that tomorrow starts October. I'm doing my vacation penance by taking call for myself and OtherDoc for the next two weekends. This is actually an improvement from my previous situation, where I was taking call 24 hours a day, every day and every weekend. I finally convinced other doc to do call sharing for the weekends. It only took a year. (!) Last night was a late night. I had two laboring patients. One was a nurse on the L&D floor, so her entire shift was in the room being "support people." It was hilarious, and so nice to see how much they cared for their co-worker. Even more interesting, she had her older child in delivery with her. This kid is pretty bright, and has accompanied her to multiple prenatal visits with great interest in the baby. However, this child is only about 7 or 8 years old. I was a bit taken aback that they were going to be there for the entire process (I think birth can look pretty scary to a kid!) but, it was her labor and her choice, so I just went with it. The child handled the situation extremely well, and even cut the umbilical cord! Best quote of the afternoon, though was the exclamation shortly after birth "Look at his {insert crude slang name for testicles}!" I guess a kid still has to be a kid, especially in such an intense situation!

My second laboring patient was the one that I worried about. After so much time being an OB, you can start to get a sense of the patients that are probably going to necessitate a cesarean delivery very early on in their evaluation. It comes down to simple pelvimetry, usually done on the first prenatal exam. Now, much pelvimetry has sort of fallen by the wayside as far as actually measuring out diagonal conjugates, etc., but, with experience, it is easy to identify women with a narrow pelvis as more likely to end up with a surgical delivery. Regardless of my clinical opinion, which I do keep to myself, I believe every woman needs a shot at a vaginal delivery, as our bodies are generally designed to give birth. I have definitely been proven wrong before with respect to who will and who won't deliver vaginally.

At any rate, my second patient laboring yesterday was a patient whose pelvis was borderline narrow, meaning that all of the labor stars needed to line up just right to achieve a vaginal delivery. She was just past due, measuring 2 weeks larger than gestational age, and dilated 4 cm. We admitted her for augmentation of labor after no cervical change in one week, continued contractions, and elevated blood pressures. So far so good, right? Her water actually broke on it's own about 8 in the morning, filling the bed with about 3 gallons of fluid! After her membranes ruptured, the baby, while still reassuring, was not as reactive as I would have liked. We started an amnio infusion and low dose pitocin, as she was only contracting every 7-8 minutes, and waited. Her progress was excrutiatingly slow, yet she progressed with every check...Centimeter by centimeter. Around 7 in the evening, mom's temperature started to creep upwards, sending the baby's heart rate from the 140-150s up to the 160s. She was 9 cm dilated and about zero station, the baby was starting to develop caput. The strip, while moderately tachycardic, was still reactive, so I tried to let mom get to complete so that she could start pushing. It was not to be. Mom's temperature zoomed up above 101 degrees, and the baby's heart rate raced into the 180s. It was time to get the baby out. We went emergently to the OR and delivered the baby by stat cesarean section. It weighed a mere 9 pounds 10 ounces. I'm not sure that she would have been able to deliver vaginally at all! Today, both mom and baby are doing great. No more fever, and baby has no lingering effects of distress, thank goodness. Despite my best efforts, this patient ended up with a cesarean delivery, but she also ended up with a healthy baby. I think it was an equitable trade off.

Wish me luck for the rest of the weekend, I'm hoping for just a few hours of uninterrupted sleep and some quality time with Mr. Whoo and CindyLou Whoo. Have a great Saturday!


Jawndoejah said...

It is good to read an ob's perspective. I have had 5 babies born and 3 miscarriages. Needless to say, I can easily feel I know a lot about childbirth, but in reality I only know what I have read and what I experienced from my own body. I don't know when I'm truly supposed to be worried with heart rates and meconium and the like. (I have had mec for all 5 deliveries...sorry to my ob and the nurses). I enjoy reading your thoughts and your experience. I adore my ob but try to not be too "star struck" with her. I actually feel she could be a friend if it were possible, but I respect her professional distance. Reading your blog allows me to remember that she has much on her mind, and though she is good at making me feel like I'm her "most important" patient, reality is she has many people to deal with and a real life besides. Maybe now I can quit wishing I had an excuse to see her! In reality, I think I just associate her with the most important moments in my life besides my wedding, and those intimate birth moments and vulnerable times of miscarriage cause me to feel closer to her than I should. Probably the Florance Nightingale syndrome, only not in a romance sort of way. Wonder if anyone has done any studies about how patients feel about their ob's?

Liana said...

Dr. Whoo, in my humble first year family med resident's opinion, I agree with your approach to a trial of labour.

I also really like your blog (stumbled here via Fat Doctor) and would like to link to your site, if that's okay.

Look forward to reading more!

medstudentitis said...

Wow, every day on call... how did you do it before other doctor? A mentor of mine told me that when she was in practice in British Columbia she was on call 1/3 all the time and I thought that was rough!

I wish my mother had had another babe after me and I'd been allowed to watch. I think I was the only one who enjoyed watching the birth video in grade 10 biology.

I think it's great that you allowed that mom to try delivering vaginally for so long, many people think that their OB has made a judgement before hand and never gives them a chance for a vaginal delivery. I think it makes people feel cheated in some ways. I know that there are situations where an attempt at a vaginal delivery just isn't possible to maintain the health of the baby, but I think giving most people the benefit of an attempt is great!

AtYourCervix said...

Hope you got some good sleep this weekend. It's been awfully crazy busy at my hospital lately. Non-stop busy it seems.

PS - you've been tagged! See my post from today :-)

Justbeingreal said...

I found this blog, (well not THIS one, but another I will list below.) I was just wondering what all you blogging doctors think about someone posting this information. I made me furious. This at home, DIY attitude cannot be good for women.

dr. whoo? said...

jawndoejah (interesting name!)~ Hi and welcome! I think it is a great tribute to your OB/GYN that you think so highly of her. We do get to play such a role in a woman's life. It is a privilege. I'm sure that you would find a mix of patient's feelings about their OB docs, just as with all people. There are some with whom you just "click." Thanks for reading! :)

Hi Liana~ Thanks for the compliments! It's funny, the responses I get here, because where I practice, if patients don't deliver by 5 pm they invariably get sectioned. I am the odd one out with respect to waiting on labor to happen! Good luck with your residency, don't work too hard! I don't mind you linking the site at all, and I promise to check your blog out once the baby boom abates.

medstudentitis~ Yes, every day, on call, unless I was taking scheduled vacation time away. When I first started, my patient load was very low, and I rarely got called, much less did I have to go in to the hospital. Contrast that with now, where 2 of the last 3 nights I've been stuck in the hospital well into the evening. Sucks.

atyourcervix~ Hello! Yup, it is crazy here, as well. The weekend itself was ok, but the week (so far) has been out of control. Gotta love the full moon. Ack, tagged! I'll get to it, promise, but maybe not until the weekend?

justbeing~ I have yet to check the link. I assume it has something to do with pregnancy termination, though. I may expound upon this another day. Thanks for reading.

Anonymous said...

Justbeing - did you read the actual blog? It's a statement about outlawing abortion - in effect she's saying that if the Republicans have their way, this is what American women will be facing. And that is a BAD thing.