Wednesday, October 04, 2006

Busy Week

I see a full moon a'risin'...whew, what a week! I had two babies on Friday, one on Monday, one on Tuesday, one today and one more on the way (hopefully sometime today) and an induction for Friday. When it rains, it pours, and I am always the one being followed by a little black cloud. I am totally whipped, and it is only mid-week. I am grouchy, sleep-deprived, out of sorts, and, I fear, in the grips of the PMS monster. I have been living on L&D these last few days. I had to physically extricate myself from the nurses' station on labor and delivery, because I'm staring at the strips way too much.

I've had a really worrisome week with respect to my patients. On Monday morning I received a call from labor and delivery at 9 am. One of my post due patients had broken her water the evening before and was in early labor, about 1-2 cm. Immediately alarm bells started sounding in my brain, because I knew that Ms. PostDue was GBS positive. It turns out that she had likely ruptured membranes at about 10 pm the evening prior. She was started immediately on prophylactic antibiotics, but little danger signs were dancing through my head. I finished the rest of my clinic day as expeditiously as I could. When I arrived on labor and delivery in the late afternoon, the patient was 7 cm, and had just gotten her epidural 2 hours prior. The baby was reactive, the patient was resting, and her contractions were 3-4 minutes apart. I settled in for a rather short wait (or so I believed). Three hours after I arrived the nurse approached me, stating that Ms. PostDue had a low grade temperature (99.7), the fetal baseline had shifted upwards by ten beats per minute. The baby was still reactive, though mildly tachycardic at this time. Her cervical exam was only 8 cm, just 1 cm of change in three hours. Uh oh. There had been very little descent, and the cervix was starting to swell. The patient seemed to have an adequate pelvis, but she was petite, and the baby was measuring at just over 9 pounds. We sat her up, hoping gravity would work with us. I really thought that she could deliver vaginally, so, I sat and watched the strip creep from mildly tachycardic to moderately tachycardic. Just an hour or so later, the patient had a temp of 100.4, the baby was tachycardic, and her cervical exam remained unchanged. Off we went to the OR, whereupon delivery, the (almost exactly 9 pound) baby appeared slightly acidotic. "Good call, Dr. Whoo," the pediatrician, "(The Baby) couldn't have taken much more labor." The Apgars were 6 and 9, we finished the surgery, and I fell into bed shortly after arriving home around 11pm.

The next day, the baby was having trouble breathing outside of an oxygen rich environment. The white count was elevated, and IV antibiotics were started. Sometime during the day, the baby's pulse started hovering around the 80-90s (low for a newborn babe). After 24 hours of IV antibiotics, a clear chest x-ray, no obvious signs of sepsis, and failure to wean from oxygen, the pediatricians were starting to suspect a heart condition or pulmonary hypertension. Today the baby was transported to University Medical Center. I keep going over and over in my mind the progression of events, wondering if there was anything I could do differently. Maybe I could have called the section earlier, when the temp and tachycardia first appeared? I find myself going back and forth between trying to advocate for a vaginal delivery versus jumping at a section on the first sign of trouble. I have got to find a happy medium with which I can live. With this patient, I beat myself up for having to do a c-section, and then I beat myself up for not doing it sooner! For those anons that would criticize my delivery stats, this woman never had pitocin or AROM or internal monitors. She was 41 weeks, and she went into labor all on her own. She was not induced or augmented in any way. She did choose to have an epidural, but it was placed after she was in active labor (her choice, by the way, I wasn't even in the building when she asked for one) and her contraction pattern never changed or spaced. For whatever reason, she arrested descent and dilation at 8 centimeters. Maybe the baby was malpositioned, maybe there was CPD, maybe, maybe, maybe. The bottom line is, I am worried sick for that little baby and her family tonight, and I hope that waiting around a little longer for a try at a vaginal delivery has not harmed her in any way, great or small.

The same evening that I delivered Ms. PostDue, I also admitted Ms. PTL (pre-term labor). This patient had been contracting off and on ever since she was 32 weeks gestation. She had been in and out of the hospital, and she had received both mag sulfate and brethine tocolysis. I stopped all tocolytics at 35 weeks and waited for her to labor. She made frequent trips to triage in the intervening weeks, but she never changed her cervix...until Monday evening. She had been in both my office and then triage earlier in the day, and she arrived back in triage around 8 in the evening. She was 3 cm and ballotable earlier in the day. One of our most seasoned nurses was running triage that evening, and I begged her to tell me that Ms. PTL was not in labor. She said, "Dr. Whoo, she's a definite 4 cm, and I think she *is* in labor." I never doubt a seasoned L&D nurse, so we admitted Ms. PTL for overnight observation. I arrived back on the L&D floor around 7 am on Tuedsay morning, and I found that Ms. PTL had slept all night long. Hmmm. Her fetal tracing looked a little flat, but she had pain medicine overnight, so I attributed the lack of variability to the meds. On exam she was already 5 cm and the head was well engaged. Since the nurses were having difficulty monitoring contractions, I broke her water and placed internal monitors. At the moment of AROM, a torrent of muddy brownish-green amniotic fluid flooded the bed and trickled onto the floor. Meconium. Ms. PTL has a history of rapid deliveries, so I cancelled clinic for the morning, thinking her delivery was imminent. I was wrong. I waited for nearly 6 hours before she delivered, and even though DeLee suction was used at delivery, the infant had some trouble transitioning from mom to the outside world. Luckily, the little one only needed oxygen for a short while before being back with mom and dad. Despite being pre-term, they will likely get to go home together.

In other fun news, I have one patient whose endometrial biopsy pathology came back as adenocarcinoma, and I admitted a second lady from the ER on whom I performed a D&C for post-menopausal bleeding. Based on the copious amount of suspiciously fluffy tissue yielded by the D&C, I presume it to be endometrial cancer, as well. It isn't always perfect deliveries, healthy patients, and healthy babies. This field can be as devastatingly bad as it can be unbelievably good. Tonight, I am just hoping for a good delivery outcome for both the baby and the mom...hopefully in time for me to catch the season premier of Lost (if not, Tivo, I heart you).


Anonymous said...

I think the obgyns do the best that they can with what info they have. They say hindsight is 20/20. You know, the lady would have ended up with a csection regardless. You just tried to give her what every woman wants (well most women) and that is to birth her baby naturally. Sometimes things happen. Good thing is baby is at the best place that care of him.

Even seasoned drs (my peri has over 25 years experience) guess sometimes. When I had my daughter and I brought her in for the peri to see (I had comanaged care with my ob and peri), she said WHEW that was such a good decision to deliver you (I delivered at 35/5). I said you mean you didn't know????? Neither ever told me that they were worried sick till AFTER I had her.

Anonymous said...

Dr. Whoo, I love you!
Not the way lawyers love to sue
or the way Mountaineer Fans love to boo
more like how a car smells when it is new
or the feeling you get when you buy new shoes
Whether I'm blue or smiling the day through, my life is better because of Cindy Lou Whoo
And You.

Anonymous said...

Don't be too hard on yourself. You'll never be able to predict completely accurately which babies need to come out quickly, and which ones can afford to wait. You know that babies can look ok on the monitor, and mom have no warning signs, and they still have trouble. You did your best with both of these babies.

Anonymous said...

Sounds like a rough few days. I hope the baby that was switched to another hospital is doing better!

dr. whoo? said...

hi anon~ It is so hard to keep a brave face in front of the patients sometimes! I know that we doctors are supposed to be all confident and all-knowing, but we are human, too. I haven't gotten any updates on the baby, yet, but I will post as soon as I hear.

Mr. Whoo! You are the best, and I love you!

Alice~ Thank you for your kind words. I know, intellectually, that I make the best clinical decisons that I can make. Emotionally, I fear I get too involved at times. I have to maintain the professional distance!

3carnations~ It *has* been rough! Just one more weekend, then I am off for the next weekend. I'm waiting anxiously for news of the babe we had to transfer. Hopefully they are home with Mom and Dad soon!