Saturday, November 18, 2006

Week in Review

Finally, a day off! I am so thoroughly exhausted, all I want to do is occupy a corner of my couch and vegetate. Monday's busy start was just the harbinger of the week to come. On Tuesday I had nearly 50 patients scheduled in the office. Mr. Whoo had a late work meeting, so I had to dash out of the office at 5:45 (minutes after seeing my last patient) to pick up CindyLou before the daycare closed. Needless to say, I left in my wake a mountain of patient charts to complete so enormous you couldn't even see the wood surface of the desk. (More on that later.) On Wednesday I only had two surgeries because a patient had to cancel at the last minute, but I had 3 labor patients.

Labor patient number one had been plagued by pre-term contractions since her 32nd week of pregnancy, but finally came into labor on her own at 39 weeks. I checked on her before my 7:30 surgery and found that she was 4 cm and getting comfortable with her epidural. The nurse requested an internal monitor, because her contractions weren't tracing well, so I broke her water and placed an intrauterine pressure catheter. Her contractions were just one minute apart! I predicted she would be the first to deliver, but I was very surprised to be called out of my second surgery (a hysterectomy) at 10:00 because the patient was ready to push! Fortunately, I had another physician assisting me with the hysterectomy, and he stayed with the surgery patient (we had half of her uterus dissected already) while I ran upstairs to deliver the super speedy baby! I was in such a rush to get back to the surgery patient that I ended up sticking myself with a needle whilst repairing LP#1's perineal laceration.

Stupid, stupid, stupid. I berated myself all the way back to the OR. Most of our OB patients are very well screened for communicable diseases, but it is always scary to get a needle stick. I hadn't had one in over 3 years (back when I was a resident, on night float, and pregnant to boot). I re-scrubbed and finished up the surgery with my colleague. It went very smoothly, as it always does with another physician assisting. I wish I had this luxury all the time! After the hyst was finished, my surgery day was over, and I went to the depths of the hospital basement to complete the necessary forms and get the requisite blood drawn for the needlestick panel. Ouch. Everything came back fine, with the patient's bloodwork and my own, thank goodness.

My second delivery of the day was an induction for mild pre-ecclampsia at 38 weeks. I had used m.isoprostol overnight for cervical ripening, and the patient was already 5 cm on her first cervical exam. It wasn't surprising when she delivered the baby shortly after noon. The delivery itself was quite smooth and very touching. I just love it when the Daddy cries. It really tugs at the heartstrings. Even better, the patient's blood pressures stabilized almost immediately after delivery.

My third (and most unexpected) delivery of the day was an induction of labor for an LGA baby at 37 weeks. The baby was macrosomic (measuring just over 9 pounds by ultrasound) and the mother was a primigravida with an unproven pelvis. The patient is employed by the hospital in a health care capacity, so that usually means some kind of complication. I know it sounds paranoid, but physicians, nurses, physician's wives, and health care professionals in general have some of the most complicated and bizarre labor and delivery outcomes of any other group. I have no idea why. At any rate, upon her initial exam, her cervix was so closed and so thick and high that my stubby little fingers could barely reach it. I psyched her up for a 2 day induction, reviewed c-section risks, and placed misop.rostol the evening prior. Overnight she had gotten a total of 3 doses of mi.soprostol. The night shift nurses told me that they never could find her cervix overnight, so imagine my delight to find her 2 cm dilated and 90% effaced when I checked her!

I immediately broke her water to place internal monitors because the patient was a little, well, "fluffy" and the externals were not even registering contractions and the fetal tracing was spotty at best. The patient had been asking for an epidural for a few hours, so she finally got her wish, and I got on with my surgeries and other deliveries of the day.

I still fully expected the labor to last well into the evening. I walked out of my second delivery to find that my third patient was complete and pushing! Crazy. In true primigravida form, it took her a little time to get the hang of pushing, and after a little over an hour, the labor nurse came to me, expressing concern about the patient's pushing progress. She had also started bleeding a little more briskly than usual. The epidural was turned off, and I stayed in the room for the next 45 minutes and helped push with the patient. When I checked, I could feel a posterior vaginal laceration, and I worried about a posterior fourth degree. She did very well with just a little encouragement, and she was able to push the baby out without forcep or vacuum assistance. The laceration was a cell membrane away from a fourth degree, but did not go completely through. However, it did extend along the left vaginal sidewall all the way up to the posterior fornix, and due to her habitus, was more than a little difficult to repair. I put two layers of suture in, and the repair took nearly 40 minutes. I guess she didn't completely escape the health care provider curse, after all. The baby weighed over 8.5 pounds, and I am certain that her mother did not have even one more millimeter of room to push her out, so I was very glad that we induced labor when we did!

Thursday was more clinic, more paperwork, and a stat c-section for fetal bradycardia. (Mom and baby both came through ok.) Friday was a half day of clinic and a half day of charting. I didn't leave the office until nearly 6 pm, but I finished every last one of this week's clinic charts. I can actually see my desk! Now I have to tackle my delinquent dictations this weekend (alas, my weekend off is not even a *true* weekend off) and I may finally be caught up...until Monday starts the process all over again. I am also covering for OtherDoc for the whole of next week, so I am hoping that he delivers all of his November patients this weekend! Geez, I am tired just writing about this week, and I am sure you are all snoozing at your computer by now. Happy Saturday!


Fat Doctor said...

Just reading this post is exhausting - you deserve a good long nap.

Anonymous said...

Oh no, I was not snoozing at the end of this post, your anecdotes are always fascinating. I wish you a great week!

Amanda said...

I have to agree that the curse of the healthcare provider exists. I am a nurse. My first was born at 33 weeks, after over a week on Mag Sulfate and tons of Brethine. I also had trouble with the second pregnancy, though I did not have to be admitted. My daughter came at 36 weeks.

This is a great blog and I enjoy reading it.

Midwife with a Knife said...

What a week! Hope you're appropriately vegetating. :) Sounds like your primip patients are having babies like they mean business!

Just wondering, why did you consistently put a period in misopr.ostol? Trying to avoid web searches?

dr. whoo? said...

Hi FD~ I was afraid that reading the post may be exhausting! No napping (I've always been a terrible napper) but I did get to sleep in! Heavenly.

arturo~ Hi! I'm so glad that I didn't put you to sleep, and that you enjoy the stories. My life is definitely always changing and moving.

amanda~ Welcome and thanks for reading! Wow, another strike of the health care provider curse! How are your kiddos, now? I should do a case series (if it weren't for the whole hating research thing).

I had so many things going on in my pregnancy, I was certain that it was meant to be part of my obstetrical training (you know, so I could tell my patient..."Oh yes, that happened to me, too!")

midwife with a knife~ Ha! One of my weeks pales in comparison to one of your call days, but thank you. Most of the time, if they don't come in labor on my own, my primips take forever! This is why I am such an advocate for laboring on your own (when medically feasible, that is). I definitely took full vegetative advantage of the weekend.

I picked up the period trick from reading infertility blogs. When I mention medicines, I try to alter the spelling with periods to avoid searches. I just don't want my blog to be a high hitter for certain meds, I guess. Paranoid = me.

XE said...

Wow, I love reading all about your patients! I don't think I'm going to do OB/GYN, but you make it sound so interesting that you may soon have me convinced!

Amanda said...

Hi again.

Thanks for asking about my kids. They are great. However, my son, now 6, has a history of developmental delays... hypotonia, gross/fine motor delays, speech delays, sensory integration dysfunction. At one time he was even diagnosed with PDD. However, he was recently discharged from all therapies. This is the first time he has been therapy-free since age 6 months. He is also doing fine in a regular Kindie classroom! The big question for me will always be "was this related to prematurity?" The stats show that 33-34 week babies have virtually the same outcome as fullterm. Hard to say.

My daughter,now 3, has had no developmental issues.

Anyway, I hope you have a great week.

dr. whoo? said...

xavier emmanuelle~ It is definitely an interesting specialty, but you have got to love what you do to tolerate the more inconvenient aspects! Glad that you enjoy reading, thanks!

amanda~ Wow, it must have really been rough going in the early years for you. How wonderful that he is now thriving in Kindergarten and therapy free!

It is amazing the difference in development that a few more weeks inside the womb can make. I wish that I could explain that to my more impatient mommies, sometimes.

I'm glad both kiddos are doing well, and thanks for the well wishes! :)