Sunday, March 11, 2007

I'm Still Here

It has been a very wild two weeks, and in keeping true to fashion, I've been slacking on all that is not essential to day to day survival. Unfortunately, blogging is one such thing, though I do find myself half-composing posts in my few stolen minutes between home and hospital quite often. Believe it or not, last weekend we actually tackled several tasks on the dreaded to-do list. In the last two weeks, I also had another birthday. Yet another reminder of how ancient I am becoming.

As I have mentioned before, I feel like my mind is stuck somewhere in 1998/1999 (not coincidentally, this is circa the early medical school years for me, when I ceased to be a person and started to become a bot). I am now finding myself emerging from my "bot haze" with most of my faculties intact, save this faulty sense of time. It is still jarring for me to realize that the time with which I most identify was 8 years ago! I suppose I could allow myself to be really bitter that the better part of my 20s (supposedly the greatest years of a young life) were spent slaving in med school and residency, but I also know that I wouldn't be reaping the benefits of that hard work a little earlier in life. All of that aside, I know that I am still relatively young and hopefully I have a lot more life in front of me, so I am trying to bring myself into the now. At any rate, I had a really nice birthday, very low key, as birthdays tend to get when you get older.

I had a really scary delivery recently. The kind that makes you feel completely helpless, even though you have done everything "right." The labor was quite innocuous, actually, which can lull you into a false sense of security. She was a primiparous patient, just a few days over forty weeks, and she came into the hospital in the early morning hours in early labor and progressed, more or less, on an unremarkable labor curve throughout the day. I was very pleased when she came in laboring, as she had an induction set for 41 weeks, and I much prefer patients to labor on their own, if possible. One notable characteristic of this young mother is that she is pretty terrible with any kind of discomfort...She just doesn't "do" pain very well. Any time I had to check her cervix in the office (even for the GBS swab) she would clench and scream. Needless to say, she got her epidural early during the course of labor, and was generally happy until it came time to push.

Right about the time that she had been pushing for about 30 minutes, her epidural began to wear off. Her labor nurse came out to the nurses' station and told me that the patient was having a full blown panic attack and refusing to push. When I entered the labor room, the patient's fear was palpable. She was completely out of control, clawing at the nurse, punching her husband, and kicking her legs and feet. She reminded me of a frightened, trapped wild animal. It was a sight to behold. The baby's head was at +2 station, and while the fetal heart tracing was still reassuring (as it had been throughout labor) the baseline had started to creep from the 130s into the 150s. I tried to calm the patient enough to try an operative delivery, but the patient would have none of it. She refused and demanded a section. She kept screaming, "There's too much pain. Something is wrong! I can't do this." After a few minutes of trying to reason with an irrational person, I left the room to call the OR for an urgent section, fuming the whole way. As the nurse began to prep the patient, I guess that the primal urge to push outweighed irrational fear, and by the time I returned to the labor room with the consent for the section the baby was crowning. The patient was no less panicked, but now she was pushing in earnest. The baby was delivered in three pushes, it had a triple nuchal cord, and was as white as a ghost. I had never seen a live baby that white before, and for that split second, I thought the baby was dead.

Then *I* began to panic. Oh my lord, she was right! There *was* something wrong, and despite the reassuring tracing, the baby was in trouble. I milked and clamped the cord and stimulated the baby, and thank God, she opened her eyes. I handed her off to the nurse, and after the longest minute of my life and a little blow-by 02, she began to squall. She remained white as a sheet, and rather floppy, but she was breathing well and her heart rate remained normal. My mind raced through the occult abruption? There was very little bleeding, and once the placenta was delivered, there was no more than a 5% marginal separation of the placenta, certainly not enough to constitute significant fetal blood loss. Uterine rupture? Mom's vital signs had remained normal throughout, and an inspection of her uterus revealed it to be intact. The baby's blood counts were normal, and though she had signs of volume depletion (decreased blood pressure, mild tachycardia) and received IV fluids overnight, there never was a satisfactory answer for her distress at delivery. She was able to go home with her parents on her second day of life, pink and sassy.

An interesting aside, as related to me by the baby's father's family, was that he (the baby's father) was born at full term, white and not breathing, and he had to be intubated for his first few days of life. There was never an adequate explanation for his distress, either. Needless to say, I earned a few gray hairs over this (possibly familial?) trait, and it served to make me even more aware how very unpredictable this field can be, and how close we come to the brink of tragedy for either mom or baby with every single delivery. Truly humbling as a physician, and frightening as a pregnant mother.

(Bah, CindyLou unplugged the computer immediately before I completed the post, so I had to go back and write it all over again. I feel like the truncated version somehow loses it's punch, but it's the best that I can do. Ah, well.)


3carnations said...

If this was the abbreviated version, then the original post must have been amazing. :)

What a scary situation for everyone. I'm glad everything turned out OK. To see a laboring mother SO out of control must be terrifying, since there are very limited options of how to calm her down...Yikes. I'm just glad the baby is OK.

Anonymous said...

Yeah - and you didnt mention at what point YOUR heart started beating again and when you were able to start breathing! Am glad I was not at that one!

We recently delivered the patient who had to have a central line in place because at 3 weeks of pregnancy (yes, you did read that right) she started with hyperemesis which turned into being unable to take anything PO including medications...even the OB (who is rarely concerned about his patients at all) has stated that he is afraid what will happen to the baby after they are d/c from hospital...Yes she is under psych treatment and apparently the whole family needs to be also.

Liana said...

Still a punchy post, methinks!

I just finished my obstetrical rotation and am pretty sure that I would like to include low-risk obstetrics in my practice. So it's humbling to see that even the obstetrician gets scared silly sometimes.

Anonymous said...

I'm curious whether you considered the possibility of prior sexual abuse in this woman, and if so, what you and the rest of the staff did to help this woman through her ordeal. For it truly was an ordeal, way beyond what could be expected in a primip unmedicated birth.

And as for the baby, have you considered that the she may have been reacting to her mother's fear and that was why she was "not present" at birth? I think I might have reacted the same way if I were that baby, knowing what my mother was going through at the moment of my birth. Maybe a bit of a reach for you (?) but I thought I'd put that out there...

Labor Nurse, CNM said...

I guess I am confused with the reason for c-section. Was it because the FHR baseline was increasing or because this woman was totally freaking out and refusing to push?

I also wonder, is this woman a victim of sexual abuse or assault? Her fear around exams and pain of the pelvic region seems classic.

Anonymous said...

I came across your blog in a VBAC search and wanted to say that I find your posts refreshing and interesting. I am sick and tired of hearing moms piss and moan about the medical community and insisting that all of them are anti-VBAC. I had my VBAC last August, and I completely credit my OB for making that happen. I just wanted to tell you THANK YOU for being open-minded to the subject and for letting those patients choose.

Bo... said...

It's a great post! I've also lost a blog posting once or twice and then had to re-write it. (And whenever it happened, I could still hear my dad in my head harping "always save your work often"---but when I get on a roll I forget to do that...)

Anonymous said...

Thank you for sharing that with us. OB has got to be one of the most difficult branches of medicine ... so much can go wrong.

Hope that you are well ...

Sara said...

Hmm, genetic variation in surfectant? Not enough to do the really serious disease, but something less serious?

Ok, medical question for future non-OB. How do you see the placenta and tell what separated when?

Anonymous said...

Hi! I'm a 3rd year med student in Ca, and stumbled over your blog a few months ago when hunting out residency info. Thank you for writing out these snapshots of your life! It has encouraged me so much to see that there are people out there who love medicine, Ob in particular! I want to specialize in Ob/Gyn, and have learned to brace myself for the inevitable questioning of my sanity that follows disclosure of this fact!

Congratualations on your little boy-bean. It will be different, but no worries. You will all adapt, even CindyLou!

Jawndoejah said...

I know you don't diagnose, so ignore this if you want. I'm not wanting a diagnosis online anyway, it's quite impossible. After a quad screen I was told I have a 1/53 chance of having a baby with trisomy 18. I try not to worry, but this is scary. I go for a sonogram on Wednesday (this week). Have you ever had false positives in this disorder? I read a lot about false positives with down's, but it appears the false positives are less with t-18.

Anonymous said...

Hope everything is ok since you haven't updated for awhile. Hope it is just the stresses of the Ob/Gyn world and nothing too serious that is preventing you from blogging. You are sorely missed in the internet world!

Jawndoejah said...

Since I sent you such a scary message I wanted to update that my sonogram showed no markers, but we are a 8 days behind in size from the first sonogram. I'll know in three weeks at a third total sonogram if baby has grown appropriately. They will look again for markers of trisomy 18 or another disorder related to my low numbers. The perinatologist thought my dates could be wrong, but I wonder how often a 9-10 week sonogram is off by 8 days? Of course, baby was moving a lot and that sonogram was so very fast. If my date on the first sonogram was off, that means my quad was taken at 14 weeks instead of 15.1 and then it is invalid. Ugh. A lot of worry for errors...but it's better to catch the trisomy 18's than to leave it to the birth day in my opinion. No one can be blamed if it was mistake, in my opinion, and I appreciate all that has been done to make sure my baby is healthy.

dr. whoo? said...

3carnations~ Well, I don't know about amazing, but the original post was a bit more fleshed-out and longer.

It can be very difficult when a patient is so panicked, but the key is to stay calm and focused and make eye contact with them. Shouting does no good, even when you just want to shake them!

anon~ Ha, I know that it took a good hour to get over the adrenaline surge. Thank goodness all turned out well. Yikes on the central line patient! Surely the hyperemesis had resolved after delivery? I hope she had good follow up and social service involvement.

liana~ Thanks! Yes, as hard as I try to banish it, I still am human every now and again ;) The more you see, the more you realize can go wrong. I think it is great that you want to include OB care. I think you are in Canada, is malpractice as bad there as it is here for FPs doing OB?

hi anon~ Yes, actually, in the original post I made the comment that she was behaving as though she had a history of sexual abuse. She had relayed no such history to me, and I do specifically ask, but there is no way to know for certain. As soon as the delivery was complete and the pain gone, the patient was remarkably calm. As for the baby, it is certainly within the realm of possibility, though the triple nuchal cord probably had a lot to do with the acute asphyxia.

labor nurse~ The reason for the section was the patient refusing to push and demanding the section and refusing an attempt at an operative delivery, trust me, cutting her was the last thing that I wanted to do. Luckily, mother nature took over and she pushed in spite of her fear.

As I stated in the comment above, I agree that she exhibited classic signs of an abuse history, yet she has denied this. Always a possibility.

michelle~ Hi and thank you! Congratulations on your successful VBAC! That is such a satisfying thing. I know of quite a few OB docs that are in favor of VBAC, for the right candidate, of course. We in the medical community are not always the pariahs that the anti-med community would have one believe.

I have another VBAC due the end of this month and I am really hoping for another success.

brn~ Thank you so much. Sometimes when you get on a roll, you just don't think about just pours from fingers to screen. I am trying to be better about this.

moof~ Aw, thanks! Each branch of medicine has its very own pitfalls. The stressful thing about OB is balancing the care of two patients in one! I am hanging in there. I hate not being able to update as much these days. Hope you are well.

msilf~ The genetic variant in surfactant is an interesting postulate! As for the placenta, once it is delivered, you can inspect the cotyledons. An abruption is usually evident as a disruption with clot. There is no way to tell when, per se, just whether or not it happened.

hi anon~ I am so glad that you have enjoyed the blog and that it has given you a small glimpse into the chaos that is my life. Thanks for the congrats on the bean, too! Ob is awesome if you love it, not so much if you don't. Good luck with the rest of your training and as for sanity? It's way overrated. ;)

jawndoejah~ How is everything going? Are you planning on having an amniocentesis? I wish I had some concrete data on false negatives/positives for each trisomy, but I don't. I *can* offer prayers and good thoughts for you and your small one. Please do keep us posted and hang in there!

anon~ Aw, it is kinda nice to be missed. I miss writing, too. I'm just trying to keep above water here. Nothing serious, just life and work! Thanks for checking on me! :)

Anonymous said...

Great post, I am almost 100% in agreement with you