Saturday, February 16, 2008

A Good Day's Work

Some days this job is frustrating, irritating, exhausting, and difficult, other days this job is exhilirating, wondrous, amazing, and wholly satisfying. I was fortunate to have such great day in the not so distant past. It was edifying to feel as if I was doing exactly what it is that I was made to do. The morning started out like most others, rushed and sub-frantic, prepping kids for school, consolidating bottles and pump parts, and departing for work just not quite in the nick of time (ie. just enough to be about 5 minutes late). This day the gods were smiling upon me, and the operating room was behind by about 10 minutes as well, so my surgeries were not delayed due to my tardiness. It was also fortunate that the OR was running a bit behind, as I had a moment to check up on one of my patients that was admitted overnight for observation.

This young girl (YG), a long standing patient of mine, seems to carry the very weight of the world on her shoulders. She was pregnant with her fourth child, six years after her youngest child; a child that was very much wanted, as she had prolonged interval between pregnancies. The day we diagnosed her as pregnant she cried in dismay rather than joyful tears. YG, you see, has severe depression. The depression had been somewhat controlled by several medications that she had weaned in anticipation of the pregnancy, but now that the pregnancy had arrived, she feared the long road ahead without the medications that worked best for her symptoms. Of course we attempted a different, safer, regime to continue throughout her pregnancy, but it was not as effective. The pregnancy was long and fraught with many tearful visits, poor weight gain, and many fears, as her previous delivery had been by emergency cesarean, and she desperately wanted to VBAC. She also approached her due date with apprehension, as she had an induction of labor with all of her previous deliveries, and, while I explained that natural onset of labor would give her the best chance of a successful VBAC, she dreaded the unknown sensation of a spontaneous labor. This initiated no fewer than 14 triage visits in the the weeks leading up to her due date.

Fast forward to this morning, where she had been admitted for irregular contractions early in the morning. Before my surgery began, I checked her cervix, and it was 3 cm, a change from her office visit earlier that week, but not by much. Labor and delivery was full, and the nursing staff was a little short, so we continued to "expectantly manage" her, we felt, very early labor. The thing about VBACs in my hospital is that the OB must be on hospital campus during the duration of the labor, for saftey reasons. So she and I were there, both waiting.

My first surgery was a hysterectomy on a 4 pound fibroid uterus, a little tricky, as it was quite enlarged, but extremely satisfying, and only 100 cc of blood loss! I saw YG walking the halls in between my cases, and hoped for cervical change, for both her sake and mine! My next case was a repeat cesarean section. It was truly a beautiful moment, as the baby was delivered, both mom and dad could see her lifted from the womb, they had chosen music to play in the OR, and they cried along with the perfect baby girl. Say what you will about cesarean deliveries (and this patient was offered VBAC, as well, but she declined emphatically, citing 72 hours of hard labor and little cervical dilation in the previous pregnancy) the birth was still beautiful, and it made me very happy to be a part of it. After the cesarean, I scurried up to check on YG, now contracting every 2-3 minutes, and dilated to 4-5 cm. She requested and recieved her epidural, water was broken and internal monitors were placed, and I went back down for the last case of the day, a short and sweet endometrial ablation.

After my third surgery, I grabbed a little lunch and retreated to the doctor's lounge to catch up some dictations, anticipating a somewhat long wait for YG's baby. I was surprised to get a text page, a mere hour later, that she was 6-7 cm and feeling pressure. I quickly wrapped up my dictations, and luckily so, as in the next 5 minutes I got the "get here now" page. I sprinted up the stairs and into the labor room to see that the "get here now" was a bit premature.

I was already gowned and gloved, so I settled in to help YG with her pushing. Something for which, I admit, I am not often present. It has always bothered me a bit when the nurses get a little yelly with their counting, all in the patient's faces and tell them to "get mad" to push their babies out. I just don't feel like "getting mad" and pushing out your baby jibe all that well. This labor nurse, despite the whole "get mad" business, was really very sweet and supportive, which YG needed most of all. I tried to get YG to listen to her body and let the pressure she was feeling guide the baby out.

After about 45 minutes of good pushing, the crown was visible, with thick, wavy hair, half-dollar size at the introitus, and I knew that this baby was going to be a very nice size. YG was starting to doubt herself, and I told her that her baby was going to be delivered at 3:45pm (in about 10 minutes). She laughed, a rare sound, and renewed her efforts. After a few more pushes, I eyeballed the nurse to get ready for a possible dystocia, and YG concentrated all of her energy to deliver her baby to the world. The head delivered oh-so slowly, I reduced the first nuchal cord on the perineum, felt the shoulders give a little catch which resolved with only McRobert's and a little bit of suprapubic pressure, and reduced the 2 additional nuchal cords as the baby's body was delivered up to his mothers waiting arms at precisely 3:45pm. She had an intact perineum and only a small right sided periurethral tear. Her largest baby prior had weighed 7 pounds 11 ounces; this young man was 8 pounds 11 ounces! YG was ecstatic, and back on her old medicine regime. She has a long road ahead, but she seems hopeful and empowered by the birth of her new son.

So a VBAC, a hysterectomy, a c-section, and an endometrial ablation, all before 4 pm. All in a good day's work, helping different women in different ways. This is what keeps me going through the less savory aspects of my job. Weird for me not to whine, for once, huh? Have a great week.


ER's Mom said...

I swear, we have the best job in the world.

Margaret Polaneczky, MD (aka TBTAM) said...

Nice post. I'm exhausted just reading it.

Glad it was a great day.

ccinnkeeper said...

It's lovely that you posted about your wonderful day, thank you!

I had an endometrial ablation about three years ago. Absolutely the BEST thing I've ever done for myself. I sing the praises of that procedure to anyone who will listen.

Anonymous said...

I am so happy to hear you had a good day. I think it's great how you helped women that day with births they chose. It's wonderful for an OB to do that. I know my OB has her opinion on things, but she's always supported my decisions when it's safe. Unfortunately, coming from a large group with on call docs, and that I have babies at night often...and quickly once I'm there usually, I have yet to have my OB catch a baby of mine. I've never had an OB there for the pushing stage. I did have the yelling RN's this last delivery. I hated it, but couldn't say anything as I was busy with their demands. They even said, "you can do this, you've done it so many times before." I WAS doing it, didn't need them to tell me what to do. When baby was OP none of the pushing was doing anything. OB on call declared baby "high" even though I was only 10 minutes from delivery...all the pushing was just putting baby up against my pelvis or whatever it was doing. No progress...still high and floating. Then, when he told the nurse I could move, it was 10 minutes and bam, baby went from being "up high" to born. I think you OB's are in a tight spot often, between nurses who follow hospital rules and style and patients who have their wishes. If you're old school and medical interventionalists, nurses probably fight you as do patients, if you are more toward patients letting their bodies work, you probably get flack for that or see how you are undermined there. You get blamed for things the nurses do, or for what the patients don't understand. I'm sure it's tough. You actually remind me of my OB (why I've stuck with her) as she is very caring and cautious when she feels she should be. I don't always agree with her, but she lets me do what I think is best if it's still appropriate. She respects my choices. Still, because an OB has missed delivery the last three times and nurses have caught, I may go with a midwife if I ever get pregnant again. We'll see...


Anonymous said...

What will you do to help your depressed new-mother (of 4!) get through the post-partum period?

I'm a bit mystified why someone who is depressed would want to take on a new baby -it's an awfully big challenge even for the cheerful.

Somenurse said...

Its to refreshing to hear a doc with a good and patient attitude. The last few deliveries I have seen or heard of the doc was very impatient and acted as if they had better things to do. That attitude frustrates me to no end, but sadly I will have to keep bitting my tongue if L&D is what I want to do. It was a very productive day!

BTW, I am loving the blog, I only just found this great way to kick back and relax and read about other people's days. I am loving yours!

Anonymous said...

I'm a MSIII (hopefully!) going into OB/Gyn and it's refreshing to hear someone who still loves it!