Friday, August 07, 2009

Stuck, stuck....STUCK!

As my time in Whooville was drawing to a close, I found myself in a very harrowing situation. As per usual, I was extremely busy delivering all of OtherDoc's patients, as well as my own patients during his vacation. (I never understood why he wouldn't limit the number of OB patients he would take when he knew he would be gone for half the month...oh, right, all about the dolla bills, y'all.)

There was a young patient (YP) that I had seen in the office earlier that day, she had been contracting, and while she was not yet dilated, she was beginning to soften and efface. I wasn't too surprised to see her later that evening at L&D. She was extremely uncomfortable, contracting every 2-3 minutes, and had dilated to 2 cm/90% effaced. It had been a long day, so I assumed that we would get her comfortable (she was requesting an epidural) and then she could labor through the night. The day shift left and the night shift came, and sometime in the middle of her bolus for her epidural, YP began to get a little out of "I'm in transition" out of control. If you've never seen it, it is kind of like that seen from the Exorcist, minus the rotating head. I checked her, and surely enough, she was 8 cm. She had gone from 2 cm to 8 cm in the space of about an hour and a half. So much for the game plan.

The patient progressed quickly from 8 cm to complete, and that, dear friends, is when the fun began. As the patient began to push, the baby began to get unhappy. The more she pushed, the more unhappy the baby became. There were persistent and prolonged, deep variable and late decelerations. After tolerating the strip as long as I could, I talked to the patient and talked to the OR. preparing for a C-section. One problem, the anesthesiologist was not in house. Just at that moment, the baby decided to express her extreme displeasure with the proceedings by dropping her heart rate. To the minute, two minutes, reposition, oxygen, scalp response. Three minutes, four minutes, more maneuvers, still no response. The patient was pushing with all of her might, her family was a step a way from hysterical, the baby was in trouble, and there was no anesthesiologist. The vertex was just barely at +2 station, so I attempted an emergency vacuum delivery. I pulled descent...I pulled twice...small descent...I cut an episiotomy and pulled one final time to no avail. We had to go to the OR, and we had to go right then, anesthesiologist or not. At that point the baby had been in the 60s for about 10 minutes. "Please don't let my baby die." were the last words I heard before we left the floor.

We ran to the OR, and I told the CRNA to put the patient to sleep, anesthesiologist or no. I remember that the staff was moving as slow as molasses, even though I had relayed the urgency of the situation. We splashed the belly with betadine, draped her, the CRNA put the patient to sleep, and I went from skin to baby in under a minute. The nurse had to push up from below, and it was difficult to elevate the head out of the incision, but, thankfully we finally got her unstuck. All 9 pounds 8 ounces of her. She was a little pale and a little floppy, but pinked up almost immediately to get Apgars of 6 and 9. She was ok. Mom was ok. The nurses and I were puddles of goo. The adrenaline surge was so strong I was shaking.

I think the anesthesiologist finally got there as I was replacing the uterus. Thank God we didn't wait for him. After the C-section was over, I repaired her episiotomy. It didn't seem quite fair to be sore both places, but she had a happy, healthy baby. I kept turning the situation over and over in my mind. How could I have changed it? What could I have done to avoid the outcome? I felt like I had failed her in so many ways. It seemed incongruous when the nurses told me how "awesome" I was, and how the family cried and hugged me after the surgery. Afterwards, both mom and baby did wonderfully well. It was better than I could have ever hoped for, and an experience that I never, ever want to repeat.