OB-RAMA: Thursday, 4:30am - Noon

Last summer I posted about a long day (or two) of continuity deliveries (meaning my own pregnant patients laboring & delivering, as opposed to someone else's patients). I had another extended day of moms-to-be becoming moms this past week.

I woke up, sort of, on Thursday morning to my pager doing the single-beep-and-vibrate thing at about 4:30am. It was my colleague, Jessica, holding down the inpatient service on nights (I was on the week before). She had one of my two post-dates patients in triage, in labor and in pain. She was moving over to a delivery room. I told her I was on my way, but that I'd be moving slowly. And I did. Move slowly. I think I fell back to sleep for a bit, then got in the shower, tossed on some green scrubs, and headed out. I felt a little bit guilty leaving Brooke to wrangle both Zoë and Elliott, but what could I do? It's my job.

My patient, let's call her Frances, was dilated to 8cm when I arrived at the hospital, but the baby was still high in her pelvis. She had an epidural block, so she was comfortable, but neither she nor her husband could really rest, for they were both nervous and excited about what was happening. I got a little nervous too when I saw the fetal heart tone strip, which showed some prolonged rate decelerations, indicating that the umbilical cord was being compressed with each contraction. Decels themselves aren't alarming, and the cord compression variety are fairly benign, but these things were going on for longer than I would like. I chatted with my attending, Jay, about my options for managing this situation. He reminded me that in general there aren't that many options for managing labor, which is both a blessing (fewer decision to make) and a curse (in medicine it's nice to have options). The basic choices here were to start an amnioinfusion (put some saline into the uterus to create a bigger pocket of fluid around the baby) or do nothing. Amnioinfusion is one of those interventions that the evidence says doesn't do a whole lot of good in most situations but is fairly harmless. If these were actually cord compressions, it should help. So why not try, right? I also took a moment to curbside an obstetrician, who helped me feel better about infusing.

It helped! She labored on with a happier strip and eventually got to full dilation (10cm) and the baby descended nicely. Time to push, which she did, with coaching, for about an hour before the decels came back. Again, not terribly alarming, but we thought we'd feel better if we could just deliver this baby into the world and free her from being compressed every two minutes--clearly she did not dig the squeeze. Jay and I talked about a vacuum assist and got the OB involved to help with placement, as the baby's head was still a little high. A novice with the vacuum, I got two attempts (or "pop-offs"), then, by previous agreement) handed the vacuum over to more experienced hands. Frances pushed and we pulled and out came a lovely baby, who immediately enjoyed the change in atmospheric pressure. With nearly all vacuum-assisted deliveries, there is some tearing of maternal tissues, and this was no exception. A few stitches and that was that.

Then of course, paperwork. A delivery note, post-partum orders for mom, a newborn exam, note, and orders and the odd surveys, code status declarations, and face-sheet (billing) stuff that litters the chart.

It was noon when I finished that, and this post is long enough, so the day will continue under another post.