OBGYN week 4 of 6

Still on Labor and Delivery. Here's a story:

The other night, I was surprised to see a familiar name of an expectant mother on our whiteboard. She had already been on our Labor and Delivery floor for 3 days. I usually don't have night shifts every night, and so there are never familiar names on the board because moms usually delivery within a day or two.

This particular pregnant woman was a 25 year-old first-time mom. She was petite at 5 feet, and only weighed 150 lbs pregnant (considering how most patients are encouraged to gain 25-40 pounds during pregnancy, this was quite small).

There were problems with her delivery from the start. She couldn't feel her legs from the epidural, and couldn't push effectively. She tired easily and asked to rest and fell asleep in between contractions because she didn't feel them. She was a difficult patient also--she complained that her nose was stuffy and she couldn't breathe through her nostrils so she couldn't push. She complained that her arm was full of IVs and they hurt so she couldn't push. She complained that she had heartburn and vomited every 5 minutes onto us/the container I was holding. She complained that her back hurt and would I massage her hip? Lower, higher, harder, keep going....

She pushed and dozed on and off for two hours with zero progress. The baby was not coming down.  We started getting worried at around sign-out time, which is 5:30pm.  A new night team came on. The residents leaving gave sign-out and passed on the information. The night team was left with the impression that she was "the world's worst pusher."

The night team then met her and checked her cervix for progress. Still complete, baby still high, high up with no descent. However, the baby's head was getting squished against the pelvic brim and causing a little halo of edema to form ("caput" or "molding"...essentially forming a cone head). He was stuck.

We went to emergency C-section after the chief resident made the call. The mantra on Labor and Delivery is, "Do the right thing."

Doing a c-section after hours of pushing requires that the baby be pushed back UP through the vagina and pulled out. However, because the baby was so stuck, his head was literally suctioned into the pelvic brim. The chief had to stand on a step stool and pull the baby's head with such great force that it caused the baby to flip in utero to be breech. They had to pull it out feet first. It was the craziest thing I've ever seen in L&D, and I've seen some shizzzz....

Then there were issues with bleeding. So much bleeding. Upward-shooting bleeding. And vomiting. And meconium stained fluid. That was a terrible sign. Babies release the contents of their intestines (baby's first poop) into their amniotic fluid if they are distressed. They can go on to inhale it into their lungs which can cause respiratory distress and in some cases, death.

We tracked blood footprints everywhere in the OR.

The baby was whisked away by the neonatal resuscitation team. He looked flaccid and blue.

Later he was found to be lethargic, had no suck reflex, in decorticate posturing, and pupils fixed. He had had seizures. He had hypoxic ischemic encephalopathy. There was a good chance that he would be mentally disabled if he lived.

In the aftermath, the resident went to the mother's room. She was distraught. Understandably. She couldn't even see the baby for 72 hours due to their cooling/heating treatment regimen.

The resident said she was sorry. That no one signed up for this. That no one in their wildest dreams could've imagined that this would happen. The parents said, "It's not your fault. You saved our lives. The baby would've been dead if not for you. Just pray for us."

In the team room, we talked about what we thought happened. It was like an investigation. We looked at all the fetal monitoring graphs. The baby looked fine for the most part. There was no way of knowing. Perhaps the baby's brain was always malformed and he would've had seizures regardless of the birthing process. Perhaps the baby's brain was damaged in the pushing process. Perhaps the mom's pelvis was too narrow (it was) and pushing should not have been prolonged. Perhaps the sign-out process was too rushed and everyone wanted to get home after a 24-hour shift without realizing that the baby's life was in danger.

And yet, the outcome was terrible.

Whose fault was it? We'll never know. The hospital lawyers were called. The residents were just as distraught.

And that is why I can never do Labor and Delivery.