A Parade for Your Birthday

When last we counted:Baby Counter:
Births witnessed:  5
Babies delivered:  5
C-sections witnessed:  1
After yesterday's Call night:Baby Counter:
Births witnessed:  9
Babies delivered:  8
C-sections witnessed:  3

Ok, so in one day I made up for about a week of no deliveries.  After morning rounds, I presented to the L&D ward and was just getting settled in when suddenly a patient started pushing and the Family Medicine resident was no where to be found.  Normally, they deliver their own patients, but when he failed to show even after being paged and told his patient was pushing I wandered into the OR after a shout out from the nurses for a doctor.

I barely got gloves on as the woman pushed and suddenly the head was visible.  I barely had time to get a grip when she gave another push and the baby was out!  Luckily, I got another hand up and on the legs in time to catch the baby.  No time to think about "control the head, pull up, pull down and deliver."  It was more like, "DON'T DROP IT!"  I was passing off the baby to the nursery RN when the FM resident plus my senior resident walked in.

I left them to sew up the laceration the woman sustained during the birth and walked out the door to wash my arms and assess the cleanliness of my scrubs since I hadn't even had time to gown or put on shoe covers.  I decided I was ok and was contemplating my solo delivery when I was called into another room because another patient was pushing. 

This time, I was able to gown and glove.  The chief resident walked me through this delivery and within less than an hour I had two deliveries.  We repaired the laceration on this patient, and I was finally able to go back to the desk and catch my breath.  We had about another 4 patients on the board, some of which had been induced overnight and were now in various stages of labor.

The rest of the morning was uneventful:  at least for me.  My medical student was in surgery almost all day with a total of 6 C-sections which were performed during our 24 hours on.  We had a planned C-section at 8 in the morning, and another set of triplets in which the mother was starting to show signs of pre-eclampsia, so the decision was made to deliver.  In between, 3 patients suddenly became more critical and needed to be rushed to surgery (one was pre-eclamptic:  moreso than the triplets' mom, one was not progressing well in labor and the baby was showing signs of distress, and the third was a non-progression of labor.) 

I think the triplets were finally taken to surgery around 2100, and I went in to see the delivery.  It was amazing.  The first birth sac contained two babies, and once the first one was delivered, the second came like almost immediately.  They then opened the second sac which contained one baby.  When he came into the world, he immediately started crying loudly which suddenly sparked the other two which joined in.  A semi-quiet OR suddenly came alive with the crying of three healthy babies.  These babies were at 33 weeks, so they had an excellent chance for survival having made it that far.  It was known they were all boys, so these parents are going to have a handful.

I am amazed at how organized and coordinated the teams are with these multiple deliveries.  Each baby had an NICU RN, the neonatologist, and another nursery RN.  Including myself, the other intern, a nursing student, the circulating RN, two anesthesiologists (resident and attending), not to mention our attending, senior, second year and medical student, the room was quite full.

I saw a number of patients for flu-like symptoms and assessment of labor, all of which I discharged home.  I assisted the Nurse Midwife with a delivery.  This was interesting in that the parents had very explicit instructions about when the cord was cut, when the baby would receive its first medications, how much fluid would be given.  The woman received no drugs, her in-laws hovered over her during the birth.  Everything was calm and peaceful.  She delivered on the bed and was so stoic throughout the entire process.

Contrast that to literally the last delivery of the day.  While I was with the stoic patient, you could hear my last patient crying through the wall.  This was around 1400.  I went in every several hours with my senior as he checked her progress.  Finally, around 2300, she started crying that she didn't want to push anymore, she was too tired, her epidural was not working as well as she hoped.

Her husband encouraged her, brought her cool cloths and ice chips while the labor RN reminded her that the patient had wanted a St. Patrick's Day baby and that she had only an hour in which to do it.  Around 2320, the patient decided that this baby was going to be born and pushed harder and got the baby further down the birth canal.  Within 20 minutes, she was actively pushing for delivery.

We got gowned and gloved and helped her deliver a 9 pound 7 oz baby boy at 2347 (she is 6'3" and her husband 6'10", they already have NBA plans, or so they joked).  She was so excited, and as the father held his son, he told him that every year on his birthday there would be a parade, just for him.  I don't know that I've witnessed two more pure expressions of love than the looks between these two couples just after the birth of their children.  I can only hope and romanticize that these are families that will have wonderful lives.



**Note, if you want to stop reading here with wonderful thoughts of beautiful newborn babies and happy families, I don't mind, but I have to get on my soapbox and write about the not-so-happy endings we sometimes see.  Fair warning.**

I think I've talked about patients leaving AMA (against medical advice) in prior entries.  Sometimes, we don't mind when a patient signs out, mostly because their reason for coming to the E.D. was not emergent, but sometimes we worry, if only for a little while, about the patient's well-being (like the man having a massive heart attack while I was on the CCU service who signed himself out AMA, we suspect to smoke, but still, is he still alive?)

During my first overnight call on the 3rd, one of the patients being evaluated was a young woman in her early 20's with a history of diabetes.  She was non-compliant with her medications and was being evaluated for DKA which is a dangerous metabolic condition related to super high blood sugars.  Add to that her pregnancy.  It's well-known that high maternal blood sugars can be dangerous, even deadly, to the developing embryo and fetus.  That's why mothers are routinely tested for any sign of gestational diabetes during pregnancy and are managed on the High Risk service if they are known diabetics.

When this woman came into the High Risk clinic, her blood sugar level was in the high 300's.  They quickly evaluated her and one of the tests they do is an amniocentesis.  Essentially, they stick a needle into the uterus and get some fluid to assess the baby's development.  Most often, you have heard it associated with searching for genetic defects, but in MFM (maternal-fetal medicine) it's almost routinely done to assess the baby's ability to survive outside the womb.

On that date, she was 36 weeks, and the amnio revealed meconium which is the first BM a baby has.  It is always a sign of fetal distress when it is noted prior to birth, and since the baby is essentially "breathing in" the amniotic fluid, meconium will go into the lungs and causes damage.  So, you have a High Risk baby because of the diabetes.  It's pre-term.  Now you have meconium.  The mother was sent down to L&D for observation and to start planning for delivery.

However...

The reason I initially heard about this patient is that she didn't want to stay.  She didn't want to be delivered.  She wanted to go home.  The attending went to her room and talked to her at length about all of the possible complication the baby might have including death.  She asked the patient to consider the implications of her actions.  And, the attending documented her conversation with the patient.  About an hour later, the patient signed out AMA.

Yesterday afternoon the patient returned to the clinic, having missed the prior weeks' scheduled clinic appointment.  She told them that she hadn't felt the baby move in several hours.  They laid a doppler on her and didn't hear a heartbeat.  She was sent down to L&D for a sono evaluation.  Yes, you guessed it, the baby was dead.  I walked out of another patient's room to hear the wails in the unit and saw the second year who had just done the evaluation.

When she began to describe the patient, I immediately remembered her from 2 weeks before.  The resident said that the attending had been worried about her and wondering what had happened.  The resident was now going to have to call the attending and let her know about the fetal demise.

When I left this morning, the patient had been induced and, at this point, may have already expelled the fetus.  Fetus, not baby.  This little one never got the chance to take a breath.

Off the soapbox, except to say, again, "If you're going to lie back on the bed and tell me that you're in 10/10 abdominal pain, that you've been so for the last two weeks, you're vomiting constantly, and that you decided at 0100 to call an ambulance to bring you to one of the only hospitals in the city where your primary care provider doesn't work, I am not really going to be very sympathetic.  Really. 

One, you're pregnant and should have seen a doctor earlier if you're vomiting 10 x a day.  Two, why didn't you go to the hospital where you normally get your care and where all of your records are?  Three, let me show you some video of the "I'm delivering before midnight" patient I just had.  SHE was a 10/10, and in between pushes, she showed her true inner strength. 

House would get to say these things.  I just politely smile, fill out the chart, order the labs I know will be normal and wonder how much sleep I'll be getting that night.  4 hours?  Ok.

Tags: St. Patrick's Day, IUFD, intrauterine fetal demise, gestational diabetes, AMA, against medical advise, triplets