The Sounds of Silence

I think most people who know me know I like hearts.  When I was a surgery resident, I seriously considered Cardiac Surgery, and I really enjoyed the time I spent as a junior fellow in Cardiac Surgery at Brigham and Women's Hospital in Boston.  I have always been fascinated by echos, and I was most excited during my Ultrasound rotation this year when I got to practice my cardiac skills.

During this rotation, one of the procedures we perform is a sono (ultrasound) on the women when they first show up.  We look to see if the fetal head is up or down, where the placenta is lying, and we calculate how much fluid surrounds the fetus.  A change from the norm in any of these areas changes our plan for delivery.  I always like to look for the heart and then show the expectant parents.  It usually brings a smile to their face as they see their baby's heart beating along to the sound they hear on the fetal monitor.

Unfortunately, sometimes the ultrasound is used to confirm the worst - a fetal demise (IUFD).  Today I went in with one of the seniors to confirm that it had occurred.  This was their sono:

In the picture at the top, I enhanced where you would see blood flow using the doppler.  You can also see a "pulse wave" at the bottom of the screen.  As you can see in this sono, where the thick line is sitting along the thinner line is the location of the baby's heart.  There was no flow color change.  And, at the bottom, no flow waves.  The baby had died. 

What I was most impressed by was the eerie silence.  Having done so many sonos and turning on the doppler to see flow and listening for the pulse wave, the absence of it was so apparent.  Also, you keep expecting to see the cardiac contraction.  But there was none.  This was a young teen mother, and when I left today, they were planning on inducing her labor so she could deliver the fetus.  They were also reviewing her records to see if somewhere they could find out what happened.  That's always the biggest question... why?

This was one of three final days on the service.  We were SO busy, and yet I had nothing to do.  I admitted and delivered a patient throughout the course of the morning/early afternoon.  Nothing unusual there, but the majority of the patients coming in today were not "normal" deliveries.  Since the complicated patients go to the senior level OB residents, I could only stand back and watch the flurry of excitement around me (just for some background, a "term" baby is from 37 weeks on, a full term being 40 weeks, a preterm baby is 25 - 36 weeks, a non-viable meaning unlikely to survive outside the womb baby is less than 25 weeks.  Just like a cake, babies needs to stay in the oven long enough to be fully cooked, er, developed.)

We had:

 - the teen mother with fetal demise at 36 weeks
 - the mother of twins at 26 weeks that went into labor and had to be taken for an emergency c-section, the twins are intubated in the NICU and it's uncertain if they will survive
 - a 31 weeker with signs of pre-eclampsia that was being monitored
 - a term baby thought to have multiple fetal anomalies, the mother only went to clinic once for a sono late in the pregnancy and never went back for prenatal care
 - another 31 weeker whose mother smoked cocaine over the weekend and who was showing signs of pre-eclampsia and who might have to be rushed for an emergency c-section
 - a 27 weeker whose water broke and was being monitored for pre-term labor
 - a woman in labor with a term baby with gastroschesis which I described in a previous entry
 - about 4 women in active labor that had been induced or had come in overnight
 - and probably about 3 or 5 other patients that were in various stages of waiting to be seen, or admitted, etc.
 - we had 3 patients on the board at sign-out and by 11 a.m. we had seen 10 patients in triage and 7 of those were diagnosed and admitted as being in labor

My poor senior starts to pull and twist his hair when he gets anxious.  Usually I tease him that he's going to make himself bald.  Today he put on a surgical hat, which is a good thing because he was starting to be like a cook with too many boiling pots on the stove and would have worried off a good chunk of his hair with the amount of complicated patients coming in.

Hmm.. that's a lot of kitchen recipes.  I guess I will have to get a snack while I read up onLimps and motion abnormalities for reading group tomorrow.  It's Grand Rounds Wednesday, so no clinical duties for me.  Two more days on the service, and then I am done with L&D.  I have to see how many deliveries my colleagues had... have to see if I can beat them!
Baby Counter:
Births witnessed:  9
Babies delivered:  15
C-sections witnessed:  3

Tags: gastroschesis, IUFD, fetal ultrasound, pre-eclampsia, cardiac echo, BWH Boston