February 18, 2008

• 400 Babies!

  I seem to have touched a nerve with quite a lot of you with the last post. The ones capable of delivering anyway.
  So if this shadow has offended, think but this, and all is mended
  that you have but slumbered here,
  while I did not because i was up for another 30 hours straight

  its no shakespeare, but its damn true. Like those xanga badges i cant seem to get

  Anywho, another call down, and several more births. But first, a brief introduction to my hospital and how it works.

  I am in a fairly large inner city hospital, with a patient population that is probably 90% black and hispanic, if not more. The patient population is also largely uninsured and undereducated, but to even attempt to comment further on that is a whole bag of worms that doesnt concern what I do, so lets not. For those of you who follow this little internet space, this is the same hospital i did my ER clerkship in. (find it by clicking on the "medical" tags sidebar)

  The labor and delivery floor consists of a waiting area, because what hospital department doesnt, an ob triage where any pregnant women are sent prior to admission to the floor, 3 operating theaters exclusively for ob/gyn cases, and of course the patient rooms, or LD suites. Suites is the appropriate word to use, as these rooms are the nicest in the hospital, and a little bit like the batcave. What initially appears as a one person hotel room with wood paneled cabinets, a shower, televison and amenities can be transformed at the push of a call button into a delivery room with recessed surgical lighting, computers, monitors, and the various equipment needed to deliver right there in the room. In fact, most of the women who deliver do so directly in their hospital room, NOT on a surgery table

  most of them do so at 6am, right before the shift changes, so all the exhausted residents, students, and nurses who have been up all night have something to briefly energize them before going home. Seriously though, why are no babies born until the hours when everyone is tired...are the preparing for the first couple years of life?

  Two more cases from the most recent call (FYI-only arrived home at 9 this morning after a 24+call, and just woke up 10 minutes ago. already on xanga...so dedicated, i am for you)

  The first was a teen pregnancy, the second for this woman, though it would be her first child. Before you go jumping to television conclusion, both her mother and bf/husband were there to support her. The girl came in to triage laughing, happy, joking around as I took her history, mostly complaining of being hungry and saying she should have eaten before. Then I did the ultrasound, and dramatic music began. The resident came in to confirm, and the baby which had been vertex a month ago when she was checked, was now in breech presentation.
  
  **Vertex means the head is down, and is how babies are supposed to come out. Breech means the baby rotated around so if it was delivered vaginally, it would exit feet first. While it IS possible to deliver this way, it is on the whole much safer for both baby and mother if breech presentations are delivered by c-section

  The girls mood quickly changed from laughing to frightened and angry as she was told the news and people began consenting her for surgery. She was convinced that her previous doctor had lied to her or screwed up since her ultrasound a month prior had showed the baby in a vertex position. It was explained to her that babies rotate during the pregnancy, and a month ago that may well have been the case, but no longer was so.

  The girl was brought to the OR, and an epidural was attempted.*

  **During an epidural, a numbing medicine, called lidocaine, is inserted into your back. Once it has taken effect, a needle is placed through your back and in between your vertebrae into your spinal fluid, where an anesthetic is administered. This numbs everything below the area of injection so what is felt during the labor (or c section) process is a sense of PRESSURE but not PAIN. This procedure is a type of nerve block, so following it, your legs will be numb and for all intents and purposes, near paralyzed for a couple hours until the anesthetic wears off. An epidural however does NOT affect anything from the level of the uterus or above, because that would make it too difficult for the uterus to contract.

  Now due to the girls (understandble) fright, she was not initially cooperating with the team in assuming the necessary position for the epidural. She either kept attempting to turn around to watch for the needle, or not thrusting her lower back out. Both of those make it harder for the anesthesiologist (gas monkey) to find the proper place to administer the second injection, the nerve block. This meant that what should have been a 5 minute procedure, ended up taking almost 20 because only the numbing medicine could be safely administered until the correct position could be assumed and held. The girl was finally calmed with a tech and nurse at either of her shoulders holding her steady, and her hands locked onto mine in a death grip while she was sobbing. Poor thing had a panic attack but post procedure finally managed to calm down enough that once the delivery was begun, her bf/husband could be brought into the room to take over the role of calming her while the team worked

  **This time, the c-section incision was the more traditional transverse (horizontal) one. The transverse incision is preferred because it leads to less post operative pain, and is more aesthetically pleasing of a scar. Occasionalyl the vertical incision is used because it causes less bleeding and possible nerve damage, and can be easily and quickly expanded if it should become necessary. However, the vertical incision does not close as well since it does not follow natural skin lines, and is a weaker closure and also less cosmetically attractive

  The cut was made through abdominal wall and uterus, and this is normall followed by some bleeding from the mother, because hey, we are cutting through tissue and it bleeds. However, what i was NOT expecting, was a spurting fountain of kermit the frog colored liquid once the uterus was incised. Literally spurting as in if the resident did not hold her finger over where she had made the initial incision, we all would have had our facemasks and top half of sterile gowns pea-soup green. With her finger in place, the resident continued the incsion and finally it was wide enough to begin delivering the baby. Turns out the first part of the baby unconvered was the rear end, which was spewing meconium (fetal baby poop). This baby literally came into the world defecating before he could breath. The baby was extracted, and once his head cleared the uterus, again the bulb suction was applied to his mouth to get liquid out and air in. The baby was then given a tag, along with the mother and husband right in the or, so there could be no mixups later, and taken to the nursery. Total time for c-section: 10 minutes.

  Of course, the remaining 45 minutes was used to close up the incisions, the uterus, fascia, and skin, and suture them tightly so only a minimal scar would be visible. To remind you, this is not a general anesthesia procedure, so the mother had been awake the entire time, and other than her fear over the epidural, had not complained of pain or discomfort once, nor had she had any complications associated with the delivery.

  The second delivery was another young woman (young being defined as anything below my age, 26 ;-P not that I am old, but they are younger) who delivered about 20 minutes before my shift was supposed to end. She was a private practice patient, but oftentimes when you go into labor in a hospital, the physician you chose may not be able to make it to the hospital in time, so instead of him, she got us. The contractions were spaced about 40 seconds apart, and the babys head crowned in about 2 pushes, less than 5 minutes after the bed had been broken down to stirrup setup. One more push and the baby cleared, crying even before she was suctioned and clearly healthy, while in the background an episode of charmed was playing on the tv. I mention it only because you notice random things during these processes. The baby was cleaned and readied by the nurse in the room where the mother could see her child while we waited for the placenta to deliver. Most placenta deliver with 30 minutes after the birth of the child. longer, and it is usually considered a problem, though not an emergency. Many placenta are often delivered even faster than 30 minutes, but this woman ended up taking 20, longer than it took to deliver her child.

  FInally it cleared and we congratulated the new mother, changed out of hospital clothes, and went home to enjoy a much needed nap.

  Now a few replies to comments from the last post

  mom2basharndanny- while choosing a natural childbirth is by no means wrong or uneducated and our hospital employs many midwives as well as docs and nurses, anesthetic procedures do NOT incur the risks you are inferring. Please clarify how something that affects only your lower half could impede nursing. Also, many labors are induced or "sped along" because the longer a labor lasts, the greater the chance of vaginal stretching or tearing. So occasionally, the staff will attempt to hurry a labor along in an effort to help the mother and prevent some of the normally unavoidable effects of childbirth. finally as for the labor position, while those cultures may have shown such a position, it is simply not practical to have the woman squatting during a labor and the lithotomy position attempt to recreate that muscle configuration which maximizes the opening of the pelvis to allow for easier delivery.

  Rainy: perhaps i overexagerrated the tearing or need for episiostomy (incising vagina to increase birth canal), as 4 of the 6 births i saw last night did not require any sutures, and the other 2 had less than one inch. Even when it happens, it is something the hosptial staff is well prepared for

  Ms insatiable: given how many times i have had to give rectals or ended up covered in someone bodily fluids, labor did not even kill my appetite, much less cause me to pass out-it comes with the territory. This is why many medical students are incapable of talking too or like normal people

  waterfall: keep me informed of your progress, i am just as interested in learning how it goes with people i (sorta) know. Different perpsectives and all that. And from this end, it almost seems that aside from the scar, the c section is a lot easier and faster on the woman

  keep commenting ladies, as it keeps me studying during those long calls. Goodness forbid i appear stupid over the internet AND at the hospital

  • 5:22 pm
  • 6 Comments