Sunday, August 1, 2010

Seriously, What Do I Know?

Obstetrics is humbling. Just when I think I know enough about OB/GYN that I can predict a patient’s course in labor, I have a patient whose uterus, cervix, or baby does something completely unexpected. It’s as if God himself is reminding me of my limits.

Take patient A. About a week into my stint as new OB 2nd year/labor floor queen, a 28 year old multip (a woman who has delivered more than 1 baby before) was admitted in active labor. When she first arrived in Triage, her cervix was 5cm dilated. This lovely Latina woman was tough as nails, but every contraction shook her to her core with pain. She asked for an epidural as soon as she arrived on the labor floor. The nurses paged the anesthesiologist and began the tasks they do with every new labor admission. Ten minutes later, they called out for me. “The patient is complaining of pressure. Can you check her before anesthesia sets her up for the epidural?” I pulled on a glove onto my right hand and sat on the side of her bed. The patient was writhing in pain. Between contractions, I quickly checked her cervix. I felt the hard surface of the baby’s head. I felt the ¼ centimeter thickness of soft cervix partially covering his head. She was a good 7 centimeters dilated (out of 10). I looked up at the nurse and said, “She’s 7. We’ve got a enough time to place that epidural.” As these words left my mouth, before I had my glove off, the patient started to bear down. That’s right. She was pushing. “Ma’am” I explained in Spanish, “you can’t push yet. You’re not fully dilated.” The pain was unbearable and my words bounced right off her. She was squeezing her legs together and pushing. “Listen, you cannot push yet!” I repeated, “Let’s get you your medicine, and by then, it will be time to push.” At that moment, a guttural moan emanated from deep inside her and her knees parted. I looked down. A baby head was sliding out of her vagina. As I saw this, I threw a glove onto my left hand at lightning speed. I barely had enough time to lay my hands on the baby before it came sliding out onto the bed. I wanted to laugh out loud. This woman had gone from 7cm to baby in literally less than a minute.
Surprise! You know nothing after all!

Now take patient B. She was a 21 year old woman who was pregnant with her first child. She had ruptured her membranes (AKA broken her water) the night before, approximately 24 hours before she came into Triage to be evaluated. Given that these membranes are an important barrier for both mom and baby from the outside world, the risk of infection becomes higher and higher the longer she’s ruptured. Given that she was full term, this patient needed to be delivered. She came to the labor floor with a cervix that was 4cm dilated. We started Pitocin, a drug that works by causing or strengthening uterine contractions. How much Pitocin we give depends on how quickly her cervix responds to the medication. We started at 2 (it is not unusual to get up to 20). As soon as we started the Pitocin, the fetal heart tracing started showing late decelerations (a drop in heart rate - a bad sign the baby is not getting what it needs from the placenta). When we turned down the Pitocin, they went away…along with her contractions. We played this game all morning. Pitocin, then late decels, then no pitocin, then no contractions. We were stuck between a rock and a hard place. We wanted her to deliver vaginally, but if we couldn’t use the pitocin, we weren’t going to get her in labor. And if we used too much, we could prevent adequate blood flow to the baby. The risk of infection was too high to leave her ruptured until she did it on her own.

We finally settled at 1 unit of Pitocin. It was just enough to give her 1 contraction every 5 minutes (contractions are usually every 2 – 3 minutes in active labor). Even at 1 unit of Pit, the baby was having late decels. Everything else about the tracing was reassuring so we decided to hold course. After about five hours of this, her cervix slowly made it to 5cm (we usually expect 1-1.2 cm of change per hour in active labor). I remained doubtful. By this time, she was ruptured almost 30 hours, was still only 5cm dilated, and was not contracting enough by normal standards to have a baby. I was certain this baby was going to end up coming out the abdomen. Our team decided to give her 2 more hours. If she was still 5cm, we’d call it. We’d head to the OR for a cesarean section. If she changed her cervix, we’d keep going. So, for the next 120 minutes, I watched the tracing, and those late decels, on the edge of my seat. What if in one of those decels that heart rate didn't come back up? What if it stayed down and we had to emergently take her to the OR? I am certain I grew three new gray hairs that day.

Finally 2 hours pass. I return for a cervical exam. Based on how infrequent her contractions were, I was doubtful I’d find any change at all and was confident a c-section was in her future. I glove up and start my exam. I immediately feel baby’s head. I feel around for cervix. I can’t find it. I feel around even more. And then it hits me. This primip (or woman having her first baby) had gone from 5cm to fully dilated in two hours with contractions not closer than 5 minutes apart. Another moment of shock in OB land. Literally, 20 minutes later, a beautifully healthy baby boy was born. I swore I saw a mischievous sparkle in his eye when I caught him, saying "decels, what decels?"

Oh, obstetrics, you will forever keep me on my toes...