Delivery by Zen

I got the page for another labor admission. “K.L. 20 y.o. G1 @ 40’0 wks in labor. 8/100/0. GBS negative. Declines epidural”. (Read: 20 year old, first pregnancy, at term, 8cm dilated.)

Now it’s not terribly uncommon for our patients to deliver without an epidural. But the ensuing delivery often entails lots of screaming, crying, and the occasional out-of-control, climbing-up-the-bed-with-a-baby-head-sticking-out episode. I knew from the moment I met this patient, she would be different.

When I walked into her labor room, I found a lovely young Southeast Asian woman, sitting on the hospital bed, eyes closed, calmly breathing through contractions. She was the quintessential picture of Zen. If she wasn’t dressed in a hospital johnny, I could’ve easily mistaken her for practicing prenatal yoga. She was almost fully dilated by the time she came up from Triage. By the looks of her, I would have thought she was 2.

As she progressed in her labor, her contractions became stronger, more difficult to breathe through. She changed positions, moaned, writhed, shook – but through it all, it was clear that she had 100% control of her labor.

In most deliveries, where the patient is numb from epidural anesthesia, a lot of labor coaching is required. The patient often can’t feel much and a good deal of time is spent teaching a woman how to push. This type of birthing is an interactive process, a team effort.

The birthing experience of this young woman, however, was completely different. Because she had no inhibition of pain or feeling, she was completely in tune with her body. She could feel when it was time to push, she could feel how and where to push, and absolutely no coaching was required. In fact, she was so much "in the zone” that anytime I spoke, I felt like I was interrupting her focus. Her process of birthing was beautiful to watch. It wasn’t that she was quiet (she was definitely making noise). It wasn’t that she was still (she was moving around a lot). It was that she was focused and in complete control with what was happening to her body. It was an empowering experience to watch.

A beautiful 5+ lb baby boy was born approximately 20 minutes into pushing. The patient did 99% of the work on her own. The one and only contribution we had was to catch the baby.

What made this patient different from the other non-anesthetized patients I’ve delivered? What was her secret? Was it her expectations? That she knew it was going to be painful and developed great coping strategies for it? Was it a personality thing? A high pain threshold?

Regardless of what her secret was, I left that delivery room inspired. Empowered. And very, very proud of my patient.

You Know You're an OB/GYN When... (PART 1)

* you get splashed with amniotic fluid and think to yourself, “Do I really need to change my scrubs?”

* you can say you’ve caught a baby with only one glove on.

* respiratory mucus grosses you out more than cervical mucus. 
 
* you think ferning under the microscope is beautiful.

* you can’t remember what the sex of the baby you just delivered was… two minutes ago.

* you can say that your clogs have come in contact with every single body fluid produced by the female body.

* you think placentas are pretty.

* you’ve been baptized by baby pee. And poop.

* you say things like “whiff of pit” or “shrom”.

* seeing a new dad cry makes your eyes well up with tears.

* you refer to your patients as “primips” or “multips”.

* you understand that this means: “This is a 19yo G3P2012 who is PPD#2 s/p SVD c/b PPH after IOL for severe PEC “.

* you can diagnose bacterial vaginosis before you’ve placed the speculum.

* you think Trichomonas under the microscope is really fun (not for the patient of course!)

* you think Mirena IUDs are by far and away the best birth control method. Ever.

See One, Do One...Teach One?

One of the things I love about residency is that the learning curve is just so darn steep. Just when you’ve got one thing down pat, it’s time to learn about something else. The process of self-improvement just doesn’t end.

Example 1: The first half of my intern year was dedicated to learning how to get through the basic steps of a vaginal delivery or cesarean section. I was happy just to get through a delivery without fumbling the baby. If I finished a delivery and the baby wound up in a nice football hold, if I could cut and clamp the cord without dropping the instruments, I was glowing. Same goes for a c-section. If I could hide my intern tremor for the duration of the surgery, I was happy. If I could sew up the uterus and the attending didn’t need to throw in a ton of extra sutures afterwards, I considered it a job well done.

Example 2: The second half of my intern year was dedicated to finesse. It was about maintaining order in a labor room, creating a positive birth experience for my patients, catching a baby with grace, and knowing when and how to intervene if a baby dropped its heart rate or if mom had more bleeding than usual. It was about developing my own style and routine of baby catching. In the operating room, my focus was on doing the c-section start to finish, calling for instruments, delivering the baby without struggling, re-loading my needle driver without touching my needle. It was about a beautiful subcuticular stitch to close the skin. It was about dictating from memory before I walked out of the OR.

Now, a year later, the start of my second year is dedicated to a new learning objecting: teaching. I’m no longer standing at the perineum and coaching a soon-to-be mom with her pushing. I am not catching the baby and handing it off to its waiting mother. I am walking our new interns through it. I am helping with their delivery maneuvers, their laceration repairs, and everything in between. The good is that it’s been extremely rewarding. There is a certain pride you feel when your intern does a beautiful delivery or repair. And with every delivery, they get better and better. As if that weren’t reward enough, their excitement and enthusiasm for these new experiences is incredibly contagious.

The challenge for me in all of this is making the personal transition from the “do-er” to the “teacher”. Struggling with something, be it getting the baby into a good football hold or delivering the placenta, is an important part of the learning process.I know this. Watching it without jumping in, however, is harder. It’s like being the kid in class who actually knows the answer to the teacher’s question but not being able to answer it. It’s like waving your hand in the air saying “Pick me! Pick me!” knowing full well that it’s not your turn to talk. A couple days ago, I hip-checked my intern out of the way when we had a tight cord around the baby’s neck. Afterward, I realized that I had missed a great opportunity to teach my intern how to deal with this situation. What makes me feel even worse about the whole thing is that I remember being in this intern’s shoes. Just a year ago, I remember being so eager to do a delivery, by myself, start to finish. I remember being hip-checked myself and thinking, “Just give me a chance! I can do this!!!”

Reflecting on this experience, I realize that I had panicked in this week’s delivery because, as the next senior person in the room, I felt ultimately responsible for the outcomes of this mom and baby (which is true). Looking back, however, there was plenty of time to walk her through a nice somersault maneuver and still have a happy baby.

Intern year, for me, was about stepping into my role as a doctor. It was about stepping up to the plate and getting my hands dirty. As a second year on the labor floor, I’m learning that my job is to take a step back and teach. It’s to trust my intern with a straightforward delivery. It’s to trust myself that I know when to step in. Like I said earlier, there’s always something to work on in residency.

Babies Having Babies

She was 15 years old. She looked like any other youthful teeny bopper, with her silly band bracelets and hot pink nail polish. She should have been at home, in bed, dreaming about the Jonas Brothers, her high school crush, or what she was going to wear to school in the morning. Instead it was 3:00am and she was in our Triage, alone, and 30 weeks pregnant. She sat tearfully on the hospital gurney as the contractions came and went every 3 minutes. Like clockwork.

Concerned she may have broken her water, I did a speculum exam. Through a dilated cervix and amniotic membrane, I saw a head of hair. It was then that I knew my patient was going to deliver early. By the morning, this baby was going to be a mother.

Explaining the implications of delivering an infant 2 ½ months early to a 15 year old girl was not easy. I’m not sure if it was the fact that she was alone, in pain, or still a baby herself, but nothing I said seemed to sink in.

I explained, in the simplest way I could, that we were going to give her steroids in an effort to mature the baby’s lungs prior to delivery. I talked about the role of tocolytics and its purpose in slowing down the labor long enough to give steroids. I discussed the role of magnesium in protecting the baby from the perils of cerebral palsy. After all was said and done, she looked up at me blankly. Her only response was, “Can I take this off now?” referring to the fetal monitoring system attached to her belly. The next question that followed, “Can I just get a c-section now?”

Her lack of insight was profound. I pulled out my doctoring skills, asked her to tell me what she understood about what was happening. She recited back to me the facts of the situation at hand. Her explanation, brief and without detail, was notably void of any emotion or understanding about the gravity of delivering a 30 week infant.

“Do you have any family with you?” I asked. “Can you call anyone to be with you right now?” Apparently her mother had dropped her off at the Emergency Room and left. Despite several phone calls by both the patient and the resident team, she failed to show up. Our young friend delivered a 2 ½ lb baby girl, alone, at 9:00am the next morning.

Anyone who argues against comprehensive sex education, condom distribution in schools, or unlimited access to family planning for minors needs to meet patients like these. These are young girls with little to no family support or financial resources. Their neurologic development will not be complete until their early 20s. Most of them lack the maturity or understanding it takes to raise a child. Their bodies, underdeveloped for childbearing, put them at risk for severe pregnancy complications like preeclampsia, obstructed labor, and having low birth weight babies. Having a child drastically decreases their likelihood of completing high school and increases their likelihood of relying on public assistance in the long term.

There is also a gender issue here – it takes both a man and a woman to achieve pregnancy. Yet time and time again, it is the young girls who suffer the consequences of pregnancy. It’s their lives that are forever changed, their dreams that are forever shattered. Unfortunately, it is just too easy for boys/men to walk away from their responsibility. When my patient delivered, it was her alone in that delivery room.

The most conservative of parents should know that none of the aforementioned interventions (sex ed, condom distribution, access to family planning) have been shown to promote earlier sexual activity in teens. These teens will start becoming sexually active at the same time as their peers. The difference? They are more likely to use birth control or condoms when they do it.

Of course, we all want our youth to postpone sexual onset. But the fact is, they make mistakes. Are we so dogmatic that we don’t want to give our children room for error? Are we really that strict that we will force our kids to suffer life-altering consequences of unprotected sex? I hope not. For every young girl like this one.

For more info, check out: www.advocatesforyouth.org

“Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness, that frightens us most. We ask ourselves, 'Who am I to be brilliant, gorgeous, talented, and famous?' Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There is nothing enlightened about shrinking so that people won't feel insecure around you. We were born to make manifest the glory of God that is within us. It's not just in some of us; it's in all of us. And when we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others."
- Marianne Williamson

Big People in Pregnancy

Let me first say that I believe healthy women come in all shapes and sizes. I don’t believe that one body type fits all. I also strongly believe that too many women feel shame, rather than pride for having a body that is less than the super model standard. In other words, our body image as a nation has a long way to go.

On the opposite end of the spectrum, however, is the epidemic that is eating our nation up alive – the obesity epidemic.

What people don’t understand about their obesity is how difficult it makes it for us to provide them with good medical care. On pelvic exam, I can’t accurately assess uterine size or feel for adnexal masses. Fetal monitoring can be near impossible in morbidly obese patients simply due to the amount of tissue between mom’s abdomen and the baby inside. These patients are at much higher risk for both pregnancy complications, like pre-eclampsia and gestational diabetes, and birth complications like shoulder dystocia (when baby gets stuck in the birth canal). Perhaps the most dreaded place to treat a morbidly obese patient is the operating room.

It was my first day as a second year resident on my nights rotation. Instead of the quick and easy primary (or first time) cesarean sections, I was being graduated to repeat and crash cesarean sections. I was excited. It was about 2:00am when I got my first page from the OR in this new position. The patient was a morbidly obese woman with a history of 3 prior c-sections who presented in labor.

From the moment we started prepping and positioning the patient, we knew it would be a challenge. Her belly was too large to see her lower abdomen so it had to be pulled up and held in place with tape. After I made my first incision, I had more than 7 cm of subcutaneous fat to get through before I got to the fascia and muscles underneath. Her fascia, the usually thin layer of tissue covering her muscles, was thickened with scar tissue from her multiple prior c-sections. Instead of cutting easily through a Ziploc bag-like material, it was like cutting through leather. The muscle underneath was no better. In a primary section, you can separate the abdominal muscles in the middle easily and make your way into the abdominal cavity. In this patient, however, her muscle was attached to her uterus was attached to her bladder. She had so much scarring in her belly from her prior c-sections, even my attending and chief resident were having trouble identifying what was what. As if this scarring weren’t a challenge enough, we struggled to keep that thick layer of skin and fat from obstructing our visual field. We tried retractor after retractor and finally settled on using not one but three large retractors. Our poor medical student got a serious arm workout that day. Finally, after almost half an hour of careful dissection, we made our way inside her abdomen.

At this point, we had finally exposed the uterine surface. I made my incision and reached for the baby’s head inside. I grabbed it easily enough but trying to deliver the baby out of the uterus presented a new challenge. Normally, one surgeon applies pressure at the top of the uterus to create the force needed to push the baby out while the hand of the second surgeon is lifting the infant’s head to the uterine incision to guide its way out. In this case, her body mass so much that it was difficult for my chief to apply enough pressure in the right place to push the baby out. She was leaning most of her body weight on the patient’s abdomen to deliver this baby. Knowing this wasn’t going to be easy, we called for a vacuum. This suction cup was applied to the baby’s head and slowly, we were able to pull her out. Delivering this child took probably about 3-4 times as long as normal.

Finally it was time to close up the uterus. Normally, we pull the uterus out of the abdomen, stitch it up under good visualization, then return it to the abdomen. In this patient, with her thick abdominal wall in combination with the scar tissue that made everything stick together, we were forced to stitch her uterus up while it was still inside her belly. Again, the thick layer of fat continued to get in our way and obstruct our field of view. And again, it took us twice the amount of time as usual to close up the uterus. Take note, that a patient continues to bleed until that uterus is closed. By the end of the case, her estimated blood loss was 300-400cc higher than we usually expect. Almost an hour and a half had elapsed since we started to c-section (compare this to the usual 30-40 minutes).

The danger for this patient isn’t over now that the surgery is completed and her baby is delivered. She has got a high risk of poor wound healing and infection. Her belly hangs right over the incision, and as you can imagine, sweat and moisture are not conducive to healing wounds well.

My intention with this post is not to poke fun at morbidly obese patients in any way. I acknowledge that obesity is a struggle and getting/staying thin is not easy. I write this more to point out when one is morbidly obese, pregnancy should not be taken lightly. It benefits both mom and baby to get healthy before pregnancy happens. This particular patient was having her fourth c-section in the setting of morbid obesity. Let me just say I am thankful she wanted her tubes tied that day.

For more on the issue, check out this great New York Times article on the subject: http://www.nytimes.com/2010/06/06/health/06obese.html

Passing the Torch

As we welcome in the new interns this week, I pass on my position as the new kid on the block. What better way to make that transition than to hand down the valuable lessons I’ve learned throughout the year? As such, here is my survival guide to life as an OB/GYN intern:

1. Don’t take anything personally. In our field, people have many reasons for being grumpy: lack of sleep, hunger, stress. As an intern in any residency, you will inevitably be the one who gets lashed out on. Sometimes it will be justified. Most of the time it won’t. The key to getting through your newfound role as Lowest-Person-On-The-Totem-Pole is not taking it personally. When you feel the sting, remember. It’s not you, it’s them.
2. Residency is four years – for a reason. You WILL make mistakes. You WON’T always know the answer. You may not be able to find that cervix. You may not be able to deliver that head in a c-section. You may not be the one to resolve that shoulder dystocia. It is OKAY. Beating yourself up will not change this. Take a deep breath and use it as a learning moment instead.
3. If you don’t know, ask. Dovetailing off the previous point, don’t be afraid to ask questions. Your senior residents and attendings have tons of experience – and pointers. How do they usually handle a tight nuchal cord? What’s their trick to getting the baby’s head out of the uterus?
4. Read like the wind. Okay, so this is a tough one. Who has time as an intern to read? As daunting as this goal might be, the payoff is twofold. First, the benefit of learning is obvious. Second, the act of learning something new is just as much a boost to your confidence as it is to your knowledge base – and when you spend the majority of the day feeling like you just don’t know enough, your confidence will need all the boosting it can get.
5. Anticipate, anticipate, anticipate. Part of being a good physician is being prepared for badness. With every patient, you want to think about the worst case scenario possible and prepare for it. That patient with the Estimated Fetal Weight of 9lbs? As you walk to her delivery, you should be thinking about every step of management in a shoulder dystocia. A patient who is a grand multip who has delivered 6 babies before? You want to be prepared for a postpartum hemorrhage and have the doses of all the drugs you would use memorized. Not only does being prepared help you keep your cool in an emergency, but it also wards off bad juju. Murphy’s law, you know? Badness happens when you’re least prepared for it.

Take the torch. No, really, take it!!! 

 

6. Play nice with others. This especially includes the hospital auxiliary staff. Nurses, scrub techs, nurse assistants, cafeteria workers, housekeeping - they can make your life heaven or hell. If they like you, they can make you look really good in the OR or labor room. They can make things happen for your patients quickly. They can be the shoulder you cry on when you’re having a bad day. These folks have a wealth of experience and knowledge that you don’t in this stage of the game. So be nice. Value them. Make the effort to learn their names. And be humble. Having an MD behind your name does not make you entitled to anything.
7. Be a team player. If you have any gunner-ish tendencies, pack them far, far away now. Intern year is not an independent endeavor. You need your co-residents to get through it – both literally, figuratively, physically, and emotionally. If you see a resident struggling, help out. There will invariably be a time when the roles are reversed and you need some sort of help. Karma definitely exists in the world of medicine. The next time you are swamped in clinic or need a call switch made, you’ll be glad you have people to call on.
8. Remember, everyone has a story. Just like out in the real world, you have people that only ask for help when they really need it AND you have people who whine like the sky is falling. It is hard to be compassionate with the non-pregnant vaginal discharge patient who rolls into Triage at 4am. But if you take that moment to sit down with her, open your mind, and listen, you’ll hear that she just found out her partner has been unfaithful and is paralyzed with anxiety with the thought of having a sexually transmitted infection. All of a sudden, instead of passing out diflucan like candy, you can use this as a good teaching moment about safer sex practices. The chief complaint is usually just the tip of the iceberg. Being an effective physician means taking the time to learn the bigger story.
9. Exercise: Residency is busy. You don’t eat regularly and when you do, it’s easy to eat crap. “I haven’t eaten in 8 hours, of course I deserve these fried chicken strips!” You don’t sleep regularly. You don’t always release stress in appropriate ways and it often builds up, builds up, and builds up inside you. Exercise can be a life saver in dealing with every single one of these issues. It has been my lifeboat in the world of insanity. I honestly attribute 50% of my positive work attitude to the couple of hours I take per week to pound the pavement in my running shoes. Besides, how can we preach healthy living to our patients if we can’t do it ourselves?
10. Remember to be you. Think about the person who filled out those residency applications. That person who prides herself on her cooking skills, who has traveled the world, who played tennis in college, who was a kick-ass salsa dancer. These things make you you. And as easy as it is to let these hobbies fall by the wayside when you work 80 hours per week, you’ve got to do everything in your power to keep this from happening. You will become a very sad, sad person in residency otherwise. Think about it. Your self esteem, no matter how healthy it is now, will take a serious bruising intern year. To keep yourself balanced, you’ve got to have a couple of areas of your life where you feel like a success. Trust me, it’s worth the sacrifice in sleep. You are a doctor now, yes, but don’t forget the dozens of other things you are as well.

Finally, for extra credit, HAVE FUN! What we do day in and day out is such a privilege! Enjoy it!

* Readers, any tips you'd like to add? Add them in the comment box!