Tuesday, May 14, 2013

Oh the Familiar Feeling...

Yesterday I was working in the OB ward. It was quiet so I was reading a book when I watched some people carry a woman down the hall on a stretcher.  It was Saturday which meant it was a half day and since it was almost noon, I figured that the outpatient department had closed a little early and they were bringing the woman to our “ER” when the outpatient department is closed. It’s a very sophisticated ER……a green bench in the hallway outside the nurse’s station.  I turned my attention back to my book. Until I heard….”Emily!  It’s a pregnant woman!”  Commence stomach dropping and palms sweating. 
She was able to get up from the stretcher pretty easily, which was comforting to me.  As I led her back to the labor room I asked her how many times she’d been pregnant and if she’d ever had a c-section. She said this was her fifth pregnancy and she’d never had a c-section.  (Small “darnit” in my head.  If she’d had a c-section before it would be a simple matter of calling the OR staff and doing another one).  This meant I was going to have to think and try and problem solve.  Double darnit!

We got to the labor room and I started doing the check in things like vitals, listening to the fetal heart tones, etc.  Everything looked ok. The baby’s heart rate was strong.  Ok, so why was this woman here? She said that she’d been in labor since yesterday (which is always a slight help…..but lots of women like to fudge a little on the time because they don’t want to get yelled at for staying in the house so long).  The information that it does give me, is that she’s been in labor longer than usual and it’s been so long that the traditional birth attendant or whoever was trying to help her deliver, became concerned and sent her here.

So why isn’t she delivering?  It’s her fifth pregnancy. By now it should be like a slip n’ slide and the kid should just shoot out of there right?  I did a vaginal exam and she was fully dilated. The head was the presenting part, but it was still a little high.  Her bladder looked a little distended so the first thing I did was put a foley catheter in to drain the urine.  Ok, she didn’t produce a lot so that probably wasn’t what was holding things up.  Next option.  Five pregnancies.  I’ve learned in the past that sometimes these women who have delivered quite a few times (especially if they do it in a short time) will have uteruses that just get tired.  So I started an IV with some oxytocin to see if that could get things moving a bit.  After I started the IV I decided to check things down there again.  Although the woman had said that her water had come out, as I was feeling around, I thought things felt a little too squishy and that her membranes were still intact. Since we don’t have any of the fancy tools to break someone’s water, I pinched and used my fingernail until I could finally make a little hole.  Sure enough, more water came out. 

And then things moved fast! In the next five minutes I saw the head had moved down quickly!  But wait, what was that squishy thing? Was that the cord?  Did the cord come down with the head???  I’ve had that happen before and the baby died when it did, so I’m always afraid of that happening!!  I listened to the baby’s heart rate again and it was much slower.  Shoot. It’s a half day. Who else is around?  I ran down to the outpatient department to see if there was anyone there. Fortunately, my friend who frequently saves my butt was there, even though it was his day off.  I told him what I suspected and he and I ran back down to the OB.  I saw the anesthesiologist from the OR team so I asked him not to leave yet, as we might have a c-section to do.  As I entered the OB ward again I saw one of the midwives who has been doing this whole baby borning thing forever!  As we all headed into the labor room I remarked to my friend…..”See how much Jesus loves me?!?!   I was all by myself and now look at all the help I have!”  J  My friend did a vaginal exam and said that he didn’t feel any cord.  Good!!  (And bad, as I once again proved that I didn’t really know what I was doing!)  Two pushes later the head was out. The cord was wrapped around the baby’s head so I clamped it and cut it. One more push and a bouncing baby boy was born.  8 pounds!! I told them that was an American sized baby!! 

The placenta was delivered just fine and mom had no complications.  I was talking with my friend later about prolapsed or presenting cord (when the cord comes down in front of or in conjunction with the presenting part, thus putting pressure on the cord and essentially cutting off the blood supply and oxygen to the baby).  He gave me some tips on things you can do if you have that problem. In the States they will immediately go for a c-section but here, it takes an hour to get everyone into the OR so the outcomes are also not great.  But praise God this woman delivered just fine!! I think it was probably the combination of a tired uterus and intact membranes that slowed things down. I was a little bummed at the end because if I hadn’t suspected the cord issue, I totally would have delivered her by myself!!!  But I thank God that even though I had to eat some humble pie, the woman and baby did fine and I got to learn some more.  

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