On a busy night (or Women’s Health/Pediatrics: a post-mortem)

For the most part, my week of nights on Labor & Delivery was quiet. Saturday night, then Monday night, and finally Tuesday night. Then, a day of standardized patient interviews on Thursday and the final exam on Friday leading me into Spring Break.

Saturday night was quiet. The resident and the attending both disappeared around 2a and left me in the workroom to study for the Shelf exam. Around 530a, I decided to head home.

Monday night was also quiet. The resident sent me home early once the evening settled in and no births seemed imminent. I expected Tuesday night to go the same way. I thought my time on the Labor and Delivery floor would end with a whimper.

When I arrived Tuesday around 6p to the resident sign-out, I realized this night would go a bit differently. The floor was relatively full, more patients in labor at once than I had seen all week. I followed the resident around, hoping that she would tell me to go home but knowing that she wouldn’t.

An umbilical cord could prolapse. We’d rush to the OR with the resident elbow-deep in the patient to keep the cord in place and blood flowing to the baby. I would assist the attending with the emergent c-section. All hands on deck to be safe, even if I didn’t really know what I was doing.

Around 11p, a vaginal birth occurred while I was fumbling with my sterile gloves. I knew the delivery occurred because the room filled with supporters burst into tears. Again, I massaged the uterus and brought the placenta into the world.

Throughout the night, we had been watching this one patient and hoped that her labor would progress so she could delivery a healthy baby. The attending and resident tried every cocktail they could for the IV drips that would enhance her cervical change and quality of contractions. The experienced floor nurses tried positions like squatting, all-fours, and feet up on the railings. Nothing seemed to push the baby over the final hump. With each wave of contractions, she got three good pushes and with the second and third efforts, we could see the baby’s head poking out of the introitus.

At about 3a, the attending had to make a decision: continue trying to push, attempt a vacuum-assisted vaginal birth, or bring her to the OR and perform a c-section to get this baby out of there. Patient had been pushing in earnest for about three hours. Good contractions. The baby is coming out, but just can’t get over that final ridge. Mom wanted a vaginal birth but just couldn’t muster any more energy to push; over the past hour, she had begun to fall asleep between contractions. She didn’t have anymore to give.

So, the attending made the call: grab anesthesia, get a scrub nurse, rally the NICU.

We’re getting this baby out.

This patient had to be put under general anesthesia because of previous spinal surgery that precluded an epidural placement. The attending told me that they had about five minutes between the mother going under and the anesthesia affecting the baby’s respiratory drive. Five minutes marked by the anesthesiologist saying go, to the first transverse incision, to spreading the rectus muscles, to the cut through the uterus to access the baby.

The resident and attending shocked me with their speed and intensity. The procedure resembled, in form only, the scheduled c-sections that I had seen last week. The pace differed completely. The attending and resident had no banter, just focused instructions and requests for tools. They didn’t stop along the way to cauterize small bleeds, they barreled ahead to the goal: the baby.

When they made the cut into the uterus, to extract the small life, the resident drove her hand into the depths and rooted around like an ice fisher trying to grab their catch. Yes, they had administered some compounds to stop the contractions, but the baby was still in the birth canal with the head deeply lodged in no-man’s land. Not far along enough to deliver vaginally, and too deep to pop out with the amniotic fluid.

The room collectively held its breath. We all watched with great intensity and hope as the resident shifted her weight this way and that, trying to find purchase on the small life that approached the five minute mark. Because we had placed the patient under general anesthesia, they decided to play some music off an iPhone during the procedure. Oldies from the 70s and 80s. I cannot remember that exact song that played during this moment, but I do remember that the lyrics spoke of life. Living life. And I thought how proper a hymn while threading the needle.

The resident turned to the attending and asked for help. Every eye in the room, from the scrub nurse to the NICU staff to the anesthesia team behind the drape to me, turned from the resident to the attending. We all watched the attending as she drove her hand into the depths without any hesitation.

While she rooted about, I realized with great humility the eventual goal of my medical education. To be the person that everyone in the room turns to. The buck stops with her. If she cannot get this baby out, then who can? What to do with a mother under general anesthesia, the five minute countdown almost complete, and a baby who might not make it? I wonder how many times she had failed, like the resident, without anyone to turn to for help.

And suddenly, she had the baby in her hands.

Blue, too blue to my eyes, and not moving. The attending placed him on a sheet and we all began to stimulate the baby. After a minute, we clamped the cord and separate silent infant from silent mother. We hand off the blue-nugget to the NICU nurses while we turned our attention back to the mother. There’s still placenta to deliver and a uterus to sew back together.

Tension in the room until finally, we heard a whimper. Not quite a cry. I looked to the table and saw tiny, almost pink, limbs waving in the air. I watched the attending and resident bleed off a bit of the edge in their postures. The only way I knew that they still had adrenaline pumping through them is the small shake of the resident’s hand and the silence of the attending.

By 530a, the baby, the mother, the resident, and the attending all left the OR. The resident went straight from the c-section to another patient in labor. I spoke briefly with the attending, who gave out a long sigh as she sat down.

Earlier, we had talked about the changes in Obstetrics that she had seen in her career. They used to give women ethanol to stop premature labor and the floors would smell like a frat house. They used scopolamine during labor as an anesthetic and women would run up and down the halls in the nude, without any recollection of the events.

I wondered what kind of changes I would see in my own practice during my lifetime. I wondered at the responsibility of the attending, to be that place where the buck stops. But when she asked me if I had any questions about what I just saw, I just told her that I was glad to see her work.

It’s not often you get to see someone at their edge, where the difference between success and failure is in decades of trial and error. And so, I thanked her for her time and made my way home, to end my week of nights.

I still had the standardized patients to see on Thursday and the final exam on Friday. And my partner and my housemate were up and about getting ready for a day of clinic as I began to wind down for sleep. But for that early dawn as the sun rose and lit up my bedroom, I allowed myself to just be glad that everything worked out alright


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