Monday, October 12, 2009

Weekend Part II

Patient #4 delivers that morning - uneventful and well done on her part. The baby was 8-6 over an intact perineum - not bad!

I get a call from a patient (#6) who has been harassing us to induce her since 37 weeks. Because she has big babies. That's her reasoning. Oh, and she's dilated 4-5cms and keeps getting sent home from the hospital. She knows she's 4-5cms because she checks herself. And the baby's head is low and the membranes are bulging. I'm amazed and impressed as it takes most labor nurses a minimum of 6 months of practice to get this skill down. wow. In reality, she's 3-4 and the head is -2 per one of the midwives in the office last week. Her biggest babe was 10 lbs. This one isn't that big. But she's now almost 39 weeks and calling me to let me know how uncomfortable she is. I've spent more time on the phone with this patient then I do with my mother! I tell her to come in and I will see what I can do for her. When she arrives, she's actually really 4-5cms so I send her out walking while we wait for a bed to become available for her.

Patient #5 arrives...she's truly a pre-eclamptic. While BPs aren't too bad 140's over 80-90's, her labs have changed significantly in two days' time. Her cervix has also changed a little since the day before to 3-4/60/-3. So I chat with the doc and she agrees that now is the time to have a baby. It's her fourth so ought to go fairly smoothly. I decide to do some cytotec first to get her cervix really really ready....I also wasn't planning on starting an induction this late in the afternoon if it wasn't truly critical.

So I now have one delivered patient and 5 in the works. Oh, I'm lovin' life at this point!

Patient #6 progresses rapidly (it's her 5th kid) after I break her water. She gets one dose of Stadol and pushes out an adorable baby weighing in at 7-10. Not bad, she was very well controlled and did a great job. Had some placenta issues requiring the doc to come in (who was laready in the building at least) - that was the only down side.

It's time to focus on #1. She had gotten an epidural so I broke her water earlier in the afternoon. She was 4/100/-2 at that point, with some caput bulging through the cervix! Naturally, her contractions start to space out. That's about typical for how my weekend is going. So eventually I had started pitocin. When I finally went to see her again almost four hours later, I asked her if her nurse had been changing her position, because she was in the same position I had left her in. This particular nurse, we'll call her Nurse Sucky, spends lots of time the nurse's station or if she is absolutely required to be in a patient's room...ya know, like, for delivery....she starts through the whole darn delivery. Drives me insane because she pays no attention to what's going on...ya fetal heart tones....shoulder dystocia in progress, etc. Nurse Sucky had not moved the patient a single time! I promptly change the patient's position and mention turning the pit up as if we might want to have a baby *dripping sarcasm here*. It's just about shift change and I have requested one of my fav night shift RNs, Beetus, to take over. I ask Nurse Sucky what the patient's most recent temp was as the baby was a little tachy and the patient had felt a little warm, not to mention her heart rate was a little tachy as well. Nurse Sucky says "I haven't checked recently, let me go do that now". Yes, go do that. I know good and well, that she probably hadn't checked one at all this shift! I look it up and low and behold she 8am, almost 12 hours previously. WTF???

Nurse Sucky comes out and tells me it's 98.5...really? I'm surprised. I decide to go check her (vag exam #3 since breaking water - including the exam when I broke her water) and she's now 8/100/-1 but the caput and molding are lower. This kid is trying to come before she's completely dilated...strange. Plus she's feeling some pressure soon thereafter and is 9cms. Then we get stuck. We have adequate labor (I put in an IUPC at one point) but I know we are running out of time. Baby is looking ok but less and less happy with the process. We spend about 3 hours at 9 then 9 and a half, then a very persistent anterior lip. We change positions frequently, use the peanut, etc. The patient is pushing involuntarily the last hour and a half of that. The lip just would not go away...but the baby wanted to come...the head kept moving down. Finally I call for a section but I put her into one last position - all the way on her right side with the HOB flat. I tell her I will check her one more time before we move to the OR. She's still pushing involunatrily with each contraction, despite repeated boluses on the epidural.

I check her before we get ready to move....the lip is still there but much smaller and a little further back on the head (the caput is just about crowning at this point!) so I have her push while I successfully reduce the lip. I'm so excited - she's gonna do it! I tell everyone to hold on the section and instead she delivers her baby after pushing for fifteen minutes. I did cut a small epis (the equivalent of a first degree perineal lac) due to the heart rate issues and long crowning. Baby came out kicking and screaming with a helluva lopsided molded head! Asyncliticism was the culprit for the cervix not going away. It was all very unusual because if the head is asynclitic then you usually don't get much descent of the head. It also goes to show how inaccurate non-reassuring fetal heart tones are on EFM - as the evidence tells us. But it's still very difficult to wait out a bad strip. This is another prime example of why it's bad to be induced and get epidurals sometimes. Because then you are obligated to use EFM.

Anyway, Beetus and I were very happy that she had a vag delivery. I don't think the patient truly appreciates how close she was to a section. Most OBs would have cut her long before I made the decision to do so.


Patients #2,3, and 5 are all quiet. Patient #2 was on cytotec at this point. I had stopped her pit that morning when I cam in and discovered she was NOT 4cms truly. The foley bulb must not have been all the way through her cervix. Her external os was 4 but the internal os was 1cm! So, I go home to get four hours of sleep...

...when the nurse of patient #2 calls to say she's 9cms and I need you to come. WTF??? Naturally I missed the delivery (it was her third baby). Instead the doc happened to be in house for another delivery so she caught. I was p*ssed. Turns out the nurse had checked her earlier in the night to discover she was 4, then 5 cms. She should have called me at that point. I was so mad. But I know she was just trying to let me sleep. But I told her, it's my job to be there...especially when they are planning natural childbirth!

Patient #3 and 5 are quiet so I round on postpartum and go home to take a nap. Once the pager quieted down anyway! I slept for about 2 and a half hours. I called up to L&D to see what's going on...patient #5 is 5cms but not really feeling them, says Nurse Newbie. Ok, I decide to run to the grocery store then will head to the hospital. Naturally, I get a call from Nurse Newbie an hour later....#5 is 8cms with a bulgy bag and pushy. Greeeaaatttt. I go like a bat out of hell and miss it by 2 minutes. F*ck. Apparently she did a fab job though :)

Patient #3 is all that's left and she continues to do nothing after 4 does of oral cytotec, 2 cervidils. So, cervidil #3 goes in and I leave her for the midwife who left all this for me Friday :p But I'm back on call tomorrow....I bet she's still pregnant.


Joy said...

I'm glad the woman with the asyncliticism baby was able to give birth vaginally!!!

pinky said...

Great post. So this is what I get to look forward to. If I ever stop reading blogs and start the 2 papers I have due on Sunday.