Sunday, August 1, 2010

Ode to the Bestie

I just gotta say that my BFF rocks. She really pushes my intellectual boundaries all the time. Lovin' it! We are currently reading the same book together so we can discuss it as we move through the book. I've not ever done that and am really enjoying it.

Can't trust them multips

Had a couple interesting births lately. Both were somewhat complicated with risk factors, which always makes for some excitment :p Both were multips - one having her 4th baby and the other having her 5th.

The first lady came in complaining of bleeding. She was contracting with a good bit of uterine irritability. Was only mildly uncomfortable with her contractions. However, there was enough bleeding that it had ran down her leg prior to her arrival. She has a history of substance abuse and has been in treatment for three months. She had only a few visits in the office, poor historian, being confusing when giving her history. She did not have any of her previous babies, but was hoping to 'keep' this one. She didn't have any idea when her last period was so I only had a third trimester ultrasound for dates (which can be off by 3 weeks either way). She had been measuring appropriately for that EDD. Her exam on arrival was 2-3/60/-1. The baby was very active. By her EDD, she was 38 weeks (which means she could be anywhere from 35 to 41 weeks). After watching her for a bit (she was also having the occasional small variable but otherwise had a very reactive strip) then re-checked. She was 3-4/80/-1 with just a small amount of blood on the glove. She continued to be quite comfortable. I decided to just sit on her for the night and admitted for expectant management. I just felt very uncomfortable with sending her home. Her UDS was negative btw.

Eventually, she got uncomfortable and asked for an epidural at 4/90/-1. She putzed along. Hours later she was 6/90/-1 so I broke her water figuring we were pretty committed at this point. She continued to have periodic bleeding that was always just a little runnier and heavier than normal show. She progressed to 8cms fairly quickly but then kinda stalled out. We flipped her from side to side and she eventually arrived at 10cms with no further intervention. She began to push once she was feeling the urge to do so. She took a good half hour to push the baby out and baby came out screaming covered with a small amount of bright red blood. I expected to see evidence of abruption on the placenta but none was apparent except for a sort of thrombosed vessel at the placental border. Not sure if that was the source of bleeding or what. No lacerations were evident. She was absolutely fine afterwards.

The second lady was being watched very closely due to suspected chronic hypertension. She'd had this issue with each pregnancy and a possible abruption with one previous pregnancy. She would have elevated BPs prior to 20 weeks (which means increased likelihood of chronic hypertension as pre-eclampsia doesn't present prior to 20 weeks). We were treating her with medication for her blood pressure. She came in complaining of contractions, just barely shy of full-term (37-42 weeks). She came in requesting an epidural with an exam of 4/50/-3. She got her epidural and then after a few hours went by, no progress had occurred.

The head was too high for rupturing her membranes so started pitocin instead. I broke her water a couple hours after that, her being 4/80/-2. She took off after that. By 2 hours later she was 9cms. We had just enough time to finish a delivery in another room :p

When I checked her she was 10cms but still very high so even though she was feeling some pressure, I suggested lying on her side (Nurse Crappy was the nurse assigned so you know how that goes!) to let the baby come down on its own. 5 minutes later, it was time. The delivery was great the baby just oozed out on its own. I had dad literally catch. It was awesome to watch!

So you would think that women who have had several babies would just spit those kids out. but not always! In fact, once you get up into 5,6, or more kids, the possibility of complications and labor dystocia increases :p