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is on the way. The neonatologist is also en route as a safety precaution
in case she actually delivers here. The patient and fetus appear to
be stable, and while still contracting around every 3-4 minutes she
isn’t fully dilated. I make the mistake of leaving the room assuming
that the patient will soon be swept away to have her baby properly
on a L&D floor. About 5 minutes later, another call comes from
the room and I walk in to see the beginning of this baby crowning.
The nurses wheel in their delivery kit as I gown and glove up. I
apply a few packets of lubricant jelly, have the nurses move the patient closer to the end of the bed and attempt to create a semi-sterile
field with the supplies available.
Problem 3: It’s nice and easy to set up to deliver in a room with a
bed designed to deliver a baby. Unfortunately for me, this situation
involved a nurse/tech on each leg and the patient mostly laying flat in
a bed, with bag to collect fluid half-hanging off the table, but mostly
just shoved under her bottom as best as I can with no real drainage.
Problems 4 and 5: Did I mention she didn’t speak English? Also,
I have no idea what the word for “push” is in her language. When
you are on the L&D deck you have all kinds of cool toys, like a
tocometer, to help you know when to tell the patient to push. I do
not have that luxury.
I attempt to put a hand on her abdomen to feel her uterus contract so I know when to tell her to push and hope that she figures
out what we want from her. Maybe that was a good thought, but I
have no idea - good thing she does - and she is pushing every few
minutes and the head is progressing. After a few good pushes the
progress seems to slow a little bit. I start to worry a little bit that,
what I now know is a 2-week-late baby, may get stuck. What was
that mnemonic for shoulder dystocia again? All I can remember is
McRobert’s maneuver, but for anyone curious, Rosen’s has a nice one:
But, turning back to the patient I realize she is bleeding a little
more than I expected. It’s hard to figure out where she is bleeding
from, so I deliver the placenta which appears to be intact. I even
sweep and massage the uterus just to be sure, which seems to be
contracting well.
Problem 6(?): Not really a problem because it seems her bleeding
was not coming from the uterus, but I have no access to the medications typically used to help control uterine bleeding after a delivery,
such as pitocin. (Not that it matters because I didn’t know what the
dose would be anyway- it’s just another interesting thought that I
had during this whole process.)
Since the placenta is whole, and seems to be firm, I look for other
sources of bleeding. This is when I realize the patient has a nice 2nd
or 3rd degree tear (Dr. Sterrett would be very disappointed that I
didn’t control the head well enough). I check to make sure it isn’t
a 4th (thankfully it’s not), and start contemplating my next course
of action. The attending asks what kind of suture I want to use to
repair her tear. My only reaction was to smile and say “nothing,”
followed by explaining that since the bleeding is slowing it’d probably
be better to let the OB-GYNs fix her. I plan to pack her to make
sure she doesn’t bleed too much in transport.
Problem 7: No one had ever seen a vaginal packing kit in the
ED before, so we improvised and used some kerlex with a tail for
easy removal.
Pressure Suprapubic pressure: shoulder pressure
By the time this had finished the neonatologist had arrived, and
began assessing the newborn. I think we ended up giving him apgars
of seven and nine. I started the patient on some fluids (because we
didn’t have an IV when all of this started, another