The perfect storm

I was so glad to see the sun come up this morning. It meant there was only about an hour left until I could turn the steering wheel of this out-of-control bus over to someone else.

I was so glad to see the sun come up this morning. It meant there was only about an hour left until I could turn the steering wheel of this out-of-control bus over to someone else.

Every time I have a busy night I think it’s the busiest I’ve ever had but I’m pretty sure that this one, hands down, was truly the busiest night I’ve ever had. Really. Until the next one.

It seems like every week has a special on some complication. Two weeks ago it was ruptured tubal pregnancies, last week it was high blood pressure, and this week it’s abortions. Nobody over here calls them miscarriages. I think in the States the word abortion is so politically loaded that everybody avoids using the word. Even in practice in the States we were always careful to clarify it as a spontaneous abortion in the chart.

Over here when someone says abortion it’s understood that it’s a spontaneous event. Four patients had been admitted with incomplete abortions but the doctor on call before me had been too busy to take them to the OT. There were two patients in labor. One of those patients had had a Cesarean with her first baby and it was pretty clear that this was a big baby and she was going to need another Cesarean. While the nurses were getting her ready for surgery I checked the other patient and I thought she had a pretty good chance of delivering. She was already fully dilated and the head seemed to be coming down.

We took the patient with the previous Cesarean back to surgery and found that she had a ton of scar tissue between the uterus and all the tissues around it. The front of the uterus looked like it had been dipped in glue. It was tough getting through all of that without entering the bladder but we finally got the baby out and then, after checking to make sure all the bleeding we had started was controlled, starting closing the abdomen.

Right then an ambulance pulled up and brought us a patient who was screaming at the top of her lungs. We knew nothing about her, just that she had been found laying on the side of the road, screaming in the same way. The nurses were getting her checked in just as I finished the Cesarean and as I put on gloves to check her she screamed again and the baby’s head started delivering. I got my gloves on and caught (almost literally) the baby, a screaming little girl.

But then the mom started screaming again and there was a gush of water as the bag of waters broke on the second baby she was about to have. She didn’t know she had twins, having never had an ultrasound during her pregnancy. Like most of our patients she hadn’t even had a prenatal visit during her pregnancy. I reached in to feel for the presenting part and felt a pulsating umbilical cord come sliding down, not the sort of thing that is ever welcome, particularly when the patient you just operated on is still on the bed of the only operating room available and that room is still dirty and bloody.

The only option was to get the baby out as quickly as possible. There was still a pulse in the cord but it was slowing down as the baby settled against the bones in the pelvis, putting pressure on the cord. I reached up and felt the baby’s back presenting against the pelvic bones, another thing that you would hope not to find. Ideally you would feel the head and could have the mom push while you put on a vacuum extractor or forceps to speed up the process, knowing that with the cord being compressed you have just a few minutes before the baby starts suffocating. The next best option would be a foot that you could grab on to to help pull the baby out as a breech. But a back doesn’t give you anything and the back sure can’t come out first.

I was able to follow the back bone in one direction and found the baby’s head but the uterus was already starting to contract after the bag of waters broke and I couldn’t get the baby’s head to budge. There was no way to guide it into the pelvis. All this time I could feel the pulse in the umbilical cord; it was still there but it was noticeably slower. So I went the other direction and followed the back to the buttocks, down the legs to the feet. They were so high up in the uterus that I almost couldn’t reach them.

I can’t even imagine what type of pain the mother must have been experiencing while I was doing this but there wasn’t another option and the nurses were great in keeping her focused. I lost my grip for just a second but then grabbed again what I thought was the foot until I realized it had a thumb now. The last thing I needed to do now was to pull out an arm. So I started over, followed the back to the butt and then up to the foot. This time I grabbed it, verified there was no thumb, and started pulling.

There was no movement at first. Maybe it was during the middle of a contraction or maybe I just wasn’t pulling hard enough. I pulled harder and felt what I thought was a small change in the position but it was hard to know for sure. On the third pull, though, there was a definite shift and the foot started to come down. I kept pulling and soon had the foot out of the vagina. I had the nurses push on mom’s belly to keep the baby’s head flexed, chin towards its chest. After delivering the foot the buttocks came out and then I was able to deliver the other leg. And it was about that time that I noticed that this baby was huge compared to its sibling, the female twin who delivered easily.

When you’re delivering twins and the second one is breech, ideally the first one will be the big one, opening the pathway for the second one. That hadn’t happened here. The rest of the delivery is still kind of a blur to me. I know that several minutes had already passed and the pulse in the umbilical cord was slow and weak. I remember that the arms would not come down, I remember that even after finally getting one arm to come down the second arm wouldn’t budge, and I remember that even after finally getting the second arm down the head wouldn’t deliver. I would guess that by now at least 5 or 6 minutes had passed since feeling that umbilical cord come sliding down. I don’t know exactly what finally gave way; I had a finger in the baby’s mouth, trying to flex the chin downwards and suddenly the mother gave an enormous push and the baby’s head delivered up to the eyebrows. One of the nurses gave a strong push on the mom’s belly and the head finally delivered completely.

The baby was a limp rag. I was certain that it had died during the delivery. We took it over to the table and checked for a heart rate but couldn’t find one. We started chest compressions and I starting breathing for the baby. We called for a pediatrician but the nurse came running back and told us they were coding a two-year-old who was in septic shock and had stopped breathing and could not assist. I remember thinking that this was a perfect storm; if anything could go wrong it had. We continued the chest compressions and the bag and mask but I didn’t think the baby was alive. I just couldn’t acknowledge it so we kept up the resuscitation.

Several minutes went by. We would stop every minute to stimulate the baby and check for a heartbeat but felt only a weak, thread pulse. After about three or four minutes we were all ready to stop. And it was right around then that the baby tried to breathe on its own for the first time.

I know this: I will never again underestimate the ability of babies to survive. I had all but written this baby off. It stayed floppy for another five minutes but ten minutes later he (it was a boy) was screaming his lungs out and acting as if nothing unusual had happened. I keep going back and thinking that if we had quit at around the time I had given up hope then the baby might actually have died. He obviously needed all the help he could get to recover from the build up in acid in his bloodstream that had occurred as a result of the long period without enough oxygen. I worry that he still might have experienced some brain damage but it’s a real healthy-sounding cry and he he’s moving all arms and legs and hasn’t had any seizures. I don’t really believe in miracles but if I did I’d be inclined to put this one in that category.

The nurses and I all took off our gowns, double gloves, hat, eye goggles, and rubber apron. We were drenched. We were also a little giddy. Did that really just happen? But you don’t look a gift horse in the mouth, at least not for long. We went through the routine, charting everything that had happened and moving on to the next patient. As it turned out, the girl twin, the first one weighed 5 pounds 2 ounces. the boy twin, the one who took five years off my life and added a lot of gray hair to my head, weighed 8 pounds and 4 ounces, over 3 pounds more than his sister.

And the delivery times show that the second baby delivered 9 minutes after his twin. That’s a long time to go without oxygen. He was probably getting some flow through his umbilical cord, just enough to give him a fighting chance. And he turned out to be a fighter.

It stayed busy from that point on. The other patient who had been in labor ended up delivering shortly after that. I was able to get two of the incomplete abortions taken care of before midnight but the labor ward filled up with patients again and I had to leave the other two to my replacement. All in all last night I had five normal deliveries along with two Cesareans and two incomplete abortions. And, oh yeah, a set of twins that I don’t think I’ll forget for as long as I live.