Assume the Position: Memoirs of an Obstetrician Gynecologist Page 6

  Obesity is just a bad thing. No two ways about it. No matter what causes it, no matter why a person is obese, it only serves to make their own lives shortened and worse than whatever else life would have been for them. And it certainly doesn’t make it easier as a physician to deal with obese patients. But in medicine, as in cards, one has to learn to deal the hand one is dealt. One patient came into Labor and Delivery during residency weighing somewhere between 500-550 pounds, best guess, since there was no way to weigh her. She said she had prenatal care elsewhere, but certainly not in our clinic and we were unable to retrieve any records. If she hadn’t told us she was pregnant and in labor we would not have known. We were able to pick up an occasional fetal heart tone with an external Doppler ultrasound device, but were unable to pick up anything with fetal monitoring. When it came time to examine her in the labor bed, I put on a sterile glove, pulled down the sheet and asked her to let her legs drop to the side. She told me they already were. Instantly I knew I was in trouble now since I couldn’t even see the vagina to do a cervical exam. There were layers of thigh fat obscuring the view. So I began to dig my way in, moving the thigh fat to the side with the assistance of nurses on each side to further retract her inner thighs. Eventually I could see the external vagina, but could not get my arm or hand near enough to get into the vagina, let alone up to the cervix for a pelvic exam, and she could not drop her legs to the side any further. It was futile. Kudos to the baby’s father, whoever that was! Since she was reasonably comfortable, her vital signs were stable, and we could not monitor her on the fetal monitor, we sent her away from the labor floor to a regular post partum bed to wait more regular contractions before we brought her back. About 30 minutes after she arrived to her regular bed we got a stat call to run up to her room. After one push I found a five-pound healthy baby between her legs and the rolls of fat. Some people are just lucky.

  What a contrast of experiences one sees at a teaching hospital! One lady, again in the 500-pound range and a patient of our obstetrical clinic during residency, was scheduled for a repeat Cesarean section. She was brought to the operating room and prepared for surgery. The anesthesiologist had opted to administer a regional anesthetic, or spinal, rather than a general anesthetic with intubation that he had determined to be riskier in her case. After a difficult and valiant attempt at the spinal, he laid her on her back in preparation for surgery, and while she was having her abdomen prepped she began to have a grand mal seizure, likely a result of the spinal medication. I had a 500-pound woman in front of me seizing on the operating table with a baby inside of her that we could not monitor. The table and literally the room were shaking in rhythm with her as she seized. All we could do was try to keep her on the table without injuring herself. Mindful of the first rule of medicine, “Primum non nocere” or “Do no harm”, I could not do a stat Cesarean section on her until she herself had been stabilized, which everyone around her was working so hard to do. When the patient was finally in stable condition, intubated and medicated to stop the seizures, only then could I begin the surgery. Cutting through that many layers of adipose tissue (fat) is always an experience. Much like a knife going through butter, it begins rather easily, but then as one incises further and further deep into the adipose tissue, one realizes how much further down are the other layers of the abdomen, the muscle, the fascia, the peritoneum, the uterus, and then the baby. It was like digging a ditch with a scalpel. In this situation it is not something one can rush through. I had no idea what shape the baby was going to be in, but I was not about to jeopardize the mother’s life. As luck would have it, the baby was in good condition, and all turned out well for the Mom. But what a huge layer of risk she added to her life, and that of her child.

  Lucky, too, was a patient of mine who walked into my office one day in Phoenix, a first time Mom near her due date. I can still picture her walking down the hall way with that uncomfortable open leg waddle most term pregnant patients have, one hand behind her back. I greeted her, asked how she was doing, and she replied great, but that she wasn’t sure what was going on and just wanted to come in for a checkup. My nurse put her in the exam room, got her into a gown, and told her I would be right in. I came in about five minutes later and chatted with her, and then said, “OK, time for an exam”. She put her legs comfortably in the stirrups. I proceeded to examine her, and ran smack into the baby’s head sitting right on the perineum ready for delivery. We had an emergency delivery kit in the office that my nurse hurriedly retrieved. I had her push once, and out slid a healthy baby girl. Everyone in the office was excited, especially the other women in the waiting room as we wheeled her through with the newborn in her lap on the way to the hospital. I am sure most of the women waiting said, “If she could do that, so can I”. I just never saw it happen before or after, but she totally missed her labor. Good for her. Lucky.

  As a new obstetrician on staff at my hospital in Phoenix I was clearly being observed carefully by the nursing staff who of course wanted to know what the new kid on the block had to offer, and whether they were comfortable with me. First impressions were important. Before the first week passed, I was indeed dismayed to find that the first three pregnant patients that I managed did not make it to the delivery room. One in fact delivered hurriedly in the emergency department before she ever got to the Labor and Delivery suite. One was an emergency Cesarean section and delivered in the operating room, and the third was a late spontaneous miscarriage also handled in the emergency department. I felt as if the staff were wondering if I would ever get someone to the Labor and Delivery suite. But that quickly passed as I settled in and the nursing staff came to know me better. I always did as much teaching as I could, and always had the family practice residents at my side since I frequently supervised them on their own patients and let them deliver many of my own. In those early days at the 250-bed community hospital in Arizona adjacent to our office, I felt like I had taken a step backwards from the high tech teaching institution from where I had come in Pennsylvania. The equipment was outdated as were the monitors, the facility was old and in serious need of updating and modernization, there was no NICU, and epidurals were not being given. In fact, I was the only obstetrician on staff trained to give epidurals. If a patient wanted one, the anesthesiologist would have to be called in, often in the middle of the night, and they were reluctant to come and sit with the patient for hours until they delivered. So I just took to administering my own epidurals again, which everyone advised me against in the fear that something would go wrong since I had no back up. But I did so for the first few years. I was trained to do so and comfortable doing so. I eventually became chairman of the OB-GYN department, and set up an epidural program whereby epidurals were administered by nurse anesthetists and supervised by anesthesiologists. The old adage applied that if you want something done right do it yourself.

  One weekend when I was on call, a new patient whom I had only seen once in the office, with her husband in tow, came into Labor and Delivery in active labor on Sunday afternoon. I was at home and got a call from the OB nurse about her arrival, but with the comment that her husband said if I was on call and came in to the hospital and touched his wife he was going to kill me. I had no idea what his problem was, but she needed attention, and I was it for the day. He demanded another Doctor be called to care for his laboring wife. I made an attempt to find someone else who would care for these people. Not surprisingly I was unsuccessful. Asking someone to give up a Sunday afternoon to care for a patient with a violent husband was met with expected resistance from others. I informed the nurse I was on my way in but that she was to get hospital security and have him removed from the labor suite first. When I arrived I saw this gentleman from the rear, wearing a cowboy hat and snake skinned boots glancing over his shoulders at me while being forcibly hauled off by two armed security guards. He muttered rather loudly that he would kill me some day. He was distraught about something. She turned out to be very nice and had an uneventful delivery. Forcibly remov
ing someone from the labor room was not my thing but I saw no other way to deal with it in this case.

  The next day in the Doctor’s lunch room at the hospital, with this episode fresh in mind, I went through the food line and sat at a table with a good dozen or so physicians who were eating their lunch, heavy into a conversation about guns. I listened for a while as I ate my spaghetti and meatballs. They were into a heavy discussion about guns and gun laws in Arizona, and it became clear to me that most of these physicians owned guns. I chimed into the conversation at the right time and asked how many of them owned guns. Every single one of them, surgeons, cardiologists, pathologists, anesthesiologists, obstetricians, pediatricians all owned a handgun. For someone that never owned a gun and never permitted my kids to have anything other than one squirt gun for backyard pool play, I was astounded. I then asked if they would all use the gun to shoot someone if necessary, and again it was unanimous. These were physicians, sworn to care for the sick and injured, Good Samaritans. If every one of them had and would use a handgun then everyone in Arizona had at least one gun- except me, that is. I was stunned and obviously the odd man out. But this was America, it was the Wild West in Arizona, and it was a fact of life, like it or not.

  Another time when I found myself raising my voice was with a longstanding patient of mine. She was an intelligent and mature woman, however consumed with many neuroses. Her care was not easy and often required extensive reassurance that there was nothing wrong with her and she would be alive and well next year when she came in for her annual exam. Then she got pregnant with twins, and I cared for her for nine months, which went remarkably well despite all the neuroses. She chose not to see any of my partners. She had a birth plan that we went over ad nauseam to satisfy her needs. Of course when she went into labor the birth plan went out the window, and all her inner fears came unhinged the whole time she was in labor. When she finally got into the delivery room, she was unglued, unable to control herself or her movements, arms and legs flailing, swearing at the top of her lungs and jeopardizing the healthy birth of her twins since she could not be examined. Her husband was with her and utterly dismayed and embarrassed, but stunningly silent. I expect he had never seen her like this. Delivery of twins can be complicated depending on their position and time between birth. It was not a time for her to be out of control, especially after 9 months of us reviewing things on multiple occasions. So again, with the labor and delivery nurses and her husband in the room, I shut the door and had a ‘face to face’ conversation with her. The nurses backed against the wall. Underneath their surgical masks which covered their nose and mouth I could see their eyes widen with both surprise, because they had never seen me talk like this to anyone before, and joy, because they thought she deserved everything I was saying. I told her she was acting like an immature baby, worse than what I would expect of her and that I would not accept any responsibility for her safety or the safety of her unborn twins unless she listened to me and cooperated. I asked her husband to sign a medical release form. And I would walk out until she asked nicely for me to return. I was amazed at how effective this technique was the few times I was forced to use it, and quickly adopted if for my own kids when all else failed. Even the nurses were impressed. When someone never hears you talk with a raised voice, it is stunning when it happens and often brings people to listen intently to what is being said. Do it all the time and it will not command respect. The few times when my kids saw me angry, they listened, too. For this patient, in the end all went well and she was most apologetic when she returned to the office several weeks later, with two healthy twins in tow.

  Instrumental vaginal deliveries require special skill, expertise, and knowledge of the limits of a normal labor and delivery, when intervention is necessary, and when one’s own strength can be injurious to the baby. Choosing the kind of intervention required, the length of time one safely attempts the instrumental delivery, and when to bail after having failed in favor of a Cesarean Section is critical to the good outcome of birth for both mother and child. By instrumental vaginal deliveries I mean that a patient has gotten to the point of complete dilatation of the cervix, she has pushed effectively and for sufficient time so that her powers of pushing and the powers of labor are no longer effective. Intervention becomes necessary because the baby will no longer come out on its own or with the mother’s help. Thus delivery needs to be effected by an obstetrician. One’s judgment, experience and expertise now come into play. The options are vacuum assisted vaginal delivery, forceps delivery, or operative delivery by Cesarean section. Each requires knowledge of a number of things; maternal bony pelvis size and shape, size of the baby, exact position of the baby’s head, an empty bladder, and a seated obstetrician from which not too much force can be applied.

  As with most vignettes I have recounted, it is only the outlying cases that one tends to remember and which stand out. My first week as an intern started two weeks before the Chief Residents at the time finished their four-year program. One day one of the Chief’s was performing a difficult forceps rotation, a forceps delivery that not only required traction but rotation of the fetal head with the forceps in place, a difficult and potentially dangerous maneuver for both mother and baby. He was an enormous, overweight guy, and word quickly spread on the Labor and Delivery floor that he was having trouble. Many of the new residents gathered outside the labor room behind closed doors and peered through a window into the delivery room, which afforded us a view of his seated body in front of the mother. His scrubs were tight and short, and in the seated position we could all see more of his butt than was attractive. More interesting was the force he was using to pull on the forceps, an impressive site on its own. And yet there was no movement of the baby’s head despite his forceful efforts. He pulled mightily on numerous occasions. I was frightened just watching but assumed at the time this was normal since ostensibly he knew what he was doing and I didn’t. At just one of these moments, for reasons still hard to fathom, the forceps handles, which lock in place when applied to the baby’s head, came disengaged while he was pulling. He rolled backwards off the stool and fell against the wall, the heavy metal forceps hit the floor with a clang, and I looked around the room to find the baby’s head, assuming incorrectly that he had pulled it off. There was a stunned hush that went up amongst those of us watching. What a site to have seen though, never before, never since, but I developed a healthy lifelong respect for forceps deliveries from that day forward.

  There are two scenarios in Obstetrics that one has lifelong nightmares about with the hope that one never finds one’s self in such a situation. If there, though, one needs to know what to do since they are both obstetrical emergencies that may result in death of the baby or permanent injury. The first scenario is called a shoulder dystocia. The shoulders of a delivering baby can get stuck in the maternal bony pelvis such that the head has delivered and is outside of the vagina, but the shoulders remain hung up in the bony pelvis and the rest of the body doesn’t deliver. Once this occurs, the obstetrician has an obstetrical emergency on his or her hands with time being of the essence. There are obstetrical maneuvers that one must know how to perform rather quickly to deliver the baby. Time quickly becomes a factor in this scenario since although the head is out, the chest is not, so breathing is not yet possible due to chest compression, and oxygen no longer gets to the baby because the umbilical cord is trapped in the vagina and compressed, cutting off oxygen. Fetal hemoglobin is forgiving in a sense because it will hold onto oxygen for a good five minutes before brain damage occurs. Five minutes seems like a long time or a short time depending on one’s frame of reference, but to an obstetrician sitting on the delivery stool, in this scenario, it goes by pretty quickly, especially if all the maneuvers one is trained to do are not working. One tends to panic, pull too hard and quickly in an effort to get the baby out, and can result in delivery but with a damaged arm from stretching of the nerves in the neck. So one must avoid traction in this scenario, a very hard thing
to resist even though it is one’s gut instinct to do so with time ticking away. Maneuvers must be repeated in sequence, and often repeated again, all designed to effect delivery without excessive traction. One night while my wife and I were having dinner with two of our resident friends in their apartment nearby the hospital, one of the chief residents got a stat call to run to the hospital for just such an emergency that was happening on the labor floor. When he returned about an hour later, he related the sad outcome. The baby’s head had been delivered and despite everyone’s best efforts and maneuvers, the baby suffocated because none of the maneuvers were successful at freeing up the impacted shoulders. He was as white as a ghost when he returned and I don’t think he ever completely recovered from this nightmare. And of course even though I was not there, I could only imagine this happening to me someday. One tends to scrupulously avoid ever getting in this situation and to always remember the risk factors that predispose to being in this situation – an excessively large baby or mother, a dysfunctional labor that is not progressing properly, a difficult instrumental delivery which is not going well, a diabetic mom with a large baby and large estimated fetal weight, among others. One never forgets the maneuvers that must be applied in rapid succession to free the baby’s shoulders up and effect delivery. This scenario has been the cause of many malpractice suits due to permanent damage that frequently will occur to the baby’s shoulder and arm, causing it to wither over time from muscular atrophy secondary to the damaged nerves. Many courtroom arguments exist over what is too much traction, how it was applied, what maneuvers were attempted, what caused this horrible outcome and whether it could have been avoided.