Wednesday, April 6, 2011

Art vs. Science


beep…… beep……beep…..

The fetal heart rate is in the 60’s. I recognize the cadence of tones, without having to look at the monitor. The nurse looks at me anxiously, waiting for instruction on what to do next. Glancing past her, I see she has all the supplies in the room to prepare for a cesarean section.

This is the patient’s* third pregnancy. The first two pregnancies culminated in beautiful 'Kodak moment' vaginal deliveries. However, this labor was not going quite as dictated by the birth plan...

Earlier that day, she had started her labor with a bradycardia, where the baby's heart rate had dropped to the 70's for several minutes. Luckily, it resolved nicely when we changed mom's position. The baby’s heart rate becam reassuring, showing signs of adequate oxygen and health. Her labor had progressed quite well until 8 cm at which point the baby’s heart rate tracing began to have late decelerations, which can be an indication of poor oxygenation. We rolled her onto her left side and applied oxygen, but despite our efforts, the decels worsened. With the next cervical exam, there was only a small amount of cervix remaining (“anterior lip”). The cervix is essentially like a very tight turtle neck that the baby's head has to squeeze through as it passes through the birth canal, with only the strength of the uterine contractions and gravity to help it escape. I placed her in 'knee- chest' position, hoping that gravity and physics might help dissolve the anterior lip of the cervix. I rechecked her and found that my attempts to convince her cervix to dilate were not working.

Time. How much time do I have to get this baby out? Assessing a baby during labor is like taking care of someone in the ICU with only one vital sign. No physical exam, no pulse OX, no stethoscope, just a 1 lead EKG to make your diagnosis. In obstetrics, we have only the fetal heart rate tracing and can infer limited information from it. There are a number of fetal heart rate patterns that can tell us the baby is healthy. Most of the “bad” patterns are not very accurate. Around 97%of the time even though the tracing looks “bad” the baby is still OK… but there’s no way to know for sure. Studies suggest that it takes up to 30 minutes of decreased oxygenation to lead to brain damage.

I look to my patient, knowing that she wants a vaginal delivery very strongly but she also has put her trust in me to help her have a safe delivery and a healthy child. I look at the clock, and see the pattern has been questionable for about 20 minutes. I need this baby out in 10 minutes or less.

Do I take her to the OR? Do I try to have her push?

If she pushes through the lip, I’m the hero for helping her achieving the much desired vaginal delivery. If it doesn’t work, we may have to rush the delivery and do a stat c-section.

I search the fetal heart rate tracing for one sign of reassurance. Come on give me something I can hang my hat on: an acceleration or some variability. I know the patient can do this vaginally if only we could buy her some time. The tracing, however gives me no reassurance.

Let’s try to push one time, I tell the patient. If you can’t bring the baby close enough to deliver were going back for a cesarean section.

The OR team begins to set up. I position her at the angle I think gives her the best shot at pushing past the anterior lip of the cervix.

With the push, the multiparous cervix dissolves and I feel the baby entering deeper into the birth canal.Yes, I think internally, this is going to work. As the contraction finishes, the head retreates back up into the pelvis and the cervix reappears. Crap.

beep…… beep……beep…..

The fetal heart rate is in the 60’s. I recognize the cadence of tones, without having to look at the monitor. I meet the nurses anxious gaze. The art of obstetrics has failed me and now the science of it is pounding in my ear drum telling me that time is up. I have to call a stat section or the risk to harm to the baby will quickly climb above the risk of cesarean section to the mom.

The moment I call it, the room becomes well-oiled chaos. As we sprint to the OR, I wonder to myself if maybe we should have tried one more push? But on arrival to the OR the nurse rechecks the heart beat, finding it still in the 60s.

Moments later I pull a screaming healthy baby girl through a low transverse uterine incision. The cord had been wrapped tightly around the shoulders, preventing her descent. The baby comes out screaming, filling her lungs with much needed oxygen and quickly turning a healthy shade of pink. The mom cries gentle tears of relief.

Later in the waiting room, I let the family know mom and baby are fine.

I await their reaction.

The dad thanks me, with tears in his eyes.

These are the hardest calls to make. I had mere moments to decide the fate of this precious woman and her child. In this situation, the safest thing for the mother was a vaginal delivery whereas the safest thing for the baby was a cesarean section. I try my best to use the science available to balance the pendulum of mother's and baby's safety to achieve a healthy delivery for both. In the end, that's what matters most.

Photo credit to: www.amandamcnealphotography.com

*All patients examples are either used with the patient's permission or are a fictitious conglomerate of multiple patient encounters.

Also posted at ThePregnancyCompanion.com

20 comments:

  1. Wow, Rh+. You had me in goosebumps. This is fabulous. I skimmed it, cause I really gotta get back to my prostate cases, but am looking forward to reading again slowly tonight.

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  2. Truly beautiful post.

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  3. Plan to go into OB/GYN, and I absolutely loved this post. Thank you for sharing a peak into your day.

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  4. Very well said! I've had to make the same decision many times, it is not easy and not taken lightly.

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  5. I loved this.

    I hear so much about "unnecessary" c-sections from non-medical folk, but I think they would look at it very differently if they were in the OB's position, having to make those life and death decisions in these situations. I might have to point some of them in this direction! ;)

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  6. Thanks, Anon and Giz

    Good luck on your journey, medstudent
    You might also want to check out this post about how I fell in love with OB.
    www.mothersinmedicine.com/2010/04/why-i-became-obgyn.html

    Kyla, thanks. The national CD level is too high. I don't have answers as to why. I try not to worry about my 'rate' but instead try to take the best care of my patients that I can.(incidentally, I recently figured out my rate to be comparatively low)

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  7. Wonderful story. I was this mom last June. I appreciate my OB very much. I don't have words for how grateful I am to have a happy, healthy Babyboy.

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  8. Mixed feelings about this story...not a lot of good scientific evidence to support many of the major medical decisions we make on behalf of our patients. Somedays we are the hero...somedays not.

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  10. Very exciting post!
    After having a pretty rough experience giving birth to my little boy, it's so good to hear how much consideration you give to both the mom and baby. Loved reading your perspective.

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  11. I loved how you described the monitor. This year when I labored with my second child listening to his heartbeat was really something. I remember feeling him move- a familiar sensation from throughout the pregnancy- but while on the monitor also hearing the heart beat. He made me laugh when a kick would be followed by an increase in HR! As a cardiologist the sound of the monitor is an everyday thing, but the opportunity to hear what is going in utero... amazing.

    On another note, when approaching labor I did not have a birth plan. For some reason after my OB rotation in med school I developed a negative connotation toward the term. I was worried about a million things, and figured my main hope was for a healthy baby- and if a vaginal delivery great- if a section fine. Rh+ you write how your struggle included the fear the mother would be upset to not have the delivery she hoped for. What a tough spot to be in. As if having the responsibility of getting the little ones out safely was not enough! Your effort to balance the two is admirable, I am certain you have many grateful families.

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  12. Beautiful post, got a lump in my throat of anxiety then happiness... made me think about hearing similar decels during the birth of my son (remembered just enough of OB from med school to get myself completely freaked out during the delivery). Part of me is jealous that you get to take care of such an intensely emotional period of patients' lives and the other part doesn't envy you for feeling that responsibility of two patients at once... I love being an internist, but you have an amazing job.

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  13. Thank you for the insight into your world. Wow. Us moms definitely appreciate the expertise that doctors like yourself have to keep us and our babies safe!

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  14. Oh my gosh, I could never be an OB. But hats off to you. I'm grateful there are steely-nerved docs like you to deliver the babies of chicken docs like me!

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  15. Hi RH+ -as I've commented before, I get just where you are coming from with this (sounds like my recent nigth shift!) And that moment when they first start to turn pink- its just magic, everytime...

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  16. i am an internist and also am incredibly grateful to my OB, who put my baby's safety first, and made right the call. I desperately wanted a vaginal delivery, but am happy that I put my trust in her knowing what really mattered was a healthy baby.

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  17. Thank you so much for this post! I'm finishing my first year in med school, but OB is totally on top of the list for me, and this keeps it up strong and high on the list! Thank you for your time writing it!

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  18. I have spent many years being a childbirth educator that had less than nice things to say about OBs in general. I really think that what needs to happen so that less "unnecessary" c-sections happen is educating the mom/dad/partner so that they take some of the responsibility back on themselves for the health of their pregnancy, and how they approach labor and birth. C-sections can be life saving for moms and babes! I am so thankful we have the technology and know-how for when it is necessary....it is just all too often a domino affect that starts even early in pregnancy (or before) and culminates at birth.
    I wish and hope that more and more OBs encourage moms to get a great education during pregnancy! Thank you for being willing to make these tough calls! All of the "unnecessary" sections are not necessarily the OBs fault.

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  19. Thank you for this--it's beautiful! I really appreciate the depth of your knowledge and your caring. I wish all birthing moms had an advocate like you. There's no one-size-fits-all birth, but care and respect are universal needs. Thank you!

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