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Tuesday, 13 May
The day started simply enough: rounds on the post-op OB and
gyn patients. I met Dr S on the ward and
together we checked all the patients.[1] We
started a feverish patient on antibiotics, we cooed over babies and oohed and
ahhed over well healing scars. One
patient was a bit worrisome: a woman who
was about 29 weeks into her 3rd pregnancy, carrying spontaneous
triplets. Her water had broken about 1
week ago – we were hoping to keep her pregnant until 30 weeks. She had already gotten steroids to mature the
babies’ lungs and this morning was complaining of labor pains. A speculum exam revealed what appeared to be
an unchanged cervix. Tocolytics
(medicine to stop labor) were prescribed and off we went, done in plenty of time
to get breakfast. (It helped that we ran
into the surgery team still doing rounds.
One of the attendings was pimping the residents and I overheard this
gem: “Well, it’s hard to have an ectopic pregnancy with a negative pregnancy
test.” That alone gave us hope that the
OR wouldn’t open up for at least another 15 minutes).
The first case was a myomectomy. The patient, a young woman, presented
complaining of abdominal pain and infertility.
An ultrasound had revealed what appeared to be a dermoid cyst (a cyst
composed of all 3 germ lines – the kind of tumor that grows hair, teeth,
etc). Our job was to remove the
cyst. The case was a relatively easy
one, and went fairly quickly.
We had just finished the case, and were talking about the
next one lined up (another myomectomy) when one of the scrub techs burst into
the room and said only, “cord prolapse coming now.” He had no further information other than
that, so I set off down the corridor to find out who this was and if it was
real. As I stepped out of the OR suit, I
see two of the OB nurses flying down the corridor, pushing a stretcher. One of the normally sanguine nurses was
repeating over and over, like some sort of awful mantra, “cord, there’s a cord,
cord…” [2] Now, the double doors leading to the OR suite
go directly into an area that requires proper shoes, a face mask and a head
cover. So, the nurses just slam the
gurney through the doors and then disappear (they usually eventually reappear
once appropriately dressed, but that can take what seems like a really long
time). I yelled for gloves, and checked the woman’s
cervix. Now, I have never seen (felt?) a
cord prolapse before, but it was not a subtle finding. As soon as my fingers touched the cord, I
knew that the nurses were right. Happily,
the cord was still pulsing, and thus supplying the baby with blood and
oxygen. My job was to use my fingers to
lift the baby’s head off the cord until the child could be delivered.
Dr. S had come out of the room by this time, and I
confirmed that this was a real cord prolapse.
And soon, the nurses from maternity were back. The patient, who I had not recognized, was
the woman with triplets. The tocolytics
had not worked (as they often don’t) and when they saw the
cord on the most recent cervical exam, they just ran with the woman down the corridor.
29 week babies in the US survive in NICUs all the time. 29 week babies in Cameroon, in a hospital
with no pediatrician (let alone a NICU doc) and ancient incubators, do less
well. But, there were no more options at
this point. The patient had declared
herself.
The time from the call announcing the patient to that
same patient being sedated with ketamine was probably no more than 15
minutes. But, standing there, with my
hand in her vagina, holding that tiny (though oddly heavy) head up, felt
like a very, very long time. I heard Dr.
S say, “Just get the betadine on her belly!”
The scrub tech kept trying to keep me clean, and in doing so, was going
a bit slow. “It’s okay to prep me,
too” I said, and he visibly relaxed and
preceded to paint my arm orange. Then
the ketamine was in, and I was mostly covered in the drape, and the belly was
open and soon I felt another hand above mine, lifting the head. The first baby, a boy, was out. For some reason, no one was ready for the
baby. The cord was cut and clamped and the baby lying on the drape, but no one
was coming to collect it. Dr S had moved
on to the next baby, so I picked the baby up wrapped in my scrub top and walked
over to the baby table (just a table with warming lights). Luckily anesthesia was there with some oxygen
and the nurse had gotten the kit open so we had towels to wipe and stimulate
the baby with. Soon all three babies
were born – 2 boys and 1 girl. All doing
okay. We determined that all were stable
enough to move back to maternity.
[1]
Dr. S is a 4th year OB/Gyn resident from the USA about to start a
MFM fellowship. She is incredibly kind,
and from what I have witnessed, very skilled.
She is here for 1 month together with her husband, an internist.
[2] A
cord prolapse is when the cord slips out of the cervix before the baby. With the cord dangling out the cervix and the
baby’s head simultaneously pressing against the cervix, the baby can cut off
his blood supply and die.
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