Friday, August 31, 2007


There is a monster(1) lurking in our midst. In medicine, especially obstetrics, ninety eight percent of the time this monster is unseen waiting for the time when chaos strikes. Here is an example:

One Sunday evening I was caring for a patient whose bag of waters had ruptured but labor contractions had not begun. This being her fourth child and the baby's head not yet engaged in the pelvis, I chose to remain in labor and delivery for the evening. The unit was relatively quiet as it was a weekend. The residents and I were reviewing some information and discussing one of their clinic patients.

Suddenly the nurse caring for my patient called out on the intercom: "I need a doctor in here STAT!" Yes, we do use that word and it usually makes my heart go cold when I hear people I trust speak it. On the weekend night shift most of the nurses have seen more than I when it comes to complicated obstetrics.

The two residents and I rushed into the room where we found the nurse on the bed with the patient pushing the baby's head up into the uterus off of the umbilical cord which had prolapsed or worked its way out into the vagina and beyond. On admission the patient had refused placement of an I.V. since she used natural childbirth for her other three deliveries and was planning to do so with this one.

"Call anesthesia. We will meet them in the operating room." I asked in a voice only slightly louder than my normal one. I opened the bedside drawer, extracted an IV kit, prepped and then jammed a large IV catheter in to the big vein in the woman's arm just opposite the elbow. In a voice much more serene than my racing heart told me to use I ask the husband to go to the front desk for clothes to wear to the operating room as I began pushing the bed out the door. We moved toward the operating room with the nurse still on the bed holding the baby's head up.

Now there were six people helping, the nurse anesthetist was drawing up medication and I was talking to the patient. "I know this is not what you planned for your delivery but to save your baby's life we will need to do an emergency C section. The head is on the umbilical cord and it will compress the umbilical cord cutting off oxygen to the baby if you delivery the baby through the vagina. We must deliver the baby as soon as possible."

The patient was staring at me with her wide eyes. Terrified but saying nothing she nodded. In an effort to calm the patient and get everything in place I began explaining to the patient that the anesthesiologist would be giving her some medicine through the IV and she would soon be asleep. We had been listening to the baby's heart beat which remained normal, unlike mine that was pounding wildly in my chest, as we moved the patient into position on the operating table. One resident and I pulled on gowns and gloves as the patient's abdomen was prepped with a splash of antiseptic and draped with a sterile sheet open in the middle.

This is the most dangerous part. The patient must be completely asleep with a tube in her airway before any surgery begins. I have seen over anxious surgeons try to make the incision before the anesthesiologist gives the O.K. Once the patient could no longer see me because of the drape I took the scalpel from the scrub nurses as I kept talking in my calmest voice. "We will be taking very good care of you and your baby while you are asleep. When you wake up you will be in the recovery room with your baby." This could be a lie if the baby is having problems at birth but I usually take the chance and say something calming to the patient. A nurse was holding her hand. I felt it was too traumatic for the husband to watch his wife while the anesthesiologist placed the endotracheal tube in her throat.

Once she was asleep and the endotracheal tube was in place and her airway secure, it took only a minute to make the incision and deliver the baby, an eight pound boy who came into this world screaming his head off. Great! That is what babies are suppose to do. I talked with the dad who was now at the baby warmer staring at his new born son as the pediatric team checked the baby over.

Mom was doing fine, though unaware of all that was happening as she slept under the general anesthesia that had been required for her delivery. This is the happy ending. The one where the chaos monster was thwarted by an extremely skillful group in labor and delivery. "Seven minutes," the nursing supervisor called out. It had taken us seven minutes from the time the nurse noticed the umbilical cord prolapsing through the cervix below the baby's head until the baby was safely delivered. It was seven minutes that I felt like screaming my head off but had managed to do as I had been taught and calmly proceed.

Now I am thinking of times when the chaos monster could not be contained. Times when babies for whatever reason had been stillborn, born prematurely, or born with birth defects. Times come to mind when parents of children I have delivered died of disease or injury. Children I had delivered that have been hurt by unstoppable disease. Two young men I have known from birth have died in car crashes. These were times when nothing, it seems could be done in the face of this monster. Chaos reigns. I want to scream my head off or run away as fast as I can.

In this moment when chaos has retreated I realize that screaming, running and loosing sight of who I am and what I am called to do only increases chaos. It is not I alone but the whole of labor and delivery that stood against this monster. By remaining calm and working together the power of the chaos monster is diminished until the day I longer for when the chaos monster ceases to exist.

1. I am indebted to the Rev. Jimmie Johnson of Waco, Texas for fleshing this monster out for me in a sermon preached at Austin College in Sherman, Texas.
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reverendmother said...

I loved your comment at my place (about John Knox) and had to come over and read a little.

Wow, this was riveting. Being pregnant for the third time is a blessing and a challenge. It's a blessing because I trust my body to know what to do--it's done it twice before. Challenge because the more I learn, the more I know all the random things that can go wrong.

Moms like me are so glad there are people like you who keep their heads in the midst of chaos!

And as an aside, I am good friends with Jimmie Johnson's daughter. A heck of a family.

local MD said...

Thank you Reverendmother. You have been a major source of inspiration for me. I could hardly believe my eyes when I saw your comment.