Thursday, January 28, 2010


This week we are working on our skills managing the complications of labor. I would prefer exercises from a book or a lecture series but it seems the scenarios are coming courtesy of the unassigned patients. Two days ago I was receiving checkout and a premature laboring patient's bag of waters ruptured spontaneously and the umbilical cord prolapsed. This is an emergency and we quickly moved to the delivery room to preform an emergency Cesarean section.

Today a patient rolled in by ambulance almost completely dilated with her fourth baby. The baby did not appear particularly large, the woman was not obese, and none of us were there that long before we had a shoulder dystocia on our hands.

To me having the baby's head out and the shoulders stuck behind the pubic bone is the most frightening situation in obstetrics. I called for the nurse to put the patients legs back as far as they would go on her chest, McRobert's maneuver. Asking for suprapubic pressure, I tried first to screw the anterior shoulder counter clockwise, Wood's screw maneuver, then the posterior shoulder clockwise, Rubin's maneuver, and finally I reached in and was able to get the posterior hand and bring the arm out reducing the diameter of the shoulders and dislodging the baby. She is fine and not a huge baby, only 7 and 1/2 pounds.

Precipitous labor is a minor risk factor for shoulder dystocia but unlike the prolonged second stage, from the cervix becoming completely dilated until the baby delivers, which is normal less than two hours, precipitous labor gives you less time to think about the maneuvers you will preform if the baby does get stuck. Today we got it right. Tomorrow there will be other problems. More practice. I wonder when we will be "knowing medicine."
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1 comment:

Jennifer K said...

wow. I can only imagine how quickly all of your decisions have to happen. And you do it all with complete calm...that was my observation! We were just watching the video of Billy's birth (in honor of his second birthday!), and I couldn't help but notice how quickly the room became calm and focused when you walked in! Those residents are so lucky!