Holiday weekend

As an obstetrician my most difficult days are holiday weekends on call. These typically begin with calls from patients who have been trying to go into labor all week. Patients who know their own OB will be off for the next three days and they can't bear the thought of delivering their baby without him. Some of these patients actually make it in to labor, usually after their physician has left town. When they labor, the obstetrician on call delivers the baby and the patient is happy feeling so much better in her un-pregnant state. In these cases the on call obstetrician will be the hero by virtue of the fact that she drew the short straw and was the one who remained.

Of course there are patients who don't go into labor, many of whom are miserable near the end of pregnancy. Some of these women need to call and explain how terrible they feel. If these calls are between the hours of 7 AM and 10 PM and my family has left out of town for my weekend on call, these needs are easily met. I do what I do most days. I listen to the complaints, many of which come under the heading of "discomforts of pregnancy." Included in this category are maladies like indigestion, swollen feet and ankles, heat rash, and insomnia. Asking a few pertinent questions to determine there is no emergent need for the patient to be seen, I give her reassurance about the normalcy of her pregnancy along with tried and true home remedies for alleviating these discomforts.

What I do not do well with are calls at 2 AM and especially those that begin, "I have had this problem for the last two weeks and ...." Hearing this my first thought is "Well if this has been a problem for two weeks, why on earth did you not call your physician, who knows you much better than I, during daylight, weekday office hours for his advice and treatment." I never verbalize this however.

If an symptom that prompts these emergency calls in the middle of the night has been present for more than twenty four hours, I usually begin with, "What about (name the symptom) has made you call me now." The answer will usually fall into one of two categories. The symptom has gotten worse. Or, the most likely reason, at night the patient has time to think more about this symptom and how long it may have been there. Her thinking is compounded by the fact that she found out yesterday her mother's youngest sister, was diagnosed with breast cancer and she fears that she may have the same.

Again, if this is not a true emergency, I try reassurance and a promise to get the patient into the office as soon as the schedule will allow. If there is a need for someone to be seen in the emergency room for a gynecology complaint the wait can be a long one. The number of true emergencies rises as the holiday weekend wears on. More traffic on the highways and lakes along with increased consumption of alcohol will put ER space at a premium.

So, as the holiday weekend approaches, I have stocked up on message pads. I have two books to read and a movie to watch if I am stuck at the hospital with laboring or emergency patients. I have been playing classical music since I arrived this morning. And I could be pleasantly surprised with opportunities to do yard work, rearrange the den furniture and walk the dog between hospital rounds, deliveries and phone calls.

Natural childbirth

I am always curious about the patient's expectations when she informs me that she desires a natural childbirth. For some women this simply means that they do not want a Cesarean section. Others want to labor and deliver completely unmedicated: no drugs, no epidural, no interventions of any sort. A patient once stated that for her natural childbirth would mean that she did not have time to put her make up on before leaving for the hospital. A few months ago I was a participant in a birthing experience that was natural by any definition.

The patient, her husband and their two children arrived at the hospital in the middle of a week day when the labor and delivery unit is typically the busiest. She had called him at work when her contractions were three minutes apart. This was their third baby. The second baby delivered within two hours of the first contraction. The dad, who I will call S, left his high profile job downtown to rush home. Shuffling his wife and kids into the family minivan he rushed the entire family unit to the hospital.

When I arrived in labor and delivery the entire family, including the two older children were in the labor room along with two labor nurses frantically trying to fill out all paper work. Monty Python may have taught us that a delivery cannot occur with out all the proper noise making equipment* but the modern legal profession and hospital administration has hammered into the nursing staff that no baby may safely arrive with any blanks on the admission form.

"She's 5 centimeters." Michelle the primary nurse assigned to care for the patient called out as I walked in the door.

S, still dressed in his three piece Brooks Brothers suit complete with tie in place, informed me that they did not know the gender of the baby. "When the baby delivers, don't tell us the baby's sex," he instructed. "I will cut the cord." Continuing his role as the one in charge he told me, "I will be the one to hand the baby to L." L, his wife, mother of the baby, was lying in bed panting through a contraction oblivious to our conversation.

Always sure of my role as "captain of the ship" (a phrase attorneys use, usually when something has gone wrong), I was not bothered by S's assertions. I have long given up a need to tell everyone I am making the decisions. When there is a crisis usually everyone wants me to make the decisions and they give me their attention quickly. Otherwise I do my job and hopefully help make the birth the joyful experience that it truly should be for all who are present.

As soon as I received my instructions from S, L's bag of waters broke in a huge gush of pea soup appearing fluid. This is called meconium stained fluid and means the baby has had a bowel movement in the bag of waters. By the color the meconium looked old meaning the bowel movement probably occurred sometime before the onset of labor. Not a problem by itself, meconium stained fluid is dangerous if the baby sucks this thick, irritating material into her lungs as she takes her first breath. Called meconium aspiration, this is a condition can result in the need for a ventilator, lung damage and even death in the newborn. To prevent the occurrence of meconium aspiration the obstetrician must use a delee, a suction device to suck out the baby's nose and mouth after the head is delivered but before the shoulders arrive. This feat requires a controlled, cooperative patient, a skilled obstetrician, a helpful husband and a nurse to assist. It seemed that at least two of these four were present.

This is when I noticed the double stroller. The kind where there is a seat in front and one behind. Four year old big sister sat in the front seat playing with her dolls and a two year old about to be big brother was behind her with one of those "board books," the type with the thick cardboard pages that are easy for toddlers to turn. Both kids seems to be fairly calm and satisfied for the moment. Turned away from all the action they were facing into the corner of the room.

Looking around again to make sure all the equipment ready, I noticed a cord blood collection kit. The patient expected me to get a bag full of the baby's umbilical cord blood, after the dad had cut the cord of course. Coming from the umbilical cord and the placenta after the baby no longer needed it, rich in embryonic stem cells, this blood would be cryoperserved in a cord blood bank in case any of the family needed a stem cell transplant.

L cried out, "I need to push!" Checking her cervix again, I confirmed that she was completely dilated and should being pushing. Delivery was imminent. As the green head crowned, the future big brother began to harass his sister sitting directly in front of him in the stroller. Watching the baby's head with one eye, I saw the stroller begin to gyrate out of the corner of my other eye. I ask the second nurse, still attending to paper work, to please check on the older siblings. S was fully focused on his wife and helping her breathe and push. For them, it was as if these other two kids did not exist.

Some how even with S's arms grabbing for the as yet undelivered baby, I managed to delee the baby's nose and mouth removing a great deal of meconium stained fluid from them. Satisfied that he would not aspirate the meconium, I delivered the rest of the baby and continued suctioning until he began to cry.

At this point over in the corner, the now big brother was taking advantage of the opportunity of being totally ignored. He whacked his big sister over the head with his book and she began to wail louder than the newborn. Again, the parents were totally oblivious to anything their older two children were doing. I again ask one of the nurses present to please break up the fight.

L was holding the baby on her abdomen, helping the nurse to dry him off and wrap him in warm blankets while S photographed them both. The two kids in the corner continued to fuss with each other fortunately now without bodily contact while I collected the umbilical cord blood and the second nurse did more paper work.

The placenta delivered and I began massaging L's fundus, the top of the uterus, to prevent hemorrhage. S looked directly at me and commanded, "Stop that! She won't be able to smile for the pictures." At this point my patience began to wane.

Stopping the fundal massage for a moment, I explained to both S and L, "Without fundal massage L, you will bleed." Finally having their attention I continued massaging, "After a third baby there could even be enough bleeding to require a blood transfusion. There will be time for pictures in a few minutes."

With the post partum uterine bleeding at a minimum, I cleaned up the delivery table and the middle of the room, carefully placing all the trash and linen in their proper containers. Covering L appropriately with sheets and blankets, I then invited S to take all the pictures he wanted as I walked over to the stroller and turned it around so that the two occupants could meet their new baby brother.

This delivery was about as natural as a birth could possibly be in a hospital setting today. One of the nurses informed me that the patient had been there all of nine minutes when the baby was born. At this point, I congratulated the couple excusing myself to do my portion of the paper work.

*from the movie "The Life of Brian."

Job description

From before the moment of our first breath we are on the path to our last, our hearts beats a finite number. As physicians we are charged with preventing disease, curing disease, restoring patients to health. Our training makes anything less seem a failure. Yet, life is such that disease and death are inevitable.

For those who practice medicine a worthy goal is also alleviation of suffering. In doing so disease does not always have to be eradicated to make and keep a person whole.