Monday, I hit the ground running on my obstetrics rotation. It was crazy!!!!! We start with rounds at 6AM - dividing up all the post-partum patients on the floor between those on duty. I only had to see three patients, but it took me a good hour just learning how the charts are organized, how to write up the discharge orders and prescriptions, etc. After rounds, we had morning board rounds, where the folks on duty overnight check out the patients they were following to the new folks coming on the floor (i.e., me). I got three ladies to follow at the start, all in the early stages of labor. My job was to check on them every hour or so and see how they were progressing, how the baby was doing (looking at fetal heart rate monitoring) and update the attending physician. I also got assigned to assist on a c-section right off the bat.
Now, I've seen several c-sections, but I've never done much assisting before. Normally, the attending allows the first-year residents to actually DO the c-section with supervision and teaching. But I must have looked pretty green, so in this case I was only allowed to assist. As it turns out, I wasn't even a very good assistant, so the nurse had to do most of what I should have done. I felt more in the way than anything. But, hey, there will be plenty more opportunities and I can only get better (can't get much worse, I don't think). Overall, it was a good experience to be back in the OR, and next time I will be able to better anticipate my role as assistant (I'd like to assista a couple more times before being the primary surgeon).
Once I was done with the c-section, I checked on all my laboring patients. In medical school, I didn't get the chance to do the cervical exam on many of the patients, so I am still quite inexperienced at assessing the degree of dilation and baby's position. If only you could SEE what you're feeling! The first few times, I couldn't tell WHAT I was feeling, but eventually it got a little easier and I was guessing the level of dilation pretty close to what the nurse or upper level resident was getting. I will still have an experienced nurse or resident check after me for the rest of this month I think to make sure I don't miss anything important. I mean, it's pretty obvious when the baby is crowning, but in between, there a lot of room for error.
After checking in with the two attending physicians for my patients, one wanted me to artificially rupture the membranes (break her water) to help get labor going a little faster. The supervising resident ended up doing that, since I was not sure exactly how to do it and wasn't sure I could even find the cervix, much less the amniotic sac! Later, I did get to place an intrauterine pressure catheter in that same patient (successfully, I might add!). This is a device that goes into the uterus, beside baby, that measures the pressure generated by each contraction. It allows us to assess the quality and sufficiency of contractions to see if we need more pitocyn (a hormone used to enhance labor contractions). A few hours after that, the same patient's baby was having lots of sharp decelerations in heart rate, which usually are caused by the umbilical cord being compressed by baby during contractions. When we ruptured this patient's membranes, she had very little amniotic fluid, so there wasn't a lot of fluid for the cord to float around in, probably explaining the frequent cord compressions. The intrauterine pressure catheter can be used to infuse sterile saline solution into the uterus to provide more "cushioning" for baby. Once we started infusing fluid into this patient's uterus, the baby's heart rate leveled out and did not show those sharp decelerations for the rest of labor. The patient's labor progressed throughout the day. By the time I left, she was almost ready to push, but I didn't get to attend her delivery.
Meanwhile, my other two patients did complete labor and deliver healthy babies. I got to help with both of those deliveries. The attending was present and did a lot of the work, but I was definitely a significant participant in both cases, getting to help baby out, clamp the cord, deliver the placenta, and sew up lacerations. What a wonderful experience! Although I felt a little unsure about my role and not always certain of what to do, the attendings walked me through things. Next time I will be a little more confident and step in to do more and ask more questions. My supervising resident, who was with me all day, was amazing! She was so encouraging and managed to keep a calm and cool attitude despite having a LOT of work to do with two new interns on the floor and a lot of patients.
In the midst of all these deliveries, I also had to check in two patients from the PSU (prenatal triage area). One was in active labor, so she was admitted, and I followed her all day until I left. She was actually ready to deliver when I left, but the night-duty resident got to deliver that one. The other patient was not in labor, but was having some lower pelvic pain (probably muscular). However, she had been having high blood pressure over the preceding few weeks and came in with elevated blood pressure, so she needed to get some labs to rule out preeclampsia. If she did have preeclampsia (I wasn't there when the labs came back, so I don't know what happened), she probably would have been induced, since she was already term (39 weeks). There is so much to learn about what to questions to ask, what to look for on exam and in the prenatal records, what to tell the attending, what forms to fill out, what labs to get... It was definitely an overwhelming first day!
And tonight I will be on duty from 5 PM to 7 AM. There will be one other resident (a second year I think) on duty with me, but I am expected to manage most of the cases I think, and he is simply there for back-up in case I get swamped or need help and to do any emergency c-sections. Whew!!
Yesterday I spent the morning in a non-profit clinic called Choices. They offer free ultrasounds and counseling for patients who are not sure they want to keep their babies. They also provide prenatal/perinatal hospice services - counseling and guidance for patients whose babies have been diagnosed with any sort of severe or fatal problem. Incidentally, Choices is located next door to a late-term abortion clinic - they have a very interesting history. But more on that later. Time to go get a nap before my night shift!
Oh, by the way, when I got home yesterday, my weather guage was showing an outside temperature of 112 degrees!!! But only 20% humidity, so that's good, right? I was going to go for a run but decided against it. By 9PM, the temp was down in the low 90s. It's supposed to be cooling off to the high 90s for the rest of the week.
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