Arrive 5 PM. Get check-out from resident going off duty. 2 patients laboring. Two patients in the PSU (perinatal support unit - where all pregnant ladies over 20 weeks come for urgent care and labor check-in).
5:15. Check on laboring patients. Call OB attendings to update.
5:30. Go to PSU. Do history and exam on new patient. Complains of contractions that are irregular but sharp at 40 weeks, first pregnancy. Check cervix - still closed. Plan to recheck in an hour to see if any change and still contracting. Patient to walk around for a while.
5:45. Call from post-partum ward - post-partum patient with high blood pressure. Go see patient. Patient asymptomatic. Discuss with upper level resident. Write orders for blood pressure medications.
5:55. Call from PSU to check second patient with nausea/vomiting/abdominal pain who has just finished getting IV fluids and nausea medications. Do I want to come see her? Sure. She's feeling a little better but not entirely.
6:00. Call from labor room. Patient feels like pushing. Can I come check her again? Check patient. She is nearly completely dilated and feels pressure/pushy with pain in back. Baby doing fine. Write note. Ask nurse to call anesthesia to give more medicine through epidural. Call attending and update her. Attending says to let her continue laboring for a while before trying to push.
6:10. Call from post-partum floor. One of the newborns had a high bilirubin level. Okay, thanks. Not an emergency, but I'll check on him in a bit.
6:15. Call from PSU. What do I want to do with the patient with nausea? Talk to upper level resident and discuss what to tell attending. Call attending and recommend discharge home with nausea meds. Attending says patient has tried various nausea meds to no effect but she can go home and see him in the office tomorrow. Discharge patient and explain that we can't do much for her. She should take her nausea meds prior to eating and try to keep fluids down as much as possible.
6:30. Recheck PSU patient. Still contracting but not as much. Cervix unchanged. Call attending and discuss options. He says to send her home. It could be a while before she's in active labor and she will be more comfortable at home for now. Explain this to patient and discharge her.
6:45. Call from labor and delivery room on a lady who has come in for induction of labor. They start the night before with a prostaglandin that helps to "ripen" the cervix - make it start to dilate and soften. Then we start pitocin (the hormone that stimulates uterine contractions) in the morning. I've never done an induction before. Discuss orders and procedure with upper level. Nurse states the patient speaks Vietnamese and they are waiting on an interpreter but husband is present and speaks some English. Do history and physical exam, review prenatal records. Do quick bedside ultrasound to verify baby is head down. Call attending and verify what she would like to have done. Write orders and give to nurse to get prostaglandins for the first step of induction.
7:05. Check on laboring patient. Now completely dilated. Patient feels like pushing -uncomfortable. Call attending and update. Attending gives okay to have patient start pushing. She's on her way.7:20. Call from floor. Another high bilirubin. Thanks. I'll follow up. Talk to upper level resident about high bilirubins. Look up information on when to start bilirubin lights. Look up patient's risk factors - not preterm, no infection, no mismatch between mother and fetal blood types. Baby not feeding that well yet but pooping and peeing okay, so probably just physiological. Write orders to recheck bilirubin in AM.
7:30. Check on pushing patient. Not making a lot of progress, but it's her first baby so no surprise. Encourage her to keep pushing.
7:45. Back to induction room. Interpreter available and Cervidil (prostaglandin agent) in room. Explain to patient, through interpreter, how the prostaglandin is used. She will have to stay lying down in bed for 2 hours after placement. Place cervidil near cervix. Write note in chart. Text page attending to let her know induction started.
8:00. Back to pushing patient. Attending now present. I stay in the room to help with delivery. Baby is occiput posterior. This means he is facing up instead of down (or front instead of back), which is harder for mom to deliver. The head has to be molded more into a cone to get baby through the birth canal, and this takes time and effort pushing. After another 30 minutes (seems like longer), the attending decides to assist with vacuum delivery (applies suction to baby's head to help mom get baby out). Baby out and okay. Mom has some pretty ugly looking lacerations that take some time to sew up.
8:55. Check in with upper level resident. The other lady who was in labor at the start of the shift is going for c-section. This means the upper level will be out of commission for an hour doing the c-section.
9:00. Time for a quick dinner and bathroom break - while I can. Check in with nurse on post-partum floor to see if that patient's blood pressure is back to normal.
9:10. Call from PSU. Another patient presenting with "contractions" and dizziness at 35 weeks. Likely dehydration (it was 110 degrees today!). Do history and exam. Check monitor. Fetal heart tones are fine. No real contractions showing on monitor. Review mother's records in computer - frequent visitor to ER. Suspect desire for pain medications or mom just tired of being pregnant. Order urinalysis to check for infection (common cause of preterm contractions) and dehydration. Do pelvic exam with cultures for other types of infections that can also cause contractions. Also check for cervical dilation - no significant dilation noted. Plan to recheck in one hour and follow up labs.
9:30. Visit to post-partum floor to check on hypertensive patient. Blood pressure in normal range now, patient still asymptomatic. Write note on chart and orders to increase dose of blood pressure meds for next day.
9:45. Enter previous delivery in my procedure log. Check email.
10:00. Upper level done with c-section. Check in regarding preterm patient in PSU. Review her lab results (equivocal). Recheck cervical exam - no change. No contractions on monitor. Call attending to recommend discharge and treatment of infection. Explain results and treatment plan to patient. Encourage her to drink lots of fluids and take medications. Discharge patient.
10:30. Call from PSU. First patient seen earlier in evening is back with stronger contractions, this time 3 to 5 minutes apart. Redo history and exam. Check cervix - more dilated than previously. Patient admitted to labor and delivery. Call attending and let him know.
10:50. Call from labor and delivery room on patient I delivered a few hours ago. She passed out in the bathroom. Go see patient. Her vital signs are stable. She's not bleeding. I order a bolus of IV fluids. Discuss with upper level resident. Call attending to notify her of the event. Patient doing better.
11:05. Another patient in PSU in labor. Do history and exam. Review prenatal records. Patient is definitely contracting. Cervix dilated to 4 cm. Plan to recheck in one hour.
11:30. Check on laboring patient. In the process of getting epidural.
12:00. Check on PSU patient. Dilated to 5 cm. Admit to labor and delivery. Call attending to get orders.
12:15. Patient now has epidural and is comfortable. Recheck and still progressing. Call attending to notify. Write note.
12:30. Back to induction patient. Place second prostaglandin tablet for cervical "ripening." Write note.
12:45. Check on fainting patient. Doing fine now.
For the rest of the night, I alternate on checking the laboring patients (room to room), with PSU patients to be seen and examined in between. At some point during the night, I rupture membranes (break the water) of both patients. That speeds things up. One patient begins to push at 5 AM and delivers around 6. She has some extensive lacerations that take a while to repair. The upper level has to cover PSU calls and check on my induction patient during this time. My other patient's nurse calls several times with updates (patient wants to push, please come examine...). The upper level takes care of all of this and updates the other attending. When I'm through with the first patient (about 6:30), I head to the next room, thinking she will already have delivered. But she is just barely complete and beginning to try pushing. Turns out she is also occiput posterior, which takes a lot longer. She pushes for 3 hours and finally delivers with vacuum assistance. I stay till 10:00 AM for her delivery and repairs. I've now been up for 28 hours straight. But it was a great night!
Oooo, this is very interesting. I don't know how much you know about our newest little boy, but he was occiput posterior too. I knew that it was harder for babies to come out that way, but I had never heard why ("head has to be molded more into a cone to get baby through the birth canal"). I ended up with a c-section after pushing for two hours. Turns out, he has saggital craniosynostosis, therefore his head was not able to mold into a position that would allow him to come out. I figured this was the case, but after reading your post, I am pretty positive that was the reason he was unable to be born vaginally. Good to hear what you're up to and glad you are enjoying L&D. :)
ReplyDeleteI got tired just reading about this. I can't imagine actually being there!
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