Assume the Position: Memoirs of an Obstetrician Gynecologist (10 page)

     The next day in the Doctor’s lunch room at the hospital, with this episode fresh in mind, I went through the food line and sat at a table with a good dozen or so physicians who were eating their lunch, heavy into a conversation about guns.  I listened for a while as I ate my spaghetti and meatballs. They were into a heavy discussion about guns and gun laws in Arizona, and it became clear to me that most of these physicians owned guns.  I chimed into the conversation at the right time and asked how many of them owned guns.  Every single one of them, surgeons, cardiologists, pathologists, anesthesiologists, obstetricians, pediatricians all owned a handgun.  For someone that never owned a gun and never permitted my kids to have anything other than one squirt gun for backyard pool play, I was astounded.  I then asked if they would all use the gun to shoot someone if necessary, and again it was unanimous.  These were physicians, sworn to care for the sick and injured, Good Samaritans.  If every one of them had and would use a handgun then everyone in Arizona had at least one gun- except me, that is. I was stunned and obviously the odd man out.  But this was America, it was the Wild West in Arizona, and it was a fact of life, like it or not.

     Another time when I found myself raising my voice was with a longstanding patient of mine.   She was an intelligent and mature woman, however consumed with many neuroses.  Her care was not easy and often required extensive reassurance that there was nothing wrong with her and she would be alive and well next year when she came in for her annual exam.  Then she got pregnant with twins, and I cared for her for nine months, which went remarkably well despite all the neuroses.  She chose not to see any of my partners.  She had a birth plan that we went over ad nauseam to satisfy her needs.  Of course when she went into labor the birth plan went out the window, and all her inner fears came unhinged the whole time she was in labor.  When she finally got into the delivery room, she was unglued, unable to control herself or her movements, arms and legs flailing, swearing at the top of her lungs and jeopardizing the healthy birth of her twins since she could not be examined.  Her husband was with her and utterly dismayed and embarrassed, but stunningly silent. I expect he had never seen her like this.   Delivery of twins can be complicated depending on their position and time between birth.  It was not a time for her to be out of control, especially after 9 months of us reviewing things on multiple occasions.  So again, with the labor and delivery nurses and her husband in the room, I shut the door and had a ‘face to face’ conversation with her. The nurses backed against the wall.   Underneath their surgical masks which covered their nose and mouth I could see their eyes widen with both surprise, because they had never seen me talk like this to anyone before, and joy, because they thought she deserved everything I was saying.  I told her she was acting like an immature baby, worse than what I would expect of her and that I would not accept any responsibility for her safety or the safety of her unborn twins unless she listened to me and cooperated. I asked her husband to sign a medical release form.  And I would walk out until she asked nicely for me to return.   I was amazed at how effective this technique was the few times I was forced to use it, and quickly adopted if for my own kids when all else failed.  Even the nurses were impressed. When someone never hears you talk with a raised voice, it is stunning when it happens and often brings people to listen intently to what is being said.  Do it all the time and it will not command respect.  The few times when my kids saw me angry, they listened, too.   For this patient, in the end all went well and she was most apologetic when she returned to the office several weeks later, with two healthy twins in tow. 

     Instrumental vaginal deliveries require special skill, expertise, and knowledge of the limits of a normal labor and delivery, when intervention is necessary, and when one’s own strength can be injurious to the baby. Choosing the kind of intervention required, the length of time one safely attempts the instrumental delivery, and when to bail after having failed in favor of a Cesarean Section is critical to the good outcome of birth for both mother and child.   By instrumental vaginal deliveries I mean that a patient has gotten to the point of complete dilatation of the cervix, she has pushed effectively and for sufficient time so that her powers of pushing and the powers of labor are no longer effective.  Intervention becomes necessary because the baby will no longer come out on its own or with the mother’s help.  Thus delivery needs to be effected by an obstetrician. One’s judgment, experience and expertise now come into play.  The options are vacuum assisted vaginal delivery, forceps delivery, or operative delivery by Cesarean section.  Each requires knowledge of a number of things; maternal bony pelvis size and shape, size of the baby, exact position of the baby’s head, an empty bladder, and a seated obstetrician from which not too much force can be applied.

     As with most vignettes I have recounted, it is only the outlying cases that one tends to remember and which stand out.  My first week as an intern started two weeks before the Chief Residents at the time finished their four-year program. One day one of the Chief’s was performing a difficult forceps rotation, a forceps delivery that not only required traction but rotation of the fetal head with the forceps in place, a difficult and potentially dangerous maneuver for both mother and baby.  He was an enormous, overweight guy, and word quickly spread on the Labor and Delivery floor that he was having trouble.  Many of the new residents gathered outside the labor room behind closed doors and peered through a window into the delivery room, which afforded us a view of his seated body in front of the mother.  His scrubs were tight and short, and in the seated position we could all see more of his butt than was attractive.  More interesting was the force he was using to pull on the forceps, an impressive site on its own.  And yet there was no movement of the baby’s head despite his forceful efforts.  He pulled mightily on numerous occasions.  I was frightened just watching but assumed at the time this was normal since ostensibly he knew what he was doing and I didn’t.  At just one of these moments, for reasons still hard to fathom, the forceps handles, which lock in place when applied to the baby’s head, came disengaged while he was pulling.  He rolled backwards off the stool and fell against the wall, the heavy metal forceps hit the floor with a clang, and I looked around the room to find the baby’s head, assuming incorrectly that he had pulled it off.  There was a stunned hush that went up amongst those of us watching. What a site to have seen though, never before, never since, but I developed a healthy lifelong respect for forceps deliveries from that day forward.

     There are two scenarios in Obstetrics that one has lifelong nightmares about with the hope that one never finds one’s self in such a situation. If there, though, one needs to know what to do since they are both obstetrical emergencies that may result in death of the baby or permanent injury.  The first scenario is called a shoulder dystocia. The shoulders of a delivering baby can get stuck in the maternal bony pelvis such that the head has delivered and is outside of the vagina, but the shoulders remain hung up in the bony pelvis and the rest of the body doesn’t deliver.  Once this occurs, the obstetrician has an obstetrical emergency on his or her hands with time being of the essence.  There are obstetrical maneuvers that one must know how to perform rather quickly to deliver the baby.  Time quickly becomes a factor in this scenario since although the head is out, the chest is not, so breathing is not yet possible due to chest compression, and oxygen no longer gets to the baby because the umbilical cord is trapped in the vagina and compressed, cutting off oxygen.  Fetal hemoglobin is forgiving in a sense because it will hold onto oxygen for a good five minutes before brain damage occurs. Five minutes seems like a long time or a short time depending on one’s frame of reference, but to an obstetrician sitting on the delivery stool, in this scenario, it goes by pretty quickly, especially if all the maneuvers one is trained to do are not working.  One tends to panic, pull too hard and quickly in an effort to get the baby out, and can result in delivery but with a damaged arm from stretching of the nerves in the neck. So one must avoid traction in this scenario, a very hard thing to resist even though it is one’s gut instinct to do so with time ticking away. Maneuvers must be repeated in sequence, and often repeated again, all designed to effect delivery without excessive traction.  One night while my wife and I were having dinner with two of our resident friends in their apartment nearby the hospital, one of the chief residents got a stat call to run to the hospital for just such an emergency that was happening on the labor floor.  When he returned about an hour later, he related the sad outcome.  The baby’s head had been delivered and despite everyone’s best efforts and maneuvers, the baby suffocated because none of the maneuvers were successful at freeing up the impacted shoulders.  He was as white as a ghost when he returned and I don’t think he ever completely recovered from this nightmare.  And of course even though I was not there, I could only imagine this happening to me someday.  One tends to scrupulously avoid ever getting in this situation and to always remember the risk factors that predispose to being in this situation – an excessively large baby or mother, a dysfunctional labor that is not progressing properly, a difficult instrumental delivery which is not going well, a diabetic mom with a large baby and large estimated fetal weight, among others. One never forgets the maneuvers that must be applied in rapid succession to free the baby’s shoulders up and effect delivery.  This scenario has been the cause of many malpractice suits due to permanent damage that frequently will occur to the baby’s shoulder and arm, causing it to wither over time from muscular atrophy secondary to the damaged nerves.  Many courtroom arguments exist over what is too much traction, how it was applied, what maneuvers were attempted, what caused this horrible outcome and whether it could have been avoided.

     The second nightmare scenario is a breech delivery with a trapped fetal head.

In a breech delivery the baby’s bottom comes out first, then the body, with the head last.  The baby’s head is the largest part of the body, and it is bony as opposed to the soft body.  When a baby comes head first, if the head comes out, the body follows with ease. When faced with a breech delivery, the body will always come out since it is smaller and softer than the head, but if the head gets stuck in the maternal bony pelvis, one is faced with a body in hand, and a head still in the maternal bony pelvis, an untenable and often life ending situation for the fetus.  So nightmares abound surrounding breech deliveries.  I was trained in the day that still allowed us as obstetricians to do breech deliveries.  The reality is that the large majority of them go smoothly if selected properly, the labor monitored closely, and the maneuvers to deliver a breech baby are carefully followed.  But selection and experience are critical.  Make a mistake here and a nightmare scenario follows. That is why today most obstetricians will simply just do a Cesarean section if the baby is breech either because they have never been trained to do a breech vaginal delivery, or are just too scared to even attempt one.  But I was from the old school where we did attempt them and successfully complete them when selected properly, although there was always risk involved until the head was out.  Imagine then the horror of watching one of my attending physicians during residency faced with a breech delivery, the feet out, and looking at a foot that was probably half the size of mine (perhaps an exaggeration, but that is how large it was, and over the years seems to have even gotten larger in my dreams). An audible gasp went up in the delivery room when everyone saw the size of the foot that portended a huge baby and even larger head.  He obviously had not selected this patient well, for had he estimated the fetal weight correctly or had assessed the other risk factors properly, would not have found himself in this position.  Fortunately for him, he performed the breech maneuvers quickly and effectively, and even more fortunately for him the mother had a huge bony pelvis with ample room.  A 13-pound baby came out, the largest I have ever seen, without damage.  But the nightmare persists to this day.  I have performed many vaginal breech deliveries because selection was a key lesson I learned, and knowing what a normal labor versus an abnormal one looks like, as well as becoming good at estimating fetal weight and evaluating risk factors.   Many of today’s obstetricians have never seen or performed a breech delivery and just opt for a Cesarean section, which of course increases the Cesarean section rate and maternal risk.  But everyone has a different level of skill and comfort with situations that Mother Nature presents, and if one is uncomfortable with handling a situation either because of lack of training or fear, a Cesarean section is a better option in order to avoid a catastrophe. No argument from me on that one. Skills change. Experience varies. Teaching programs differ. The ability to handle stressful situations varies from human being to human being.  Thus the art of obstetrics changes over the years.   What doesn’t change is the constant state of exhaustion.