Ok, first things first. C/s baby continues to go well. His persistent cyanosis, sleepiness and generally weird behavior was attributed to asphyxia – ostensibly from his snug double nuchal cord I continue to be suspicious though that he has something else going on, and am more inclined to look askance at the Misoprostol induction. He finally woke up this morning, after an evening spent enjoying O2 and IV hydration, and wailed for his mama. He went reasonably quickly to the breast and nursed well for the remainder of the day. We’re all hopeful that he will do well. Still looks funky to me, but hopefully he’s just an FLK* who had a rough ride to planet earth to one unlucky mama.
The second miso induction, this time for postdates, from yesterday was still laboring this morning when I pottered onto the ward. We popped her back onto the CTG machine where she’d been monitored occasionally since the miso was placed. The tracing was ominously non-reactive, we put her on some oxygen and almost immediately baby perked up, as did her contraction pattern. I sat and watched for a bit, trying to get a feel for what her labor pattern was like, when the toco tracing (which monitors the uterine activity) and mama both indicated the onset of a contraction. The contraction continued, and continued, and continued. At about minute 5 after the onset of the contraction I was edgy – it should have relented by now. I turned the O2 back on and changed her position. At about minute 7 the baby’s tracing, which had been perky and reactive was again flat, and then deceled decently with slow recovery.
At about that time the OB wandered in. I grabbed him and pointed out the weirdness in the tracing. Tetanic contractions (those that don’t go away) can be an indication of an abruption and can be seen with uterine hyperstimulation which miso is somewhat notorious for. I quizzed mama about her pain, she pointed to a spot low on the front of her on her abdomen and said “It doesn’t go away and it really hurts here.” OB agreed that an abruption may be occurring and immediately asked for an amnihook. He proceeded to break her water - I’d never seen that done at 2-3cm (early!). The contraction abated immediately (about 20 minutes after it started) and the baby immediately began to improve. Within minutes we had good variability back again and shortly thereafter lots of fetal movement had me reassured that breaking her water had done whatever needed to be done in the interim. We agreed (me and the doc) that we would continue to monitor her, but to be on the safe side I drew blood to send to the lab for type and cross match and started an IV. An hour later all still looked good so I got her up and had her wandering about to try to move the labor along.
At about noon she appeared to be in active labor and I checked her – She was 8ish and the baby was so high I could barely bump it’s wee noggin. I popped the CTG on and while she was having strong contractions, the baby’s heartrate tracing was again ‘flat’. The other thing that had changed was that the fluid she was leaking was now the murky pea soup which no midwife is ever pleased to see. I called the doc and the decision was made to prep for C/S. 5 minutes later I’m preparing to insert a foley cath before transferring her across the breezeway to the operating theater and when she rolls over she informs me she wants to push. Gorgeous charge MW cackles with what can only be described with glee and tosses me a pair of gloves, while hollering for the nurse aid to bring us a “mid-bundle” as we were in the admission room rather than the Labor ward/delivery room. About 2 minutes later a pretty floppy babe was born into my hands, MW still cackling next to me. Baby came around swiftly and everyone breathed a sigh of relief a) that we had a happy babe, and b) that we avoided a C/S.
It was the messiest birth I’ve done so far which is not so much fun when you’re the one scrubbing the filthy sheets in the sink… I should note that the active management they’re doing here WORKS. These women barely bleed (~100-150ccs) at all – this birth was particularly mec-cy though which while not terribly offensive, per se, sticks like the proverbial and is hell to wash out. But I digress.
I made sure to check the placenta well (which never seems to get done here – they’re just tossed into the “bin on the right”), and sure enough I found a decent sized retroplacental clot: more evidence that she did, in fact have a, mercifully, small abruption. I asked the doc later why it was that breaking her water seemed to work so well to change the contraction and baby’s heart rate. He said that her ultrasound had shown a lowish anterior placenta and that by breaking the bag, even with the baby at -3 (or however high) and dropping the baby down further into the pelvis this way the pressure of baby’s head might place sufficient pressure on the placenta to arrest it’s theoretical bleeding. Makes some sense. Even though no-one but me will likely ever read it, I charted the crap out of it, as much for practice as anything else.
Super fun case. Which he then made me “teach” two fourth year Australian med students. Actually felt like I had some skills here! Happy days.
*FLK= Funny looking kid. No clinical reason aside from sheer luck. Fortunately the vast majority of FLK's go on to become decent looking humans. ;)