Sigh.

Kinda would quite like to title this post with a stream of profanity, but it would be very tired and emotional profanity, so I won't. Another long day today.

Yesterday's little man expired at about 7.20 last night. His mother was no longer on the floor this morning. There was much shrugging and sad shaking of heads.

***

I rushed to the labor ward as the head midwife for the day called "Who wants to do this delivery!". The mother was bent over, clearly trying not to push. She climbed up on the table, and before I got my gloves on, before I even turned around, a splashing sound heralded the arrival of her obviously very, very preterm baby. Curled in a puddle, still cloaked in his amniotic sac, he wriggled weakly there for a couple of seconds while I finished pulling on my gloves, tore away his sac then quickly cut and clamped his cord. I took his tiny body to the resuscitaire again all the while thinking about how similar he is in size to the small boy wriggling in my belly.

I got him there, limp and floppy, not breathing, quick stethoscope to his chest: HR around 60. I grabbed the ambu-bag, and the tiniest mask I could find in the box of assorted masks piled next to the table and bagged him gently. Chest rise. A few puffs later, some small noises. I listened to his chest again, still below 80. I did 20 seconds or so of chest compressions, along with the bagging.

Had a moment of looking down at myself doing this, thinking "holy crap, you're doing chest compressions by yourself on a preterm baby who's fixing to die."

It's funny how the protocols tell you to do one thing and your gut says try something else in the moment. I listened again to his chest, his HR was now well over 100, and I picked up a towel and rubbed on him, flicking his tiny shiny feet. He opened his eyes and mewed at me and began trying in ernest to breathe. With the O2 flowing through the ambubag (I have no idea if it was functioning 'properly' but we seemed to have something which approximated a positive pressure ventilation system happening. I alternated between suctioning his mouth and nose with the machines and encouraging him to continue to breathe. As I took care of babe, midwife colleague snapped on gloves, delivered the synto which comes automatically with the birth of any baby here, and lifted the clamp to deliver the placenta. The scrawny looking cord lengthened, and then flopped limply into the waiting kidney dish with no placenta attached to the other end of it. Crap. Bloody cord had torn right off the placenta.

A passing OB was snagged, loaded her with morphine and proceded with a manual removal of the nastiest looking placenta I've ever seen. She continued to bleed though and about an hour later (things happen slowly here) she pushed out several large chunks of placenta. Officially now in hemmorage territory she was eventually taken to U/S to confirm retained products and then to the OR where a curette was needed to remove said products.

This woman had had no prenatal care, had no idea what her due date was, or even her LMP. We strongly suspect though that 'castom meresin' had been used to induce her labor. Based on her baby's size we estimate him to be 8-12 weeks early, probably around 30 weeks. He weighed in at 1.1kilos (2.4lbs).

I spent the afternoon convincing everyone, from the midwives to the pediatrician to the consultant docs to give him a crack at it. Initially the MW looked 'iffy' as I began his resucitation. I'm quite sure that he would have been left gasping on the table had I not been the one to pick him up. Honestly, had he been born dead, I could have left him be, but he wasn't dead, he was trying to breathe and his heart was beating! I'm not sure if helping him WAS the right thing to do as I write this, but I could only do what I've been trained to, which is to resucitate flat babies when they need it. As it was his breathing gradually improved, his RDS symptoms lessened and his color began to look decent. He was alert and responsive to handling, was rooting weakly by the end of the day (not that he'll be put anywhere near a breast for quite a while) and his O2 sats and HR were peachy (97-99% and 120's-130's).

Call me the eternal visiting optimist, but I would really like this little man to beat the odds. It's clear that I'm about the only person who is naive enough to think he's really got a cat's hope in hell. I scavenged a tiny knit cap (purple) and mismatched tiny preemie socks from a cuboard. I carefully changed his bedding - rolling the edges of a soft quilt up around him. I wrapped his tiny bum in gauze (no nappy small enough) and tucked him in before I left. I hope the night staff watch him closely and make sure he's warm enough.

I'm due to be off for a couple of days of much needed R and R. I suspect I may have to swing by and see how he's doing before Monday though.

***

As I was leaving a mama walked in. She had had her baby precipitously at home, attended by a TBA, but her baby had died (the body had been left at home). She had come in for a 'check-up', her eyes red and swollen from the crying she's begun. All I could do was rub her leg gently and say "Mi sorry tumas."

Too many dead babies for this student midwife.
So it goes somewhere south of the equator.

Lessons Learned

Castom meresin (custom medicine) might cause outrageously precipitous labors, but it also causes shithouse APGARS and neonates who seize at 8hrs of life.

***

(Almost) No pap smears in a population with epidemic HPV infection pretty much equals outrageously high rates of cervical cancer. I've spent a couple of days observing scary, scary colposcopies which will have me getting my pap smears religiously for the rest of my life.

No fewer than 4 women aged under 40 lost their uteri in the last few DAYS here. Here's hoping that is all they lose. I'm officially on board with the Gardasil vaccine. I wish we could be giving girls HERE that vaccine.

***

I hazard to guess also that docs in the US very rarely see cases of metastatic gestational trophoblastic disease. She's 32 and a mother of 4. Aside from also losing her uterus, there is little else to treat the metastases in her lungs, liver and spleen (and they're just the ones we can see without a PET scanner). All of which could have been prevented with a little methotrexate back when her molar pregnancy began.

***

And finally, sometimes after a normal pregnancy and an uncomplicated birth, you end up with a cute as a button kid who struggles, who just looks off from the word go. I cared for him during his first two hours yesterday, and then this morning was shocked to find him gasping in an isolette on 10l of 02 in the head box, cyanosis like I've never seen, O2 Sats in the teens. The peds worked on him, finally got him satting in the 60's (high 90's on room air is the goal), and set about trying to figure out if he had a fistula, or a diaphagmatic hernia, or most ominously a massive congenital heart defect (ToF was debated at length). Portable X-ray came by twice to take films of his tiny retracting chest, and even to my completely untrained eye, the large whitish shadow on the left side of his chest looked too much like a heart that is just way too big. I ran the films up to the consultant surgeon who confirmed what we all feared. That heart completely fills his left chest. We have no way of finding out exactly what congenital defect we're looking at as we don't have any of the equipment to run any of the tests. All we know is that a kid can't live with a heart that big and there isn't a pediatric cardiologist in the country. He's blue now, and working so hard. Soon, probably tonight, maybe tomorrow, or even the next his huge heart will fail.

I went back, relayed the information quietly to the staff, washed my hands, and gave him a little love stroking his cheek and his tummy before again encouraging his mother and father, who've been standing next to that isolette all day, praying on and off to love on him with their hands as well. I hope like crazy that someone will see to it that he's in his mother's arms when he finally flies away.

They have a shrug here which I've not seen before. It's the shrug that goes with horrible realities like this one. It's a shrug that says "there's nothing we can do". I saw it when that tiny baby was left on the resucitaire to expire, and again today from the surgeon. I'd really like to not see it again this trip.

The calm and then the storm.

Both metaphorically and literally...

Yesterday was very quiet, no babies, not even any laboring women, just scrubbing things (and there is much to be scrubbed!) and chatting with midwives and trying madly to not get too dehydrated.

Last night, replete with rumbly sky and lightening it rained, and rained and rained. I rustled up an umbrella this morning and strolled through the rain to the hospital this morning. By 8am we were hopping. Three women presented for inductions, two in spontaneous labor. I did the intake for one of the spontaneous mama's. I checked her first (we don't admit women unless they are at least 4 cm dilated) and found her 2-3, her cervix busily effacing. I then took her vitals which were all normal and popped her on the CTG for a quick strip. Her contractions were coming steadily every 5 minutes or so, and her baby was having variable decels like clockwork with every one. So I sat and watched the monitor and rubbed her back and watched her baby's heartrate rise and fall, waiting to see if anything more ominous would happen. Sure enough within 10 or so contractions, the bell curve shifted a little to the right, and we slid into late decel territory. I grabbed a doc, who proceeded to break her water apparrently with the intent to rule out a cord compression (by tempting a prolapse I thought!). Oddly though, the decels stopped and shortly she was taken off the CTG and was sent off to labor.

I then admitted a woman who's last baby was born still, with no cause ever determined. She was scheduled for another miso induction at 38 weeks. Her admit checks all looked good, the miso was placed, and she too was sent off to labor.

Mama number three for the morning was a woman who started her pregnancy only a few months after her 14th birthday. She too was being induced, having reached 42 weeks.

Shortly after 9, the mother of a woman grabbed me and pointed to her friend who was clearly thinking seriously about pushing a baby out. I grabbed her chart, beckoned her into the Labor ward and did a quick check, confirming that she was in fact complete and her baby was beginning to decend. I noted the scar on her belly, and realized that she too was a VBAC (my second in a week!). In hindsight the reasonably quick decent followed by a sloooooow crown, should have been a tip off, but I was so busy guarding her perineum that when the head finally delivered and then failed to restitute, it took me a 30 seconds or so to collect my thoughts and then address what turned out to my my first solo shoulder dystocia.

I thought for a second how I would ask her to flip to her hands and knees, then abandoned that in favor of instructing the nurse assisting me to pull her knees into McRoberts and do some suprapubic pressure. A couple of pushes but no movement from the shoulder. I felt deeply around baby's neck, and got a good sense of how tight it was in there (noting as I did how tight that nuchal cord was!), I attempted Rubins, still nothing. Baby's head is getting quite dark. I'm frustrated by the lack of options I have with her in lithotomy, so I insert my hand along the side of baby's head, and ran it around quickly, sliding my hand into the curve of her sacrum, feeling that carefully preserved perineum 'give' as I did so but finding baby's posterior shoulder, then reaching past it into baby's armpit then easing it and baby's arm up and out. Baby spilled out with a small torrent of thick mec, was a little flat, but came around quickly. She had pushed her a little girl into the world, her first vaginal birth. She sobbed with what I imagine was relief and no small amount of joy that she had her much wanted daughter. She reached up the way a few of these gorgeous Ni-Van women have and stroked my cheek silently, but with a big smile.

All I had to say quietly, with a big smile was "You did it!"

With impeccable timing the two med students walked in just as my still shaking hands delivered her placenta, and I asked one if he was interested in doing the repair. He did, and I helped him repair his first 2nd degree lac.

As we finished up with that birth we walked out just as the earlier woman with the variables was wheeled quickly out the door to the OR after the next CTG tracing done showed a very unhappy baby having deep, deep (to the 70's for a minute or so at a time) decels. I looked at the head MW and we agreed that decels of any description at 2-3cm probably never bode well for a normal labor course. Baby was delivered happy with a tight double nuchal cord (so much for no cord compression) but went to breast with no problems when her mom was returned to the floor.

An hour before I was due to head home, another mother was put in the labor ward with some funky irregular contraction pattern, a bag of fluids and some Synto was hung to try to even things out. Mama was desperately unhappy. Shreiking and slapping at her mother who was supporting her, and thrashing about on the bed. I sat down with her, held her hand and asked her to focus on me. I spoke soothingly with her, explaining that the contraction was waning, that she could have a rest, and that that contraction was one less. She calmed a bit, and a bit more again when I told her she could get up off the bed and walk about with her IV if she wanted. She seemed to be calmer and coping better, so I stepped out to complete some paperwork.

A short while later she was screaming and as I walked in the MW was trying to examine her. She virtually levitated off the bed, refusing abjectly to the exam, tears coursing down her cheeks. Everyone in the room was yelling at her. I squeezed in next to her, got her attention, took her hand and began speaking quietly to her, asking for her to look at me. She calmed down a bit and the midwife tried to examine her again. Once again she began screaming, begging for her mother to take her away, shreiking that she was dying. I very nearly got, but narrowly dodged a swift kick in the belly, which I think freaked out the midwife more than me. I went around the other side of her bed, sat down next to her head, held her hand and began talking quietly to her. The next exam attempt was successful - in that the exam could be performed - and the MW reduced the last cm or so of cervical lip with her first few virtually hysterical pushes.

I've rarely seen a woman so completely terrified and undone by the sensations of labor, this was more than simply pain, she was absolutely out of her mind with fear and pain and God knows what else. All I kept thinking was "What on earth has happened to you?" Though appallingly the answer to that seems pretty clear. I've never wanted pain medication for someone so badly as I did working with this woman this afternoon.

As she began pushing she gradually seemed to dissociate, her eyes glazed over and rolled back, she found a rhythmic rocking rhythm and assumed a keening breathing between contractions. Gradually, as she calmed outwardly, more and more people left the room. This relieved me. I felt acutely that I wanted as few people as possible in the room with us as she did this work. And work she did. She seemed to be somewhere else entirely but she pushed her baby down. Another sloooow crown, the largest caput I've ever seen, and as there was 6 or 7 cm of head visible, there were bony sutures palpable at 1 o'clock which had me thinking I might be shortly looking at an OP presentation. Instead, when baby's head did slide out, it did so offering me his right coronal suture and the top of one ear first. The most stunning acynclitic molding I have ever seen, and a very stunned floppy baby who took some work to get him to come around properly.

Likewise his mother took some coming around. She seemed stunned, and disinterested in her baby as he was worked on across the room. I continued to talk to her quietly and kept explaining what was happening, everything I was doing as I delivered her placenta and then inspected her (intact!) perineum. I encouraged her mother to stay with her. In a short time baby was whisked off to the nursery (some respiratory distress) and she was left there with her Mom, curled up on her side, apparently asleep but when I touched her hip, she opened her eyes, smiled faintly at me, and reached up to touch my face with another whispered "Tankyu."

Today, with her, I wished over and over that I could speak more than my presently fractured Bislama. Odd though, that her birth is the one I found hardest today, and not the heartstopping "stuck-ness' of that first shoulder dystocia.

Your wish is my command...

I hear your requests for updates. It's been a quiet few days with only three babies for me to report, all uncomplicated deliveries and swift, easy postpartum stays. I've also had a friend in town from Aus and I took a day off to go snorkeling and lie about in the sun. I'm contemplating doing that again tomor

We have had a rash of preterm labor mamas coming in at 30-33 weeks contracting, and with cervixes making ominous changes, in all cases malaria was the preceding event, all of the women were febrile, all the babies were tachy and I learned very fast how to start women on IV mag. sulphate, monitor for toxicity and have the calcium gluconate standing by. Have also administered malaria meds, beaucoup antibiotics and the occasional indomethacin suppository to try to arrest their labors as well as the standard steroid therapy to oomph up tiny fetal lungs (all things I will never do when I get home!!). All of the women have now been discharged and we all keep our fingers crossed that they come back in active labor at 37-42 weeks or thereabouts.

We've also had a rash of babies readmitted for feeding issues and weight loss accompanied in a few cases with some pretty spectacular neonatal jaundice as well. Have spent much time teaching teen moms (16, 17ish) to hand express, cup feed and then latch babies as they improve and are less lethargic. Can now officially say I've seen some babies with "oh my God" jaundice and some TTNB. Conspired with the neonatal nurse to "Rescue" a baby from the nursery and return him to his mama for some serious skin to skin and breastfeeding action. RR fell from 110 to 80 within 30 minutes. Felt good about that.

Hemorrhage mama will go home tomorrow after recovering well. At 23 (and the mother of 4 children) she is now in abrupt menopause and her Hemoglobin this morning was a measley 5.9 after 7 units of (still-warm med student) blood. Med Students incidentally, are feeling very noble. There's little doubt that their donations saved her life. No signs of Sheehan's Syndrome which was my next concern - her breasts are full of milk and her baby is growing apace.

The twins went home on Day 2 of life, nursing and growing like little weeds. Vertex twin #1 is on the right, his footling breech brother is on the left.
Tiny baby Henri also went home with his mama a couple of days ago having made it to 2.0kilo (4.4lbs) up from his 1.9kilo birthweight (below). We think he was about 33-35wks gestation, but dates are hard to firm up here, as prenatal care is so sparse, most women don't make it in to the antenatal clinic till well after baby starts moving, and rarely if ever keep track of their periods...

Started doing some clinic today also, which was a helluva change from the leisurely 45mins-hour long visits I'm used to at home. In 1 hour I saw 8 women, and in my broken bislama managed to counsel them a bit on the importance of their diet (trying desperately to get more protein into it), drinking lots of water, and actually triaged some minor pregnancy concerns ("legs blong me soa morning"= My legs cramp in the mornings - we chatted about increasing her intake of island cabbage which is an insanely nutritious wild green and bananas and milk - hoping for a bit more Cal/mag in her diet) and some more major ones: "Man is blong yu is im killim you?" = Does your husband/partner hit you? - sadly, three of my 8 morning clients replied that yes, they did. We then talked about how often... My mission now is to devise some strategies to be able to perhaps HELP them with this situation. Not so easy when you don't have much language, but at least now it's in their chart, so more folks can hopefully address this with them. Learning curve about vertical, but that's why I came here.

So it goes somewhere south of the equator...

Twins! And DIC/Couvelaire's Uterus.

To the midwives in my life who've been quietly praying for twins and breech babies this trip - THANK YOU! Today those requests paid off when the supervising midwife thrust a chart at me to admit. I wandered into the admitting room, greeted the mama, introduced myself and opened her very abbreviated antenatal chart. My eyes skimmed the data, and stopped dead on the ultrasound report which, like all ultrasound reports here consist of a hand drawn sketch of baby's lie, and are otherwise completely illegible. Big difference with this particular report: there were two stick figures drawn. Sure enough after some further investigation I realized I had a mama in active labor with two babies. Twin A was easily palpable as a vertex, Twin B was much more ambiguous but as supervising MW and Doc said - we'll deliver them vaginally regardless.

After a little kerfuffle about whether they were 35 weeks or later, some steriods and a little nifedipine to try to slow the labor down (didn't work) later she was shortly complete and asking to push. A short while later she pushed her first 2.8kilo baby boy into my hands. I quickly clamped and cut his cord, and we auscultated twin B who was sounding very happy. MW asked me to feel for a presenting part - I reached up and felt what felt like tiny toes inside the second bag of waters. Several minutes tick past as we waited for her contractions to pick up again, and for that presenting part (no one was overly convinced we had either a breech or a vertex presenting). To my inexperienced hands, it seemed like it could have been a head, or perhaps a compound presentation (a hand?) to engage in the pelvis. A couple of contractions later, as baby sank further down into the pelvis, the bag was broken, and in a rush of fluid and fresh meconium, a footling breech babe slid out. Another boy, about 700gms smaller than his brother. Both babies were howling at each other within minutes, as her giant placenta was born. I expect both babies will hang out here till Twin B makes 2.500kg.

Too much fun. :)

The twins were actually babies 2 and 3 of the day for me, and were followed shortly by babies 4 and 5. All NSVD's with no complications. The last one though (a G1P0) pushed out a substantial baby and tore pretty spectacularly down both posterior sulcus'. I took a good look at the tears (which actually started as baby was descending) and decided that the senior MW on the floor should do that repair. So I assisted, with both med students looking on. I used some of my BYO lidocaine and am now officially convinced that it works much better than the lidocaine we have available to us here.

The day though, started with a helluva complication, as a mother who delivered in the night bled torrentially. I immediately asked the Doc to check her first thing during rounds. Swiftly the decision was made to move her to the theater for exploration. Some small lacerations were repaired while they were there, but the blood loss was clearly originating from her uterus. Some very small fragments were removed, by this time it was estimated that she had lost some 2500cc's of blood and her uterus was still not behaving. Medications were administered, both into the myometrium directly, as well as sublingually and IM. An hour later, suspecting DIC (faucet-like, watery bleeding), an emergency hysterectomy was performed when the doc discovered a Couvelaire uterus, which was bleeding through the myometrium into her peritoneum, her uterus was simply incapable of contracting at all. TEBL at the end of the day >5000ml/cc's. She's had 7 units of blood when I left for home this afternoon and her pulse was still in the 130's. Two of the med students (one a universal donor, and the other compatible)parted with two units of their own blood before we had to send them home, dizzy. Hanging nice warm bags of 'doesn't get any fresher' whole blood is definitely something I'll remember.

She is the first woman I've worked with who literally might not survive the experience of delivering her baby who was, incidentally, born healthy and happy (no abruptio placentae which is usually responsible for a Couvelaire's uterus). Little babe has an auntie who's breastfeeding her tonight.

Thoughts tonight toward the pacific if you will, for a swift recovery for this mama.

In which I catch 3 babies in less than an hour.

Didn't think it possible to have so many women decide to have babies within minutes of each other.

Day three, three med students in tow (assigned to me by hospital OB)and instructions to help one of them catch a baby, I arrived to find the admission board with no 8 names on it. Three of them at 8cm, the rest beyond 6, only a couple of them primips. First three hustled into the labor ward. Mama #1 (a G5P4) delivers rapidly, her petite baby (2.4kgs or so) wailed his way into the world. 3 minutes later she pushes out her placenta (I didn't even have to pick up a cord)into my waiting dish, splashes blood on the shoes of med student. Oops. ;) hand off baby to one of the other MW as grunty sounds issue from across the ward. Bolt over, changing gloves en route. Open mid-bundle grab a couple of gauzes as baby crowns. Just barely get mama to slow down a bit, she does, and another baby slides into the world to the sounds of the supervising midwives laughing at me juggling deliveries as they change sheets and threaten to break the waters of the women waiting at 6cm outside the labor ward.

More relaxed second stage to the sounds of Mama #3 fighting an urge to push with an anterior lip.

Young, clearly frightened, and in lots of pain, the three "baby doc's" and I supported her last few minutes of active labor, whispering "it's ok" in her ear, rubbing her calves and hamstrings which were cramping almost constantly. Finally (about 10 minutes later) she was pushing in earnest and we coached her into second stage, tears rolling down her face. I carefully delivered baby's head (she was a primip and respectfully there was no way I was going to let her perineum be a casualty of a 'baby doc's' first catch - aside from the fact that I'd be the one who would then have to repair it!) and then took a first year medical student's hands and helped her catch what wound up being (to me) a shockingly small baby.

For the baby's size (1.8kg's) he was a feisty little thing. Cried quickly, breathed well, and given that I immediately suspected he was either a) pre-term or b)IUGR I handed him off the the RN behind me who bundled him and stuck his tiny head under the ubiquitous plastic box with the O2 tube snaking inside it. I then handed the clamps to the other med student and he delivered her matching tiny, but healthy looking placenta. After I quickly weighed and poked the baby with his mandatory vaccinations I sped him back to his mama (who was lying there sobbing quietly), and quizzed her in my broken French about her pregnancy. "How long was your pregnancy?" "8 months" was her reply. After he went to breast - and sucked, albeit weakly - I rustled up her antenatal chart and sure enough, her babe was a good 6 weeks early. Interestingly, by dates the first mama of the morning was supposed to be less pregnant than this woman, Her baby was 8 weeks early on paper. But certainly wasn't as small or as weak as this little guy.

She called him a lovely French name, somehow appropriate for his delicate little body and he's beautiful. He's in the nursery hanging in there.

My last patient/client for the day presented early on after prodroming for three days, but was sent away with a cervix too posterior to even evaluate. When she returned at about noon, she was 8 cm, and when I broke her bag, as instructed, I found a substantial quantity of moderate, particulate meconium. She was monitored closely, baby's tracing was a bit dodgy (some variable and very occasional lates, all with quick recovery) so the OB instructed me to start some synto, and recheck in an hour in the hope that we could get her baby out sooner, rather than later. Augmentation here consists of 10u of syntocin in 1L of fluid and eyeball 10drops per minute. I started her IV, whacked in the synto and rubbed her back for an hour. At her next check her cervix was found to be the same, and baby was clearly direct OP, with a deflexed head at that. By this stage she was continuing to leak large amounts of increasingly mec stained fluid. "Up the Syntocin." was the instruction from the doc. She has 1 hr and then we get the baby out.

Long story made short: An hour later she was prepped and headed off to the OR where a fat, lovely babe was fished out of a bunch of thick meconium.

Wish I hadn't had to break that bag. But, as small consolation the Doc's parting words to mama this morning at rounds: "You'll be able to have a lovely vaginal birth next time, dear". Wish more docs would say that at home, eh?

Madness.

Internet access is a bit dodgy all of a sudden... Hope to be back on more frequently soon. Haven't dropped of the face of the planet :)

Miso Mama #2

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. ;)