29.05.2020 Last Round: 3 Surgeries and 1 case of Preeclampsia

Incredible, I finish here at the same pace I started off with in January!  This Friday evening we were sorting through our cases.  Currently my board was filled with 4 obstetric patients - prolonged delivery with suspicion of macrosomia, prolonged delivery post c-section, suspicion of pre-eclampsia and as we are sorting out these patients the fourth comes in with contractions and transverse position!  We begin with her as the contractions are starting to increase.  Our initial approach is to try an external cephalic version in hopes to bring the baby into axial position possible for birth.  The version is initially successful but ultrasound confirms the head is not quite were it is supposed to be and only tiny parts (hands and arms) are presenting. So off to surgery we go to the first of three this evening.  Surgery goes well, Dr. Joselitto does the delivery under my supervision and it goes smoothly.  I am soooo pleased.  

The little one is cute as a button!

After coming out of surgery I went back to the labor and delivery room to check on my other patients.  The patient post C-section was slowly progressing but with the help of low dose oxytocin things were steadily moving forward. The other with slow delivery progress had nearly stagnated and would only progress with further intensive midwife support and oxytocin. Together with the local midwives and our volunteer midwife from Hamburg we had discussed referring our patient with pre-eclampsia to focus on the two that needed our immediate attention and support.  Head midwife Tanja had other plans and instead had called in a general surgeon she knew from earlier times.  She had decided to take the patient with stagnated delivery progress and suspicion of large baby to surgery, surely not a wrong decision but one I would not have made at this point in time.  My resident trainee Dr. Joselitto went in, only to assist this case, while I tended to the others including the pre-eclamptic patient.

Already cuddling with mommy and not as big as expected

Once surgery number 2 had finished there was only one left in the delivery room with contractions.  The patient who had had a previous C-section and who I have been most worried about this evening.  She was dilating extremely slowly and support with oxytocin was limited due to previous surgery.  Continuous support and monitoring would have been necessary to potentially avoid ending up in the operating room a third time this evening but the midwife team was exhausted.  In addition my growing concern for a uterine rupture as well as pressure from the team and situation resulted in a third and final operation this evening.  Not a pretty case to end on (this was my 30th and final C-section at MHM hospital). Her rectus abdominis muscle had from the previous operation completely healed together with the fascia on the right so it was next to impossible to avoid some muscle damage.  I truly wish we could have avoided this operation due to the collateral damage but in the end, avoiding a uterine rupture with all the consequences is not something I would like to experience again either.  Here a picture of our last little baby this evening that decided on the alternative route:

Exhausted but happy after hours of labor and a bundle of joy

Oh and the pre-eclamptic patient?  Well we had lab work done and received notice that all was in norm range.  We continued induction overnight.  The following morning another HELLP lab would have been indicated but the lab was closed because it was weekend.  I suggested to refer her to the university hospital where she could be better monitored.  Things came differently than expected.  As we were preparing to put her in the ambulance she developed strong contractions and we barely had her back in labor and delivery room where she delivered a beautiful baby girl.  Delivery number 141 this year at MHM and the final one for me here. The C-section rate during my stay was at 22,69% and I'm quite content with that too!

Baby girl and delivery # 141 

Mom's blood pressure was returning to normal as were the other clinical signs post partum so we were all very relieved to avoid a possible eclamptic situation

*****

So many surgical cases this evening and a plan that went very different from what I had hoped but in the end all mommies and babies are alive and well and that is most important.  I for myself have learned a lot about the decisions and the weight they bear when working in labor and delivery.  It is not always easy and sometimes you ask yourself if the other way would have been better but it teaches you to always reflect, trust your instinct, ask lots of questions and learn continually to make the best decisions with all the information you have acquired.