by Barbara Ebel
“What kind of questions?”
“Was she already obese before her pregnancy? Did she also lump on excessive weight gain during her pregnancy … which would be over thirty-five pounds?”
“We talked about her weight gain. She gained forty-seven pounds. And she weighed in at two hundred twenty pounds on admission, which did make her obese before her pregnancy. Before, she must have been around one hundred seventy pounds.”
“Very nice. Which means you did a very thorough history and it also means she is positive for both those factors. Now there is another additional risk factor. She’s having a prolonged second stage of labor.”
Annabel moved her book to the couch as Roosevelt added, “We didn’t want to call you before, but now is the time to be in Mrs. Santana’s room.”
“Thank you for letting me study. The risk factors you’re referring to … what is the possible problem?”
“Shoulder dystocia upon delivery of the fetus.”
She furrowed her brow with only a vague impression of what that meant.
“You’re coming with me.”
In Room 2, Laverna was in full lithotomy position, working hard at her delivery with her husband and nurse nearby. Jed might not like needles, Annabel thought, but apparently he had no problem with childbirth. Caleb was in blue attire at the bottom of the bed and his tense facial muscles relaxed when Roosevelt came beside him.
Laverna had a moment between contractions. She spooned an ice chip into her mouth from a paper cup and grimaced up her face like she was in agony. “What the hell is wrong with these? Jed, get me new ice.”
Jed sighed and hustled out of the room. Laverna’s pain was much diminished from the epidural but there was still some to contend with. She accepted the fact that a solid block of numbness would render her unable to push, but she still voiced her complaint.
“Make me …” she screeched with pain, “knocked out …” she yelled, “or numb …” she squealed, “like my body’s got no nerves in it.”
Jed walked back, his eyes going from one person to the other. He handed the cup of ice to Laverna. “Just don’t throw it back at me.”
“You’re not funny. Besides, didn’t your mama teach you anything?”
Jed kept his lips plugged together. No way was he touching that remark.
“Men die in battle …” she panted, “and women lose their sense of humor in childbirth.”
After Laverna had her way with words, Caleb gave her a big nudge. “You can do this,” he said. “Next contraction, give it all you’ve got.”
Lucky for Dr. Gash, Laverna gave him no back talk and did as he requested. With a mighty push, the soft skull of the fetal head popped out.
But the baby’s head did not keep sliding forward. It retracted back towards Laverna’s vaginal opening.
“Let’s push some more,” Dr. Roosevelt said.
“Whaddaya mean by ‘let’s’? There’s no ‘us’ in my pushing.”
“Sorry, Mrs. Santana. You are right about that.”
“Of course I’m right. The customer is always right.”
Annabel heard Roosevelt exhale in a puff. Another contraction came quickly and Laverna pushed. Caleb glanced up at Dr. Harvey. The fetal head was still retracted back toward the maternal introitus and the fetal shoulders were not being delivered.
Annabel realized, like many attending doctors, Dr. Harvey had years of experience. After seeing so much in his career, he anticipated this as a problem. Laverna’s risk factors were his first clue. She shuddered for the unborn baby, the mother, and the two doctors next to her and wondered how they would solve the problem. She figured an emergency C-section was always an option.
“Mrs. Santana,” Dr. Harvey said, “there’s a problem. The top of your baby’s head is here, but the rest of him is slow to follow.”
Jed stood and took a spot next to Annabel. Laverna pushed again.
“Or will not follow,” Dr. Gash mumbled.
Jed’s eyes bulged. He had watched their first baby be born, but this one was not proceeding as it should. He backed up next to his wife.
“To clarify,” Roosevelt said, “your baby’s anterior shoulder is impacted behind the symphysis pubis. Dr. Gash and I will try and free it up.”
Roosevelt signaled to the nurse to help him and he gowned and gloved like Caleb. He motioned for the resident to change place with him. Annabel figured he would only take over if it was an emergency and his proficiency was needed. Caleb went to the side of Laverna’s leg while Roosevelt wrapped his hands on the fetus’s head.
Caleb placed his right hand on Laverna’s right foot. He hyperflexed her hips onto her abdomen. With his other hand, he applied suprapubic pressure and checked for visual clues from Roosevelt if his technique was correct.
“Dr. Gash is trying to push your baby’s shoulders into an oblique plane,” Roosevelt said to Laverna and Jed. He gazed at Annabel. “I’ll explain the McRoberts maneuver later.”
Annabel felt like her heart was paused while she observed the situation unfold. Caleb pushed downward or laterally, trying his best to manually push the fetus’s shoulder into an oblique plane. Dr. Harvey struggled at his end.
“Call peds,” Dr. Harvey said.
“I did a few minutes ago,” the nurse responded.
Roosevelt nodded.
Caleb exerted pressure downward again while pushing Mrs. Santana’s hip up as much as he could. The woman’s large size made it that much more difficult to obtain a good flexion. As he did so, the baby’s head began to further descend with Dr. Harvey’s hands wrapped around it. The shoulders miraculously turned appropriately and slid out behind the baby’s big head.
Dr. Harvey now held a full length, moist, slippery neonate. With a suction bulb, he suctioned the baby’s nose and mouth to clear secretions and then rubbed his back. Baby John Doe took his first breath and began crying.
Jeb popped up. He mimicked talking on the phone with his right hand. “Houston,” he said, “we have a baby!”
Roosevelt continued working and handed the baby to Dr. Thomas, who had sneaked in during the emergency. He stepped to the warming unit, where he dried off all the moisture and sought to minimize the infant’s loss of core temperature. After five minutes, he announced the newborn’s one and five-minute Apgar scores.
“Here’s your baby boy,” Dr. Thomas said, holding him over his parents. Laverna’s eyes moistened and she tapped her finger on his button nose. “Welcome to the world, you little troublemaker.”
“Can I hold him?” Jed asked.
“He half-battled his way out of your wife’s birth canal, so as a precaution, we better bring him right over to the nursery to the warmer and finish our pediatric evaluation. There’ll be plenty of time, and years, ahead for all of you to be together.”
-----
Annabel waited in the lounge as Dr. Harvey and Dr. Gash discussed and documented Mrs. Santana’s delivery outside. She frowned at the muddy coffee in the pot, dumped it in the sink, and began a fresh pot.
“How’d it go in there?” Emmett flashed his usual broad smile. He opened the cupboard and reached for Styrofoam cups for both of them.
“Another crazy delivery for which I have more questions for Dr. Gash and Dr. Harvey than answers.” She took the cup he handed her and turned her back to the counter. “I bet over the years, you saw and observed so much, you could answer some of them too.”
“Maybe.” He beamed with enthusiasm. “I read a lot over the years too. Been in a few situational experiences as well.”
“Situational experiences?”
“Yeah. I could call it that. Like a year ago, I transported a lady up the elevator in a wheelchair. She was one of them multi-multiparous pregnant ladies that end up plopping each baby out easier’n easier. The baby started coming. I got the elevator stopped on this delivery floor and yelled for one of the docs. It was me that stood guard at the elevator door blocking the view so visitors couldn’t gawk at her while the senior resident caug
ht that baby in the elevator. I never want that to happen again. Later, it was me who had to mop and scrub out the elevator!” He laughed and added, “But it turned out okay. Guess what she named her baby girl, her fifth kid?”
“Tell me.”
“Ellie, short for elevator.”
“Oh no! So, back in the day, did you ever think about going into medicine?”
“Wouldn’t have never been able to afford all them big tuition bills. Nowadays, it’s different. There’s money to be had with easy, available loans and free money from grants and scholarships. The doors are wide open for young people of all ethnicity and backgrounds, and whether they’re rich or poor. No excuse to not make something of yourself these days.”
“I think you’re right, Emmett. Ever think about changing anything now?”
“Nah. I’m better than okay with my simple life and what I got. I love my routine and making changes makes me uneasy like a bear watching a bulldozer knock down his forest. Hands-on medicine is for other folks. You know, everyone has a place in this world. I’m lucky I found mine.”
“I’m glad you’re content. Living with less stress is good for your health.” The coffee stopped dripping. She poured him a cup first and then herself. He handed her a flavored creamer, guessing she wanted one. She dumped it in and tossed the container in the trash.
“I’d better chug this down fast,” he said. “Rarely do I drink coffee in here.”
“I’ll stand right here with you. We’ll enjoy it together until the other two docs arrive and then I’ll be summoning up my nerve to ask my naïve questions.”
CHAPTER 25
Emmett passed Dr. Harvey and Dr. Gash in the doorway as he left to finish his shift. Roosevelt patted the resident on the shoulder as they came in.
“Dr. Annabel,” Roosevelt said, “you witnessed a perfect outcome for a shoulder dystocia delivery.” He jockeyed his shirt into his pants with a shove and beamed his love for obstetrics all over his face.
“I don’t understand why you didn’t apply fundal pressure like I’ve seen in other deliveries. Wasn’t that the problem … getting the baby out?”
“You noticed the difference. We absolutely avoided that maneuver in this situation since it’s associated with an increased incidence of neonatal injury. We performed, and you witnessed, the first-line treatment … which is the McRoberts maneuver. Most cases of shoulder dystocia are relieved by doing it but, if not, there are a host of other named actions which can be used. You should look them up: the Zavanelli maneuver and the Wood’s corkscrew.
“The delivery can be fraught with trouble,” Roosevelt added, shaking his head. “The longer the delay from the delivery of the head to the body, the greater the risk for significant fetal hypoxia. Other complications for the fetus are things like brachial plexus injuries, clavicle fractures, or even death.”
“And the mother,” Caleb said, “can suffer consequences too. Like lacerations to her vagina or perineum, or a postpartum hemorrhage similar to the one you witnessed the other day.”
“Studying this subject will now be so much easier,” Annabel said. “Thanks so much.” She turned to the counter and pointed. “I made fresh coffee.”
“We’ll help ourselves,” Roosevelt said. “We’ll round on patients, update the board, and then you’re out of here. And, Caleb, you give report to the night team.”
-----
Annabel decided to go home wearing the hospital scrubs she had on, so she folded the nice clothes she wore for the funeral service that morning into her bag. She booked her ride home using her iPhone app, waited in the lobby, and was soon in the back seat of a minivan.
The driver, clean shaven and crisply dressed, fiddled with his GPS app and then pulled forward. A small picture of him and a woman was stuck on his vent and a shark’s tooth dangled from the mirror.
He turned his head. “How are you doing today?”
“Not bad for a long day. How’s the rush hour traffic on the interstate?”
“Moving like a stream down a mountain.” He glanced into the rearview mirror. “Hospitals must be interesting places to work. Are you an X-ray technician or a nurse?”
Strike one, she thought.
“What if I told you that female medical students now outnumber male medical students?”
“That would be crazy. Then sooner or later, there will be a glut of family practitioners.”
Strike two, she thought.
“Why do you think that?”
“Because females don’t possess the physical strength of a man. For instance, to do orthopedics. Those surgeons ream rods into bones, like hips, or reset fractures. Stuff like that.”
Strike three, she thought.
“Even if that were true, there are many other specialties.”
“Yeah. Like heart surgeons. My uncle had open heart surgery and the male surgeon used a saw to cut through his sternum. You know … the breastbone. A woman can’t do that.” He laughed. “At least I wouldn’t want to be the patient under a woman coming at me with a power tool. She’ll miss and split open my heart.”
Annabel rolled her eyes. At least the updated rider service gave the customer a chance to leave a tip. She would have the last laugh then. She didn’t equate his ignorance with his occupation, however, because his views probably represented a minority of men in any field outside of medicine. She took a deep sigh.
After a spell of silence, he turned on Annabel’s street.
“So what nursing unit do you work on back at the hospital?” he asked. “You may take care of me someday.”
“I hope so. I’m a medical student, so someday I’ll be your cardiothoracic surgeon. You’ll be asleep with anesthesia and I’ll be above you wielding my power tool.”
He jerked his head around to look at her. After creeping along to her address, he stopped and she jumped out with her bag.
“Thanks,” she said, closing the door. He totally lost his tongue as she stepped on the curb. In the staircase, she took two steps at a time to her apartment. She felt bad after saying those things to the driver, but apparently, she couldn’t help it.
-----
Annabel hung up her dress clothes and stood at her window. Over the last week, the usual squirrel had reinforced his nest in the front tree and it busily nibbled away at an acorn it held in its paws. She needed to buckle down for the night; the pressure to study and work on her Power Point presentation weighed down on her shoulders. Yet she was overdue for some exercise.
She donned running clothes and lightweight sneakers and hit the sidewalk. After passing the garden around the corner, she zipped down half the staircase, over the major road off the interstate, and to the path by the Ohio. She picked up speed but didn’t fail to notice the spot where Bob had sat down while running with her and had picked up the tick which had made him ill. Next time she ran or walked the path, she thought, Oliver would be with her. Just thinking of the dog trotting at her side put a smile on her face.
The moon reared its majestic white ball in the sky rising up over the bridge from the Ohio to the Kentucky side. It looked like it was going to be full. Maybe Emmett was correct about the effect on pregnant women and the ward would be jumping overnight.
When she slowed her pace in front of her apartment house, she kept going up the block. Needing to eat something, she rationalized a trip to Pete’s Café. She swore to herself that she’d work the rest of the night like a fiend.
She stood in front of the coffee shop counter and Pete turned around.
“Annabel, nice to see you. Which of your male friends will be joining you tonight?”
“I’m solo, Pete. Heck, you’re making me wonder why I don’t have any female friends.”
“I’ll ask the question, then. Why not?”
“Except for sleeping, ninety percent of the time I have is for medical school and whatever rotation I’m on. The people I hang with come from whoever’s with me on the wards. Of which, there was one female who is gone now, but she couldn’
t befriend a woman if she tried. My most precious time is spent with either a boyfriend or a best friend.” She eyed the menu on the blackboard. “Of course, you’ve met both of them.”
“Sometimes I’m not clear which one is which, however.”
She narrowed her eyes and twiddled with her hair. “Dustin’s the cop. He’s the boyfriend.”
“Oh. Okay. I’ll try to remember that. Ah-ha, he’s the one who picks up the bill more often.”
“That’s him.”
“So what can I get you?”
“A fried green tomato BLT and cole slaw and an iced tea with caffeine, which will give me zip for the work I’ll be doing tonight.”
“Coming right up darlin’.”
“And Pete, may I borrow a pen and paper? I can scribble notes while I wait.”
He reached under the counter. “Here, keep them instead of borrowing them.”
Annabel selected a booth against the wood-paneled wall. She jotted the major topics of her grand rounds lecture and began scribbling in highlights of her topics that she already knew. As the waitress bused over her drink and food, she came up with more and more points and made notes of what she still needed to research. Finally, she bit into her sandwich.
“Annabel,” Pete said. She glanced over while noticing she was the last person in his café. “We’re closing in five minutes. I’d give you more time, but this place opens at 7 a.m., so I have a quick turnaround.”
She looked at her iPhone. It was eight o’clock. “Sorry, Pete. Nothing like being absorbed with what I’m doing. The time also passed quickly because of your tasty sandwich. “Thanks a lot,” she said after paying her bill and folding her notes.
“Come back soon.”
Back at her apartment, she lined her notes next to her computer, ready to be integrated into slides. Taking a break, she texted Bob.
How was your day with Oliver?
