by Barbara Ebel
Kristin hated when an accidental wet tap occurred. Laboring patients were already in pain, but that headache was a real burden in the postpartum period when a mother should instead be enjoying her newborn baby.
Kristin was also slick at the paravertebral technique, so she numbed off to the side of where she’d been and went in at an angle. She advanced the needle gingerly and also pressed her finger on the end of the syringe, which was filled with air. Since Kristin was lanky and trim, she had to work at her maneuver to get through Laverna’s back. After a few moments, she encountered the correct epidural space and her syringe encountered a loss of resistance and she tapped a few cc’s of air into the space. No wet tap occurred and Kristin sighed with relief.
The anesthesiologist took off the syringe from the end of the needle and uncurled the thin, long catheter from the plastic kit. She threaded it into the needle and advanced it correctly and then removed the needle over it.
“You can relax just a bit,” Kristin said as she adjusted the end of the catheter to the pieces where she could deliver drugs. She secured the epidural catheter on Laverna’s back with a see-through bandage and gave Laverna a test dose of local anesthetic which contained epinephrine. Since her patient was hooked up to monitors, her heart rate would increase if the catheter was incorrectly placed and the epinephrine raced into a blood vessel.
Everything so far checked out perfectly and Kristin’s job was now to dose the epidural. She began opening the drawers of her cart. “You can settle back on the bed. Worst part is over.”
Annabel pitched in to help while Laverna wiggled on the mattress to the top of the bed. Kristin opened and shut drawers again and frowned. She tinkered with the two sets of earrings on her right ear lobe.
“The anesthesia tech restocked those drawers this morning,” Pam said, noting Kristin’s displeasure. “Is there something missing?”
“I heard the drug shortage of local anesthetics is getting worse. Do me a favor and call the tech. Only thing in here is the stronger concentrations of bupivacaine. Ask her if she has any 0.125% bupivacaine.”
Pam called the front desk to send in the tech and the woman soon poked in her head.
“What’s going on with an eighth of a percent of bupivacaine?” Kristin emphasized her discontent and threw her arms in the air.
“Sorry, Dr. Fleming. I double checked with the FDA website this morning, so I know that Ohio is not being singled out. There is a national shortage of what you want and not much of the .25% bupivacaine left in our carts either.”
“Thanks. It’s not your fault.”
Kristin shook her head. This was a situation she had no control over. “These shortages of drugs, which has been going on recently, affects more than anesthesia. Outpatient caregivers and patients have to seek out other methods of pain relief, which, I believe, worsens the opioid crisis. And in the hospital, surgeons can’t use the numbing drugs at surgical sites, which again ramps up the need for injectable opioids like fentanyl and morphine.”
She tapped her foot. Laverna squirmed and pleaded with her eyes for some pain relief.
“Usually I give a bolus dose of ten cc’s,” Dr. Fleming added, “but I’ll give less and do my usual short increments. We don’t want Mrs. Santana to get a heavy motor blockage with the higher dosage. What we normally want is a sensory blockade with little motor deprivation.”
Kristin aspirated from the catheter to make sure there was no blood on return and then injected three cc’s of the .25% concentration. After four minutes, she injected another three. She wrote an order for the pharmacy to make up a bag of a bupivacaine solution with very low dose fentanyl so they could put it on a pump and infuse it into the catheter.
“My pain has eased. Thank you,” Laverna said after a while. “Anesthesiologists are angels that fly down from heaven when a woman goes into labor.”
“Hmm. I’ve never been called that before.” She cleaned up her mess and looked at Annabel. “Are you staying to do Mrs. Santana’s H&P?”
“Yes, and thanks for letting me watch.”
Kristin glanced at the fetal heart rate monitor and cycled Laverna’s blood pressure cuff one more time. Satisfied, and with a spring to her step, she headed out.
CHAPTER 24
Annabel finished asking Laverna about her past history, surgeries, and previous pregnancy. The twenty-nine-year-old had no problems from the past that should pose a problem for this delivery. So far, that was what she liked about obstetrics. The patients were young and mostly healthy, unlike internal medicine, where cardiovascular disease, COPD, and diabetes was rampant in most patients who walked through the door.
But for the last few minutes, Laverna grew paler. “I don’t feel so well,” she mumbled.
Annabel cycled her patient’s blood pressure cuff and at the same time noticed the fetal heart rate monitor, where she detected evidence of fetal distress. The baby’s heart rate did not seem to change in response to Laverna’s contractions and the rate was slowing down from the brisk hundred and forty beats per minute that he’d been exhibiting.
The pressure registered on the bedside monitor as 96/68. Annabel stepped to the doorway and glanced up and down the hallway for Dr. Fleming. The room was close to the nurses’ station, so she called out for the anesthesiologist.
Kristin stopped what she was doing in the supply room and came running. “I learned that a hollering medical student is to be taken seriously!” she exclaimed as she surmised the entire situation with one scan of the room.
She took Laverna’s blood pressure again, with the same result as when she came in the room. She popped out a vial and a syringe from her anesthesia cart and drew up a concoction. She injected it into Laverna’s IV.
Kristin moved her patient’s gown off her belly and took a dull needle and poked it on her skin at various spots above and below her umbilicus. “Do you feel this?” she asked each time and asked her to differentiate how much numbness she felt from the epidural block she had placed.
Jed burst into the room. Some soda splashed out of the paper cup he held, so he slowed his pace. “I was in the cafeteria and overheard a conversation about recent life-threatening situations happening to unsuspecting patients on the OB ward. And then I get to the floor, and a nurse tells me to hurry in here!”
Kristin eyed the monitor. The baby’s heart rate had picked up; otherwise she was two seconds away from calling the obstetricians stat. Laverna’s pressure was also better. She took in a deep breath.
“She had a spell of hypotension, low blood pressure,” Dr. Fleming told them. “How do you feel now, Mrs. Santana?”
“Not like I’m going to faint anymore.” She glanced at her husband’s paper cup. “Don’t drink that in front of me. I’m dying for something to eat or drink and you’re making the temptation too great.”
“I think she’s feeling better,” Jed said. He turned around and sipped the rest of his cola and tossed the cup. “There, that should make you happy.”
“Really? The only thing that would make me happy right now is for you to be having this baby and me standing there watching you.”
He rolled his eyes. “You’ve turned into someone I never knew existed.”
-----
Annabel followed Kristin back to the supply room, where Annabel chuckled. “Some of these couples are hilarious. Seems like a lot of women get testy during labor and take it out on the guy.”
“Sometimes keeping a straight face in the rooms is quite difficult.”
“So what went on in there?”
“It can happen … a more intense sympathetic nervous system block than anticipated. In this case, it may or may not have been due to the concentration of the bupivacaine that I used. In any case, medical drug shortages are another problem to deal with. During my training, it appears like they are increasing in frequency, but imagine being a patient waiting nine months and then being told she can’t have an epidural because the anesthesiologist doesn’t have the correct drug?”
&n
bsp; “I guess I wouldn’t want to be on the receiving end of that statement.”
“Me neither.”
-----
Besides doing scut work and seeing two other patients, Annabel managed to study for an hour. She was out of view from the nurses’ station because she huddled at the end of the couch. Traffic increased into the lounge as some nurses changed shifts and reassigned their names on the board and Caleb came in twice to change the status of patients’ stages of labor.
She managed to read a synopsis of gestational diabetes, which was a different affair than what happens with a non-pregnant person. An extra consideration was how it impacted the fetus. She slipped the open book down to her thighs and stretched out her arms as Dr. Harvey walked in.
“Annabel, I know the answer to my question because I read over Mrs. Santana’s clinic record. I’m wondering how astute you were with her history? Did you ask any questions about her weight?”
“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 caught 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.”
