Babies, Babies, Babies, and Babies
Luckily for most people, having a baby is a happy event without significant complications. However, in my experience, when things in OB go badly, they really go badly.
The following are cases in which I was the Primary Care Physician (PCP) doing OB and in which the cases went very badly. Most had a good outcome despite some scary moments.
When I did OB as a PCP, I was in a 20-bed hospital with no back-up. There were no Anesthesiologists, no Obstetricians, no Pediatricians. I was “it”. Just me and nurses, and at night only one nurse. There were two nurse anesthetists who worked at the nearest big hospital 75 miles away. They worked at our hospital when the itinerant surgeon was in town on Wednesdays and when they were in town they could and would respond to emergencies. They were two of the most dedicated clinicians I ever knew.
If they weren’t in town and you had an emergency, you were SOL for anesthesia services.
As most people probably know, when a baby is born, they are given an APGAR score at one minute after birth. The APGAR score a baby gets determines the level of intervention needed, if any, to treat a newborn and improve their clinical status. An APGAR of > 7 at one minute is considered normal. APGAR scoring has five components 1. Heart rate (over or under 100), 2. Color (pink vs. blue) 3. Reflexes (+/- grimace, cough), 4. Respirations (rate and force) and 5. Muscle tone (limp to active motion).
The following are stories of OB cases when things didn’t go normally.
APGAR Zero
I was in clinic seeing patients one morning when I was called to the hospital to intake of one of my patients who was at term pregnancy. She had had an uneventful pregnancy; her prenatal checkups had been perfect.
Back in the late 1970’s and early 1980’s the birthing room had begun to emerge. Before that mothers-to-be labored in a labor room and were wheeled into a delivery room for the actual delivery. The delivery room looked just like an operating room. The birthing rooms looked more like a home bedroom and the husband and sometimes other family members or significant others were allowed to be present. When I got to my National Health Service Corps site, the little 20 bed hospital had no birthing room. A birthing room was one of the first improvements I championed at the hospital. The mothers-to-be all wanted to have their babies in the birthing room. Of course, they were told their prenatal courses had to be textbook for that.
This mother-to be was no different. She wanted to have her baby in the birthing room. Since there was no contraindication to this, she was admitted there. I did my intake, which was normal, and went back to clinic to see patients.
One thing about our 20-bed hospital was, there was no fetal heart monitor. Fetal heartbeats were monitored by a nurse assigned to that birthing room; caring for the mother-to be was her only duty. She took the fetal heartbeats at predetermined times and during contractions. A paper actually came out in the OB/GYN literature around then that said a nurse with a fetal Doppler taking heartbeats was more accurate than a fetal heart monitor.
The nurse had noted no signs of fetal distress. No heart rate decelerations or low heart rates.
I got a call a few hours later that the mother-to-be was 10 cm dilated and was wanting to push. I left the clinic, ran across to the hospital and ran down to the birthing room.
Now, the birthing room was all the way down the hallway from the labor and delivery room, at least 100 feet. If something went wrong, mother, and perhaps baby, had to be transported down the hall to the delivery room.
I arrived at the birthing room. The baby’s head was crowning. I gloved up while asking the nurse if anything unusual had been observed or had happened. She said no. We had the woman push with her contractions. I ironed the perineum. The baby delivered uneventfully, no prolonged Stage 2 labor and delivery. But, when the baby came out he was limp and not breathing and he had no pulse. I stimulated the baby for about 30 seconds with no response. The baby seemed essentially stillborn! That was an APGAR of zero!
I clamped and cut the cord and told the nurse to deliver the placenta and immediately began CPR (that included mouth to mouth resuscitation) on the newborn while running down the corridor to the delivery room where there was the usual delivery room bassinett which had warming lights, suction, oxygen and other equipment to resuscitate a newborn.
By the time I got to the delivery room the baby had a pulse of about 60 and after suctioning, he began to breath. At about 3 minutes post-delivery the baby finally let out a cry. His APGAR at five minutes was 7.
We watched that baby closely during his two-day hospital stay. His exam, including neurological was normal. I took care of him as one of my patients until I left town two years later. He passed all of his milestones without problems.
I never met another person who had performed mouth to mouth on a baby just out of the birth canal.
APGAR 1
I was on call for the weekend. It was a very, very busy weekend with a busy Saturday morning clinic, steady emergency room activity and several admissions including an elderly septic man requiring continuous attention until he coded and died. I got practically no sleep between Friday morning and about 3:00 in the morning on Monday. I never made it home the entire weekend until then. I got home and jumped into bed at about 3:30 AM. Two hours later, the phone rang. I picked up the phone and heard, “Doctor come in right away, we are going to have a baby right now!….(click}”.
I jumped out of bed and into my clothes (sort of like a firefighter jumping into his gear when the fire bell rings). I bolted down the stairs and out of the house and ran down the street to the hospital. I ran into the labor room and there was a woman lying in the labor room bed with a sheet over her. Out from the right side of the sheet was an umbilical cord which led to a surgical towel on which there was a squirming baby. The nurse was standing to the right saying, “He just came out all on his own!”
The nurse had opened a delivery kit. I quickly gloved up, swaddled the baby, and was clamping and cutting the cord when I noticed that the woman’s abdomen still looked unusually large. I asked the woman, “Are you having twins?” She said, “No!.”
I handed the baby to the nurse and I pulled off the sheet. To my surprise, there were two feet and a prolapsed umbilical cord sticking out of this woman’s vagina. I grabbed a scissors from the delivery kit and said, “Ma’am, you’re having another baby. I’m going to have to cut you and you have to push this baby out immediately!”
I did an episiotomy without prep or anesthesia, had the mother push and gently pulled the baby out. A double footling breech with a prolapsed cord. Ask your OB friends about that.
The baby came out limp with no respirations but a heart rate of about 60. An APGAR of 1. I clamped and cut the cord and ran into the delivery room with the baby while stimulating the baby’s feet. I got him into the delivery room bassinette and suctioned and stimulated him. He started to breath and then cry and then move all extremities. His APGAR at five minutes was 9.
I turned the care of the babies over to the nurse and stitched up the episiotomy. Then we handed the babies to the mother after the second baby was stable and asked her why she didn’t know she was having twins. She said she only had one prenatal visit at 12 weeks of her pregnancy with a doctor in a town about 40 miles away. She didn’t have insurance and couldn’t afford the prenatal care. I guess no one there talked to her about getting on Medicaid.
The second twin did well in the hospital, despite the difficult delivery. I saw her for her six-week post-natal care and also did the well-baby checks. She established with another primary care physician 40 miles away.
Prolapsed cord
It was about noon on a weekday. I don’t remember which day of the week. I was on my way to lunch at the hospital when the nurse came up to me and said she just admitted one of my mothers-to-be and I had to go see her immediately. She was in the labor room.
I hurried over to the labor room. I was saying hello to the woman when the nurse said emphatically, “Examine her first!”. I gloved and pulled the sheet down and did a vaginal exam (which the nurse had done, obviously) and felt a 9 cm dilated cervix with a prolapsed umbilical cord.
Yikes!! This is an OB emergency! If we were in a larger hospital, this woman would have been rushed off to the OR and had a C-section.
Since we had no OB back up and no Anesthesia Services, we normally would have had to ambulance this woman to the nearest big hospital 75 miles away. This woman was going to deliver by the time we got there and the baby would be dead by then since the cord was being compressed by his head.
Suddenly I remembered that the 20-bed community hospital 30 miles north of us had just hired a Family Practitioner who had spent a year following a surgeon and OB/GYN around to get proficient with appendectomies, gall bladder surgeries and C-sections. I called that hospital, quickly explained the situation and they said, “Bring her on up!” The volunteer ambulance crew was summoned.
I ran to the labor room, gloved and pushed the baby’s head up off of the cervix until the ambulance was ready to transport the laboring woman. We ran to the ambulance and sped off to the nearby hospital. During the ride up there, I intermittently pushed the baby’s head up off the cervix. The mother was now at ten cm and wanting to push. The EMT and I coached the woman on breathing through contractions and avoiding pushing.
We got to the hospital and the ambulance backed into the ER ambulance entrance. The back door of the ambulance opened, and the following scene was like something out of Ben Casey (anyone remember that TV show?).
There were six or seven people in scrubs waiting for us. We got the woman on the stretcher out of the ambulance and four people, myself and an EMT began running across the asphalt, through the doors and down the hall pushing the stretcher. While we were running, one of the hospital staff pulled the sheet off of the woman and started splashing betadine on her abdomen. We crashed through the OR doors where two Family Practitioners were already gowned and gloved and the OR staff stood ready. One Family Practitioner quickly started intubating the woman while the nurse anesthetist started giving anesthesia while the second Family Practitioner started a vertical incision of the abdomen. They called it a “crash induction”. Myself and the two EMT’s who came with me stood at the doors of the OR as the two FPs performed a rapid C-section, getting that baby out in less than five minutes. Wow!
The baby cried immediately and had APGARs of 9 at one minute. The FPs closed the uterus and abdomen in normal fashion.
We thanked the staff and doctors profusely. The mother and baby did just fine. I followed the baby until I left there and there were no health issues relate to this complicated birth.
Sisters-in law
This is a double story about two women who were sisters-in law (wives of two brothers) and their pregnancies. The names in this story have been changed from their real names. I’ll call them Jane and Mary.
Jane had come in for a first prenatal visit at about week 12 of her pregnancy in late February. We calculated her delivery date and it was December 25, Christmas! From then on we both called her baby the Christmas baby.
About two months later, her sister-in law, Mary, came in for her first prenatal visit. According to her information, her delivery date was in February.
So, now we had the two sisters-in law having babies within two months on each other. This created a lot of happiness and joy in that family and the sisters-in-law shared the journey of their pregnancies.
Now, back then, the ultrasound (U/S) technology was still somewhat rudimentary. Two-dimensional U/S was just emerging. Our Radiology department had purchased a used first generation 2-D U/S machine (already obsolete when the hospital bought it). The images were somewhat “muddy” but that’s all we had. The newer ones weren’t much better back then. We did OB U/S three times during pregnancies. Both of these women had normal U/S tests.
I saw Jane in clinic the week before Christmas. Her exam was normal, the baby had normal heart rate. Jane said the baby was very active. On exam the baby hadn’t “dropped” yet (when the baby’s head enters the pelvic canal getting ready for birth).
It was December 24th. I was still in morning clinic when the nurse called and told me Jane had come in in active labor. She asked that I come right over to see Jane.
You’ve probably figured out that nurses saying get over there right away wasn’t a good sign…
I excused myself from clinic and hurried over to the hospital. The nurse met me at the door to the labor and delivery suite. Jane wanted to be in the birthing room. I asked the nurse what was going on. She said, “I can’t find a fetal heartbeat. Could you check her?”
I went into the labor room as if nothing was going on. I did a normal OB intake, asking about what her week was like. She said the baby stopped moving two days ago, she thought it was normal as the baby was getting ready for delivery, so, she didn’t call us to tell us.
As was usual for my intake process, I did my own fetal Doppler. I couldn’t get a fetal heartbeat. I told Jane that we were going to get an U/S to check on the baby. She was wheeled down to radiology and back to the labor room. I reviewed the U/S with the U/S tech. There was a term fetus with no heartbeat. The baby had died, likely two days before.
Now I had to go back to the Labor Room and tell Jane. It was one of the hardest things I ever did as a physician. She cried. I had to be stoic and hold in the tears myself. Unless you’ve been an OB or Midwife, you wouldn’t understand the bond between the patient and the OB/midwife. I had to also tell her that we had to deliver this baby as soon as possible. We had no way to do a C-section. Jane had to deliver a known stillborn on Christmas eve.
I left the labor room. The nurse was right outside the door. We both cried. I had to go back to clinic and see the rest of my afternoon patients. It was hard to do that.\
I got out of clinic. Jane had progressed well and was almost at transition. We wheeled her into the delivery room. She reached transition and began pushing with every contraction but the baby wasn’t coming out. She was starting to become exhausted. I had to get that baby out.
I went over to the instrument cabinet. I looked through the glass doors and found delivery forceps. I had never used them. I had only read about how to use them. I knew I had to use them now.
I pulled out the forceps. Walked over to Jane and told her what I was going to have to do and it might be painful. She nodded.
I went back to the foot of the delivery table and inserted the forceps just as Jane was having her next contraction. I yelled for her to push and I manipulated the forceps as I had read (you don’t pull on them). I got the baby’s head out and it was apparent what had happened. He had a triple wrapped umbilical cord around his neck. There wasn’t enough length in the cord for him to come out. When the baby dropped several days before, he was essentially strangled. I had to cut the cord from his neck to further extract the baby from the birth canal.
The baby was perfect in every way. It was very sad.
Jane had an uneventful two days in the hospital after delivery physically. Emotionally, was another story. She went home with an appointment to see me in a week.
Jane came in for her one-week check with her husband. I entered the room, said “Hi” to Jane who was sitting on the exam table and touched her left arm. I went over to her husband shook his hand and said how sorry I was.
Then Jane said, “Doctor, come here.” I turned and went over to Jane. She held out her arms and gave me a big hug. “They told me how this was as hard for you as it was for us.” I glanced over to her husband who nodded. It was a pretty powerful moment.
But, the story doesn’t end there.
Remember Mary, Jane’s sister-in-law?
Mary also had a normal prenatal course and three normal OB U/S’s. She came into the hospital in labor the next February. Her baby was still active. The baby had normal fetal heart sounds and rate on intake exam. Everything seemed normal. Mary breathed a sigh of relief.
Mary had chosen to be in the Labor Room, I think because of Jane’s story. Her labor went uneventfully. She reached transition and was transferred to the delivery room. It turns out, her choice was a good one.
Mary’s delivery actually went according to the textbooks. However, when the baby was birthed, there was a shocking discovery. The left side of the baby’s face was malformed. He was active and crying with an APGAR of 10.
Instead of immediately showing the baby to Mary, I handed the baby to the nurse and told Mary that we had to examine the baby. I told her there was a problem. “What is it?”, Mary asked. I told her it looked like there was a congenital defect that I would explain to her after the baby was examined.
While the nurse was cleaning the baby in the bassinet so we could get a good look at what the issue was, I was waiting for the placenta to deliver. All of a sudden, there was a waterfall of blood coming out of Mary’s vagina. I tried to tug on the cord to remove the placenta so I could give Mary some methergine (that’s what we used back then to contract the uterus to stop or prevent bleeding) and massage the uterus to stimulate the uterus contracting, but I couldn’t get the placenta out. It was a trapped placenta! The cervix had contracted before the placenta had come out. With this degree of bleeding, this is an OB emergency! If you couldn’t get the placenta out right away, the mother would bleed to death! The only way to get it out was, you had to anesthetize the mother which allows the cervix to relax and release the placenta, then you inject the woman with methergine and aggressively massage the uterus to stop the bleeding.
That meant we needed an anesthetist. Remember, the nurse anesthetists (NA) were only available if they were in town and not up at the big hospital. I barked for someone to call the NA. I placed two large bore IV’s into both the patient’s arms and ran IV Normal Saline full bore. We wheeled the woman into the OR. The Nurse Aid came in saying the NA was on her way.
Five minutes later, the NA ran in. She Induced the patient as fast as possible, while blood was still pouring out of the patient. Once the patient was fully under I tugged on the cord again. After a few tugs, the placenta delivered. I barked the order to give the methergine and began vigorously massaging the uterus. The uterus shrank quickly and the bleeding stopped. The patient became stable with a normal blood pressure but was tachycardic. After several liters of IV fluid, her vital signs were normal. Her blood counts showed she had bled about four units of blood. We gave her two units of blood. She did well post-partum.
Her baby had a branchial cleft deformity, not picked up on U/S. He had some of his left jaw missing and only a partial ear and no ear canal on the left. Otherwise he was normal and had a normal newborn stay in the hospital.
I referred Mary and her baby to a tertiary care center where he was evaluated by a group of specialists. The baby’s care plan was a series of reconstructive surgeries that would take at least 16 years, in phases as he grew. Luckily, all of the stars aligned the day of his birth and we were able to save the life of his mother.
It was one of the scariest medical events I ever expe