Delivering physicians as patients.

Yesterday I delivered a fellow physician. A 37 year old cardiologist at 40 weeks.

She started her labor naturally, a few hours after breaking her water. The labor progressed well, naturally and on it's own. She arrived in the hospital at a very appropriate 3-4 centimeters dilation, and progressed at better than 1 centimeter per hour (this is the standard rate for the first baby).

She received her epidural at 5 cm, as she didn't want to continue with the natural discomforts. She still felt some pressures and a bit of pain with the contractions, but I assured her that feeling some of the contractions is a good thing. She certainly did not appear to be in any distress from the pain.

This physician was medically healthy and was planning a normal labor. And she and her husband were really nice to be around.

The thing about physicians, nurses, and pretty much any other licensed professional, is that their life may be bit more stressful than, for instance, a hairdresser, a truck driver, or a chef, for instance. And undue stress makes any pregnancy high risk.

Because of the requirements of being a licensed professional, I consider a licensed professional to be a high risk pregnancy. This is my opinion. I don't know if the textbooks or medical journals would confirm this or not. High risk pregnancies would of course include lawyers.

Malpractice attorneys are even higher risk. Most physicians hate taking care of malpractice attorneys. I don't. They are people too. They require very good care. I provide that for sure. Most physicians think that malpractice attorneys are lying evil bastards. The attorneys don't think of themselves like that, but as defenders of the weak, downtrodden, and injured. The attorneys believe that they are seeking the truth for justice sake. Most physicians believe contrarily that they are liars one and all. Physicians call them "Trial Liars", which is a play on the name the lawyers call themselves, "Trial Lawyers". In any case, they are also high risk pregnancies. It is clear that the trial lawyers have an unbelievably stressful life. And you can see it in their eyes when they are not working.

There is a big disagreement on the meaning of "truth" between doctors and lawyers. The lawyers engage in what they call "truth seeking" behaviors in courtrooms and pretrial activities. The physicians see those same courtroom activities as remotely disconnected from the truth. Physicians see trials as complete shams, as nothing but highway robbery by brigands and liars. With briefcases instead of guns.  Why such a discrepancy in the belief in truth? Physicians see truth scientifically. Especially if it has been experimentally established, as is done in medical science. Lawyers see truth as a culmination of belief, by whatever method makes it believable. The lawyers believe that truth is whatever the Judge and Jury believe it to be.

Personally, I believe that truths exists in the space of ideas. There are real, absolute truths, as Plato would have described them. They are not physical things. You cannot weigh a truth with a scale. This is similar to a human soul, and mathematical theorems. These truths are real, but you cannot hold them in your hand. Only in your head, and written down on paper. So, physicians and lawyers will never agree on what the truth really is. Physicians ignore this reality of truth at their own peril, when a skillful attorney rips them apart as part of a trial strategy.

Anyway physicians are not immune to the stresses of being a professional. Therefore physicians have a high risk pregnancy. I think this risk is manifested in several ways.

One, they work ungodly hours. Pregnant women are supposed to be off their feet once every three hours, resting for 15 minutes. This will let the natural adrenaline of a normal day fade down a bit. These are work rules that are enforced by the federal government for everyone. But most physicians will not stop working after three hours. Especially if there are sick patients that need their attention, and they are behind schedule. All physicians are behind schedule, because there are people with unpredictable needs. And no one wants to say to someone, I think you have a tumor, but we will talk about it next week. So, we do our best to comfort the patient in front of us, and then get behind schedule a bit.

Two, physicians know about pathology personally. They see it on a daily basis. And if they do not see it in themselves, they will be hard pressed to believe that it is there. So many physicians will ignore indications of serious trouble.

Three, physicians still get "medical students disease". This disease is an inappropriate belief that some pathology affects them. To mix a metaphor, they are in a forest but cannot see the forest because they can only see the trees. Physicians make poor doctors to themselves, and have a fool for a doctor, and a fool for a patient. These are old sayings in medicine. Every doctor should have a good therapeutic alliance with another good doctor, to keep these anxieties in check. And the doctor for the doctor should have a calm demeanor, and a lot experience. This will prevent medical students disease by proxy.

Anyway, this particular patient was doing beautifully in labor. She was physically strong, and a very good pusher when it was time to push. But, as a physician, we need to consider this is a high risk patient, and we need to be ready for complications.

So, after pushing for an hour, the babies heart beat starts going much faster than normal. I discussed with her and husband the reasons why this might be the case. A common reason might be infection. Another reason might be the babies head getting squished in the birth canal. Ultimately this was the cause for her. But no one wants to leave the baby in a stressed out condition, so I decide to help the baby come out a bit sooner. Before the baby really gets stressed from the rapid heart beat. She obviously agrees.

When the baby was on the "outlet" of the vagina, I decided to use the vacuum forceps. This will help the baby be born a bit sooner. And there are many studies which show that "outlet forceps" have as good a prognosis as natural labor, or better.

So I used the vacuum. True to form, the high risk factors start coming in to play.

First of all, there was a loose nuchal cord.

Then, there was a "shoulder dystocia". This means the baby is stuck with it's head out, and the shoulders are holding the baby in. Shoulder Dystocia is a bad thing to happen. Babies can get injured or worse by the difficulties associated with delivery past the stuck shoulders. I have an entire blog post already written about shoulder dystocia. I still need to edit it some before it becomes good enough for publication on this blog, but that blog post is coming.

So, we wind up doing two basic maneuvers to relieve the shoulder dystocia. We did a McRoberts, and suprapubic pressure by a very skilled nurse. The shoulder dystocia was then released and did not cause any harm to the baby, thank God.

Then we had the third stage of labor. The placenta came out. And then she had a postpartum hemorrhage.

In a normal pregnant woman, the baby gets about half of the mothers cardiac output of blood, directly to the underside of the placenta. The uterus gets it's blood supply from the mom via very very large blood vessels. They may be as thick as your thumb. What stops the blood flow normally is that the uterus contracts down tightly. These uterine muscles, which just finished pushing the baby and placenta out, need to continue to contract, and get very tight, to close the placental blood flow. Without the placenta blocking it, and if the uterus doesn't contract, the blood flows out of the mother like a river. It literally pours out like a thick waterfall. In the presence of postpartum hemorrhage, a woman can bleed to death in minutes. Postpartum hemorrhage is the number one cause of maternal death in advance countries. The last I looked, about a hundred women a year die from postpartum hemorrhage in our country alone.

So here we are with a high risk pregnancy, a fellow physician, and we have already dealt with a shoulder dystocia. Now we have blood pouring out like a faucet. What to do?

The first thing is to get the uterus to contract. We literally compress it with our hands. One had in the vagina, and one hand on the top of the uterus. At the same time we compress the uterine vessels with our vaginal hand, and give the new mom some medicines that will further tighten the uterus. We not only compress it, but we massage it. That seems to work better than just squeezing it. A hemorrhaging uterus can be more or less controlled by physical pressure. In fact, all bleeding, from anywhere, responds to pressure, if there is a way to press on either the bleeding place or the blood vessels feeding the bleeding. In this case we can do both. Just remember that pressure stops all bleeding, no matter where it comes from.  Anyone can save a life by remembering that bleeding stops with pressure. That is the point of a tourniquet that all boy scouts learn about.

So then I stopped the bleeding with pressure, massage, and medicines. Thankfully she had an epidural. Without the epidural these pressures are very uncomfortable, to say the lease. I even had our anesthesiologist come and boost her epidural quite a bit. This worked to keep her comfortable.

After the pediatric physician checked the baby, and declared the baby healthy, our new mom got her new baby while I finished up the vaginal repairs.

The next day on rounds, she and the baby looked wonderful. She was walking around with a big smile.

So, we have to be ready for pathologies like Shoulder Dystocia and post partum hemorrhage at any time.

A good obstetrician will review the protocols many times in their career, and stay up to date, and ready, willing, able, and confident, to manage these things on a moments notice. For that matter, midwives need to stay on top of these things as well.

Thanks for reading my blog. Comments are encourage.

Available at doctorjohnmarcus.blogspot.com

Doctor John W Marcus MD FACOG PC
89 North Maple Ave
Ridgewood, NJ, 07481

Phone 201-447-0077
Fax     201-447-3560

Thanks for reading.