Sunday, September 12, 2010

Delivering babies

Let's see... what is going on in my life since last time I wrote?... I did a month of Toxicology at Bellevue hospital which was fascinating as always. I did two weeks in the Columbia ER where I got pretty effectively bitch-slapped once or twice (can always count on Columbia for that) and I caught babies for 2 weeks up at the Allen Hospital (Inwood) on Labor and Delivery. Basically, life has been good.

I wish I could regail you with "The tales of labor and delivery!" I basically walked away from my time on L&D thinking "wow, what a wasted, boring two weeks! I saw about 2 patients a day!" However, upon further reflection, I realized that I saw some very important things.

An eclamptic mother in status epilepticus seizing uncontrollably all the way to the operating room to emergently c-section her baby. She has since been in and out of the ICU twice for further complications of eclampsia.

A woman who I now have the highest respect for who did the entirety of labor and delivery without ANY pain control (and let me tell you, it was NOT an easy delivery by any means even if she would have had pain control). I'm actually not entirely sure if she deserves an award or a brisk shaking and an exclamation of "why in the world did you DO that?"

There was the "day of post-partum hemorrhage" where it seemed that every patient was bleeding uncontrollably after delivery (I got very good at calling for HemeAbate). Those are interesting. Looks like a faucet running red water.

Then there was my last day on L&D. I had a 23-week patient who presented in active preterm labor. There was no way to stop the process. The issue is this: there is a 50/50 chance of survival with all of the modern NICU technologies possibly available if a baby is born at 24 weeks. Younger than 23 weeks, there is no chance. 23 weeks is the grey zone. 10% chance of survival, only 5% chance of survival neurologically intact. As we laid the facts out for a distraught couple whose primary language was not english (we used a spanish interpreter for ALL conversations), the emotional stress began to completely block their ability to understand the situation.

Finally, they were able to make a decision, to rationalize SOMETHING out of the entire situation. The attending who had been explaining for an hour that the two options were to a) deliver the baby and provide warmth until the baby passes away in a few minutes or b) delivery the baby and intubate the baby and do everything humanly possible for a long-shot of survival. Finally the father looks at the attending and says "we want an abortion."

HUH?? Abortion wasn't even an option. The word abortion was never even SAID and yet, this was how they were able to rationalize their desire not to have the potential of having a severely disabled child for the rest of their lives (assuming best case scenario). Our jaws dropped and there was silence where we didn't know how this leap had been made. Then the husband went on to ask for us to just take our instruments and tools and go inside and take the baby out. We went through all of it again... explicitly. Mom was going to have to push the baby out. It was a delivery. She was in labor. We were NOT going to go in and take the baby out, it was coming out on its own. The family agreed to let the baby be born and pass away. No heroic measures.

An hour later we are called into the room. It's almost time. There is a new person there -- an extended family member who is fluent in english. She turns to us and demands, "What are the options? Why are they telling me that they are getting and abortion?" If I ever felt like smacking my own forehead, THIS would be the moment. The attending, however, handled the situation with grace by simply stating, "The matter is closed. We have discussed it extensively with the parents and we have agreed to let the baby pass away after it has been born. This is NOT an abortion. This is early labor." We got the interpreter again and went through it again with the parents. Their faces showed complete confusion. But then it was too late for more discussion -- the baby needed to be delivered.

I delivered at 1lb baby boy. He made a single cry and then had no further respirations. He did not move. The room was full of crying, wailing family members. They named the baby, held him, cried and screamed his name, took photos. After all the technical aspects of the delivery were completed and condolences were given, I left. I've never dealt well with rooms full of crying people. I'm a sympathy crier -- not a good trait as a physician. After the parents said goodbye, the baby was taken to the Neonatal ICU and finally pronounced as deceased 3 hours later. I filled out a birth certificate. The pediatrician filled out a death certificate and the matter was closed.

I don't know how those parents will eventually think of the events of the birth and death of their first child. Will they realize what happened -- early, preterm labor -- or will they always rationalize as somehow "choosing" an abortion at 23 weeks? If they rationalize the latter option, how many more pregnancies will they loose because they are passing on incorrect information to future physicians who may be at a different hospital and therefore not have access to our records? It is a terrible dilemma, the stress response of the human psyche.

1 comment:

  1. Leah, that's a beyond horrible situation, and I cannot imagine having been in that room with you. It does however, seem like you handled it well -- no sympathetic crying from you. Hopefully that's a situation you'll never have to observe again, especially since you won't be working in L&D. And I hope you and the pediatrician and the translator were able to accurately communicate to the parents what actually happened!