Last Saturday went like this. (As an aside I went to the hospital at 7:45 AM and did not get home until somewhere around midnight! During that time I did not eat or drink anything because I was too busy to go to the cafeteria or run home and eat something. It was sort of fun.)
7:45 AM – I go to the hospital to start rounds. I am greeted at the door by a medical officer who tells me there was a delivery just recently completed with a possible third degree vaginal laceration with resultant loss of rectal tone. I go directly to that patient to examine her. It actually looks more like a very deep and long second degree tear, but because it is so extensive we decide to take her to the operating room to repair it.
8:45 AM – I start obstetric and gynecology rounds with the medical officers and clinical officers who are working during the weekend. Most significantly we are concerned about a mother who had a post delivery vaginal hemorrhage who now has a medical balloon placed in her uterus to control the bleeding. She is stable, but has received a lot of blood overnight to maintain her blood pressure and level. Also there are several severely ill patients on the gynecology ward, one with a bad abdominal infection and the other with vaginal bleeding associated with HIV and a already low blood count related to an inability of her body to make blood.
10:00 AM – We finish rounds and head to the operating room to repair the vaginal laceration.
11:00 AM – I rush out to see a private patient who is three days post cesarean section and discharge her to her home.
11:30 AM – I am informed that we have a woman who has arrived with what appeared to be an acute abdomen, but she is also 28 weeks pregnant. She has been taken to the ultrasound room, and her pregnancy does not look right although it is not clear what is going on. The infant is under a lot of distress, the placenta does not appear to be attached well . . . something is not right. So we decide to do a cesarean section despite not being completely confident what we will find. What we do know is that patient appears very ill, and that her baby looks on the verge of dying if we do not do a cesarean section to rescue the baby. Before I start the surgery I am palpating her abdomen and feel what seems to be the baby’s arms and legs just under the muscles near her stomach. You can feel that on a rupture of the uterus, but there is no reason to really suspect that in this patient. On opening her abdomen we see something completely unexpected. The placenta is in the abdomen. Obviously it should be inside the uterus. No wonder our ultrasound report was so unusual. Since I had felt the baby from my abdominal exam already just before surgery (although I had not been completely sure that was what I was feeling at the time), I knew where to reach. I placed my hands inside the abdomen up near the stomach and liver and pulled out the little preterm infant. This patient had presented with an abdominal pregnancy which is very rare. The placenta had attached to the outside of the uterus. Unfortunately because of her bleeding, she ended up receiving a hysterectomy with the help of Dr. Chen, the gynecologist on call, to control the blood loss.
2:00 PM – Another mother who is laboring begins demonstrating signs of stress to the baby. In addition she has not dilated her cervix for the previous 4 hours. She is brought back for a cesarean section.
3:30 PM – We have a twin pregnancy that is classified as monochorionic / monoamniotic which means the babies are sharing the same placenta and amniotic sac. Also one twin is noted to be significantly bigger than the other which indicated that one twin is basically stealing nutrition and blood from the other. Her case is also complicated by a pregnancy related cardiomyopathy or heart failure. All of these signs are indications for delivery, and she is taken for a cesarean section. Indeed, the first twin is quite a bit larger on delivery than the second, but both cry immediately on delivery. After surgery she is noted to have some respiratory failure related to the shifts of body fluids that occur with anesthesia and delivery of her baby via cesarean section. She is given medicine to decrease the lung congestion, and she responds well. She goes to the higher level of care (HDU) unit for close observation after surgery.
5:00 PM – I go to see a couple patients in the gynecology wards who are having some difficulties. One is developing respiratory distress (trouble breathing) with fever and a high heart rate. She is already being treated for abdominal / pelvic infection. I order imaging studies, lab work, a urine test, and advance the strength of her antibiotics. Probably the best thing we do for her is give her a big dose of intravenous fluids to get ahead of possible sepsis. She responds well over the next few hours. I also see a woman who has HIV, anemia, low platelets, and chronic vaginal bleeding from a protruding uterine fibroid. She is relatively stable, but she has had some increased bleeding so we get a blood count and start looking for blood to give to her and help support her.
7:00 PM – A woman with two previous cesarean sections presents to the obstetric ward with contractions. Because having two previous uterine scars puts her at risk for uterine rupture with labor she is taken to the operating room for a repeat cesarean section. She is noted to have significant scarring and adhesions so that we are unable to bring her uterus out of her pelvis to close her uterine incision. Bringing the uterus out of the pelvis makes the operation much easier. However in her case, I repair it with a little bit of difficulty deep inside the pelvis. Overall she does well.
9:00 PM – I step out of the operating room to be told there is a mother in the pushing stage of labor who has stalled and may need a cesarean section. I go and check and it appears to me that she can continue pushing. She gets close to delivery, but in the end begins showing signs of distress to the baby. So I use a vacuum to delivery the baby who does well.
10:00 PM – I make round on all the sicker patients of the day checking on the 2 patients in the gynecology ward, the cesarean section, and the patient in the HDU. Everyone is stable.
11:00 PM – I go back by the labor ward and I am told there is a patient who is in the pushing phase of labor who has become acutely psychotic. She is hallucinating, talking to nobody, and refusing to push. I look at her and the infant’s head is almost delivered. I grab my second vacuum and help her finish the delivery. The baby does fine, and interestingly, her psychosis clears after delivery.
12:30 PM – I lay down on the living room floor to catch some sleep if possible after finishing a very late dinner and drinking about 100 tall glasses of water.
3:30 AM – I am called to be told that a patient has a 4th degree laceration after delivery. This means the tear goes through the bottom of her vaginal all the way through her anus and rectum. I tell them to get her to the theater for repair. The stabilize the patient and wait for an orthopedic emergency to finish to move her to the operating room.
6:00 AM – With the help of Dr. Chen we repair her 4th degree laceration.
8:00 AM – The 24 hours of call end.