One of the Theatre Nurses, J, has been pregnant for what seems like 5 years. This is her first pregnancy. Her due date passed about 6 days ago, and every time I run into her, I ask “So where is that baby?”
Finally, yesterday she came in complaining of contractions. I knew she wasn’t in active labor – you can tell by looking (although I've been surprised before). But she looked somewhat uncomfortable. She was 3 centimeters dilated, and the cervix was pretty thin. Latent labor – not bad! She was admitted to wait for active labor.
Today, I am in a meeting with various hospital staff when my co-worker calls me twice in a row. I call her back after the meeting. “They came to find you from Labor Ward. One of the staff is in labor and not progressing, and they want you to see her.”
I suspect it’s J. I go to the Labor Ward and I find I am right. I review her file, and it looks like she went into active labor sometime overnight, but since then has progressed slowly. I look at her – she looks too comfortable for active labor. She has 1 contraction while I am in the room, but she cringes only a little. I doubt her contractions are very strong. It is now 11am, and by my exam she is still 6cm – the same as 2 hours ago. I can feel a prominent bag of water, her amniotic membranes. I break her water, hoping to augment her labor.
I write a note, and the midwives (and J) that I expect her contractions to pick up soon.
I come out of the room, and the midwives have several more patients for me to see. Miscarriage, malaria, menopause – I see them all, do ultrasounds on some. After about an hour, J comes out of her private room, huffing and puffing, cringing visibly when contractions come - more like what I expect for active labor. She says to me “OK, what are we going to do? Pitocin?” She desperately wants her labor to be over – that’s a good sign. I encourage her and go back to the clinic to get some work done. I tell the midwives not to examine her for another 1-2 hours, unless she is delivering.
When I come back 1.5 hours later, she has been examined, and is now 8cm. Great news! She is huffing and puffing still. She is in such pain, so uncomfortable. “Please help me,” she says. I apologize that I can’t do anything except help her baby come. One of the head nurses is with me (the one who examined her) and I start telling her about the pain control options we have in the US for labor – epidural, narcotics, etc. She loves the idea of the epidural. “Doctor! When are you going to get us that one? Maybe with you here, we can get that one soon. We need it!” I try to explain that you need trained professionals to place the epidural. “Is it expensive?” she asks. “I don’t think the medications themselves are expensive, but you need someone who knows how,” I say. “You find out how and you bring it to us,” she commands.
I tell J she is doing really well, and I will come back to check on her. 2 hours later, she is still going, but she doesn’t look very uncomfortable anymore. The contractions have subsided somewhat. On my exam, the head is lower and there is a thick portion of cervix left anteriorly. The midwives and I both agree that this phase has slowed, partially because the baby is facing forward, not backward (occiput posterior).
Internally, I think “Oy.” At home, this would be easy. She needs gentle labor augmentation. You would set up a pitocin pump, and start a very slow infusion of pitocin at a controlled rate not to overstimulate. But – what pump? How can I induce? But I know she doesn’t need a c-section. The baby is small, her pelvis has plenty of room, and she just needs that extra push. It would be such a shame to do a c-section now.
The midwives tell me that J had bought some pitocin just in case (the hospital ran out last week – surprise). I tell them to inject 10 units into a bottle of IV fluid. We hang it and I set the IV catheter to run the fluid very, very slowly. Then I exhale deeply and cross my fingers.
Two hours later, I return to the Labor Ward. It’s 5pm, and I’m worried. What if she hasn’t progressed? Maybe the pitocin drip is too slow. Should I increase it? But then, what if it becomes too fast? It could overstimulate and hurt the baby. My kingdom for an IV pump! It’s getting late – maybe I should just do a c-section because if she needs one later and there’s no anesthetist, that could be really bad. What to do, what to do?
I arrive on Labor Ward and open the door to the private room – it’s empty and clean. “She has delivered!” says the midwife on duty. She has already been transferred to the postnatal ward. I race over there and see J lying on her bed smiling with her baby daughter next to her. We laugh together and I give her a Ugandan handshake and an American hug. She says the pain increased soon after I started the pitocin, and she delivered after about 30 minutes. Her whole family is there, and they thank me. I look at the baby – she has a squashed top of the head from the occiput posterior, but she looks great.
I find the midwife who cared for J the entire labor. “You are still here?” I say. “I worked last night, I was here the whole day with her, and I am coming back to work tonight. I am very tired,” she says. Then she lowers her voice and says, “Thank you. Your pitocin worked. I was very worried.” I say, “You know what? I was too.” We breathe a sigh of relief together.
I know I have written about tragedies, but there are happy stories here, too.