Bad outcomes

Obstetrics is a weird specialty. We're always super-obsessed (often to my chagrin) with documentation and CYA-type practices. These first couple months on service (since I started on medicine/ICU this year) have had their share of moments of me saying, "But on medicine we didn't worry about this." But I also do know that when things go wrong in medicine, a 90-year-old pt might have a bad outcome, but it's inherently easier to tolerate than when things go wrong with a 20-year old woman -- or a 1-day-old infant. (That doesn't make the loss of someone's grandmother or grandfather any less important, but for the general population, we tolerate the death of a 90-year-old moreso than of a 20-year-old.)

The aftershocks of the death of our post-partum patient from H1N1 pneumonia continues to ripple through the department and hospital. As of this week, the hospital is not allowing anyone under 16 years old to enter the hospital at all (H1N1 is widespread among children). We continue to screen and test our pregnant patients for H1N1, and have a positive test result at least a couple times a week. Tamiflu is a godsend, though; we start our patients on it early and we haven't had any other bad outcomes yet. And I got my H1N1 vaccine, so I feel better that I won't get sick and 1) feel crappy myself and 2) spread infection to patients.

This morning I got to deliver a patient who I admitted the night before. She is a 33-year-old primiparous woman at 36 weeks and 3 days who came into our triage unit for rule out labor. She was contracting every 3 minutes or so for sure, but her cervix was only 1 cm dilated and not effaced. We watched her for a little while because her blood pressures were really elevated, so we wanted to check labs. And 3 hours later, her cervix was still 1 cm and not effaced, but given her high blood pressures, we kept her for more testing. Not in labor. An hour later, the third year resident saw me and asked, "Was Ms. B really 1/long/-3* when you checked her? Because she's 80% effaced for me." And for once, I was really confident in my exam, and I knew she hadn't been effaced an hour prior. Since it was 2 am and my turn to go down for an on-call nap, I went to sleep for 2 hours. And when I got up at 4, the third-year said, "Guess what! Ms. B is in labor! She's 5 cm now."

So in 3 hours, she went from 1 and long to 1 and 80% to 5 and 90%. Off to L&D she went, and got her epidural. And an hour and a half later, she was complete and +1 station, and ready to push! And I was there and able to do it! So we started pushing and she did really well, and in about 30 minutes she was ready to deliver. The head delivered nicely, and at first I didn't feel a nuchal cord. But then we saw a nuchal cord -- a tight one. Both my attending and I tried to reduce it, but couldn't get it at the first pass, and as I was trying a second time, my attending told me to stop, and grabbed the clamps, and we ordered the patient to stop pushing while we clamped and cut the nuchal at the perineum. The rest of the baby delivered fine. It gasped for breath as usual, and I suctioned the mouth and nose, and handed the baby up to mom's belly, just like normal. And then the nurse grabbed the baby and brought it over to the warmer, and while I was collecting cord bloods and cord gases, it all of a sudden hit me: I hadn't heard the baby cry yet. Gasped, yes. Cry, no. And the mom realized it, too.

So the pediatricians rushed in and did their thing (I couldn't see it; I was busy doing my thing), and while we delivered the placenta and repaired mom's tears (the shoulders busted out all at once, so she had a couple little ones), the silence in the room was overwhelming. A nurse called out the time. "Seven minutes." As in, seven minutes without a cry. I start feeling sick.

And then, finally, the baby cried. Everyone breathed a sigh of relief, myself included. But I'm anxious to go to work tomorrow to see how the baby's doing.

And while I gripe, I know why we document up the wazoo. Because when a 90-year-old woman with multiple medical comorbidities dies, chances are you won't get sued. But when a 23-year-old woman dies 1 week after delivering her baby, or a baby ends up with a bad outcome, everyone is going to be scrutinizing what you did over and over. We scrutinize it, and try to learn from it. And we hope we won't be scrutinizing it in court.

Why couldn't I have gone into a less stressful field?