Adrenaline

Been awhile since I blogged... but here is a good one from back in the day!

::Scenario::

42yr-old primigravida, absolutely no prenatal care beyond a visit to the abortion clinic where (19yr old!!) boyfriend and her decided they couldn't afford one and decided to have the baby instead. Shows up to our unit at the end of the night shift in early labor and stating that "something's been squirting out of me now and then since 0230am", "eww..."
Upon admission the her cervix was found to be 1cm/25%/-2 station. Gestational age by ultrasound was 33.0wks but by the patient's "adamant" report she was anywhere between 42 and 43 weeks!! Report was handed off to me and I got orders to start pitocin.

Two hours later she decided that she needed some iv medication for pain management - since she was in early labor we decided to wait til later for the epidural. I went ahead and gave it to her without checking her cervix because she had been checked not that long ago and had just started contracting regularly after the pitocin had begun.
The drugs did the trick, knocking her out to "happy land" - a short time later I noticed the baby's heart rate was dropping rather noticably with each contraction. I went in to change her position and found her moaning loudlywith contractions - I checked her and found her to be dilated to 5cm/100% effaced/0 station. After repositioning her to make the baby happy, I informed her of her great progress and notified her that if she wanted an epidural she should think about getting it sooner rather than later. She decided that she wanted to wait a little bit longer so I went out of the room and updated the doctor of her progress.
Five minutes later she called out saying that she had changed her mind, I went in and found her PUSHING with contractions, baby's heartrate was dropping significantly and I was beginning to get a tad concerned...
I checked her and felt the baby's head "right there" - WHOA! I buzzed out for some help, telling them to call my doc for immediate delivery and to notify the nursery.
I stayed at her side, coaching her through contractions - she was pushing spontaneously with each contraction and I could see the baby's head, more and more with each push. As the room begin to hum with activity as various personnel got all the necessary stuff ready, I realized that the chances were good that we were going to deliver before the doc arrived.
A lot of things happened all at once then - amazing how your brain speeds up and you can run through a TON of scenarios in a few moments.

::My Thoughts::
"I need my doc, Lord... Baby's been down now for quite for awhile, 50s...60s...70s with turning her to a different position... where is my doc? ...she is pushing great and should have delivered by now if it was going to be easy, that means that the potential for a complicated delivery is a bit on the high side... Lord, help us out here... where is my doc?? ...okay, her perineum is tight and that is why the baby cannot deliver, baby is in the 70s still, she needs an episiotomy... where is my DOC??? ...okay, enough of this..."

I turned to the NICU nurse standing there with big eyes watching this play out and told her to go and get me an ETA on my doc, get a neonatologist and the anesthesiologist in here and then to find me an ER doc NOW!! She ran out quickly and I turned back to the task at hand as the girl continued to push and the baby continued to drop its heartrate. My other nurse who was there helping me out, looked at me and said, "...we need to just deliver her, the baby is down..."

::My thoughts::
"Okay Girl, get your panic moment out of the way now, you are probably going to need to clamp and cut the cord that is most likely wrapped around the baby's neck, look for your instruments now BEFORE you need them... where are they, where are they - - okay! There they are! You may need to help deliver a shoulder, get mom in a good position for that, okay... Lord, help me out here... baby's down, I don't know what is going to come out - preterm or who knows what... God help me please! She needs an episiotomy but I CANNOT do that - they will probably take away my license... I can just see it now in the headlines!! ...but the baby's heartrate is down... God help this baby deliver, PLEASE!!"

I looked the girl in the face and told her to push with all she had as I supported the baby's head to prevent her from ripping open. She did and, hallelujah, the baby's head slipped out! I quickly checked around the neck and... sure enough, there was that "tight nuchal cord", I quickly clamped and cut it, releasing the baby from its strangle hold but also removing it's blood/oxygen supply, I then told the mom to push again and... the baby didn't budge!!

::My Thoughts::
"Oh God, it is a shoulder dystocia - no way! Lord, what do I do??? ...okay, mom's knees all the way back, feel for that shoulder... I can feel it, why is it not moving? "PUSH HARDER" Still not moving much, "PUSH AGAIN, HARDER THAN THAT, COME ON, YOU CAN DO IT" Ah-hah! There is the culprit, a hand up by the baby's chin - stinker! Oh, praise God - the baby delivered... and immediately started screaming!!"
Pass the screaming baby off to the NICU nurse, deep breath... look up and meet the eyes of my comrades in arms and... BIG GRIN!! Awesome... I LOVE this job!!

By the way - no major lacerations for mom... just a "skid mark" or two!! hehe...