May 29, 2014

Labour ward day

Yesterday was labour ward day.

There's a woman in High Dependency Unit (HDU) D2 post-op hysterectomy and bilateral tubal ligation after having 4th degree perineal tear from SVD. The tear extended up to the uterus and it nicked one of the uterine arteries. She lost 12L of blood can you imagine that? I thought human body can contain up to 5-6L of blood? Anyway, her body was literally made up of other people's blood. She had two stomas on her both flanks (colostomy, I think. Doesn't look like ileostomy. I don't know!) as her anal sphincter is a gone case and she looked moderately dehydrated.

It was, however, a slow and boring morning in the ward overall.

In the afternoon there's a woman I clerked earlier in the morning who started screaming in pain as her contraction started. She is G1P0 at 40 week gestation age, BMI of 38 (severely obese) with known GDM with good dietary control, admitted to labour ward for induction of labour. While waiting for her to enter active phase of 1st stage of labour (yes, all the screaming and she wasn't even actively in labour. Scary ass stuff, being pregnant) there's a shout "Cord prolapse!".

Being an ignorant medical student who stubbornly left the prolapse chapter untouched and unread, I regretted not knowing that cord prolapse is an emergency situation. Anyway, what happened was that one of the housemen did a VE on a different patient after finding out the CTG ( a machine used to monitor the baby in the womb) is abnormal. From the vaginal examination she (or he, I wasn't there) felt with her fingers something that is definitely not the cervix or the head. You can highly suspect a cord prolapse when you can feel something cord-like (duuh!) or that it's pulsating (pulsating means that the baby is alive, as in the pulsation you feel is the blood flowing from placenta via the cord to the baby).

Okay, explanation. Cord prolapse is when the cord that connects placenta and the baby finds itself at the cervix, which is kinda like the mouth or entrance or exit of an uterus that holds the baby. So naturally, when the mother is contracting, the baby is pushed outwards and downwards, right? As the baby's head reaches nearer to get out, that head presses onto the cord. So the cord is also being pushed down and out (prolapse). Now as the cord is connected and all tangled, the more the head pushed the more the cord will get pressured. This pressured cord (imagine you tightened a water pipe. The flow will become less, yes?) caused the baby distress as the baby cannot get oxygen. And when the baby is in distress, they will poop out and aspirate the poop. We call this meconium aspiration. Anyway, the point is, when prolapse happens, the baby will get distress, blood perfusion will be compromised, and the baby will die fast without intervention. So you see, this is an obstetric emergency.

I think what happened next was that the HO called for an MO (Dr Kelvin) to confirm it. He's the one who shouted earlier. After that the doctors and nurses all ran to that room. We also joined running. It's quite a panic scenario. The MO who shouted still had his fingers up inside the woman's vagina. He had no choice but to sit on the end of the patient's bed as he really should not remove the fingers out. They started putting up catheter in order to fill up the bladder back. You see when pregnant women go to labour their bladder will be emptied using a catheter. The reason to it was that you cannot contract well with a full bladder because it will just block the uterus. So during a cord prolapse you really don't want contraction to make it worse so you reverse the whole thing. They filled up her bladder with normal saline up to some specific volume. Later on my lecturer said that other thing that you can do is to prop the mother's bottom upwards so that the baby will have to go against gravity, thus prolonging the labour.

After that the woman need to be sent to the operation theatre (OT) for emergency caesarean section. The labour ward is at 4th floor and the OT is one floor up. There's only one male HO (Dr Harith) from HDU there and us (Akmal and I) so the task of transferring that woman to OT fall on us. Dr Kelvin was unavailable as he had to maintain his fingers inside her vagina so that he can hold the baby's head from continuing descending and making the prolapse worse. He had to sit with legs crossed with knees tucked not hanging over the bed. 2 nurses were also with us.

So the race again time started. We ran out of labour ward and went for the lift. I saw that there is no way it would fit all of us so we raced upstairs on foot and resumed pushing the bed to the OT. The OT team already waited from behind the glass wall, ready to accept the transfer. Another HO came bringing the consent form and handed it to the OT. After that we went back to labour ward, the doctors continuing their work and us continued to watch delivery.

The screaming fat lady screamed a lot more when she's giving birth. Her contractions were very short, she didn't know how to contract well and she easily gave up. The nurses kept telling her not to scream but to channel it down to contract longer. Long story short she managed to do SVD (spontaneous vaginal delivery) uneventful with only 1st or 2nd degree tear. Akmal got the chance to do controlled cord traction (gently pulled the cord without tearing it so the placental won't be left behind). I however managed to inspect the placenta and its membrane and confirming the placental vessels (AVA - 2 arteries, 1 vein). Then we watched the MO (Dr Hani) repair the perineal tear or episiotomy.

This is the 2nd and last day of going to labour ward, with total of 4 sessions. Definitely a good experience. I might consider doing O&G for my SSC in my Year 4 next year InsyaAllah InsyaAllah amin!

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