The Beginning of Your Night on Call

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There are nights (and days) on labor and delivery that defy both description and credibility. I think that when I talk to laypeople, the sheer density of what can happen in a short period of time seems overly dramatic. But it does happen, and when it does it's...crazy. It feels almost like what I think war must feel like, a bit.

I wanted to give you a taste of that, and my attempt is below. It's a pretty reasonable re-enactment of the clinical load of my first few hours of my call last week (although clearly, not of the actual patients). The labor floor is not always this dense - we spend a fair amount of time shooting the breeze at the nursing station - but when it's bad, it's bad. Here is a partial description of the start of one very busy night on call, and I think it's a pretty fair one.

Aside from changing all the patient details, I also omitted the other attending. But that's actually because he had his own stuff going on, including a patient with an ectopic pregnancy that he took to the OR. So although there were more resources available to me at times, I dealt with a lot of this as the sole attending. I did have a great cadre of experienced senior and chief residents, so I wasn't as alone as this post makes it sound in terms of getting stuff done; but I was alone in terms of higher-level decision making.

 I also omitted a large part of doctoring, which is documentation. Everything below that I did is something i then had to sit down and write a note about. It's not exciting, but it's necessary, and it uses up an enormous amount of both time and brain space. But it isn't exciting, so I left it out.

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You walk onto the labor floor at 5 pm, after a long day at the office.

Patient A. is 38 years old,  pregnant at 36 weeks with chronic hypertension and three prior cesarean sections. She was sent in from clinic with very high blood pressures, which are not that unusual for her, but things then calmed down. The day team has de-escalated, stopped her magnesium sulfate*, but now she has a headache, although it's mild. You ask the team to give her tylenol, and recheck her pressures, which are a bit high but pretty well-controlled.

Patient B is a young healthy woman 8 days past her due date who came in with her water broken. She progressed to 4 centimeters, but is now incoherent, and asking for a cesarean section. She's hyperventilating, and the fetal heart tracing looks kinda bad, probably because she's not breathing that well. Over twenty minutes, you talk her down; together you decide to try an epidural. When she's doing the yoga breathing that you do with her (with an oxygen mask on), the baby looks a lot better.

Patient C is a patient with a quiescent auto-immune disease who is 27 weeks pregnant and fell down three stairs, hitting her belly. She has no contractions, but she's very tender all over her abdomen, so you put her in the PACU** No steroids for lung maturity yet; let's see what her labs show.

Patient D had a cesarean section yesterday with uterine atony1. She had a blood level hematocrit of 21 after her surgery, so she was transfused two units and sent to the floor. The resident tells you that her hematocrit is now 20, which means that those two units of packed red cells you gave her did absolutely nothing. Concerns include that perhaps we wildly underestimated the amount of blood she lost, or that she is continuing to lose blood. You ask for a stat repeat hematocrit, and that the patient be brought to the PACU so that you can watch her more closely. She may need to be re-operated on..

Patient A's headache is now a bit worse, not better, an hour after the tylenol. Her blood pressures are still ok, and she does admit to having rare migraines in her pre-pregnant life. Perhaps this is one? She also has not had protein in her urine, so she doesn't technically yet meet criteria for pre-eclampsia. You hem and haw, but eventually give her one tab of a stronger medication, which should knock out a migraine. If that doesn't work, you'll have to start thinking that this is actually pre-eclampsia, and if the headache gets worse, it could even be a stroke.

Patients F, G, and H are all scheduled inductions in the waiting room. You can't accomodate them all safely during this busy night so you review the charts. F has a good clinical reasons for induction that should not wait; you'll bring her in as soon as you can. G will get fetal testing in triage and be rescheduled in 1-2 days. H's dating, upon review, is wrong - she's 38, not 39 weeks, and as such really shouldn't be induced for another few days, especially since the indication for induction is pretty soft. You walk out to the waiting room to talk to Patient G, who is very nice about it. Patient H is not, which is understandable, and spends about 20 minutes yelling at you, which becomes slightly less understandable as it progresses in aggression. You call her doctor on her cell phone and talk to her together about the plan and about the small but real risks of delivering a baby before 39 weeks who didn't need to be. The patient grudgingly accepts an induction in 5 days' time; she'll work the details out with her doctor. She doesn't look at you, and slams the door on her way out. 

While you're finishing up the paperwork from these discussions, Patient E rolls into triage, screaming that she has to push. She is examined in a chair - there are no available beds - and yup, fully dilated and head is at  +2 station. On the wheelchair towards a labor room, you get out of her that she had a prior cesearean but wanted a trial of labor. The triage nurse tells you that she was here earlier today but was not dilated at all. You bring her in the room, and get ready to have a baby.

Patient A now has blood pressures in stroke range, 180s-190s systolic. You cross over to her room, and push some more medications. Her blood pressure goes down; you ask to restart the magnesium, send more labs, and you go back to Patient E.

Patient E delivers. It's a girl! Pink baby girl with lovely curly black hair. The chief resident delivers the placenta  and finishes up while you keep an eye on A's pressures in the next room over.

A resident stops you in the hallway. Patient D hematocrit has come back, and praise be, it's 25.2. That earlier one must have been drawn downstream from an IV and been a diluted result. The patient looks - and feels - pretty good, so you  write a note about her adventure, and back to postpartum she rolls.

The 27-weeker with the abdominal trauma, Patient C, has labs that are mostly reassuring, except that her blood clotting level is strangely low. That result could be a sign of a large abruption. The story doesn't really fit, as she overall feels well aside from the aches and pains from the actual fall. No vaginal bleeding, no contractions, the baby looks great. Weird, so you decide to resend the labs and some other ones and watch her closely. Given the labs, and her gestational age, and her overall abdominal tenderness, you start the antenatal corticosteroid course, just in case she does go on to deliver soon.

Patient B's nurse is calling. The patient is comfortable overall, and got some much-needed rest, but is feeling some pelvic pressure. You examine her and she has an anterior lip of cervix left2, with a baby that is quite low and ready to be born. You debate having her try to push while you reduce the little bit of cervix, but your nurse is needed in another room, so you decide to let her labor down for 30 minutes.

Patient A with worsening pressures and headache on the magnesium. Labs are still normal, but you note that she had some protein in her urine at the clinic visit. Regardless, she's getting pretty sick pretty fast. You make the plan to start to head to the OR to deliver, but the headache worsens suddenly and dramatically. Plan change: get blood pressures under control, then a fast trip downstairs to the head CT scanner, with a doctor and the magnesium in tow, to assess for stroke. If head CT negative, return to the OR for delivery. If head CT positive positive? That's an excellent question. If positive, you'll call neurology and figure out how you'll get her delivered with them.

Patient B is now feeling the urge to push. Now that she's rested and is calmer, she turns out to be lovely and pushes with great energy. Twenty minutes later: it's a boy! The new grandmother is in the corner, actually jumping up and down with joy. You say congratulations and run out.

There's blood on your scrub top somehow, so you run out to change. The resident stops you to tell you that there are three new admissions in triage. Perfect, you say. Once I do this section, I'll have three more rooms for them.

You run upstairs, strip, change, glance at the clock. Somehow it's only 10 pm, with miles to go before you sleep.
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Epilogue: It never calmed down, and in fact, got rather busier with a sick antepartum patient, a cesarean that became unexpectedly complicated, and a bus full of laboring women (well, three) who all came in together at 3 a.m. I ran almost flat-out the whole night long. I think I was pretty openly grumpy about this [to staff, not to patients], which I am embarrased by now.

At some point around 4:45 am, I lay down because I needed to, and I think I slept until I got paged by an outpatient about her renal infection. I went home at 8:30 am, snuggled Rav and Dav, took Smoosh to a doctor's appointment and then crashed very, very hard. Later that day, I found an enormous bruise on my left leg; I don't know how or when during the night I got it, which seems appropriate.

*Used to prevent the onset of seizures in pre-eclampsia. 
**Post-Anesthesia Care Unit; the area where patients recover from surgery, but we sometiems use it to monitor other patients who aren't in labor.
1The uterus does not contract after delivery of the baby and placenta, leading to large amounts of hemorrhage. 
2Basically, she's 9.5 centimeters dilated.,