Serenity in the Delivery Room

I find the familiar Serenity Prayer very applicable at this time.

God, grant me

the serenity to accept the things that cannot change,

the courage to change the things that can,

and the wisdom to know the difference.

I often find myself wondering where my expertise should outweigh their experience here. What would be good to change? What is best left as it is because through trial and error, it has proven to be the most effective? When should I insist on my knowledge and when should I rely on the years of experience of the nurses? I find this to be an extremely difficult balancing act. Again, here is an example…

Last week we had slew of bad outcomes—three uterine ruptures and 1 baby who died shortly after C-section at term for unknown reason. Indeed, I learned many lessons last week about the system, discussed areas of delay or poor communication with various departments, and in general was overwhelmed with sadness at the loss of these babies. While waiting for a patient to arrive from the maternity for what was supposed to be an urgent C-section, the scrub nurse had asked almost incredulously why I was so worried. “If the baby dies, you didn’t kill it. God decides who lives and who dies.” And while that is very true, the delay of a C-section can in fact cause the loss of a baby who might have been saved a half an hour earlier. On rounds in the C-section postpartum room, only 2 of the 6 mamas there had babies in their arms. At least there were still 6 mamas there.

My surgery shoes, for some reason went unwashed this week, but were reminders to me of the bleeding from the uterine rupture as well as blue from the blue dye test where we found a vesico-vaginal fistula after prolonged labor elsewhere.

After such unfortunate results, the knee-jerk reaction in the maternity ward was to prepare and ask for a C-section as soon as anything abnormal was detected. A pregnant mom came in with the fetal heart rate very high. I was told by the students and residents that there was fetal distress and therefore a need for C-section right away. Everything from my training was telling me that tachycardia (high heart rate) in the presence of contractions is not usually a sign of distress but commonly from maternal fever. Everything from the past week was screaming at me to just go along with their thought process and get that baby out before it died.

I decided to go with my training this time, a bit reluctantly. She did, in fact, have a fever. But the fever had been present for several days. Perhaps the baby was septic (infected) and suffering. But no, when I scratched the baby’s head, it moved a lot and the heart rate increased. That was reassuring. But what might malaria do to a baby? But no, there were no drops in heart rate during or after contractions to indicate distress. We gave Tylenol and started antibiotics, and waited… and the heart rate was still high. “We need to perform a C-section, I think,” the resident said again. And one of the nurses agreed. My gut just didn’t agree. “Wait. Please just wait. I think the heart rate should normalize with a bit more time,” I replied, not knowing if that time would be detrimental to the baby.

I called another experienced staff doctor over to see if he had any further insight. At first, he advised to go ahead with the C-section to avoid having another dead baby. Just at that moment, the nurse listened to the fetal heart rate and it had finally dropped to the upper limit of normal. Upon hearing this, the staff doctor agreed with me that we could continue to wait. Just before I left the maternity ward for the night, the lab result came back positive for a high level of malaria parasite in the blood. We started treatment for malaria right away, and then made both the lower level resident as well as the supervising staff doctor aware of the situation. They both seemed a bit skeptical but agreed to just continue to wait for labor and watch the fetal heart rate closely.

Some of the sutures we have available to use during surgery

I walked into the maternity ward in the morning, certain I’d find her in the post C-section room, hopefully with a baby, but maybe not. The nurses came out to greet me with a good morning, and I asked about the lady. To my surprise, they pointed in the opposite direction, to where ladies go after a normal vaginal delivery. I may just have let out a little whoop of joy. The nurses seemed a bit surprised but definitely joined in the celebration outside the maternity building. I think they are used to doctors who like to operate, so finding my joy so abundant at a normal vaginal delivery perhaps was weird. It was just the encouragement I needed. I’ve made plenty of judgment calls, some good and some less than stellar. Hindsight is always 20/20, and this is especially true in OB. Sometimes we all just need a good vaginal delivery to make it through the day…. Said no one but me probably. :) 

Later in the week, I saw evidence for change in the vitesse (quickness) of urgently-needed cesarean sections. Because of a few conversations I’d had last week with the OR staff and maternity, we sped up the process by eliminating a few of the steps (like going to the lab and finding a blood donor and paying up front and finding an IV bag and finding a catheter and shaving the patient, etc…), and significantly reduced the time between decision to incision. We were able to perform two cesarean sections back-to-back and both babies who had previously had heart rates in the 90s (normal is 120-160) were born alive! The OR staff was pumped that the surgeries were done so quickly, and one of the medical students exclaimed, "Wow, that was great! That was so fast! You saved those babies!" I immediately thought of the conversation with the scrub tech earlier in the week and pointed out, "If I take credit for saving these babies, I need to take responsibility for the death of the others. God is the one who decides, God is the one who heals. I'm just working to do my best."

I may not understand all the time, but I trust that God is good. 

The problem: 

Your wisdom and knowledge, they have deluded you; For you have said in your heart, 'I am, and there is no one besides me' - Isaiah 47:10b

A  good reminder:

"Where were you when I laid the foundation of the earth? Tell Me, if you have understanding."- God to Job in Job 38:4

The solution:

If you seek [wisdom] as silver and search for her as for hidden treasures; then you will discern the fear of the Lord and discover the knowledge of God. For the Lord gives wisdom; from His mouth come knowledge and understanding. - Proverbs 2:4-6

For it is God who works in you to will and to will and to act in order to fulfill his good purpose. - Philippians 2:13

To end, I'll end with an adaptation of St. Augustine's quote. It is one of my favorites. 

Work as though everything depends on you.

Pray as though everything depends on God

Because it does!