I’ve talked about transporting patients to the hospital before. Prior to this week I had only been once, and that was in a non-emergency type situation. A sixteen year old patient had failed to progress after many many hours in labor and government regulations dictated that she must go to the hospital. This patient walked into the ER without much assistance and I left her waiting in chairs in the ER and I thought that was hard.
My last day shift was a completely different situation. When my patient was endorsed to me she was already 7 cm dilated. It was her first baby, but she seemed quite uncomfortable and moving right along. I instructed her to try different positions to relieve some of the discomfort, especially the labor pain in her back. I had some concern that the baby was positioned OP, which means that the back of the baby’s head was against mom’s back. Some call it sunnyside up, so that if the mom were on her back the baby would be face-up. It’s much harder to deliver the baby this way, and ideally we would like that baby to turn so it is facing the mom’s back. Position changes and being up off the bed is the best way to accomplish that. Pelvic rocking, hands and knees, and squatting are all encouraged. My patient, Rowena, was a trooper at doing all of them and her bana (husband) was very supportive rubbing her back and wiping her sweaty brow.
After a couple hours of some pretty intense labor Rowena told me that she felt like she needed to push. We really try to minimize the number of internal exams we do, so in my broken visayan I try to encourage her to breathe through the contractions as long as she can. She looks at me like I’m a mad woman, but she is compliant and keeps breathing. Ginhawa long. Just breathe.
I keep updating my supervisor and after some time of breathing, always with the urge to push, she begins spontaneously pushing and I know it is very possibly time. The supervisor tells me I can do an IE (internal exam) and check to see if she is fully dilated. I grab a sterile glove and some gel and find no cervix, just a very bulging amniotic sac. I note the station of the baby’s head and while it is engaged in the pelvis it is not very low.
At this point she is clear to start pushing, so I help her grab her legs and show her bana how he can support her head during pushing. I had been previously sitting on the edge of the bed, facing her, but stood up to help her get positioned for pushing. After 1 or 2 good pushes she rests and waits for the next contraction. When a contraction comes she pushes with all strength she has and I tilt my head down to see if there is any visible and literally a split second after I tilt my head back up she has spontaneous rupture of membranes, and does it ever rupture. It shoots across the bed and nails the opposite wall, the very wall that I had earlier been leaning my back against as Rowena breathed her way through one contraction and then the next.
Unfortunately the amniotic fluid was not the nice clear color we like to see, but stained greenish brown with meconium fluid. In late term newborns it is not uncommon to see meconium as it is considered the first bowel movement of the newborn, meconium is the protective lining in the intestines as the fetus is developing. In Rowena’s case her dates were still before 40 weeks and meconium in that case can often indicate some sort of past fetal distress. Another risk of meconium is that during labor or deliver the newborn can actually aspirate the meconium into the lungs and it a very sticky tenacious substance that while meant to line the intestines, is very harmful if inhaled into the lungs.
We immediately check heart tones and they are okay, but still lower than before. She pushes again and my supervisor sees the same as I have been noting, nothing visible with pushing. Fetal heart tones were checked again and they have now dropped to 80, then back to 90 and after head stimulation (basically tickling the baby’s head with one sterile finger) back up to 110 (normal heart rate for a fetus is 110-160). The supervisor instructs the patient to stand on the bed, her bana behind her and she squats as she pushes. The next time we check heart tones they have dropped to 60 and we are in hurry up mode. 02 is given to the patient, positions changed, and IV started (my first IV at Mercy, done while patient is semi-squatting on the bed). Even with head stimulation the heart rate only comes up to 90. It is time to transport this patient and it will be an emergency.
We switch her to a portable O2 tanks, someone is filling out papers. I am doing head stimulation and checking heart tones.. This practice of head stimulating is interesting and debatable. All current research actually says it is not the right course of action, for while it might be bring the heart rate up temporarily it may cause a stressed baby to become even more stressed and have further decelerations in the heart rate later. However, at Mercy if your supervisor tells you to do something, you do it. We are practicing under their license and whatever happens is ultimately their decision, so it is the right thing to do here.
Our guard is notified of need to do emergency transport and the stretcher is brought in. I hold the IV bag and 02 tank as another student and the guard carry the stretcher. We get to the ambulance, which is really just a big covered jeep. The floor is metal and the stretcher is just two poles with canvas across, and the patient is set as nicely as possible on the floor of the jeep.
I can only imagine how terrifying this must be for Rowena. This is her first baby, she is only 21 and we are these white foreigners putting her in the back of the ambulance and rushing her off to a hospital where they or may not take good care of her. She lays pretty still in the ambulance, though, I think she has no idea what to do. Her bana is supporting her head, and I have both of my flip flop clad feet resting alongside the top and bottom of her belly, protecting it. I have one armed stretched across her, and my hand pressed against her back as we bump down the streets to the local government hospital.
I don’t know if I have ever talked about driving in the Philippines, but it is crazy. You have to be very aggressive here or you will get nowhere ever. There are very few stop lights and absolutely no stop signs. If you want to turn into traffic you just have to push on out there, regardless of traffic. You share the road with motorcycles, tricycle type rides, and pedestrians who cross at anytime and at anyplace. So when I say that Kuya Romy drove like mad it was unlike anything I have ever seen. He laid on that horn, weaving in and out of traffic.
It was a rough ride and if it was rough for me, I can only imagine what it was like for Rowena on the floor. I prayed the whole way there and as we sat waiting for the guard to bring another stretcher when were at the hospital I kept praying. I only stopped praying long enough to give report to the female doctor who didn’t seem to care at all that we had a baby with a heart rate in the 60s. They wheeled her back to the “OB/ER” and moved her onto a “half-bed” with stirrups. I held her hand as they settled her in, then laid one hand on her head and prayed an audible prayer. There were tears in her eyes and in mine as she held my hand. I looked at the other student and asked where the pt’s bana was. It was then that I remembered…he can’t come back with her and she would have to be left alone.
I gave her hand one last squeeze and then I walked away.
One of the hardest things I have ever done. I felt useless and helpless and frustrated. No doubt she delivered, maybe with the help of fundal pressure or forceps. I pray she didn’t have a cesarean, but if she did, I just pray that the baby is healthy and she is well taken care of.
So it’s not always sunshine and roses here, sometimes it sucks, a lot.