heavenly creatures

So yesterday, there was a twenty four week pregnant inpatient with fever, loin pain and haematuria, suggestive of pyelonephritis - a kidney infection - although no organism was detected on urine testing, possibly due to the GP starting oral antibiotics before the test. Her pain and fever initially improved with intravenous antibiotics, but then started to return. This was especially worrying since she only has one kidney. Her renal specialist wanted to admit her to the big city hospital but only if she was under the primary care of the obstetric department. The obstetric department would not admit her unless she had an obstetric problem. Neither would budge. My registrar spent a couple of hours on the phone, keeping me updated. They said that I would need to speak with the obstetric consultant although I am not usually allowed direct contact with one of these sacred creatures. I gathered the information and asked to be put in contact with the consultant on call at which point we were allowed to transfer the patient. It was clearly of most importance that the consultant be spared from contamination by the outside world.


Meanwhile.... another patient had come in for assessment with irritable contraction-like discomfort and reduced foetal movements. She was an obese poorly-controlled insulin-dependent gestational diabetic with incidental obstetric cholestasis with severe itch, polyhydramnios and macrosomia( big baby and lots of fluid). The foetal heart rate monitor appeared to be showing a potentially lethal sinusoidal pattern yet the labour ward scanner showed active foetal movements. A contradiction. Perhaps the pattern was only pseudo-sinusoidal, not the real thing. On the other hand, she was a very high-risk patient, so we called the foetal diagnostic unit at the same big city hospital and sent them copies of all the tests. They thought it was pseudo-sinusoidal because it had improved a little, but she was now on oxygen. By this time she had been assessed in our ultrasound department - there was good umbilical artery blood flow and active limb movements but no breathing movements. After further consideration we were advised to deliver at once despite the prematurity. At Caesarean Section there was a true knot in a tightly tethered cord, completely unrelated to her history and potentially fatal, but there was one more twist in the tale: after delivery the baby appeared pale and was found to be severely anaemic. It was suffering from foeto-maternal transfusion. The baby had bled into the mother's circulation. I had ordered the Kleihauer test which detects this at the time of her presentation but we had been unable to get a rapid result. The report arrived today showing evidence of a massive transfer of foetal blood to the mother. The baby is now in the city hospital on a ventilator but should survive.


Meanwhile.... I raced back to finish my clinic before doing another Caesar for a failed trial of labour after two previous surgical deliveries. No lunch, no dinner, phone calls, babies in danger - obstetric heaven. On a day like this it was no surprise to be called back to labour ward for a drastic drop in foetal heart rate in late first stage. Prepared for instrumental delivery, pushed back an anterior lip and applied the vacuum to a posterior position. Managed to rotate eventually but slow descent due to an epidural and reduced maternal power. Heart rate dropped precipitously, feeling pressure, called in theatre, wished they were already there. Changed to forceps and completed the delivery, only to find the shoulders would not descend, and heart barely beating. Reached up into the uterine cavity and pulled down a shoulder, then delivered the baby, anxiously watching for a response. Then a little cry, then more crying. Sewed up a partial third degree tear and left the mother breastfeeding her perfect little angel, not feeling so exalted any more.