early start

Late to sleep as usual then woken at four by the resident. There was a noise and I knew it was important. I consulted my brain which said not enough sleep yet. I knew I had to do something before the noise stopped. I jumped out of bed determined to do the right thing and still couldn't understand what was happening but found the source of the noise. I grabbed it hastily and realised it was a phone. I pressed the button to answer.
A woman with identical twins and a history of three previous Caesarian Sections was in probable early labour but the cervix was closed. She did not want to try for a vaginal birth but could wait at least a little while. I asked if we could take her to theatre an hour before the start of the scheduled list to cause the least disruption. I went back to sleep then woke early for the operation. As soon as I was up the resident rang to say the anaesthetist refused to do the case for another hour: now there was starting to be a little concern about the possibility of the labour progressing too much when a repeat Section had been agreed, but there seemed no point in arguing with the anaesthetist who, if I pressured him, would probably just delay until he got his way anyway. I went back to bed.
The phone rang again. The operation was going to start as originally scheduled, in just ten minutes time. The nursing supervisor had called the Medical Director who had spoken to the anaesthetist who had reluctantly agreed. I raced to get dressed and rushed to the hospital, changing again quickly for theatre to find that preparations for the operation were not hurried at all. Eventually we commenced half an hour before the usual list was rostered.
There are genuine risks in this situation. The chance of an abnormally adherent placenta is significantly greater after three Caesarians, and further worsened by a lowish anterior placenta - much more likely to grow abnormally into the old uterine scar and result in heavy bleeding, which is already a greater risk in a twin pregnancy. A hysterectomy was a real possibility but, in the event, the placenta came away cleanly and bleeding was minimal.
Small but healthy identical twin boys were handed to the paediatrician then routine uterine closure was begun. Before I could finish I was called urgently to the labour ward for a baby with a heart rate of only fifty. While my resident completed the abdominal closure I delivered another baby by vacuum rotation then traction, and perineum intact. I returned to theatre to change for my busy day of antenatal clinics and looked in on mother and babies -

After a long day, I travelled to another town for night tennis, losing my singles in a tie-break to one of our recent medical students. Perhaps I was a bit tired.