Read Online Assume the Position: Memoirs of an Obstetrician Gynecologist by Richard Houck MD - Free Book Online Page B

pregnant and in labor we would not have known.  We were able to pick up an occasional fetal heart tone with an external Doppler ultrasound device, but were unable to pick up anything with fetal monitoring.  When it came time to examine her in the labor bed, I put on a sterile glove, pulled down the sheet and asked her to let her legs drop to the side.  She told me they already were. Instantly I knew I was in trouble now since I couldn’t even see the vagina to do a cervical exam. There were layers of thigh fat obscuring the view.  So I began to dig my way in, moving the thigh fat to the side with the assistance of nurses on each side to further retract her inner thighs.  Eventually I could see the external vagina, but could not get my arm or hand near enough to get into the vagina, let alone up to the cervix for a pelvic exam, and she could not drop her legs to the side any further.  It was futile.  Kudos to the baby’s father, whoever that was! Since she was reasonably comfortable, her vital signs were stable, and we could not monitor her on the fetal monitor, we sent her away from the labor floor to a regular post partum bed to wait more regular contractions before we brought her back.  About 30 minutes after she arrived to her regular bed we got a stat call to run up to her room. After one push I found a five-pound healthy baby between her legs and the rolls of fat. Some people are just lucky.
     
         What a contrast of experiences one sees at a teaching hospital!  One lady, again in the 500-pound range and a patient of our obstetrical clinic during residency, was scheduled for a repeat Cesarean section.  She was brought to the operating room and prepared for surgery. The anesthesiologist had opted to administer a regional anesthetic, or spinal, rather than a general anesthetic with intubation that he had determined to be riskier in her case.  After a difficult and valiant attempt at the spinal, he laid her on her back in preparation for surgery, and while she was having her abdomen prepped she began to have a grand mal seizure, likely a result of the spinal medication.   I had a 500-pound woman in front of me seizing on the operating table with a baby inside of her that we could not monitor.  The table and literally the room were shaking in rhythm with her as she seized. All we could do was try to keep her on the table without injuring herself.   Mindful of the first rule of medicine,  “Primum non nocere” or “Do no harm”, I could not do a stat Cesarean section on her until she herself had been stabilized, which everyone around her was working so hard to do.  When the patient was finally in stable condition, intubated and medicated to stop the seizures, only then could I begin the surgery.  Cutting through that many layers of adipose tissue (fat) is always an experience.  Much like a knife going through butter, it begins rather easily, but then as one incises further and further deep into the adipose tissue, one realizes how much further down are the other layers of the abdomen, the muscle, the fascia, the peritoneum, the uterus, and then the baby. It was like digging a ditch with a scalpel.   In this situation it is not something one can rush through.  I had no idea what shape the baby was going to be in, but I was not about to jeopardize the mother’s life.  As luck would have it, the baby was in good condition, and all turned out well for the Mom. But what a huge layer of risk she added to her life, and that of her child.
     
         Lucky, too, was a patient of mine who walked into my office one day in Phoenix, a first time Mom near her due date.  I can still picture her walking down the hall way with that uncomfortable open leg waddle most term pregnant patients have, one hand behind her back.  I greeted her, asked how she was doing, and she replied great, but that she wasn’t sure what was going on and just wanted to come in for a checkup.  My nurse put her in the exam