--
Myer S. Bornstein, MD, MMM, FACOG, FACPE
_____
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
Babycatchers@aol.com
Sent: Monday, November 28, 2005 8:52 PM
To: Multiple recipients of list OB-GYN-L
Subject: bad babies and BAD day
Dear list:
I need to vent a minute and I have a legitimate question at the end. We have
had 17 babies in 12 days, so my brain is not working on all cylinders. ( We
usually do 30 births a month)
Last Monday we shipped out 4 babies and 2 moms. One for cardiomegaly, one
for RDS (term), one that wouldn't keep his blood sugar over 40-even with
feedings q 2 hours and an IV (mom was not a diabetic-no family history) and
one for a spontaneous pneumothorax.So I am a little paranoid.
Today I had a 17 yo show up in the office. She had been to the ER on Sat and
Sun for urinary retention and pain. The ER doc put her on Bactrum and
pyridium on Sat, then when she came back on Sunday-having not voided in over
24 hours, he changed the antibiotic to amp and put in a foley with a leg bag
and did a BHCG. He told her she was 16 weeks pregnant (no US done) and told
her to show up at our office this morning. On Monday mornings it is just me
(CNM) in the office. The OB does afternoon hours on Monday. She shows up and
we work her in. She presented with the leg bag full. She denied that she
could be pregnant at all. (I forgot to mention she was 5'4" and weighed over
300 pounds.) Something looked weird about her and the physical exam made me
very nervous. Palpation of abd felt like a big baby to me. Speculum for pap
and GC/CH revealed no cervix and a head full of hair. Her pelvis was heart
shaped and narrow. I had the OB come in and do an US. He thought she was 37
weeks with a 2700 gms baby. So she is sent to OB for prenatal workup and
delivery.
We have no idea when her water broke or any idea what we were really dealing
with. She labored for several hours and pretended to push. She was 17 and in
denial and still did not believe she was actually pregnant-so why push. I
ordered 2 gms Amp and she got 2 doses. She became febrile at 101 degrees, so
the OB decided to section her.
The 2900 gram male was born with pus pouring out of his nose and mouth. The
ped was there and is doing the workup for the baby. Mom's uterus shredded
when we were going in and I lost count of the number of laps we had to use
to get the uterus clean. It has been a long time since I have seen one tear
this badly. (I first assist at all surgeries.) It took us a lot of time and
patience to put the puzzle back together again after cleaning out the uterus
and doing antibiotic fluid irrigation of the belly. She is going to be on
amp/gent/clindamycin IV.
Now my question: The OB is going out of town and the covering OB is about 30
minutes away and does not like our practice. I am trying to make sure that I
cover all the bases, because I am on my own until I can beg this OB to
visit. After tomorrow it is just me in this town. (One of the back up doc's
patients coded in our OB department and the ER doc and I ran the code. She
did not visit the patient until 24 hours after the problem).
What else should I do besides a culture of the placenta (done), send it to
pathology (done), cover her with the antibiotics that will stop a truck
(done). I didn't get blood cultures before I gave the first dose of Amp, I
didn't realize how bad it really was. Her WBC on admission was 16, but the
doc figured it was from the UTI.
She is bleeding a little more than I am comfortable with, but not time for
methergine yet. Fundus firm. BP beginning to climb. 120s/80s on admit- now
160s/80s. 1-2 + bilat pedal edema. 2+ reflexes. Temp still 101.
I am telling everyone I can find that this is OUT OF MY SCOPE-but the
administration and the OB think I can handle it. I will climb the food chain
when it gets bad. But I need to have my ducks in a row when I do it. Other
than a CBC in am, lytes, liver function tests, uric acid and chem panel -
what else should I do? What should I be looking for so that I can catch this
before she crashes?
Any help would be appreciated.
Vicki, CNM
Vicki Smith, CNM
Midwives-changing the world one baby at a time.
