Garden of Versailles - Robert Chow
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Next Time
-Laura White
On the penultimate day of my third year rotation on labor and delivery, I delivered a baby — a boy. His young Latino mother had pushed him out into my waiting hands. He was beautiful — all ten pounds of him. I glowed. I wanted to tell everyone I knew.
I could hardly wait to deliver another, but I didn't get a chance — not that week. The rotation was over, and out of twelve medical students, only two of us had delivered a baby in the past six weeks. I'd been lucky: I had delivered a baby, and it was amazing.
* * * * * * *
Ten months later the upper level resident on my family medicine team caught up with me after morning rounds. "We've got a patient in labor right now. Do you want to deliver her?"
Did I want to?! A huge smile streaked across my face. "Absolutely!"
Jenna and I headed toward the elevators, and as we walked, I tried to recall the checklist of questions to ask laboring patients, the things to include in an intrapartum progress note, the significance of the blips on a fetal monitoring strip, the feel of a cervix as it changed. Now, checking a cervix was never something I had felt comfortable doing—not because of what might seem the obvious discomfort of inserting one's fingers through another woman's vagina and fishing around for the elusive cervix but because I simply hadn't had enough practice to be confident of what I was feeling.
As a medical student on the OB service, I had been working with a new intern who was still learning herself, so that had already meant two checks for the patient as the intern's upper level resident checked behind the intern. When it comes to cervical checks, it's not like "two heads are better than one;" it's more like "too many cooks spoil the broth." Or to put it more bluntly, the delicate balance of microorganisms in the vagina can be upset by multiple cervical checks, so the more checks, the greater the risk of infection. So I'd checked a cervix two maybe three times, and I had never been able to distinguish the mushy floppiness of the cervix from the mushy floppiness of everything else around it. But now, with no intern ... I was optimistic.
I held my breath while Jenna asked our new patient if it would be alright for me to follow her progress as well. At her willing agreement, I breathed a quiet sigh of relief and smiled, thanking her for letting me be a part of this process. I was going to deliver a baby!
First, however, I was going to check a cervix. I put a sterile glove on my right hand and positioned myself by her side. The nurse squeezed a glob of lubricating jelly onto my fingers, and I went for it. Then, almost miraculously, it was there—her cervix, a distinct ring of tissue encircling my fingers, and I stretched them to feel how dilated it was. "Three centimeters maybe four," I guessed, withdrawing my hand.
Jenna checked behind me. "Yes, I would say it's about a four." She smiled encouragingly at me, and I grinned back. I'd been right!
We checked her together twice more during the day; then I stayed on with Amy the night float resident after the rest of my team had left. I didn't feel tired at all —tonight would be a great night.
Our patient had been progressing slowly but steadily, and she was almost fully dilated when her nurse gave us the bad news: she had just spiked a fever. That could be bad — bad for mom, bad for baby. We ordered IV antibiotics, but we weren't even sure there would be enough time to hang them before the baby came. Could this be related to my practice cervical checks? I didn't want to think about that.
Amy had wanted to review the steps of a delivery with me, but now with this new development requiring our attention, there was no time. And it might be my fault—this thought nibbled at the back of my mind. Amy delivered the baby, and I watched. I had wanted this delivery, but this was the right thing in this moment for this patient so I pushed away my disappointment.
The delivery went well, and new baby Ethan seemed healthy. We would watch him carefully for the next few days, but he would probably be fine. We hadn't gotten in all of the antibiotics before he was born, but we'd gotten them started—and mom's fever had come down. We could be cautiously optimistic.
It was later than I'd hoped when I changed out of my scrubs and prepared to head home for a few hours sleep, but I didn't feel tired. I had almost gotten to deliver a baby. I had delivered a placenta, and I'd gained confidence in doing cervical checks. Checks that hopefully had nothing to do with the fever our patient had spiked.
I said "good night" to Amy on my way out. "I'm sorry you didn't get to do this delivery, Laura." She knew how excited I'd been. "You'll get another chance."
And I did. A week later, Jenna flashed me a smile as I walked into the resident lounge with my lunch. "We've got a patient in labor upstairs. We'll go check on her after lunch." She didn't have to ask if I was interested in this delivery.
A healthy Ethan and his mom had both gone home a few days earlier, and I was ready to give this another go. I followed this new patient with Jenna during the day, gaining more and more confidence in my cervical checks. When Jenna left for the day and Amy came on, I felt like I was the one constant in this patient's labor as even the nurses had switched at shift change. This was a nice feeling. I liked the mom: she was young but excited, and the baby's father never left her side.
Things were progressing well. Amy and I took time early in the evening to review the steps of the delivery, so I would be ready this time. Then the baby started showing distress on the fetal monitoring strip. What had seemed like a perfect delivery for me, now turned against me as each of the pieces — first time mother, large baby, possible nuchal cord — was added together. "I'm sorry, Laura. I'm worried this might get tricky especially if the cord is wrapped around the baby's neck. I'll let you help as much as I can."
In the end, the delivery went fine. It would have been perfect for me, but we couldn't have known that ahead of time. I delivered another placenta — I've delivered lots of placentas. I reminded myself this was the right thing. Things could have gone wrong, and it was better for the more experienced person to deliver this baby. It was a little harder to push away the disappointment, but I still smiled optimistically when Amy said, "Next time."
The next week, there were no deliveries on the family medicine service.
My last week on the family medicine service, Amy entered the resident lounge where I sat at the computer putting in orders on an adult patient with pneumonia. She wasn't the night float resident anymore; she was actually doing an obstetrics rotation now. "A patient just came in for family medicine," she told me. "This will be perfect for you. It's her second delivery, and she hadn't had any complications."
"That's great!" It doesn't matter that I was on call last night; I know that I'm staying for this.
"She is one of Sean's patients, but I'm sure he'll be fine with you doing the delivery. I'll just call him and let him know."
"Thanks for watching out for me, Amy." I smiled. It was finally going to happen!
Callie, the new night float resident, came in to get report on the patients she would be covering tonight, and Abby told her the plan. "You should page Sean and let him know," she suggested.
That evening, Callie and I checked on our laboring patient every two hours. She was dilating at a good pace, and everything seemed to be going well. I had just gotten back from grabbing a quick bite to eat at the grill, which was the only part of the cafeteria still open at this hour, when the nurse came out of our patient's room to tell Callie and me that our patient felt like she had to go to the bathroom. All three of us—the nurse and Callie and me—knew that this feeling was the body's code for "it's time to push."
We all hurried back into the room, and Callie quickly checked her. "Yep, fully dilated. Do feel like you're ready to push?" she asked the patient.
The patient nodded in affirmation and Callie encouraged her to try to hold on for just a couple minutes while we got things ready. The nurse and I broke down the end of the bed while Callie got the little tray of instruments in place. I put on a sterile gown and gloves and took my place at the foot of the bed.
"Go ahead and push," I told her. I have one hand on the baby's crowning head and a sterile towel in the other, supporting the perineum as I've been taught. I'm going to deliver this baby!
Somewhere in the rush of the moments leading up to this, Callie must have asked someone to page Sean—to let him know that his patient was fully dilated and ready to deliver. After two or three good pushes giving us exciting glimpses of a wrinkled head thatched with dark hair, Sean rushed in to the room and began pulling on his own blue sterile gown. That didn't worry me. Of course, he had wanted to be here—that didn't mean I wouldn't get to deliver this baby.
"Can I get in there?" he asked, but it wasn't really a question. I moved to the side and waited. Probably he just wanted to check her progress. He talked to his patient in a calm, soothing voice, telling her what to expect and what he would ask her to do. He focused her and encouraged her at the same time — I had never seen a doctor do anything quite like this. It was a nice touch, and I filed it away in my list of things to do later when it was my turn, while I kept hoping he would soon turn the delivery back over to me. He never did. Sean was not aware of "the plan."
It all happened so fast. The family medicine attending hadn't even had time to make it in from his home, so an OB/GYN attending had overseen the delivery in his place. I wished Sean hadn't had time to make it in. I knew on some level that this wasn't fair — Sean had a relationship with this patient, it was better for her that he'd been the one to deliver her baby. But I felt like I had been robbed, and this time I couldn't push away my disappointment.
"Do you feel comfortable delivering the placenta?" he asked me after passing the wailing newborn girl into the waiting nurse's arms.
"I've delivered lots of placentas," I responded tersely without enthusiasm, but I stepped into place prepared to salvage something from this experience. The placenta clung to the wall of our patient's contracting uterus long enough for Sean to nudge me out of the way to test the tension for himself—just in time for the placenta to release and come sliding into his hands. That seemed to be a fitting ending to this night.
Perhaps, I should have stayed to write a delivery note or to check on the new little girl in the nursery, but I didn't. I was tired. The energy that carried me while I waiting for the delivery had now fizzled like a popped balloon, and I was so exhausted I felt like crying.
I plodded down the eight flights of stairs and was met on my way out by the family medicine attending who had just arrived.
"The delivery went well. She had a little girl," I told him with something that was supposed to look like a smile.
"Did you get to deliver the baby?" he asked with innocent enthusiasm.
"No, Sean delivered the baby. He got there just in time." I tried to smile again.
He headed on upstairs, and as I trudged home through the darkness, I cried.
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