A Day of "Firsts" That I Could Have Gone Without

The labor process started off like most others.... slow.... but as time went on, the calm feelings in the room started to change. Nurses were moving a bit quicker from place to place. Directions were being given in a more stern tone. The midwife paged the OB on the floor. The OR nurse was sent to open up the OR "just in case" and the father had a look of sheer panic on his face. The baby wasn't ready to come out, but the fetal heart rate (FHR) was dropping steadily.

Before I knew it, the OB had her hands inside the vagina attaching a vacuum to the baby's head and pulling while mom pushed. Pop. Off came the vacuum. "Another vac, please" asked the OB in a calm voice. Attempt #2. Pop. Again, no success. "I'm gonna need a third vac." Pop. No luck.

I can feel the intensity growing in the room as I hold mom's leg up and encourage her to push like never before. Then the OB peaks at the FHR dropping and tells the mom she has one last push to get this baby out or she will need to go for an emergency C-section. Mom, exhausted, nods in agreement. Then the OB asks for the scissors and says, "I need to do an episiotomy." I cringe and thank the lucky stars that this woman rec'd an epidural. Snip, snip.... out pops the head. The cord was wrapped twice around the babies neck, but like a rockstar, the OB smoothly removes it, clamps and cuts the cord, and delivers the baby to Peds in about 5 sec.

It was dramatic. After some work by the peds team, the baby was totally fine. Now the attention turns back to mom - yikes! As the baby came out, the remaining tissue had torn and mom was left with a 4th degree laceration (4th degree means all the way through the anal sphincter). It was the first time I had seen one and I was horrified. However, knowing how it all happened - I see that the episiotomy was necessary. Time for the repair.... and that is when it happened... the second 1st of the day... my 1st (and hopefully last) sharps-stick.

As I was holding back the labia so that the OB could better visualize the field while suturing - I felt a little prick on the back of my hand. Damn. I was immediately told to remove my gloves and wash my hands. When I pulled off my glove, I was able to see that it hadn't broken the skin. Phew. But needle stick protocol still applied so I went to the ED downstairs, got my blood drawn, the patient will get her labs redrawn, and I will follow up with Occupational Health tomorrow. All and all, I'm not that worried. I was lucky that it was just a graze, no puncture wound, and that as a pregnant woman... all of her HIV/HEP screens were recent and negative.

I did learn a couple valuable lessons from the experience:
1. Don't trust anyone with sharps around you. Even the most experienced providers make mistakes. Keep your eyes on the needles and if you feel uncomfortable having your hands so close to the suturing field - ask for retractors! Your own health is your responsibility.

2. Know the protocol for your site before something like this happens. No one seemed to really know EXACTLY what to do and if it had been a random pt in the ED or an HIV+ pt I would have been much less calm during the process of figuring it all out.


Photo: http://www.acep.org/content.aspx?id=37762