Before a doctor starts out in practice, he or she has had years of rigorous training. In the case of an obstetrician, that means four years of medical school, the first two in the classroom, the last two in the hospital working with patients. It also means four years of additional training when you are a doctor, but working under supervision. During those four years, you work 80+ hours a week, care for thousands of patients, and make hundreds of major decisions. Nonetheless, in the back of your mind, you know that you are not ultimately responsible. You can always ask the attending (senior physician).
Therefore, it comes as something of a shock the first time a nurse looks to you for the decision in the midst of a crisis. Your first thought, sometimes even said aloud, is “let’s ask the attending,” before you realize that you ARE the attending. Most doctors learn over time to automatically accept responsibility for whatever is happening, and some, like me, learn the hard way.
One of my first patients in practice was a woman expecting her third baby. Her pregnancy was uneventful, but at every doctor’s visit, her baby was in a different position. That’s pretty typical at first. Until the last months of pregnancy the baby has lots of room to move, and can easily do somersaults if so inclined. Toward the end of pregnancy, the baby takes up one position, typically head down, and no longer has enough room to change position. In this case, even in the final weeks of pregnancy, the baby was still changing position. One week it would be breech (bottom down); next it would be head down; occasionally it would even be sideways (also known as transverse, and a very unusual position).
In the last few weeks, the baby seemed to stay in the transverse position. A baby in the transverse position is undeliverable. The baby can come through the pelvis only head down or bottom down. It simply will not fit sideways. Prior to safe C-sections, women who labored with a baby in the transverse position simply died, and the baby died with them. Nowadays, the standard method of delivering a baby in the transverse position is a C-section. Sometimes, though, you can coax the baby from the transverse position to the head down position. This is called “version.” It involves using your hands to literally turn the baby to the proper position.
That’s what I discussed with this patient. She had had two uncomplicated vaginal deliveries. It seemed a shame to perform a C-section when we might manipulate the baby to the head down position.
The patient was very enthusiastic about the idea of version, even after I explained that a version was not without risks. Manipulating the baby through the walls of the uterus can potentially damage the placenta, necessitating an immediate C-section. Getting the baby to turn can potentially cut off blood flow to the baby if the turning causes an unsuspected knot in the cord to tighten. Once again, an emergency C-section would be necessary. For these reasons, versions are done in the hospital, with an OR team ready to go if needed.
We made a plan. If the version were successful, and I was able to turn the baby from transverse to head down, we would start induction of labor immediately thereafter, so that the baby would have no opportunity to turn back to an unfavorable position. If, on the other hand, I were unable to turn the baby, we would proceed directly to C-section, since the inability to turn the baby would mean that a C-section was unavoidable. I hadn’t considered that there were other possibilities.
The patient showed up for her version on the appointed day, and the baby was still transverse. Under ultrasound guidance, I gently manipulated the baby and had no trouble getting it into the favorable head down position. While we were celebrating our good fortune, the baby flipped back to the transverse position. The nurse and I could easily see it happen by watching the patient’s abdomen, and the patient could feel it. That was unexpected.
I tried again. Again I had no trouble getting the baby to move, but it promptly popped back to the transverse position. I turned it a third time, and again it turned back. I told the patient that we would need to give up. It wasn’t going to work, and we should proceed to a C-section, just as we had planned. I left the room to round up the surgical team.
A senior obstetrician was sitting at the nurses’ station and I casually related the story to him. He offered to examine the patient and give his recommendations. I was relieved. Here was someone with excellent clinical judgment and decades of experience. I would not be making the decision alone. He examined her and we stepped out to consult.
“Don’t do a C-section now,” he said. “The baby is small. You saw how it could easily be turned. Just leave her alone and I guarantee that she will be back in a few days, in labor, with the baby in the head down position.”
I was relieved, but somewhat skeptical. “Do you really think so? Maybe I should just do the C-section now like we planned.”
“I’m sure of it,” he replied. “I’ve seen it happen many times.”
I talked to the patient, and she happily agreed to the plan. She wanted to avoid surgery if at all possible.
Sure enough, the senior obstetrician was right. The patient returned two days later in labor, and the baby was head down … and dead.
After the delivery, we could easily determine the cause. There had been a true knot in the umbilical cord. While the baby moved of its own accord into the head down position, the knot had tightened, depriving the baby of blood flow and oxygen, leading inexorably to the baby’s death. Telling her that the baby had died was one of the hardest things I’ve ever done. Knowing that her baby was dead, she still had to go through labor.
It often seems that when disaster strikes, it is inevitably followed by more disaster. It’s hard to imagine how this situation could have gotten worse, but it did. The baby was big, and during the delivery, the mother experienced a very unusual complication. She ruptured her symphysis, the piece of cartilage that holds the two halves of the pelvis together in the front at the pubic bone. Much to our horror, the nurse and I literally heard it pop. The patient could not walk for months thereafter.
The patient also developed a raging infection that required a week-long hospitalization for IV antibiotics. She ultimately went home to a long course of oral antibiotics, a walker, and months of physical therapy to help her as her ruptured symphysis healed. I must have apologized to her a thousands times, but, of course, I couldn’t change what happened.
What did I learn from this dreadful experience? I learned that if I was going to have to take responsibility for bad outcomes, I ought to be sure that it was my decision and not someone else’s. I had felt at the time of the failed version that the C-section was the right thing to do, but I allowed myself to be talked out of it. It’s true that the senior obstetrician had more experience than me, but I had been looking for a way to avoid responsibility for performing a C-section on a woman who had had two previous vaginal deliveries.
The recommendation from the senior obstetrician allowed me to push off the decision, and I had naively thought that no harm could come from pushing it off. Either she would show up in labor with the baby head down, or she would show up in labor with the baby in the transverse position and we could do the C-section then. I had never considered the possibility, albeit rare, that she could show up with a dead baby.
