Sunday, 4 September 2011

First do no harm, part 2

First do no harm, part 2

1st September: In the evening we went to the delivery ward to see if there was anything going on. There was 1 lady who was having her first child and was fully dilated when we arrived but the baby’s head was not fully engaged in the birth canal. 3 hours later the doctor came and examined her and the baby still had not descended and the membrane had not yet ruptured (in other words her waters had not yet broken) and decided if the baby had not descended within 3 hours then they would perform an emergency c section as they thought there may be cpd (babies head too big for mums pelvis). About an hour later the membrane did rupture spontaneously but there was meconium (foetal stool – it is a bad sign because the baby can swallow it leading to foetal distress) in the waters, the midwife examined the mother again (it was hard for her to feel the head before as the membrane was bulging and in the way) and decided that there was no way the woman was going to be able to deliver vaginally and she would definitely need a caesarean. With this statement made the midwife sat back down and didn’t contact the doctor…

We were very confused because if the patient was definitely going to need a caesarean plus with the meconium in the water there was a risk of foetal distress, then why wasn’t the midwife calling the doctor to get the caesarean done sooner than 2 hours time – surely there was no point the patient having to go through another 2 hours of unnecessary labour pains when she wasn’t going to be able to deliver vaginally anyway. We tried to tactfully say this to the midwife and ask if she was going to phone the doctor (trying to phrase this in a way where we did not seem bossy/ rude). The midwife did not seem to understand us when we said it would save the patient a lot of pain, I really don’t think maternal pain is something they take much into account here, and she basically just said that the doctor would be back of her own accord at some point. Finally about an hour later the doctor did come back and agree the patient needed a caesarrean but sadly for the patient by the time her blood had been taken for blood grouping and the stretcher had just arrived (the patient was literally about to sit on it) another patient came in who needed a caesarean and needed one more urgently than the first patient.

The second patient had had 2 past caesarean deliveries and had presented very late to hospital, you could literally see the baby’s head on examination already, but the baby was not coming out on pushing and instead blood was indicating that she was probably having a uterine rupture due to the scar from her previous caesareans splitting. So this patient was rushed straight to theatre and the first patient had to wait even longer for her caesarean – which was frustrating because she could have already been finished in theatre by this point if the doctor had been contacted when it was first clear that a SVD (spontaneous vaginal delivary) was not possible.

We went to surgery with the second patient, the emergency caesarean was clearly very necessary as when they opened her there was a lot of blood already pooled beneath the surface. When the baby came out he was very blue, not breathing and when I checked his heart rate it was beating but initially definitely below 60bpm (guidelines say that if a newborns heart is 60 beats per a minute then you should initiate chest compressions). So AJ and me and a midwife intiated resuciation, suctioning (the baby had a lot of secretions in his lungs) and rubbing/ lightly pinching the baby to try and stimulate the baby into taking a breath. When it came to cardiopulmonary resusciatation I was doing the chest compression and the midwife bagged him for a bit before the midwife was needed elsewhere and then AJ took over the bagging and the midwife occasionally came back over to check everything was going ok. To be honest it was better when it was just AJ and me doing the resuscitation because the midwife was instructing us to do the wrong CPR ratio’s – we had looked up the current guidelines for newborn resusciatations following the caesarean the other day when the other medical students had ended up doing CPR on that baby. The midwife didn’t even have the ratio the right way round and was instructing us to do far too many breathes through the bag and not enough compressions. There’s no point putting an excess of oxygen into the baby if the heart is not pumping enough for the oxygen to reach the babies brain! This is the second time we have experienced staff seeming to be unaware of the most efficient CPR protocols since we have been here which is a bit scary seeing as it was only the fourth day and as they do not have advanced resuscitation equipment here, basic CPR is something they really really need to get right. I don’t blame the staff, I think this is probably a case of poor medical education and not being able to easily keep up with current guidelines (trust me getting on functioning internet here is akin to getting blood from a stone, which is why my blogs are very dull without pictures at the moment – will try and fix this when I can!). But as someone who is aware of the cpr guidelines, I think I probably have a responsibility to try and educate the staff about these but I have no idea how on earth to do this in a way that staff might actually listen too and follow the guidelines in the future and how to do so without causing offense to staff and making an awkward atmosphere. If anyone has ANY ideas about how we could do this, please comment below J .

We eventually managed to get the baby breathing and his heart rate was going at a much healthier 120, SUCCESS! Unfortuantely though he still was breathing a bit wheezily and was floppy and yet to cry. There wasn’t much more we could do though apart from wrap him up tight to try and keep him warm and try and stimulate him a bit more into crying but sadily he still hadn’t cried by the time he was taken from us to go to the baby room, so after checking someone was definitely keeping an eye on him we went home. Came into see him early Friday morning before the meeting and was pleased to see that he was in the middle of a full scale cry :D, for once was very happy to hear a baby crying!

The second caesarean (of the orginal patient) happened whilst we were still trying to resuscitate the baby so we didn’t get to see this birth, but I didn’t mind as was just very glad that the patient was finally receiving her caesarean after all that waiting. Her baby also initially had some problems but was breathing slightly from the start and we heard the baby give a nice loud cry whilst we were still trying to resuscitate the other baby

I’m aware my last two post are very critical, and I hope I don’t sound like an arrogant medical student, far from thinking I know everything I am very aware how little I know, but it was just scary how many simple mistakes/ things that even I could see were bad clinical practise have occurred during the last couple of days and indeed entire week. As of yet no one has died from any of the mistakes (though I am worried about the bowel obstruction patient as I can't see how she will not obstruct again) as I think the stroke patient would have died even if the CPR had been done perfectly, but I am terrified that at some point a patient will while I am here. This is only the end of the first week :S ...

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