On Sunday I planned to attend my wife Robyn’s great nephew’s christening. Robyn was overseas. I had not gone overseas with her as the trip had been organised at short notice and I had too many patients due. So, at the christening I was also representing Robyn. The christening was held in the Chapel at Newington College, Stanmore.
Just before I left home to attend the christening I was phoned by the hospital to advise me a patient had been admitted at 36 weeks gestation with spontaneous rupture of membranes. She was ‘niggling’ with irregular contractions but was not in labour. It was her first baby. As all was well, I proceeded to the christening. I advised the staff I would need early warning if I was needed that morning.
At the end of the christening service, before the christening celebration morning tea, I phoned the birth unit at the hospital for an update. I was told by the midwife that the patient was now starting to get more contractions, though was comfortable and not yet established in labour. As well another patient had just arrived in early labour. That patient was scheduled for an elective Caesarean section this coming Friday. I said leave the christening celebration and come to the hospital.
I gave my apologies, made a hasty departure and went to the hospital.
There was some delay in getting into the operating theatre as another case was happening. The patient was only in early labour. I went straight to the operating theatre preoperative area where my patient was waiting.
Before starting the Caesarean section I phoned the birth unit for an update on the 36 week gestation patient. The midwife said all was well and from her lack of discomfort she suspected she was not yet established in labour. I asked her to examine her. The midwife did this and contacted me to say she was, to her surprise, fully dilated but was not distressed and was smiling during contractions. She said the baby’s head was ‘still high’ and she had no desire to push and advised me I had time to do the Caesarean section.
The Caesarean section was more of a challenge than I had hoped. The previous Caesarean section had been done by an obstetrician working in another private hospital. I am sure she had not closed all the abdominal wall layers. There was omentum adherent to the sheath layer, considerable separation of the recti muscles and a large hole in the parietal peritoneum. The omentum was also adherent to the parietal peritoneum and the uterus. The bladder was much more firmly adherent, and at a higher location than usual, to the front of the uterus. So it took longer and more care to get into the uterus to deliver the baby. She had a healthy boy baby. It also took a lot longer than usual to appropriately close after delivery. I am very particular about closing all layers appropriately so there is the best possibility of good healing. This was the topic of a previous blog titled ‘Caesarean section closure techniques vary‘.
I then proceeded to the birth unit where I found the 36 week patient still very comfortable and having no desire to push. What an amazing labour! She behaved as if she had an epidural anaesthetic, but in actuality had no need for any pain relief of any sort. The midwife and I encouraged her to push. But without any desire and no pain and little pressure nothing was happening. I was worried her pushing would be ineffective and only succeed in tiring her out and as a consequence I would have to do an operative vaginal delivery. So we told her to stop pushing and we commenced a Syntocinon infusion to increase the strength of her contractions. The contractions increased in strength as a consequence, but still no pain. The stronger contractions were effective with facilitating descent of the baby’s head. When her baby’s head was visible she had sufficient pressure to push effectively. She pushed out a healthy baby girl. She had an intact perineal and no stitches were required. Second stage had lasted two and a half hours, though for most of that time there had been no pushing.
It was a good day but it had own surprises.