Monday, March 03, 2008

Wow, It's A Good Thing We Were So Worried About My Cervix (Part 1)

The alarm woke us up at 5:15 AM for the induction. We needed to arrive at the hospital (about 45 minutes away), by 6:30 AM. Now, I knew this was patently untrue, as I am intimately familiar with the hospital's shift change schedule after my 3 months there when I was pregnant with D, but I figured we ought not to start off our technically medically unnecessary induction at 39 weeks by being late. And, as I expected, we got there at 6:30, blew through the admission paperwork in about a minute since I had actually mailed in everything I was supposed to in advance, and then had to sit there in the lobby for 29 more minutes until the nurses even started the shift change up in labor and delivery that I knew must precede our assignment to a nurse and admission to the floor. To make a long story somewhat shorter, it took us forever to even get into the room.

Eventually we got there. I undressed and put on my oh-so-familiar hospital gown, open at the back this time, unlike my first admission for preterm labor with D, where I demonstrated my about-to-be-obliterated unfamiliarity with hospitals by putting it on opening forward (the nurse wasn't quite successful at hiding her urge to burst into peals of hysterical laughter, but that's a whole different story...). We met Experienced American Nurse, who introduced herself and explained that she'd just found out that another nurse, a close colleague of hers in L&D, had unexpectedly died that morning, and promptly burst into tears. We commiserated with her for a while, and then when there was no sign of my OB, Dr. Favorite, Experienced American Nurse went ahead and started a peripheral IV and got the pitocin going so that we could get things moving.

Dr. Favorite arrived shortly, said hello, and checked my cervix. Still at 3 cm and not terribly effaced, just like one week ago in the office. So, she left us there to let the pitocin do its thing for a bit and went off to do a couple of c-sections. In the meantime, Experienced American Nurse came back and said she was going home, as she was still a bit emotional and they were overstaffed that day. We had mentioned earlier how pleased we were to have a nurse with so many years of L&D experience, as we'd heard from one of my perinatal unit nurse friends upstairs that L&D was currently staffed with quite a large proportion of new nursing school graduates, and what with my history, yadda yadda yadda... Experienced American Nurse promised to get someone equally experienced to replace her, and soon we met Experienced Polish Nurse.

(WHOOP! WHOOP! WHOOP! FORESHADOWING!!!: This was the first minor happening of the day to probably save my life...)

Meanwhile, not much was going on with the contractions. I was having plenty, but they weren't particularly strong just yet. They slowly ramped up, though when Dr. Favorite came back I still wasn't terribly dilated, but she said things were moving along okay. She had one more c-section to do, and then she'd come back and rupture the membranes to help things along. When I had D, nothing really got moving until she ruptured the membranes, so I figured this would be the same. Dr. Favorite wanted to wait until I was in a good labor pattern before doing it this time. This was cool with us. We were watching the food network on TV. This was perhaps not the best choice for a woman who had been advised to limit things to a light breakfast.

The contractions progressed. I fired off a few text messages saying things were going slowly. It was around noon. H considerately went off to eat his lunch elsewhere so I wouldn't have to watch hungrily. I was just starting to feel like the contractions might eventually become a little painful sometime relatively soon when Experienced Polish Nurse, who had already inquired if I planned to have an epidural, suggested we get the anesthesiologist in to get that going. I wasn't anywhere near my personal level of pain tolerance, and I knew that once we got the epidural in I'd be confined to bed, so I tried to put her off, but she went off to "check [the anesthesiologist’s] schedule." She returned and said the anesthesiologist, Dr. O'Wonderful, would be going into the OR soon, so I either needed to get it now or I might be waiting a long time. I went with now.

(WHOOP! WHOOP! WHOOP! FORESHADOWING!!!: This was the second minor happening of the day to probably save my life...)

I really liked Dr. O'Wonderful, as you might guess from her nickname. We had a nice chat about my background in HIV research while I was getting my PhD, and just hit it off. Dr. O'Wonderful got the epidural going beautifully and went off to the OR and I lay back to enjoy the drugs. Dr. Favorite returned, pronounced my cervix at 5 cm and my contractions showing a solid labor pattern, and ruptured the membranes. H came back and we all chatted for a while. A little more than 30 minutes after rupturing the membranes, Dr. Favorite went across the street to meet her husband for lunch.

I now know that amniotic fluid embolisms and other complications are most likely to present within 30 minutes of rupture, which is why Dr. Favorite doesn't leave patients until this window has elapsed. Anyway, Dr. Favorite was across the street meeting her husband, Dr. O'Wonderful was in the OR, and Experienced Polish Nurse wandered back in to our room. This is where things went awry.

All I remember saying is "I'm starting to feel a little funky." I was still conscious and able to speak and breathe, although I felt very slow and dopey. Experienced Polish Nurse got the oxygen mask going on me. The only other things that I remember from that room were that all of a sudden it was full of people. Very, very full. I thought to myself, oops, here we go. Must be an emergency c-section. What was actually happening was this: some of the amniotic fluid had managed to enter my circulatory system and ended up in my heart and lungs. As a result, my lungs were filling with fluid and my heart wasn't pumping as effectively as it should. My blood pressure was dropping through the floor, and many of my internal organs, and the baby, were starting to be deprived of oxygen.

From what I heard later, this is where Experienced Polish Nurse saved my life. She decided very quickly that I needed to get to the OR as quickly as possible. Others were apparently telling her it was too soon, and that it wasn't clear what was happening, and Dr. Favorite needed to be called back from across the street, but Experienced Polish Nurse took matters into her own hands and apparently pulled me in my bed, IV poles and oxygen tank trailing, out into the hall single-handedly and headed for the OR. I also heard she injured her arm or shoulder in the process.

Next, I and as many people as would fit into the OR assembled and started the fastest c-section known to man. H was just outside with the overflow of people who wouldn't fit inside but needed to be nearby in case they were needed. Dr. O'Wonderful told me later than when we all arrived, her first thought upon seeing the bustle arrive in the OR was "Oh, no, I'm just certain it's that nice biology PhD lady I was just chatting with." Of course it was, and she recognized me immediately despite that fact that by this point I was a very deep blue color due to the lack of oxygen. There is a perinatologist always immediately available in the hospital to handle situations like these, and she began the c-section. Dr. Favorite told me later than she and her husband had just started lunch when she got a call on her cell that something had gone very wrong with me and she needed to come back immediately. She told her husband she'd call him shortly (she didn't) and she took off. She arrived sometime in the middle of the c-section, and her face nose-to-nose with mine, firmly telling me to keep breathing, is the next thing I remember, aside from a lot of tugging and pain as they did the c-section. (I had the epidural going, of course, but it was designed for a vaginal delivery, and there wasn't time to turn it up to the level usually used for a c-section.)

Later Dr. O'Wonderful told me that if I hadn't had the epidural in, and she'd had to take the three minutes necessary to give me a general anesthetic, that neither I nor the baby would likely have survived.

My own few memories of what happened over the rest of that day are jumbled. I remember being incredibly relieved to see Dr. Favorite. I remember a lot of me crying "Ow! Ow! Ow!" as Dr. Favorite left a lot of Dr. Favorite hand-shaped bruises over my lower abdomen as she firmly pressed against my uterus to try and stop it from filling with blood. I remember seeing H holding a baby floating into my field of view, and someone saying "here he is" and me asking anxiously, "Is he okay?" I don't remember the answer. I remember realizing that I wasn't necessarily going to survive whatever was happening, and not wanting to leave H to raise 2 kids on his own. I remember waking up in the surgical ICU of the major hospital next door to the hospital where I delivered. I remember asking for a breast pump and sending H home to sleep for the night. That's about it, really.

I now know a lot more of what went on that day. Many of the people involved visited me several times over the next few weeks and filled me in on what happened. Experienced Polish Nurse manhandled me to the OR, where someone figured out what was happening. Amniotic fluid embolisms are rare. My hospital hadn't had one in three years (unfortunately, that last patient had died). Most OB/Gyns go their whole career without having a patient experience one. I am extremely lucky that because of my disastrous pregnancy with D, I chose to continue seeing the same group of physicians, and to deliver at the same hospital, despite the fact that several others are much closer to the house we bought and moved into after D was born. With the traffic around here, this was no major inconvenience. Again, this probably saved my life. Someone, I think it was the perinatologist who did the c-section, came up with the correct diagnosis immediately and recognized what was happening to my body.

So, last you heard, my lungs were filling with fluid and my heart wasn't pumping as effectively as it should. My blood pressure was dropping through the floor, and many of my internal organs, and the baby, were starting to be deprived of oxygen. This oxygen deprivation continued to get worse. I turned blue, and my body went into shock and protected my brain and heart by sending what blood it could to them and only them. This had the effect of depriving some other somewhat important things of oxygen, namely (1) the baby, and (2) my kidneys. Also going on was something called disseminated intravascular coagulopathy (DIC). A direct effect of the entrance of one of the components of the amniotic fluid into my circulation was that my body's clotting system was activated. Blood clotting is mainly achieved through the combination of circulating blood cells called platelets and circulating dissolved blood proteins. These factors, when activated, clump together and hopefully plug up wherever your circulatory system has sprung a leak. The amniotic fluid caused my entire body to blow its entire stock of clotting factors at once, leaving me with none to deal with the fact that (1) I had just had a baby and the place where the placenta had been attached was now a giant open wound, (2) said baby had been delivered by c-section and thus there were now several freely bleeding incisions in my lower abdomen and uterus, and (3) I now had several more peripheral IVs and a central line into a vein in my groin added to the punctures already made for my original IV and the epidural, all of which were sites that had the potential to bleed.

This was not good.

Fortunately, DIC is a known complication of amniotic fluid embolisms, plus my blood pressure was already extremely low, so they were prepared for what I needed, which were massive amounts of fluids to bring up my blood pressure, plus extensive transfusions of blood, namely packed red blood cells and units of plasma-derived blood products that include the dissolved clotting factors that my body had just used up. I think I got about a dozen units of various blood products over the next couple of days, including 2 units of platelets that will enter the story later. Add in the none-so-gentle uterine palpitation that Dr. Favorite was providing while shouting at me to keep breathing, and they managed to control the bleeding, and save not only my life but also my uterus.

At some point during the above chaos, my son was born. I found out the next day, by looking at the handwritten note on a bracelet I found on my wrist, that he was born at 2:26 in the afternoon. "1/14/08 @ 1426, Boy" it says in someone's handwriting. There's also some stuff printed on it by a machine: a bar code, then my last name, a comma, and the word "baby" and my first name. His initial APGAR was three. He needed some oxygen, which they gave him and he recovered spectacularly from a traumatic last few minutes, and rose to a 5 minute APGAR of nine. They tell me he's fine. I don't know how they know this for sure, how we can be certain that there was no brain damage due to the lack of oxygen, but I choose to believe that these people know what they're talking about. Apparently the fact that I never lost consciousness and went into cardiac arrest and needed to be resuscitated is a good sign.

Next up: Wow, It's A Good Thing We Were So Worried About My Cervix (Part 2, or The Aftermath), containing such charming exclamations as "Wow! You're not making any urine!" and "Hopefully this won't leave you paralyzed!" and "We're just going to insert this catheter into your vena cava!" Also, what was H doing while all this was happening?


Nurse Lochia said...

All I can say is wow. I'm glad you had a nurse who wasn't afraid to act, even when others said, "oh, lets wait". I can't imagine how scary all of that was for you and your family. I'm thankful I've never seen an AFE in my career so far, but if I do, I hope they fair as well as you, and that I react like Experienced Polish Nurse. What an incredible story.

Mike & Kiernan said...

HOLY S**T!! I can't believe that story. I just read that whole post with my mouth gaping open. I was riveted, and also in disbelief for what you went through. I am SO glad all is okay and that you had the medical team you did.

electriclady said...

Holy fucking crap. I can't believe you went through all that and survived. Thank god for Experienced Polish Nurse.

Lori said...

I can see this as a show on Lifetime or Hallmark.


So glad you lived to tell.

Eager for part 2.

Geohde said...

Um. Wow.

Guess it IS a good thing there was attention on the cervix, after all...


Ann said...

Your story has left me breathless. God was certainly watching out for you. My, May, I am so glad this all turned out OK in the end. What a lot for you husband to go through, though.

MrsSpock said...

Yet another reason why we don't let new grad nurses into our trauma ICU anymore...when the s##t hits the fan, experience can mean the difference between life and death. You had an angel on your shoulder that day...


omg! i came over after you commented on my blog. ( i was recently diagnosed with placenta previa) i can't believe your labor story. so glad all is well now. i am just in awe. can't wait to hear more!