housemanship: 2 months in obgyn

2 months in OBGYN. Feels so fast. Tak sampai sebulan kena obstetrics ward, now dah turn gynae ward. Masih lagi banyak taktau. Masih tak pandai nak jahit episiotomy wound, aku macam tak boleh nak imagine macam mana nak dapatkan bentuk asal yang cantik lepas dia dah jadi macam tau fu fa. Datang kakak midwife, wow macam tak pernah beranak! Haha cantik je jahit. Experience matters in surgical based posting ni. What to expect from someone who just 2 months in obgyn? Lepastu bukannya hari hari sambut orang beranak and menjahit pun. 

My oncall last night was so eventful. It was my first time in charged labour room during oncall. Lepastu time tulah full house, then CTG semua nak poor tracing siap insertkan internal CTG lagi and then boleh tercabut pula because the patient was toooo restless! Primid. First time experiencing contraction pain. Must be tooo damn painful lah sampai dia pun dah macam apa tak keruannya. Yelah aku manalah pernah rasa. Since labour room kicap habis, 2 patients terberanak dekat ward. SO JONAH LAH. Ya ampun. 

My anti jay didnt work last night. Usually I can sleep during my night call, at least 15 minutes lah, but last night didnt even have time to scroll instagram! Ha-ha. Glad there were medical students help us throughout the night. They timed the contraction, open up the delivery and VE set, jaga CTG. Kalau takde diorang, aku taktaulah apa jadi dekat aku malam tadi. 

Hopefully ke-busy-an dekat obgyn ni menolong aku untuk mendapatkan bentuk badan ideal sebelum kawin hahahaha. Makan pun OD je sekarang. OD = once daily. Breakfast- lunch- sekalikan dengan dinner terus. Tak menyempat langsung bila dah berkicap sangat tu.

And I just had my first CBD few days back. The question was. 

26/ G7P6, unsure of date 

Unbooked, unscreened

All previous child were homebirth.

Brought by husband unconscious, you are MO in district hospital without specialist, what is your further management. 

I had thought block at first. 

This is a case of maternal collapse with perimortem Caesaren section.

First thing first, assess patient! 

Vitals unrecordable. Pulse not palpable. Start resus, insert two large bore branula, take blood for investigations, start fluid resus. Intubate patient, commencing CPR. No signs of bleeding. Uterus at 28 weeks. Scan, no retroplacental clot BUT FETAL HEART ABSENT! You are the team leader, you need to give command to your team. While CPR ongoing, see patient;s husband, ask regarding the event prior to the incident. Turned out husband taktau. He said bini okay je tetiba tengok dah tak sedarkan diri, tak pernah ada sakit apa- apa pun sebelum ni. 

I was asked regarding how to do CPR in pregnant lady. 

3 mins CPR, still no signs of life. 

Update specialist oncall. 

Proceed with perimortem Caesarean section. 

Tetiba specialist punya kereta tak boleh start pula. Kaulah yang kena buat caesar dekat ED tu. Bagitau husband, just verbal consent, no time for signature semua, the golden hours is 5 minutes. 

From RCOG Maternal Collapse: 

The concept of perimortem caesarean section was introduced in 1986,61 along with the recommendation that it be initiated after 4 minutes of maternal cardiopulmonary arrest if resuscitation is ineffective, and be achieved within 5 minutes of collapse. The rationale for this timescale is that the pregnant woman becomes hypoxic more quickly than the nonpregnant woman, and irreversible brain damage can ensue within 4–6 minutes. The gravid uterus impairs venous return and reduces cardiac output secondary to aortocaval compression. Delivery of the fetus and placenta reduces oxygen consumption, improves venous return and cardiac output, facilitates chest compressions and makes ventilation easier. It also allows the heart to be compressed easily through the diaphragm against the chest wall by placing the hand behind the heart (with the diaphragm closed) and compressing it against the posterior aspect of the anterior chest wall. This improves cardiac output beyond that achieved with closed chest compressions

Once kita keluarkan baby, cardiac output mother will improve by 60 %, dengan kuasa Allah, mak boleh revive, hidup semula. The c-section tu kena buat while cpr ongoing. Bayangkan in that situation. 

Unfortunately, the patient passed away. 

And actually this is based from true story experienced by my MO masa dia kerja dekat district. He taught me, masa first time jumpa husband lagi kena tekankan, 

"Encik, encik bawa isteri encik ni dalam keadaan yang sangat sangat kritikal. Secara perubatan dia dah tak ada. Kita dah start tekan dada isteri, kita nak cuba bawa dia kembali hidup. Kita akan buat yang terbaik" 

 

Kena bagitau husband yang dia bawa isteri dah nyawa nyawa ikan dah, but dengan empathy. Pemilihan perkataan tu penting. 

"3 minit dah berlalu daripada kita start tekan dada isteri, tapi isteri masih tak menunjukan tanda-tanda hidup, jadi encik kita akan proceed dengan pembedahan untuk keluarkan bayi dan selamatkan isteri encik" 

 

Just verbal consent, dalam time ni husband pun akan angguk je apa-apa yang terbaik untuk isteri saya doktor. Not to forget, kena mention yang baby dah tak ada juga. Akhir sekali, 

"Encik, kita minta maaf, kita dah cuba yang terbaik. Kita dah tekan dada selama 1 jam, tapi kita tak dapat selamatkan isteri encik. Saya minta maaf ya. Harap encik bersabar" 

 

This all things kena document elok-elok. Obgyn is all about medico-legal. Benda yang kita tulis hari ini mungkin masuk dalam court 10 tahun nanti, siapa tahu? 

Okaylah, macam tulah assessment first aku. Nak kena prepare untuk assessment berikutnya and CME on this coming 16. 

Nanti- nanti:)