“She’s contracting every seven minutes and liquid is coming out.” It was a Sunday morning in early March, and I was the doctor on call for family practice and pregnancy-related matters. This call from a concerned father-to-be would have seemed ordinary except that Ronnie, the laboring mother, had a May due date.
“You need to take her to the hospital right away; it looks like she’s going to have her baby early,” I told him. “Have you registered at the hospital already?”
“Then go straight to the third floor. I’ll call them and let them know you’re coming.” I did so and asked the nurse to monitor the baby, perform a sterile speculum examination to confirm that she had ruptured her membranes (her bag of waters), and to do a vaginal culture for a particular bacterium, the Group B streptococcus.
Ronnie’s baby had an estimated gestational age of 31 weeks and 2 days; 8 weeks and 5 days remained before he would reach his due date at 40 weeks’ gestational age. Women can go into labor this early for many reasons, most of which involve infections of either the urinary tract, the vagina, or the uterine contents. If the membranes remain intact and labor hasn’t yet reached the active stage, with the cervix dilated four centimeters or more, we can often delay or stop labor with medications, treat the underlying cause of the preterm labor, and give the baby’s organs, particularly the lungs, a chance to mature. We can use medicines to hasten lung maturity when we think we will not be able to keep the baby from delivering before 34 weeks’ gestational age.
When the membranes rupture, things get more complicated. Ruptured membranes stimulate labor, and almost all babies, no matter what the gestational age, deliver within ten days after rupture of membranes. Leaking membranes also give vaginal bacteria free access to the amniotic fluid, facilitating infection of the fluid and membranes if they weren’t infected already. If the mother develops a fever, foul-smelling fluid, pus in her fluid, or other definite signs of infection, it becomes too dangerous to keep the baby inside, so we treat with antibiotics and allow labor to progress on to delivery. Because of all this, definitive determination of the membranes’ status is an important part of these patients’ initial evaluation.
As I gulped down my lunch in preparation for a trip to the hospital, Kathy, the triage nurse, paged me to say Ronnie’s uterus was contracting with moderate strength every two to four minutes. I asked if the membranes were ruptured, and she said they weren’t, a pleasant surprise given that Ronnie had told me she was leaking. I ordered Kathy to give Ronnie a subcutaneous injection of terbutaline, which usually slows or stops the contractions of early labor, and I drove to the hospital.
I entered the triage area through the door just to the left of the labor and delivery area’s main desk, passed the curtains closed around the patients undergoing evaluation, two on each side of the central walkway, and proceeded to the triage desk, tucked in a corner on the right. As the fetal monitors broadcast their rapid thumps as though dueling for recognition, Kathy brought me Ronnie’s prenatal record and the news that she was still contracting every four to seven minutes. “I have the setup for the sterile speculum exam,” she informed me, “except that I haven’t found a place to plug in the light source.”
This didn’t make sense to me. I had ordered the exam to be done upon Ronnie’s arrival, so when Kathy had told me that the membranes were not ruptured, I assumed she knew this because she had done the exam.
I processed this information as I squeezed through the curtain and around the metal-tray table holding the speculum and other instruments to arrive at Ronnie’s right side. The 32-year-old African-American’s hands and legs trembled, not from fear but from terbutaline, one dose of which can make you feel like you’ve had about ten cups of coffee. She and her husband listened to me explain the exam and why I needed to do it. She consented. Kathy found a light with a long enough cord to reach the outlet across the room, so I gloved up and placed the sterile speculum between my hands, a more symbolic than effective gesture that tells my patient that I am trying to avoid putting an ice-cold speculum in her vagina.
I asked about the fluid, “When did you first notice you were leaking?”
“Friday night. I thought I was losing control of my bladder. It slowed down a lot yesterday, so I wasn’t as worried, but today the contractions came harder and I was leaking more, so we called you.” So she might have had ruptured membranes for over 36 hours, plenty of time to develop an infection. But she felt well, and she didn’t have a fever yet.
After about 15 seconds of attempting to impart some warmth to the cold metal instrument, I advanced it slowly into her vagina. Despite our attempts to be gentle, this exam is painful for many pregnant women, and Ronnie was one of those women. It didn’t help that I needed to get a good look at her cervix and therefore had to exert additional downward pressure to position the instrument, a move that brought tears to her eyes. I didn’t want to have to check her cervix with my gloved fingers because each cervical check increases the infection risk.
As I opened the speculum, a pool of clear fluid flashed into view, and I had my answer. I stuck a piece of yellow nitrazine paper in the fluid, and it instantly turned deep blue, confirming that this was amniotic fluid. Using a Q-Tip, I then swabbed some fluid onto a slide, removed the speculum, and took the slide over to the microscope. Under magnification, I could see the delicate characteristic “ferning” patterns that look like broken crystal snowflakes and complete the identification of amniotic fluid. This baby was coming very early, and I therefore needed a specialist, a perinatologist, to take over at this point, so I summoned Mickey, the on-call perinatologist. I had never met her and it was, in fact, her first day on the job at our hospital. Her short, curly hair made her look younger than her probable late-30s age, and we had a pleasant introduction and case discussion.
Mickey followed me into Ronnie’s cramped quarters, sat down, and began asking the usual questions about what happened when. Ronnie mentioned that she had called a doctor late Friday, and he hadn’t seemed too concerned. Puzzled, since a story of fluid leakage and contractions at 31 weeks is alarming to anyone who practices obstetrics, I interjected, “Who did you talk to? Was it Dr. W?” — one of the doctors with whom I share obstetric call responsibilities — “Friday afternoon?”
“No, it was Friday night, and it was another doctor.”
That stopped my questions. I maintained my calm exterior and wrote a note in her chart while Mickey continued her inquiry, but my insides were churning. She had talked to me Friday night, and I had somehow missed the diagnosis. Hers was one of several calls that came in between 10:30 and midnight, and I was having a maddeningly difficult time recalling our conversation. It took me several hours to put it together as best as I could, but I did recall that she had told me she felt a constant discomfort in her lower abdomen that would get worse “for a couple of minutes” and then diminish. I made sure she clarified that she meant minutes and not 40 to 60 seconds, which would suggest early labor. After a short conversation, her descriptions satisfied me that she wasn’t in labor, and I told her to drink plenty of fluids and call me if her symptoms worsened.
This was malpractice. When an obstetric practitioner gets a phone call from a pregnant patient, there are four symptoms that the conversation must cover: contractions, bleeding, fetal movement, and leakage of fluid. Residency faculty drill these four elements into every resident’s head. The malpractice lawyers also know them and look for them in every documented phone contact in the records they review. I somehow forgot to talk about Ronnie’s fluid, and she didn’t mention it to me. I called our answering service and asked what Ronnie had told them when she asked them to call me, and their records showed that she complained of pain and “losing control of my urine.” The service must not have relayed that second part; either that or I am losing my mind.
So, thanks to me, Ronnie walked around for 36 hours with her membranes ruptured nine weeks before her due date. If I had sent her in for evaluation Friday night, we could have started antibiotics to help prevent infection and given her two corticosteroid shots to help her baby’s lungs mature. Instead, Ronnie was coming in now in early labor. Her temperature crept up to 100.1 degrees, which was enough for Mickey to decide that we should not delay delivery. Since Mickey was managing the situation, I wished everyone well and went home.
I have made mistakes before. When I was a second-year resident, I was on call one night when I had already admitted four patients to the hospital and therefore had not slept at all. It was 4:00 a.m., and an ambulance brought in a sixtyish-year-old, cheerful, obese man with an “asthma attack.” We treated him with asthma medications and he improved, but I recognized that it is not common for someone who has never developed asthma to get his first attack in his 60s. I ordered a chest X-ray. I looked at it. His heart was big, and the blood vessels to the lungs showed excessive engorgement. I had found the sort of trouble I was looking for; the man had congestive heart failure (CHF), a condition where the heart does not contract with enough force to push forward all of the blood that comes to it, and therefore the circulation backs up into the lungs, filling them with fluid. But my body had such a strong desire to sleep and my fatigue had clouded my judgment just enough that I was able to create a new interpretation and convince myself that it was correct: the X-ray showed CHF, but his clinical course was consistent with asthma, so therefore the X-ray was wrong and I could send him home. Much to the patient’s delight, he went home and I went to sleep.
When I awoke 90 minutes later, my senses had returned. I got a well-rested resident to call him and admit him. The patient felt better than he had in days, but he did come back, which was a good thing because he had also had a heart attack. Later that morning, I went to Dan, our residency director, and offered to take whatever punishment he felt was appropriate and wondered if I should rethink my career choice. I was being too hard on myself, of course, and he pointed out that I had found my mistake, fixed it, and done the appropriate introspection afterward. The patient did well and, ironically, left the hospital thinking I was a great doctor.
I was a bit less lucky with another patient, a 22-year-old-blonde-former-cheerleader-type who came into my office a couple of years ago with a bladder infection, which I confirmed by examining her urine before going in to see her. Early in training, we learn to assume that a woman of child-bearing age who comes to a doctor for any reason is pregnant until proven otherwise. I asked her if she was using birth-control pills, and she said no. She then brought up that she and her fiancé were getting married that weekend and going to Maui for their honeymoon. My wife and I had spent our honeymoon there, so we talked some about that while I examined her back and abdomen. I never returned to the topic of her contraception. I prescribed her the standard three-day regimen of a sulfa drug and wished her the best.
Two days later, two days before her wedding, she called me to tell me, in a voice boiling over with hatred, that she was pregnant. “I knew I might be, but you never asked,” she sneered. The problem: sulfa drugs in high doses cause fetal toxicity in rats. Reports of such toxicity in humans do not exist, but the findings in rats have led the FDA to place sulfa drugs in Category C for pregnancy, which means they should not be used unless the physician judges the benefits to outweigh the risks. She proceeded with her verbal assault, accusing me of lacking professionalism and ruining her wedding. She would make sure that none of her family or friends would ever come to me for care because of my incompetence.
I resisted the urge to reply, “You BITCH! You deliberately withheld information that you knew I needed to know and put your baby in jeopardy. Is that what a good parent does? You set me up. And it’s not like I prescribed thalidomide.” Instead, recognizing that I had screwed up and that I was dealing with an immature woman who didn’t know to protect herself and her baby, I congratulated her and attempted to persuade her that taking four doses of Sulfa almost certainly would not affect her pregnancy at all, which was true. I closed with a recommendation that she not set her future doctors up to make mistakes, because we are all human beings, and if we’re given enough chances to make them, we will. Her baby must have done well because I never heard from her attorney.
With this baby, though, my oversight had the potential to lead to serious consequences, and I felt horrible. It didn’t help that my head filled with visions of malpractice attorneys licking their chops and sharpening their tongs. Patients who sue usually do so at least in part because they don’t like their doctor. From her perspective, I had missed her diagnosis, sent her into a cramped triage area, ordered a painful injection that made her shake like a leaf, and introduced myself by doing a painful speculum examination that made her cry. I couldn’t escape the thought that this was all very, very bad. Upon arriving home, I told my wife, who provided her usual comforting magic, but she alone couldn’t bring me out of my cloud. I called my boss and confessed my sins. “Not ideal care,” he reassured me, “but not terrible. I think the baby will be fine. We’ll just have to see what happens.”
I then placed a call to Mickey, because I didn’t know her at all, and for all I knew she had the common bias many obstetricians and other specialists have against family practitioners. Some refer to us as those “lazy family malpractitioners.” Mickey didn’t have that bias. “Like most experienced obstetricians, I know that this stuff happens to all of us,” she explained. “I knew she was either the one in a hundred where you just didn’t ask the question or she didn’t tell you. It’s remarkable that she didn’t say anything about it.”
“She’s not the brightest crayon in the box” was how Ronnie’s doctor explained that omission. “Don’t flog yourself over it.” Fine, I thought, but now my future happiness would depend on how well this baby did. Thirty-one-week-old babies can have severe problems, and I had a lot of reasons to expect bad things to happen.
When I called labor and delivery that night at 10:00, the receptionist informed me that Ronnie had delivered two hours ago. As fast as I could, I dialed the number for the intensive-care nursery and waited for the baby’s nurse to give me an update.
“He’s doing great.” Thank you so much. He was on a ventilator, but he had not required any supplemental oxygen, which is exceptional for such an early baby. When I went to see Ronnie the next day, she gave me a proud smile as she praised her three-pound, two-ounce baby’s feistiness. And I can thank him for the loud reminder to remember the four elements: contractions, fetal movement, bleeding, and fluid leakage. I don’t imagine I’ll forget them anytime soon.