215. Saturday Morning, 3 AM

me:  ob on call, up with a patient in active labor--she will deliver about an hour later

CNM:  recently graduated midwife, new in our practice, not afraid to ask questions.

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CNM: my patient has been on Pitocin [intravenous medicine which initiates or increases labor contractions] for 12 hours now, and she is unchanged at 3cm.  What should I do?

me: did she get Cytotec [misoprosto--another medicine to induce contractions]? Or the Cook catheter [a plastic balloon inflated inside cervical canal to promote cervical dilating]?

CNM:  three doses, each 25 mcg; I tried to place a Cook catheter, but couldn't do it; never failed before and I've done a lot

me: that's a small Cytotec dose, why not [the usual] 50?

CNM: That's what Kris did [the previous CNM]; I don't know--I'm new here.

me: Well, Kris is wimpy, if she didn't come in contracting, start with 50.  If she were to present with irregular contractions, you might want start with 25 and then increase to 50 with second dose. But here, I'd have given her 50 from the beginning.  Have you considered another attempt to place the Cook catheter?.

CNM: maybe stop everything, let her sleep and start all over in the morning?

me: what difference is a few hours going to make?  Why not just sent her home?

CNM: we're inducing her for gestational hypertension

me:  what's her blood pressure now and what was her blood pressure at her first clinic visit?

[pause while records are being searched]

CNM, 126/84 now, 124/82 at first visit

me: doesn't sound like gestational hypertension to me; that was just stuck in to justify an induction for a patient that you didn't want to send home.  I'd try the Cook catheter again, while continuing increasing the pitocin.

[Cook catheter not attempted; pitocin continued: vaginal delivery around noon]

214. Clueless

I can usually come up with a presumptive diagnosis, or at least some testing (imaging or blood work) that would work towards either a diagnosis or a tentative treatment plan.

But with Caroline, I am clueless:

This 29 year old describes severe pelvic cramps lasting for about 45 minutes upon awakening, usually from a "sexual dream." Happened rarely until last year when they started occurring every few weeks; not associated with mens. She states they do not feel like orgasms which anyway are not painful to her. The symptoms are relieved within 10 minutes of having a bowel movement although she does not necessary feel like she needs to have a BM. She denies any problems with her bowel--in general is very regular. Her only significant history is migraine HA.