Flakes of Snow

The inpatient wing recently got a makeover with mesmerizingly gorgeous simulated wood laminate flooring that makes it look like a spa. Very soothing to look at in the midst of complete chaos.  Upon arrival to the hospital this morning, I was given a heads up from the night float about a patient arriving via medevac who had given birth to a stillborn infant at 29 + 5/7 wks EGA, had retained placenta for more than 3 hours, and was being transfused in transit with 2 units of blood for postpartum hemorrhage.  By the time the patient arrived, I had already discharged 4 patients and admitted 2 new ones.  She was strapped to a gurney, very quiet, with part of a placenta (clamped umbilical cord still attached) protruding slightly from her vagina, actively bleeding.  The paramedics had given her almost 5L of IVF and her SBP was only in the high 80s to low 90s.

After drawing blood for CBC, type & cross, and bile acids (cholestasis of pregnancy is a common cause of fetal demise here), the OB nurses started infusing 20 units of pitocin.  The placenta was manually extracted, and I did a quick repair of the patient's 1st degree vaginal laceration.  Only after all the procedures were completed did the patient burst into tears.  Admit her to OB or to the inpatient unit?  The OB nurses were skilled with postpartum care, but it seemed insensitive to keep the patient where there were so many mothers with healthy newborns.  The nurses pulled me into the supply area to assess the stillborn infant.  He weighed just over 4 lbs and appeared to be at least 34 weeks old.  They debated whether it would be all right to clean him up so the mother could have photographs taken; a quick call to the Medical Examiner (autopsy is mandatory in fetal demise beyond 20 weeks) confirmed that the stillborn infant had to be left in his current condition without any alteration.

The patient was transferred to the adult inpatient unit, doing well until she suddenly developed chills and tachycardia 20 minutes before the end of my shift.  Minimal vaginal bleeding since the manual extraction of the placenta, no significant uterine tenderness, no dysuria or foul vaginal discharge.  Pt's temperature skyrocketed from 97.6 to 101.8 within a matter of minutes.  I got blood cultures, started clindamycin and gentamicin for presumed endometritis, and kept my fingers crossed.

Walking home, I noticed gentle flakes of snow falling from the sky and landing softly on the ground.