30 Something Baby Doc

I work in a teaching hospital therefore training resident physicians is part of my job description.
Our training program offers considerable autonomy to the residents. They often perform uncomplicated major and minor surgery without hands on assistance from attending staff (myself) . I went through similar training as a resident and felt this to be a tremendous confidence and skill builder. My biggest challenge in teaching is deciding when to intervene and assist the residents. Of course it's rare that residents would ask for help during surgery (esp. near the end of their training) as they fear others would perceive it as a sign of weakness or incompetence. In the past, I've seen major bowel and bladder injuries occur because residents were hesitant to notify their staff when they had encountered difficulties during surgery.

We were doing a cesarean section yesterday for a patient at term (37 weeks pregnant or greater) with a breech presentation ( infant was feet first) who declined an external cephalic version (thank God). I allowed the chief resident and third year resident to operate alone. I know these residents well and have confidence in their surgical skills. I simply observed without scrubbing (slang for hand washing, gowning & operating). We called the pediatricians to attend the C/S (cesarean section) just because breech delivery's even by C/S can be particularly traumatic to the infant requiring immediate resuscitation.

The surgery was going well, the incision was made in the uterus (womb) and the 3rd year resident located the infant's feet and was delivering by a breech extraction (delivering the infant by pulling it out feet first). The resident delivered the infant up to it's head and then had significant difficulty delivering the head thru the incision. A minute or 2 went buy (In these situations , minutes seem like hours). I asked the Cheif resident to take over, and he also had difficulty delivering the head . I noted that the amount of traction on the infant's neck was significant and this was increasing risk of injury . I suggested several maneuvers to aid the young surgeons in delivering the head but they were still having significant difficulty and the chance of additional hypoxic injury (neurological injury due to lack of oxygen) was increasing for the infant. My heart was pounding at this point. I immediately grabbed a pair of sterile gloves ran to the operating table without a gown and performed a * Mauriceau maneuver. The poor diligent medical student jumped out the way and nearly fell on the floor. The infant's head delivered with an almost audible pop and the infant cried immediately. I had faith in my residents and they would have delivered it eventually but time was a factor and patient safety at that time was outweighing medical education. The infant did very well except for a little facial bruising. I allowed the residents to take over from that point and they did an excellent job closing.

* Mauriceau maneuver, a method of delivering the aftercoming head in cases of breech presentation: the infant's body rests on the physician's palm and forearm with the index and middle fingers over the maxilla to flex the head while the other hand is placed on the infant's shoulders to apply traction. Called also Mauriceau-Smellie-Veit m. and Smellie's method.

I don't like intervening because part of the joy I receive from teaching is the feeling of accomplishment and pride I see in the residents when they succeed without help. But in the end , I'm the one that is legally responsible for the patient's well being. I have a friend who stated it simply......" It's the patient's neck that's on the line and it's your ass that's on the line"