I arranged for BIOT 4180 to take their final exam on a survey site on the web. Half the class sat in front of me in Hamilton Hall; the rest took the exam wherever they wanted—dorm room, Starbucks, London. I activated the page at 4:00 and planned to close it two hours later. Not too pressured but not too easy. Every student had my email address and cell phone number if a technical problem arose.
I watched as the site tabulated the responses. The exam grew harder as it progressed but the percentage of correct answers stayed well above 90. As they had through the entire semester, my students exceeded my expectations.
The delivery log from my first night as an attending obstetrician lists two vaginal deliveries and a cesarean for a footling breech early in the evening, followed by my outcome code: HMHB—healthy mother and healthy baby. My role was to supervise the residents and the midwives. I remember thinking about the on-call room and sleep.
“Doctor Sable—in here. A shoulder.” Sleep would have to wait.
The room was old-fashioned, not one of those “birthing rooms” with flowered curtains and a foldout sofa. No, this was a real operating room. Thankfully. The shoulder was a young woman, first baby, pushing and breathing. The baby’s head was out.
And the baby was stuck.
At 4:45 the survey site instant messaged that it would terminate the exam in five minutes. A countdown clock appeared. I linked to technical support and typed “survey termination.” Technical support recommended I upgrade to “Pro” level for longer duration surveys in the future.
My phone rang. A little red circle appeared at the upper right hand corner of my computer mailbox: 2 messages. The countdown clock showed reached four minutes. The red circle showed 12 messages.
BIOT 4180 had 65 students.
Every oral board exam in ob/gyn includes a shoulder dystocia case, and every obstetrician can recite the steps: extend the episiotomy, press on the abdomen above the pubic bone, have the mother flex her hips and pull back on her legs, pass a hand along the baby’s back and press the front shoulder to an oblique angle, rotate the posterior arm in front of the baby’s chest and out.
Break the baby’s collarbone.
I muted the phone, googled “screen capture mac,” and email-blasted “Plan B coming.” I text-searched my hard drive for the words “final exam.”
A gown found my arms. Gloves found my hands. The apprentice midwife stepped aside and nodded. The baby was blue. I figured I had ninety seconds.
I extended. I pressed: nothing.
She flexed. She pulled: nothing.
I felt the back and rotated the shoulder, gently bringing the upper arm along to avoid fracturing it, just like the textbooks say.
The countdown clock read “0:25” by the time I had compared the draft copy of the final with what I had put on the survey site, updated it, cut, pasted, formatted it into an email (“Plan B as
promised”) and hit “send.”
I unmuted the phone.
I had never broken a collarbone, had never seen a doctor break a collarbone. I was one maneuver away from learning the hard way.
I felt for the posterior arm and gently passed it in front of the baby’s chest. The arm popped out. The back shoulder slid forward. The front shoulder slid under the pubic arch and the body landed in my hands. Blue face turned pink and the baby cried.
HMHB. Healthy mother. Healthy baby.
Sixty-five completed exam emails arrived, all completed within a time-adjusted two hours. My students, as usual, exceeded my expectations. I could only hope that I had met theirs.
David Sable MD
writer, teacher, fund manager and retired reproductive endocrinologist