---

The patient is a 37-year-old gravida 3, para 2, Caucasian female, admitted at 39 plus weeks and in labor. She had a several-year history of infertility and arrived in Labor and Delivery in the early morning hours in early labor. At about 6 o'clock, she had received an epidural anesthetic and as the medication was being administered, it became clear that the medication was being delivered to the cerebrospinal fluid space subdurally rather than in the epidural space. The anesthesiologist was present at the time, and this immediately caused maternal apnea and hypotension. He corrected that with ephedrine and stimulated the patient to cause her to begin normal breathing efforts. During this time, the baby's heart rate decelerated, but because of the maternal blood pressure staying good majority of the time, the baby's heart rate never lost variability and the decelerations stopped pretty quickly. The patient, at the time of my arrival in Labor and Delivery, was still very sleepy but responding well to stimuli and was breathing without difficulty. She had good oxygen saturations, except for a very short period of time. The baby throughout the episode had reactive fetal heart tones with good beat-to-beat variability and showed no sign of distress.

Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck. These were variable decelerations occurring late in the contraction phase. The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps. The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes. The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet. Cord gases were sent and the placenta was sent to Pathology. The cervix, the placenta, and the rectum all seemed to be intact. The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl. Blood loss was about 400 mL.

Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place. She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter. The baby's father was present for the delivery, as was one of the patient's sisters. All are relieved and pleased with the good outcome.

---