“Lucky you,” my fellow chief resident smirked, “you get to do her next C-section.”

Ms. Johnson, a pleasant morbidly obese woman from West Philadelphia, was suing several OB/GYN residents for her emergency C-section two years prior. Her baby girl's heart rate had suddenly plummeted, necessitating a rapid Cesarean delivery. Ms. Johnson stood at five foot five inches and weighed 300 pounds. A layer of fatty tissue (called a panniculus) hung down from her abdomen to her upper thighs. The horizontal skin incision was two inches above her pubic bone, but the panniculus covered the incision site like a warm, moist blanket creating the perfect environment for bacteria.

Postoperatively, the incision became infected and fell apart. Only the fascia, the layer of strong tissue that holds the abdomen closed, remained intact. The six inches of fatty tissue lying above the fascia needed to be cleaned and dead tissue removed daily, a process called debridement.

Although I had not performed her C-section, as a second-year resident, it was my job to debride her open incision each morning. With my petite frame, it felt like climbing into a gaping wound.

“Hi, Ms. Johnson. How are you today?” I would inquire upon arriving in her room.

“Alright,“she would say.

“I am really sorry to have to do this, but it is the only way your incision will heal.”

I would put on my mask and sterile gloves and place sterile paper drapes on her lower abdomen.

“Ms. Johnson, could you lift up your stomach for me?”

Ms. Johnson would hold up her panniculus so I could see the open wound below.

“I am removing the old gauze now and washing you with hydrogen peroxide.”

Using a scalpel and forceps, I would then cut off any dead tissue, leaving behind the pink, healthy, sometimes bleeding, tissue underneath.

“Let me know if I am hurting you, and I'll stop and give you a break.”

“Just get it done,” she would say.

After several weeks, she was able to go home and continue to care for the wound with a visiting nurse. It took three months to heal completely. Six months later, Ms. Johnson decided to sue the residents who had performed her C-section.

Now she was pregnant again, had gained 50 pounds since, and I was responsible for her care. After her last pregnancy, she had been encouraged to lose weight, but this was difficult to accomplish with limited financial resources and few social supports. I knew she would need another C-section. The emergency uterine incision was vertical (rather than sideways) and therefore weaker, and more likely to break open during the uterine contractions of labor.

I woke up many nights thinking about her. “How can I do a C-section without her getting an infection again? And she won't fit on the operating room table.”

One night it came to me: “Make the incision starting below her breastbone to three inches above her belly button. The uterus extends several inches above the belly button at the end of pregnancy. Why not?” This was not the usual area in which to make an incision for a C–section, but it was the thinnest part of Ms. Johnson's abdomen, and the least likely to get infected. “And a birthing bed is three times as wide as an operating-room table!”

When I discussed my plans with the residency director, I explained, “I will need to kneel on the side of the birthing bed to operate on her because the bed is so high.”

The day of the surgery, Ms. Johnson said, “I washed my abdomen last night and this morning with the soap you told me to use.”

“Wonderful,” I said, “thank you.”

She climbed onto the birthing bed in the operating room. I held her hand as the anesthesiologist put her to sleep.

“Could you help me get onto the bed?” I asked the circulating nurse after she had gowned and gloved me. She held me from behind while I climbed onto the edge of the birthing bed, maintaining sterility. I washed Ms. Johnson's abdomen three times longer than usual and placed the sterile drapes, leaving an opening where I planned to make the incision. Kneeling, I performed the C-section.

Her new baby girl was healthy and the surgery uneventful. Three days later, I told Ms. Johnson, “You can go home today. You are healing well with no sign of infection.” Ms. Johnson smiled and looked incredulous.

Six weeks later at her postpartum visit, she was doing well. With a big smile, she said, “I am happy it was good this time.”

I felt relieved and proud that I had served her well.

A few months later, I heard that Ms. Johnson had dropped her lawsuit. I never found out why, but have always thought it was because I got down on my knees for her.