JUST A COUPLE MORE PUSHES AND CHERYL, A 31 -YEAR-OLD JAZZ DANCER, WOULD HAVE HER FIRST BABY.
I MET HER THE DAY BEFORE WHEN SHE CAME TO OUR SERVICE AT MARY HITCHCOCK MEDICAL CENTER. SHE WAS ONE DAY LESS THAN THREE WEEKS OVERDUE. IN SEPTEMBER OF 1991, I WAS IN THE THIRD YEAR OF MY RESIDENCY AT THE MAINE DARTMOUTH FAMILY PRACTICE PROGRAM AND GETTING ACCUSTOMED TO THE SLOWER PACE OF A RURAL LIFESTYLE, HAVING GRADUATED FROM THE UC SAN DIEGO SCHOOL OF MEDICINE IN 1989. AT AGE 28, I WAS IN THE MIDDLE OF MY FIRST MONTH AS RESIDENT IN CHARGE OF NEW HAMPSHIRE’S ONLY HIGH-RISK OBSTETRICAL SERVICE. CHERYL’S LAY MIDWIFE REFERRED HER TO US; ONCE A PREGNANCY CONTINUES TWO WEEKS PAST THE DUE DATE, THE RISK FOR COMPLICATIONS RISES.
I remember her thick, long, dark brown hair tied in a ponytail that cascaded down her back. I remember her stocky build and cheerful demeanor. We had a pleasant visit, discussing the risks of continuing to carry the pregnancy, and we decided to induce labor the following morning. My affable attending physician. Bill Young, dropped in and concurred. “At 43 weeks,” he quipped, “it’s pretty much just you and the elephants.” I proceeded to place laminaria, a rolled up seaweed product that expands when moistened, into the os (opening) of her cervix to begin the process of dilation. 1 gave her final instructions where to meet us on the labor and delivery floor the following morning.
As usual, we induced Cheryl’s labor with an intravenous Pitocin infusion. A synthetic analog of oxytocin, a hormone produced in the posterior pituitary gland of the human brain, Pitocin stimulates contraction of the uterine smooth muscle. Her team of friends and lay mid wives took such care of her, with paper fans, massages, relaxation techniques, and encouraging words, that I sat back and watched in admiration. While doing high-risk deliveries, one seldom gets a chance to see a relaxed atmosphere where optimism reigns and the intrusions of technology, medications, and decision making are few. Tamara, a calm, thirtyish, athletic, Birkenstock-wearing nurse with light brown hair, freckles, a biting sarcastic wit, and wonderful clinical judgment, also appreciated this break from our routine. We took notes together between our obligatory assessments of her progress.
Cheryl cruised through her first stage of labor — including the crushing contractions of the transition period late in the first stage when the cervix finishes dilating from five to six centimeters to complete dilation — without requesting any medication. The external fetal heart monitor, a round plastic disk through which a white Velcro belt is threaded so it can be worn around the pregnant abdomen, recorded ideal fetal heart records, showing no signs of fetal distress.
After her cervix finished dilating, Cheryl began to push the baby toward the world. Her physical strength and the motivational skills of her team resulted in awe-inspiring effort, forging the baby’s head through the birth canal until it was visible between the labia of her vagina after 30 minutes of pushing — rapid progress for a woman three weeks past her due date with her first baby.
Tamara and I sat in our positions, charting Cheryl’s progress and enjoying the atmosphere. Dr. Eric Saylor, the attending physician on duty, observed behind us. Tamara and I both wanted to do this delivery as the midwives would have, which meant allowing Cheryl to push the baby’s head as slowly as possible through the vaginal opening so that her skin would stretch with the emergence of the baby’s head. This would avoid the need to cut an episiotomy to prevent her skin from tearing.
I almost never cut episiotomies anyway. Using scissors, I cut the tissues from the bottom of the vaginal opening, where the outside skin meets the gray corrugated mucosal surface of the vaginal lining, inward along the center of the vagina’s bottom wall down to midway between the vagina and the rectum. This gives more room for the baby’s head and shoulders and therefore speeds up delivery, which is why it became so popular among obstetricians. Their justification is that it prevents more serious tears, particularly those that extend down through the wall of the rectum (called “fourth degree” lacerations), which are more painful, more difficult to repair, and more likely to result in complications, such as stool incontinence or wound infection. Recent studies indicate what many of us suspected: cutting episiotomies increases the incidence of severe tears because the episiotomies often extend during delivery.
Cheryl’s dancing led to greater-than-usual development of her perineal muscles, located between the vagina and rectum, slowing the head’s progress just before the vaginal opening. Thirty additional minutes of pushing yielded minimal results, despite positional changes and other helpful maneuvers. But we weren’t in a hurry, the fetal heart tracing still showed a healthy baby. Even Dr. Saylor, a veteran of 25 years of obstetrics and a firm believer in episiotomies, didn't stir. Women giving birth for the first time routinely push for two hours.
With the next contraction, Cheryl pushed again, and for the first time, there was a deceleration of the baby’s heart rate, but it recovered as the contraction receded. Obstetrical practitioners classify decelerations into three categories; early, variable, and late.
Cheryl’s baby had a variable deceleration, the most common of the three types. These start just after the onset of the contraction and last for the duration of the contraction, with the heart rate diminishing as the contraction intensifies and increasing as it fades. On the recording, it looks like a mirror image of the contraction. Diminished blood flow through the baby’s umbilical cord causes variable decelerations. Often the cord is wrapped around the neck. Sometimes other body parts compress the cord. Rarely is there a true knot in the cord. With ultrasound, observers have witnessed babies “playing” with their cord, even squeezing it. It’s incredible most of them make it out alive, given the trouble they can encounter or invent inside the womb and during labor.
Variable decelerations take many forms, as the name implies, and they fall into one of three categories (mild, moderate, or severe), depending on how low the heart rate drops and how long it lasts. Cheryl’s baby’s deceleration was moderate.
Moderate variable decelerations are the rule rather than the exception while the mother is pushing, and this was the first, so it neither changed my demeanor nor my approach. I anticipated Cheryl’s tracking would show decels until she had the baby, as this is often the case. Smiles filled the room as everyone awaited the appearance of new life.
As Cheryl began pushing with the next contraction, the baby’s heart began its descent from 130 beats per minute into the 100s, 90s, and 80s, as we all expected, and we encouraged Cheryl to push, as once again the baby’s bald, moist crown nudged its way between the swollen lips of her vagina and reached toward that point of no return when the widest diameter moves past the vaginal entrance, paving the way for the rest of the body to emerge.
Cheryl took another deep breath and pushed. As I heard the heart rate dip into the 60s, I shot a glance at Tamara’s eyes, which had become more focused and attentive. A few seconds later, we were in the 30s, Tamara's fingers were on the toggle switch summoning the intensive care nursery (ICN), and her lips were saying what I was already commanding myself; “Deliver it!”
Feeling every antiperspiration mechanism in my body fail and the sudden moisture of my mask from heavier breathing, I reached backward for the scissors, cut the episiotomy, and implored Cheryl to push as hard as she could. She obeyed, and the head slid out. Without the customary stoppage at this point to suck secretions out of the baby’s mouth and nose with the blue bulb syringe, I turned the baby’s head to the side, pushed it straight down until the top shoulder appeared, then pushed straight up to bring out the bottom shoulder. Then I grasped the abdomen and pulled, bringing the rest of his blood-covered blue body outside, feeling the awful limpness of his arms and legs while noting the presence of his penis. The joyful announcement “It’s a boy” would not be fitting today, because he was dead. I slapped two clamps on the cord and cut it.
This all took about 90 seconds, barely enough time to allow the ICN team to arrive
with the “crash cart” to attend to critically ill newborns. We usually have a warning when something terrible is happening to a baby during birth; this was an instance where everyone was caught off guard. I passed the baby to Tamara, who gave it to the ICN team. I then turned back toward Cheryl. With one clamp still attached to the end of the transected cord, I looked at her bloody, swollen vagina and then down at my lap, stunned, feeling as though I’d lost something. The still heaviness of the air, tinged with the odor of blood, stool, and urine, pressed down on my head and shoulders.
“Boy or girl?” someone asked.
“Boy,” I replied too quickly.
“He’s going to be all right, isn’t he?” The edge in Cheryl’s voice betrayed her expectation of an answer she didn’t want to hear.
I looked her in the eye and said, “I don’t know.” I didn’t know. Death in that situation is seldom permanent. I was sure they would be able to resuscitate him, but I feared permanent brain damage, which occurs about six minutes after oxygen deprivation begins.
Behind me in the hallway, the ICN team worked on the baby. He did not have a pulse at one minute of age. At five minutes of age, he had a slow pulse but no other signs of life.
Optimism had left the building. Nobody spoke as I collected myself arid tried to repair the episiotomy, a task that seemed meaningless next to the battle being fought a few yards away. Cheryl’s perineum was so swollen from the tremendous effort that the topography of tier lower vaginal wall was distorted beyond my ability to recognize. I spent 25 minutes searching under the constant layer of blood trickling from her uterus through the blue, red, and purple shambles of the tom lower vaginal wall and the muscles behind it. One cannot repair an episiotomy without identifying the hymen, the vaginal wall mucosa, and the underlying perineal muscles. I succumbed to the realization that a more experienced hand would need to repair the mess I made.
The ICN team put a breathing tube into the infant’s trachea to suck out anything in his lungs, and this revealed the source of his difficulties. He’d been too eager to begin life outside the womb and aspirated an enormous quantity of bloody vaginal secretions into his lungs, a surprising finding given that babies do not breathe until after they leave the birth canal. After removing this debris, they were able to blow oxygen into his lungs, so that when he was ten minutes old, he was trying to take his own breaths and had some muscle tone in his arms and legs.
At age 24 hours, he was breast-feeding and no longer needing supplemental oxygen. Cheryl, her husband, and the midwife thanked me for trying to give them the delivery they had planned. Dr. Saylor, who I knew would lecture me about the value of a well-timed episiotomy, instead chose to be sympathetic. “I could never have waited as long as you did,” he said. “I don’t have the patience."
Five years later, I am still practicing obstetrics as part of my four-year-old family practice in Berkeley. That baby should be playing with his kindergarten classmates now.