Monthly Archives: December 2013

by

A Newborn Baby’s First for the New Year.

I feel a little like Edward Snowden here but it has to come out sometime. Someone will blow the whistle eventually… There is no first baby of the New year! I know each hospital in every city competes for the honour. And then, at least in Canada, there are the provincial competitions, and even national winners… But it’s all a diversion. Smoke and mirrors. The first baby is almost like -dare I say it?- a sasquatch: a nice myth, but hard to recognize, let alone prove. Clocks in hospitals are far from synchronized to Greenwich mean time -or even with other hospitals in the city- so time claims are like low-hanging fruit: you pick the best.

I realize the event has been news fodder for as long as there have been clocks, and why not? It seems like a good idea: acknowledge and celebrate the first baby born into the fresh and untested New year. A perfect symbol of renewal and hope; a chance to begin again untainted by the past. Pure. A tabula rasa with nothing yet written on it: no blemishes, no mistakes, nothing crossed off or erased, nothing hidden. Another triumph of hope over experience -albeit in a different context from that used by Samuel Johnson.

As I said, a good idea, but the attempting to link it to a single, unique event is fraught with problems. In principle I suppose it is fairly straightforward: as the baby’s head emerges from the birth canal, look up at the clock on the wall; if it is a second after midnight, it qualifies -maybe even wins… Or should it be when the whole body is out? And yet, on more sober reflection, maybe it makes even more sense to mark the time from when the umbilical cord is clamped because then the baby is a truly independent agent. Truly in and of this world: no longer fetus, but baby. I suppose the same could be said of its placenta though, because for the entire gestation the one has been entirely dependent on the other… So should the birth of the placenta have some place in that equation? Or only the entity we name? I guess we have to stop somewhere.

But I realize I am splitting hairs here; I am missing the spirit of the game. We all want to commemorate firsts: the first person on the moon, the first person to have a heart transplant, a lung transplant… So why not the first baby of the New Year? Why am I being so curmudgeonly about the issue? Is it because I want to deny some mother and her baby their moment on the pedestal? Deny people the hope that there can be a new beginning -a car-wash for their lives? Or is there a more mundane, political reason -like, I am out of sorts because I have never delivered the New Year’s first baby for the city? Have never shared that pedestal, basked in that momentary glory, had my masked face and soiled-gown outfit featured in the local paper? Well, in response, I can only say that I’ve been close, and it was fun.

As the New Year’s Eve midnight approaches on a delivery ward, the nurses and doctors all start focusing on whichever parturient might have a chance of delivering in the right time frame. Multips are the best, because, having had children before, their probable delivery time is a little more predictable. And they’re generally in for the game. Nowadays, with epidurals to take away the pain of labour, mothers in the process can enjoy the challenge along with the rest of us.

As the time draws ever closer and the minute hand slowly creeps around the numbers, a watcher from the door can see the frequency of clock-checks increase. Intimate conversations with the nurse intensify; glances at the machine monitoring contractions become more noticeably intertwined with sighs, and explorations of the ever changing abdominal contour by sundry anxious hands increase. The importance of that moment thickens while time knife-edges. The excited nurse tries her best to diffuse the tension and the performance pressure on her patient -although pressure is what we all want and frequently inquire about. Not psychological pressure, you understand -that is a given- but pelvic pressure which might herald imminent delivery as the head enters and begins to navigate the lower depths of the birth canal. With an epidural in full effect, however, this pressure is sometimes difficult to detect, or at least to quantify.

It’s a fine balance, delivery. So many things have to coordinate: position of the baby’s head in the vagina, ability to push effectively, size of the baby, frequency and efficiency of the uterine contractions -even the experience of the mother-to-be… And to time it so that whatever we decide is birth occurs precisely at midnight is, well, a lottery at worst and a raffle at best.

I don’t know about other hospitals, but I have always felt that it would be cheating to count the time of delivery when it is assisted by forceps, or vacuum extraction, or -and especially- Caesarian Section. I mean, come on! Even if they are indicated for fetal distress, accepting them in the competition would be akin to driving a marathon runner over the finish line and recording the time.

No, it has to happen naturally -i.e. on its own, without assistance, without cheating. There must be no telling her not to push that last little bit because it’s only 2359 hr. on the clock… No saying, “Well, I know that clock’s not correct, because it’s not the same time as on my watch…” If we’re going to play the game, we have to use the hospital clock so no one can be accused of -what?- approximation? I use that word because in the glow of ‘almost midnight’, time becomes unduly, if understandably, flexible. Stretchable. Mouldable… Unruly.

My only brush with fame came in another city. In another time. We all had high hopes for winning the city’s accolades for the first baby born, but alas, it was at least 15 seconds after midnight when it could be well and truly accepted that the little girl had been born. Out. Crying… And then came the inevitable phone call from our competitor hospital across the city -a hospital whose history was fraught with rampant disregard for the integrity of its clocks- that they had delivered a little girl at -yes- one second after midnight… And penguins can fly, you could almost hear each of us thinking.

Elated as we all were with the health of our little girl, however, there was the sense that we had missed the lottery by only a few numbers. And questionable ones at that. One nurse, however, the one who had plopped the baby onto the mother’s abdomen for a little skin-to-skin contact -something that was not widely practiced at that time- smiled broadly. She was clearly not one to accept defeat -especially at the hands -or clock- of a rival hospital.

We all looked at her. Why was she smiling? Was it mere bravado in the teeth of a near victory? Knowledge of a hitherto unannounced but bureaucratically acknowledged error in our room’s clock? Or had she missed the point entirely. When she noticed our perplexed expressions she pointed to the baby, by this time happily, although tentatively, sucking and snuffling around her mother’s nipple. “First breast feeding newborn in the New Year,” she said. “I timed it at 32 seconds after midnight,” she added smugly.

“But it’s not really breast feeding,” said the pediatrician who had not been needed and was leaning casually against the bassinet. “The baby’s probably not even getting much colostrum yet (the first antibody and protein-rich fluid from the breast before the ‘true’ breast milk comes in).”

“Come on, Dr. Felder,” the nurse piped up, excited by her ingenuity. “It’s what sustains the baby until mom’s milk comes in! Gotta call it breast feeding, eh?” We all looked at each other and nodded. “Right,” she said. “I’m phoning the papers.”

And she did. But the idea never caught on; I never got my picture in the paper holding the special newborn that had obviously accomplished an even more sophisticated first than just being born. I suppose life is full of these almosts though, isn’t it? Even at the beginning of a new and unwritten New year. There’s a lesson in that somewhere…

by

An Obstetrical Christmas

Christmas means different things to different people: stories surface, myths revive and the more hopeful among us find solace in the often blatant messages of charity and benevolence they radiate. I’m not sure why this time of year tugs so much on the heartstrings, but it does. We expect it; we await it; we demand it… Maybe it speaks to an inner need for the redemption of a society gone mad with itself.

I suppose I am no different: a prairie boy come to the big city, but never fully captured by its ethos. And yet, over the years, I have adapted, I have become as accustomed to the indifference that sustains us in the crowd as any other of our kind that seeks independence of character. To fit into a group necessitates a certain pliability and compliance -surrender, even. To stand out is to invoke response; to individuate risks retaliation -if not in kind, then in spirit. Members fit in, outliers look in…

And this preferred anonymity is what I often see in those who find themselves in such desperate need that they have to seek help outside their group. Despite our boasts of cultural safety, there is still a barrier for those less fortunate, less educated, or differently acculturated than ourselves. And for some in extremis, it means withdrawal; safety lies in silence, feigned disinterest -detachment from the distress they must surely feel.

A few years ago I volunteered to be on call on Christmas Day. Perhaps I felt it would stand me in good stead with my colleagues, but more likely I assumed that it would be a quiet 24 hours on the labour ward: nobody expects a December 25th delivery; even with that as a calculated due date, it is commonly believed there is a special dispensation exempting all and sundry from the duty of Christmas labour. But for some, there is no choice.

It was early in the afternoon, when a woman was admitted to the ward in premature labour and I was called to assess her. At first glance she seemed older -perhaps mid forties- and somewhat dishevelled. Her hair was matted with sweat and her clothes seemed oddly ill-fitting. I assumed she had donned whatever was available when she began to contract, hoping the pains would subside. But they hadn’t; in fact when I entered the room, she was writhing in agony on the bed, sweating profusely, and seemed unable -or unwilling- to communicate. We couldn’t get a monitor on her abdomen to listen to the baby, and because the contractions were coming so frequently, it was difficult to get her to concentrate enough to tell us about the pregnancy.  One look at her condition suggested an abnormal separation of her placenta -an abruption- and since the placenta is what supplies the baby with nourishment and oxygen, her baby was in trouble. Serious trouble.

I did manage to piece together that she had not seen anybody for prenatal care and didn’t live anywhere in particular, but the rest was veiled: whether or not this was her first pregnancy, whether or not she had any illnesses or had used any illegal substances -even when she thought the baby was due. Despite her understandable reticence in the face of all her pain and her reluctance to cooperate -or more likely her fear of having the baby apprehended if she disclosed too much about herself- her eyes seemed to want to confess. There was terror written in those eyes -something deeper even than the agony etched in the lines of her face- a profound concern that seemed to transcend the pain. Something she wasn’t even allowing herself -or more likely me– to see.

As I stood next to the bed trying to reassure her and decide how best to help, I could see that I had misjudged her age: she was far younger up close -late twenties maybe. And despite her projected indifference, the veneer of courage and bravado was thin and cracking as the contractions became more insistent and piled one on top of each other without a break. She was just a frightened young girl, really -someone who had inadvertently wandered into uncharted and unexpected territory. Whatever had allowed her to adapt to her life outside, was out of its depth in here, in a hospital likely only glimpsed in passing from the street. The pain was unexpected and obviously never experienced before and it returned again and again no matter how she tried to ignore it… How can this be? her eyes screamed. Stay away! her body signalled.

But despite the courage of her body, the baby came and she was still for a while. So was the baby. I quickly retrieved it and attempted to resuscitate it, but with no success: it was too premature, and too deprived of oxygen from the untimely separation of its placenta in the womb. All the while we worked on the baby, huddled over its tiny spidery body, she watched, face impassive but eyes unblinking like saucers, intent on seeing any movement, ears listening for any sound. And when it was over, when it was clear even to her that there was no hope, she merely blinked and turned away -turned inwards I thought at first.

But one look at her face told another story: she was in pain again. I put my hand on her abdomen to see if perhaps she was bleeding internally and felt the uterus in spasm. Soon there was more blood that appeared on the sheets. Suddenly, another form emerged from between her legs and her eyes widened in surprise. Before I could interfere, or even decide what was going on, she reached down and gently lifted another, smaller body no bigger than her hand. It tried to move, but managed only a tiny sound before it, too, lay limp in her soft embrace.

And finally the tears gathered in her eyes and rolled slowly down her cheeks. She stroked the little head with her other hand -tenderly, lovingly, with a caress only a mother can bestow and put it down again carefully and reverently, between her legs. She lay back then and closed her eyes, a wisp of a smile on her tired and wizened face, the experience too much for her to comprehend. But as we were tending to the second baby, and swaddling it so she could see them both for a while alone, she opened her eyes and smiled at me this time.

“Thank you,” she whispered and wiped away a tear.

I walked over to her and sat on the bed to hold her hand; I didn’t know what else to do. “I’m sorry,” I said, my own voice quivering.

She reached over with her other hand and patted me on the arm. “I’m so grateful you didn’t take my baby right away,” she said, a smile reappearing under her sad, sad eyes. I was about to answer -probably with banal and reactive words, well-meant, yet meaningless- but something made me hold my silence. “You see,” she whispered, “I needed to hear it say goodbye,” and then she closed her eyes again and slept.

It is not in the stars to hold our destiny but in ourselves. I saw the world in her face at that moment: a bridge to where we all must travel. And her smile became my smile… and the little baby’s that managed to say goodbye.

by

A night on call

I got a thank you card the other day; someone had put it in my mailbox at the hospital.  I suppose it was nothing special, but it touched me: a name I didn’t recognize, an enclosed picture of a beautiful baby, and hand-written with unforgettable penmanship a heartfelt thanks that I had helped the couple in their moment of joy and unexpected need. I must have been on call when they came in, and helped out during an episode of fetal distress -terrifying for them but less so for me, because I couldn’t recall the incident…

How blasé we become when crisis is normal. No, not normal, more… expected. Routine. Few things -in obstetrics at least- are without risk at some level. Nothing can be taken for granted: a ‘normal’ labour suddenly becomes abnormal. A baby’s heart is ticking along quite regularly on the monitor, making all the anticipated accelerations as it moves about in the womb, the rate flattening a bit if it is resting or if the mother is given analgesics for pain, maybe dipping down briefly in concert with a contraction as the head is squeezed by the pressure as it descends deeper into the pelvis in the second stage -generally behaving itself- and then, suddenly, it isn’t. The heart rate decelerates and stays down, the room panics, and beepers go off frantically.

It’s three in the morning, but fortunately the obstetrician is onsite in the Call Room of the delivery unit in our hospital. In the quiet blackness of his little room the phone by the bed erupts hysterically. He is torn suddenly from an already fragmented sleep and listens to the anxious voice. He rushes out of his room into what seems to a be an overly bright corridor, his eyes watering in the light. Unlike the room he has just left, things are neither silent nor calm on the ward despite the hour, and he must run through a patina of  worried glances and frowning faces at the main desk.

There is an almost palpable agitation in the delivery room when he arrives. The mother’s eyes are wide with worry, and the father is leaning over her squeezing her hand, feeling helpless and frustrated. The obstetrician immediately slows down at the door and introduces himself with a confident smile -he must not add to their anxiety by appearing too anxious himself. He is told by the nurse that the mother has been pushing for a while; she is exhausted and at the end of her ability to cope. He examines her and quickly discovers that the baby’s head is well descended into the pelvis -it’s deliverable- and there’s no obvious reason for the baby’s distress. The mother might be able to push it out with more time, but she’s already tired, discouraged, and very worried. And anyway there isn’t more time: the heart rate is too low and it’s not improving despite the valiant attempts by the nurses in attendance to manage it by changing the mother’s position from side to side.

An immediate solution is imperative; a decision must be made -and right away. To deliver by Caesarian Section is an option, but practically speaking, even with luck it will take at least ten or fifteen minutes to get her to the OR, anaesthetize her, make the incision and deliver the baby. No, the baby has to be delivered here. And now! The head, although low down in her vagina, is still too high for a vacuum extraction. Forceps are indicated, but she has no epidural -no way to minimize the pain. So the obstetrician immediately calls for a pudendal set (a long needle covered in a protective plastic sheath that can be inserted into the vagina between the baby’s head and the vaginal wall  and then into the sensory nerve) and injects some analgesic solution. He repeats it on the other side, all the while explaining what he is doing and trying to reassure them. She must not panic and move about. And he needs her to cooperate with the delivery. It is a tense moment, and everybody is looking at him. Staring at him… He must stay calm but above all, he must appear calm. Confident. Reassuring to all around him… Much rides on trust.

Then the forceps -the metal instrument that forms a dilating wedge ahead of the baby’s head to facilitate its delivery as the mother pushes. As he applies them, he explains that they do not grasp the head as pliers would; they do not pull the baby forcibly down the vaginal canal; no, rather, they act like a helmet to protect the head from trauma as it negotiates the otherwise tight quarters that the mother had not been able to overcome on her own. The obstetrician needs to keep telling the parents this as they watch nervously from above.

He waits for a contraction, gets the mother to help him by pushing, and gently brings the head down to the opening of the vagina. He does not cut the skin of the perineum -an episiotomy- but removes the forceps as the baby’s head is crowning and the mother pushes it out on her own: a natural delivery almost… The baby cries, the parents cry and the newly-arrived paediatrician smiles. So does the obstetrician; it’s now three-fifteen and if he’s lucky he’ll go back to his room for an hour of  sleep before the next phone call. The next delivery. The next crisis…

No, every night on call is not as tense; deliveries are joyful affairs and he is usually a mere accessory, a facilitator, a shadow flitting in and out of a room -his name acknowledged in the general wash of emotion, but remembered only until he shakes their hands and leaves. He is a temporary part of the process after all; Nature has been doing this without his help since life began.

He is only special sometimes… But that is enough. It’s what keeps me going after all these years.

by

Nature versus Princess Nurture

I’ve often wondered how much of a role acculturation plays in modelling who we are. Am I a gynaecologist because my mother restricted my prairie play-things to a rather effeminate teddy bear named Girl and a doctor’s bag that probably wasn’t? Or did I choose to play with them -as opposed to, say, waving tree branches around like weapons- because there was something in my genetic code and in the epigenetic functioning of the methyl groups which switch genes on and off that whispered “Ob/Gyn” in my still-young ears? I mean, there does seem to be something to the long held suspicions that males and females are wired differently ( http://www.theguardian.com/science/2013/dec/02/men-women-brains-wired-differently ) but I’m sure there’s more to it than that: Medicine is -hopefully- genderless. A wire-free zone, I like to think…  And yet, can the equation be boiled down to the overly simplistic apothegm of ‘Nature versus Nurture’? Perhaps. But if so I suspect it’s less ‘either-or’ than this pithy assertion suggests. Like nouns, each component has many adjectives that alter the meaning, change the hue, modify the intent. It seems to me that an explanation that offers only black or white answers is always suspect.

I suppose that is why the idea of gendered toys has always puzzled me; and why I find the Goldieblox variation on that theme so intriguing. A Stanford educated engineer, Debbie Sterling, thought she should challenge the Pink Aisle concept of toy stores -you know: one side of the store is for boys and the other (the pink side)  is for girls. She thought that maybe she could interest more girls in engineering by changing what they play with: construction toys as well as (instead of?) Princess glitterati and the like -hence Goldieblox. ( http://www.huffingtonpost.co.uk/2013/11/20/goldieblox-inspire-little-girls-to-become-engineers_n_4308556.html ). The thrust to this end has hitherto been later -in high school; this just starts the process earlier. Great. It’s a start, anyway.

There are, of course, skeptics.  Some argue that Goldieblox is just a clever market ploy to sell new toys to girls -remember the pink Lionel Trains of a few years ago? (Probably not -they hardly sold). In other words, it’s just a way of moving the Princess paraphernalia further down the shelf to make room for Goldieblox -on the same pink aisle, of course. Others observe that their daughters already play with boy’s toys ( http://www.huffingtonpost.com/sandra-shpilberg/goldieblox-girls-education_b_4340094.html ). All well and good, but why should the toys be marketed like that in the first place? Is it the only way that retailers can sell them to parents wanting to please their choosy offspring? Or…to parents wanting to mold their children..?

It has been suggested that preschool children are less concerned -more confused- about gender and gender roles than older children. Perhaps it’s part of the malleability of early neurodevelopment, or maybe it’s because at that age it really doesn’t matter. The pattern of wiring is likely still multimodal -more flexible, at least, than it will be. It strikes me that we as parents should be rejoicing at that window of opportunity to widen their horizons, enlarge their choices. What will be may well be what will be, but perhaps without as many stipulations.

Maybe it’s a Societal Issue: maintain the stereotypes and stabilize the Culture. Well, but does it? And even if it did, is that what we want? What we need? Nowadays, there are very few homogeneous countries, very few places untouched by other cultures, new ideas, fresh approaches.  Paradigms shift; innovations arise; people change -and so do norms. We don’t think the same way as our ancestors; we even modify what we learned from our parents and adapt it to the current reality. It’s how we grow -how a society grows. Evolution isn’t simply a biological mechanism for acclimatization, it’s a process of learning from the past and readjusting to the present. ( http://www.huffingtonpost.com/lauren-berninger/why-girls-dont-want-to-be_b_4324255.html  ). And so we must prepare for a future that will see roles change; a future that will probably see gender in a very different light. A future, maybe, that will not so much be colour-coded into pinks and blues as opportunity-rich… equal opportunity laden, one would expect. And even though Shakespeare was poetically realistic: If you can look into the seeds of time, and say which grain will grow and which will not, speak then unto me, I am perhaps a little more hopeful. A little more directive. I will speak, albeit softly.