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.