Tag Archives: the rewards of obstetrics

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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.

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In Praise of Painted Toenails

I went to a celebration last night, an acclamation of an event so unique and yet so common as to defy -almost- the need to single it out and frame it in the usual infinite regress of hyperbole it inevitably invokes: a birth.

I have to admit that I enjoy birth, although as an obstetrician my perspective is necessarily more technical, adjunctive, facilitative. The less I have to do, the better the result, and as a consequence, the more peripheral I become. It’s an interesting role -and a humbling one- in which success is measured by anonymity. The goal is not being noticed, and after the usual thanks proffered by the overwhelmed parents, retreating quietly to the background to join the other shadows flitting silently around the room.

Birth is a special occasion; it is in turns both intimate and private and yet inclusive and universal. To finally meet the person with whom you’ve shared your body, your thoughts and your dreams after all those months, to finally know and greet the intimate stranger living in your house defies all words; it floods the mind. It is a happy, giddy moment; it is a confusing moment as reality crashes over you like an ocean wave. It is a moment that, as a man -and more distant still, as an accoucheur- I can merely acknowledge from the distance of an acquaintance, a guide hired for the trip. The joy, the wonder, the amazement is vicarious; it is victory by proxy. And yet is deeply satisfying and not at all disappointing to be suddenly in the background.  It is enough to know that journey was successfully concluded, and the destination is all that was promised so long ago.

It is what we sign up for as obstetricians: of necessity, we are creatures of the Gestalt. We are umbral-beings, content with whispering advice, treading carefully on territory we do not possess. We are the Guardians, in a way, of the chosen unborn, the yet-to-speak minority that lives so silently among us. It is an interesting career to aspire -in part at least- to relegation to milieu… To be noticed au moment critique only when there is a critical moment… And to rest content with only that.

But I suspect there is more to it. An absence of obstetrical complications has to result in more than a mere abyssal assignation and a consequential banishment to the margins. If that were the end of it, there would be little reward for the months of coaching, the commiseration, the common concern… Money is not enough of an inducement; it is never enough.  There is an infectious commonality to pregnancy: a shared joy of anticipation, an as yet unrequited expectation, a primal appreciation of ontogeny. There is magic in the hidden life, the unintroduced guest.

And yet I sometimes hope for more, but never ask: inclusion in the party. Recognition, somehow, of an important place in the process, while conceding all the while that it would and could proceed without me. It is no doubt a Sartrean hope, or worse, doomed like Sisyphus to repeat again and again, resolution receding forever backwards as the role requires.

But last night, for the briefest of instants, it changed: I became a part of the Wheel: Samsara. For a moment, I was included. I was Family. Sitting sleepily in the middle of a particularly dark and busy night in the artificial brightness of a numbered room in the Delivery Suite, my eyes happened upon some toes. Not just any toes, of course -they are rarely displayed as such in winter here. They were parturient toes, and decked out as if for Hawaii, or some closer summer sand. Rich reds, and tiny stars, with little flecks of yellow and blue -very festive. Very cheerful. I commented on them, naturally; it seemed an essential break from my repetitive admonitions to aid -no, speed– the progress of her delivery.

And between the contractions, between her pain and obvious exhaustion, she giggled. “I did them for you, doctor,” she said, before another contraction seized the words and buried them in her mouth. She could manage no more until the baby arrived, screaming and worming its way into the bright fresh new world. Then, after the congratulations and the shaking of various and sundry hands, she grabbed hold of mine. “I really did, you know,” she said, tenderly caressing her long-awaited baby on her abdomen with her other hand and tearing her eyes from it for a hurried second to look at me. “You once told me that a delivery was always special for you…” She squeezed my hand to make sure I was hearing her in the noise that surrounds a new baby. “…And I wanted to make sure it stayed special. Thank you so much!”

It was… It will always be special.