Thursday, May 22, 2008

Natural childbirth

I am always curious about the patient's expectations when she informs me that she desires a natural childbirth. For some women this simply means that they do not want a Cesarean section. Others want to labor and deliver completely unmedicated: no drugs, no epidural, no interventions of any sort. A patient once stated that for her natural childbirth would mean that she did not have time to put her make up on before leaving for the hospital. A few months ago I was a participant in a birthing experience that was natural by any definition.

The patient, her husband and their two children arrived at the hospital in the middle of a week day when the labor and delivery unit is typically the busiest. She had called him at work when her contractions were three minutes apart. This was their third baby. The second baby delivered within two hours of the first contraction. The dad, who I will call S, left his high profile job downtown to rush home. Shuffling his wife and kids into the family minivan he rushed the entire family unit to the hospital.

When I arrived in labor and delivery the entire family, including the two older children were in the labor room along with two labor nurses frantically trying to fill out all paper work. Monty Python may have taught us that a delivery cannot occur with out all the proper noise making equipment* but the modern legal profession and hospital administration has hammered into the nursing staff that no baby may safely arrive with any blanks on the admission form.

"She's 5 centimeters." Michelle the primary nurse assigned to care for the patient called out as I walked in the door.

S, still dressed in his three piece Brooks Brothers suit complete with tie in place, informed me that they did not know the gender of the baby. "When the baby delivers, don't tell us the baby's sex," he instructed. "I will cut the cord." Continuing his role as the one in charge he told me, "I will be the one to hand the baby to L." L, his wife, mother of the baby, was lying in bed panting through a contraction oblivious to our conversation.

Always sure of my role as "captain of the ship" (a phrase attorneys use, usually when something has gone wrong), I was not bothered by S's assertions. I have long given up a need to tell everyone I am making the decisions. When there is a crisis usually everyone wants me to make the decisions and they give me their attention quickly. Otherwise I do my job and hopefully help make the birth the joyful experience that it truly should be for all who are present.

As soon as I received my instructions from S, L's bag of waters broke in a huge gush of pea soup appearing fluid. This is called meconium stained fluid and means the baby has had a bowel movement in the bag of waters. By the color the meconium looked old meaning the bowel movement probably occurred sometime before the onset of labor. Not a problem by itself, meconium stained fluid is dangerous if the baby sucks this thick, irritating material into her lungs as she takes her first breath. Called meconium aspiration, this is a condition can result in the need for a ventilator, lung damage and even death in the newborn. To prevent the occurrence of meconium aspiration the obstetrician must use a delee, a suction device to suck out the baby's nose and mouth after the head is delivered but before the shoulders arrive. This feat requires a controlled, cooperative patient, a skilled obstetrician, a helpful husband and a nurse to assist. It seemed that at least two of these four were present.

This is when I noticed the double stroller. The kind where there is a seat in front and one behind. Four year old big sister sat in the front seat playing with her dolls and a two year old about to be big brother was behind her with one of those "board books," the type with the thick cardboard pages that are easy for toddlers to turn. Both kids seems to be fairly calm and satisfied for the moment. Turned away from all the action they were facing into the corner of the room.

Looking around again to make sure all the equipment ready, I noticed a cord blood collection kit. The patient expected me to get a bag full of the baby's umbilical cord blood, after the dad had cut the cord of course. Coming from the umbilical cord and the placenta after the baby no longer needed it, rich in embryonic stem cells, this blood would be cryoperserved in a cord blood bank in case any of the family needed a stem cell transplant.

L cried out, "I need to push!" Checking her cervix again, I confirmed that she was completely dilated and should being pushing. Delivery was imminent. As the green head crowned, the future big brother began to harass his sister sitting directly in front of him in the stroller. Watching the baby's head with one eye, I saw the stroller begin to gyrate out of the corner of my other eye. I ask the second nurse, still attending to paper work, to please check on the older siblings. S was fully focused on his wife and helping her breathe and push. For them, it was as if these other two kids did not exist.

Some how even with S's arms grabbing for the as yet undelivered baby, I managed to delee the baby's nose and mouth removing a great deal of meconium stained fluid from them. Satisfied that he would not aspirate the meconium, I delivered the rest of the baby and continued suctioning until he began to cry.

At this point over in the corner, the now big brother was taking advantage of the opportunity of being totally ignored. He whacked his big sister over the head with his book and she began to wail louder than the newborn. Again, the parents were totally oblivious to anything their older two children were doing. I again ask one of the nurses present to please break up the fight.

L was holding the baby on her abdomen, helping the nurse to dry him off and wrap him in warm blankets while S photographed them both. The two kids in the corner continued to fuss with each other fortunately now without bodily contact while I collected the umbilical cord blood and the second nurse did more paper work.

The placenta delivered and I began massaging L's fundus, the top of the uterus, to prevent hemorrhage. S looked directly at me and commanded, "Stop that! She won't be able to smile for the pictures." At this point my patience began to wane.

Stopping the fundal massage for a moment, I explained to both S and L, "Without fundal massage L, you will bleed." Finally having their attention I continued massaging, "After a third baby there could even be enough bleeding to require a blood transfusion. There will be time for pictures in a few minutes."

With the post partum uterine bleeding at a minimum, I cleaned up the delivery table and the middle of the room, carefully placing all the trash and linen in their proper containers. Covering L appropriately with sheets and blankets, I then invited S to take all the pictures he wanted as I walked over to the stroller and turned it around so that the two occupants could meet their new baby brother.

This delivery was about as natural as a birth could possibly be in a hospital setting today. One of the nurses informed me that the patient had been there all of nine minutes when the baby was born. At this point, I congratulated the couple excusing myself to do my portion of the paper work.

*from the movie "The Life of Brian."
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