If television is to be believed, the conclusion of labor occurs with an irresistible urge to push, followed by one or two extremely vocal expulsive efforts, followed by the lusty cry of a newborn. The truth, of course, is a bit different. Most labors begin gradually and crescendo when a woman experiences a strong desire to bear down. This desire may occur once her cervix is completely dilated, but it often does not happen for an hour or longer after dilation is complete. During this time, the fetal head descends and finally exerts a critical pressure on the lower vagina, causing an intense urge to bear down. At this point, most women--unless they have a dense epidural in place--cannot resist pushing and any attempts to get her to pant through her contractions "until the doctor gets here" are usually doomed to failure. However, every rule has its exceptions. I have known a few women who resisted the urge to push so strongly that I had to resort to drastic actions to get their babies delivered. This is the story of Dahlia, who didn't want to push.
I met Dahlia in the third trimester of her second pregnancy. The first thing that struck me about her was that she was a particularly beautiful young woman. She had a womanly figure, pregnant belly and all--fit and tanned. Her eyes were bright green and were incandescent against her dark olive skin. She had wavy, long auburn hair--probably helped along by some hair coloring--and had a way with makeup so that you were aware of her high cheekbones and slightly gapped front teeth, but what she left you with was the impression of earthly, visceral beauty.
Dahlia usually came to her appointments with her first child, a girl named Aubrey, a lovely, well-adjusted child with an impressive vocabulary. Whenever I entered the examine room, I found Dahlia reading books to Aubrey and took this as a sure sign of a good mom. Dahlia's prenatal care was the textbook example of a healthy, uncomplicated pregnancy. I hoped to be the one at her birth.
I got my wish. Dahlia went into labor early on my call day and I met her on Labor & Delivery. She already had the dreamy expression of a woman concentrating hard on the physical sensations of labor. "Hi Dr. Chan," she said when I walked in, then closed her eyes again. My immediate impression was: here's a woman who needs to be left alone to labor. So I admitted her to the labor room of her choice and made a decision to be hands-off.
Just as well, because I had two other labors to keep an eye on that day. Dahlia's nurse, Ellie, kept me posted on her progress. When her waters broke spontaneously at about 3pm, I thought the process would accelerate soon and stayed nearby to be ready for the baby.
At 4pm, Dahlia was completely dilated. "If you feel like it, you can push," I said. She shook her head. "OK, let's wait for a while." I was willing to be patient but I could tell that Mike, Dahlia's husband, was eager to meet the baby. He had his hands in his pockets and bobbed up and down on the balls of his feet nervously as Dahlia breathed through contractions.
The other two labors were keeping me occupied, so it was easy to let Dahlia labor for another hour or so. One of the women delivered a nice little boy and there was a break in the action. I went back to Dahlia's room to check up on her. Since my departure, there had been a change in her posture. Whereas she had been calm and inwardly focused, now her face was screwed up and she was holding her breath rather than breathing out slowly.
"Do you feel like pushing?" I asked.
Dahlia shook her head violently. "No, I don't want to push," she said firmly. Her eyes were closed but her brow was furrowed and the relaxation that had characterized her earlier labor was gone.
I examined her. The fetal head had labored down to +1 station, which meant that most of the head was in the vagina, rather than coming through the cervix. Looking at Dahlia's tense posture, I suspected she felt a strong urge to push but was resisting it for some reason. "You know, it might feel good to push against that pressure. Do you want to try?" She shook her head.
Ellie and I conferred in the hallway. "I can't believe she doesn't want to push," said Ellie.
"Maybe she's not ready, you know, emotionally," I said, not at all confident in my assessment. "The heart tones look good, let's just wait a while."
Within a few minutes, I heard sharp voices coming from Dahlia's room. She and Mike were arguing. He entered the hallway. "I keep telling her to push, that she's ready to have this baby, but she won't." He was obviously frustrated. I reassured him that some women won't push until they're ready. Inwardly I had a feeling something else was going on but I didn't know what it was.
I examined Dahlia again, after she'd been completely dilated for two hours. The head was even further down and she was gritting her teeth with each contraction. It was apparent that she was actively resisting the urge to push. "It's time to push, my friend," I said.
"No, I can't," she said.
"I just can't."
A thought occurred to me. "Are you afraid of something?"
She paused, her brow furrowed. "That last push," she said finally.
I didn't know it at the time, but a lot of women who have given birth before fear the intense sensations that occur at the moment the infant is born. Since Dahlia's delivery, I have spoken to a number of women about their experience and they have described the feeling of an internal giving-way, a total loss of control, and a searing flash of pain at the moment the baby emerges from their body. Some women acknowledge this fear during prenatal care, and it gives me a chance to discuss it with them and prepare myself for coaching them through the moment. In Dahlia's case, I'd never encountered this fear before and she'd never given any clue that she'd been wrestling with any fear at all.
Ellie and I tried to reassure Dahlia. I gave some posterior pressure in the vagina to show her where to push, but she hated it. "Get your fingers OUT!" she ordered. I stopped. Mike was pleading with her to push. "You've got to do it," he said. "You have to push the baby out!"
"No I don't," she said. "I want a C-section."
I tried to talk to her about C-section, how there was no reason for her to have one at this point, the risks to herself and the baby for a C-section without medical necessity. "I don't care, I want one."
Mike was furious with his wife by this time. "You'd do something to hurt the baby just because you don't want to push?" I gave him a warning look. I sensed this tone was going to escalate the situation further.
"Mikey, leave," Dahlia ordered. "Just go."
We all left the room. None of us understood what was going on with Dahlia--as I said, I didn't piece together how profound the fear of pushing can be until later--but Ellie and I had a few ideas. First we called in a doula, or labor support person, who just happened to be one of the most experienced home birth midwives in our region and an expert childbirth educator at my clinic. Kathleen had been Dahlia's doula at her first birth and knew her well.
"What about pain control?" Ellie asked. We considered getting an epidural, but our anesthesiologist was tied up in a long OR case. I offered Dahlia an intrathecal, or walking epidural, but she refused. "I want a C-section," she said. "I don't want anything in my back unless I get a C-section." She was very clear but the emotional tone of her voice was getting more and more shrill. This was not the woman I knew from prenatal visits, or the woman Mike had been married to for six years.
"I don't get it," he said to me in the hallway. "She doesn't want a C-section. She doesn't want a scar on her body. This woman is really particular about how she looks, she wouldn't want a scar on her body."
He was speaking bluntly because he was worried about his wife, but his statement was profound. I realized that Dahlia's extremely well-pulled together image--the expert make-up, the perfect depth of tan, the lithe and supple figure--was a manifestation of a deep self-control, which was now over-riding her body's need to push.
Kathleen arrived. I updated her on the situation, and she went to be with Dahlia. Her presence reassured Dahlia but even Kathleen couldn't convince her to push. "I just can't," I overheard her whisper to Kathleen. "I can't do it."
Dahlia had been completely dilated for four hours by now. The baby's heart tones had been reassuring throughout labor, so there was no pressing need to get her delivered right now, but I was running out of ideas, so I called the obstetrician on call. Thank goodness it was Dr. Laporte, a woman physician and a very level-headed one to boot. I explained the situation and said, "I don't even know what to call this. Is it a prolonged second stage if the woman refuses to push? I just don't want her to end up with a C-section without a good reason."
Dr. Laporte agreed there was no reason to proceed to an operative delivery, but suggested I start Pitocin. "Maybe she'll want to push if she feel contractions more often, or at least her uterus will labor the baby down eventually."
Dahlia didn't want the Pitocin. She still wanted a C-section. I struggled with the decision to start Pit, because I don't like to do something without a patient's consent. However, at this point, I wasn't entirely sure Dahlia had the capacity to make an informed decision about her care. Although she spoke clearly, she was visibly resisting her body's own efforts to delivery her baby, demanding a C-section and refusing all other treatments that would be less risk to her and the baby. I talked to Ellie, Mike and Kathleen about this quandary and we all agreed it would be better for both mother and child to maximize non-operative means of aiding delivery. I started Pitocin at a very low level.
Dahlia's labor continued. I delivered another baby--a girl--next door. Shift change came around and Ellie left Dahlia reluctantly, but there was no end in sight and she had to work the next day. "I hope she's delivered by the time I come back," said Ellie as she left. Laura took over Dahlia's nursing care. It was good to have new energy in the room, and Laura's brisk everything-is-going-to-be-fine attitude made all of us--except Dahlia--feel better.
Pitocin made Dahlia's contractions more frequent but she still resisted pushing. She tensed her belly and her pelvic muscles at the peak of each contraction, as if she were holding the baby in. Kathleen had talked to her about C-section, and convinced her it wasn't an option, but Dahlia still refused to push. "How about a fentanyl PCA?" Kathleen suggested.
I thought this was a brilliant idea. We often give individual doses of fentanyl to aid pain in labor, but the same medicine can be delivered at higher hourly doses if given via a patient-controlled pump. Also, I suspected Dahlia needed to be in control of her labor, and even if I had commandeered some of the decision-making, I wanted her to feel like she was in charge of her own birth. Putting the pump in her control was a step in the right direction.
Or so I thought. Within two hours of initiating the fentanyl PCA, the syringe was empty. Dahlia pushed the button continuously, without regard to the timing of her contractions. When Laura asked whether she should insert another syringe of fentanyl, I said no. Again I offered an intrathecal, but Dahlia shook her head emphatically.
I have often wished there were an intrapartum anti-anxiety medicine that could be given during labor. Much of the physical discomfort that poses such a barrier to the smooth progress of labor originates in a woman's perception and fear of the physical sensations she experiences. Although I do not agree with the notion that training one's thoughts and beliefs can produce a discomfort-free birth, as some proponents of alternative childbirth assert, I do believe that peeling away layers of anxiety and fear during prenatal care and childbirth education can really help a woman cope with her birth experience. In extreme cases, such as Dahlia's, I have wished for a safe, short-acting benzodiazepine to use during labor, although I don't think it would be an ideal solution to the problem.
By this point, it was after 11pm and Dahlia had been completely dilated for seven hours. The baby's head was descending slowly thanks to the action of Pitocin. When I examined her, I could feel the entire head at the center of Dahlia's vaginal canal. I had to admire her self-control--the vast majority of women can't resist pushing when the head is so low.
I called Dr. Laporte, and she came to evaluate Dahlia. First, we conferred in the hallway. "Would you do a C-section in this situation?" I asked.
Dr. Laporte thought about it for a moment. "I wouldn't want to," she said. "But there is a vote for getting the whole thing over with, and you can't let her be ruptured forever. Let's hope not."
After examining Dahlia, Dr. Laporte thought the head was low enough to vacuum. I'd thought so too, but I wasn't enthusiastic about doing a vacuum delivery without a clear indication. Technically we had a prolonged second stage, but only because the mother would not make any expulsive effort. Still, we explained to Dahlia that if she didn't want to push, we'd be compelled to put a suction cup on the baby's head and pull him out. Dahlia wasn't too excited about the option, and we were debating the pros and cons of the situation when suddenly the heart tones dropped to the 60s.
"Turn the Pit off," I said to Laura. The heart tones stayed down in the 60s. Laura put an oxygen mask over Dahlia's face.
Dr. Laporte looked at me. "Well?" she asked.
"I guess we have a reason now," I replied, and asked for a vacuum setup.
In a vacuum-assisted vaginal delivery, the birth attendant--usually a doctor--places a firm plastic suction cup into the vagina and over the fetal head. You then have to check to make sure there is no vaginal tissue caught under the vacuum and then activate the suction mechanism on the vacuum. As the woman pushes, the attendant pulls gently on the vacuum handle and directs the outward motion of the fetus down, then out, then up, in a "Nike swoosh" pathway out of the birth canal. Once the head is delivered, the vacuum is removed and the rest of the delivery occurs as usual. The American Family Physician has a good review article on the technique, with an illustration of how the vacuum is applied to the fetal head. This video demonstrates the technique on an anatomical model.
Laura had the vacuum setup ready to go within a minute. I applied the vacuum and told Dahlia "This is it. Your baby is telling us he needs to be born. You've got to push this time, no excuses."
Kathleen and Mike were seated around Dahlia and echoed my instructions. Suddenly the tempo in the room was much faster and more intense. The heart tones were still in the 80s and had been down for about four minutes.
Bless her heart, Dahlia took our orders to heart. With her next contraction, she pushed and I pulled. The baby began to crown. "That's the way," I said. "Let's go again." She pushed and I pulled again, and the baby boy was born.
Little Peter was born hollering at the top of his lungs. Once his body was delivered, I handed him up to Dahlia, who--after so many hours of being an enigma--was suddenly back to her usual self. She wept at the sight of her new son. "I'm so sorry, little guy," she said to her baby. I felt teary too, but for different reasons: fatigue, worry, annoyance, and plain old confusion.
I was hesitant to check on Dahlia the next day. I had so many ambivalent feelings towards her that I could only imagine her feelings towards me. She'd had such a weird labor and revealed such dark corners of her character that it felt impossible to raise the subject of her birth experience--the way you avoid discussion of a neighbor's drunken revelry when you run into each other at the mall the following week. Still, I had to ask her, "So, how do you feel about your birth?"
"Glad it's over," she said. "I don't know why I couldn't push. I'm really sorry."
"You've got nothing to be sorry about," I said, and meant it. "You had Peter, and you're both doing well, and that's what matters."
In the end, that is what matters: a healthy mother and child. Yet Dahlia's birth taught me that birth is as much a psychological journey as it is a physical one. Sometimes the psychological detours are harder to overcome than the body's physical limits.