One of the great pleasures of providing maternity care is being present at a woman's first birth. An even greater pleasure is being present at her second. Many birth attendants look forward to second and subsequent births because common wisdom has it that multips "go fast" in labor. Often times this is true. I like to tell women that their body is a trail that's been blazed; the second trek through the birth canal is easier than the first. However, I'm always very careful not to guarantee a quick second birth, because any one of a number of factors can affect the duration of subsequent labors:
- A second fetus significantly larger than the first.
- Malpositions such as occiput posterior ("sunny side up"), asynclitism (head tilted) or face presentation (face rather than crown first).
- Psychological factors such as anxiety about experiencing the sensations of birth the second time.
I've had my share of rapid second, third, fourth, fifth, and even sixth deliveries. Once, after determining a woman was completely dilated, I told her--casually--that she could push with her next contraction. She did, and the baby crowned before I could get fresh gloves on, so I had to deliver him with my hand covered with a bedsheet. On the other hand, I've also had more than my fair share of long second labors. Here's one such story.
Jessica was a delightful 27 year old gravida 2, para 1 whose first birth I'd attended 20 months previously. This second pregnancy, fast on the heels of the first, was planned because Jessica wanted to get her childbearing "over with" so she could have her kids in diapers at the same time and push through the interrupted sleep of breastfeeding in a few short years. After the kids were in preschool, she planned to return to graduate school herself, so completing her family in tight succession was important to her.
Jessica's first birth had been one of those perfect labor and deliveries you almost never see. (Most women don't read the obstetric texts before they get pregnant, which is just as well.) When she asked me to be at her second birth, I didn't hesitate. I said yes.
This practice of committing to be at a woman's birth is a bit tricky. Brace yourself for a startling truth: no one can predict when a baby will be born. So committing to a birth means that I put myself on call all the time for the birth. I warn women there are limits to my availability. Vacations, for example. Or sleeplessness; if I've been up all night the night before her birth, a woman is much better served by a provider who is well rested. Period.
And yet--I usually jump at the chance to be at a woman's second birth. There is a degree of reassurance in knowing how a woman labored the first time, what her psychological landscape was like for the labor, and how well she recovered during the postpartum period. I can develop a lovely shorthand with a woman whom I've attended before: "Remember the last time?" I can ask, and she will usually remember what I'm talking about.
I also enjoy seeing the families again. Jessica and her partner, Ronan, had her sisters and both sets of parents present at her first birth. This time, one of the grandparents were going to look after their toddler while she labored, so the crowd would be a bit smaller.
I was rounding on the hospitalist service one afternoon when I got a phone call to tell me Jessica had arrived. "She looks pretty comfortable, but she's at least 9 centimeters," her nurse told me. At least was right: by the time I ran over to our Birth Center, I couldn't find any cervix at all, just a big, tense amniotic sack which I ruptured. This was going to take no time at all, I believed.
During her first labor, I'd given Jessica an intrathecal injection, commonly known as a "walking epidural." This is one of those skills I learned during residency that I thought I'd never use again after I graduated, but it turns out it is really useful for a birth attendant to be able to do them in a rural hospital, where there is no dedicated OB anesthesia team. This time, however, Jessica wanted a drug-free labor, and since she was already fully dilated I thought she would make it.
I talked to Jessica about pushing when she felt like it, perhaps using the labor tub before she felt a strong urge to bear down. She was upbeat as always and said "I'll see how I feel as I go along." I love this attitude.
The longer I'm in the birthin' business, the more I realize that labor progresses so much more uneventfully when I'm not in the room. Seriously, more than once have I left a labor room to run out to pick up some take-away food, only to get paged back urgently when I am halfway to the restaurant. In fact, sometimes to make a labor progress faster--at least in my mind--I will often leave the building. This is tongue-in-cheek, but I have to say I am less likely to give into the temptation to initiate medical interventions if I'm not right in the labor room. So I went back to Med Surg to finish rounding on the hospitalist patients.
I was gone for about an hour and a half, during which time Jessica's nurse--Katie--kept an eye on things. Jessica started pushing about 45 minutes before I returned, using a number of different positions--straddling a toilet, standing, squatting over a towel on the floor. Not much progress yet.
I was a bit surprised, and so was she. "I thought this time was supposed to be faster," she said after I examined her.
"No money-back guarantee on that," I said. That was the kind of interaction we had with each other after two pregnancies--quips and shorthand.
"Dammit I want my money back," she grumbled, but got back to pushing like a sport.
We pushed for another half an hour. Outside, it was dark and wintery, but the labor room was hot from all of Jessica's efforts. A fan was going full blast and I kept running in and out to drink from a bottle of cool spring water. The baby's head was descending, but slowly. I re-examined Jessica and found the baby's head lower than on my previous exam, but there was a lot of space behind the head and a detailed examination of the fontanelles made it clear the baby was in occiput posterior position.
Fetal fontanelles. Image Credit
Every birth attendant should develop a modicum of confidence in examining for fetal position. It took me over two years of working on a very busy Labor and Delivery unit to develop a curiosity and commitment to learning this part of the "labor check" exam. By tracing your examining finger over the sagittal suture and the anterior and posterior fontanelles of the fetal head, you can take a pretty good guess at which way the baby is facing as she descends into the pelvis.
Occiput posterior (OP) is the position affectionately known as "sunny-side up." It is not, as is commonly misunderstood, an impossible position to deliver naturally. In many cases, an OP baby is born as quick and easy as frying an egg, with absolutely no clue to the examiner until the infant is born looking straight up (or forward, if the mother is not on her back). However, it can mean a longer, more arduous second stage of labor for a woman, and it was clear to me that this was what was prolonging Jessica's experience.
I told her I thought the baby was posterior and had her push on her hands and knees. This position is thought to encourage the fetus to rotate into an occiput anterior position. It is also excellent for maintaining a wide open pelvic outlet and also gets a woman off her aching back for pushing:
Jessica pushed heroically on her hands and knees. I felt her belly in between contractions and verified that the fetus had his back rotated to the maternal front, which suggests successful occiput anterior position, although not always. Descent of the fetal head was much faster in this position, which supported the theory even further.
When the baby was beginning to show a bit of head through the vulva during a push, Jessica said she wanted to roll on her back again. "Are you sure?" I asked her. "You're making great progress like this."
"I don't want to have the baby with my butthole up in the air," she said firmly. I swear that's what she said. Well, who was I to argue? I helped her roll over and we resumed pushing in a semi-squat with the aid of a squat bar.
Soon Jessica reclined against the back of the bed and propped her legs up on the squat bar. She felt she couldn't get her forces directed properly otherwise. She was making good progress but it was hard work; her face was puffy from pushing on hands and knees for almost half an hour, and in between contractions she fell back exhausted. She'd been pushing for almost an hour and and forty-five minutes. "Why is this TAKING SO LONG?" she asked emphatically. Not whining, but funny.
"Obviously this baby wants to come into the world in his own sweet time," I said, and her sisters laughed.
"It's not funny," she scolded, but even after two hours of pushing, she could still smile. "Wait till it's your turn, then I'm going to laugh. Oh God, here comes another one."
She was well into pushing now, and a bit more of the baby's head was visible with each push. Soon the peek of head stayed visible even in between pushes. "I see like a Tootsie-Roll sized piece of head," I told her. Then it was a dolma-size, then an apricot, then a plum. Don't ask me why I always use food metaphors during labor, but I do.
"What is it now?" Jessica asked me after a particularly mighty push.
I looked. "A supermarket orange," I told her. "Not one of the small organic kind, the big Florida navel." Even she laughed at that one.
Pretty soon after, the baby crowned. "Here we go!" I declared. I had that goofy shit-eating grin I get whenever a birth is imminent. I don't know where it comes from, but I've been told by witnesses that it makes them feel both joyful and embarrassed at the same time. I don't know if this is a good thing, but there it is.
After two more sets of pushes, the baby's head was born--looking straight up at me. "OP," I muttered to no one in particular. "Little stinker."
The body took some more pushing and encouraging tugs to deliver. The baby--a boy, Jessica's second--had his arm wrapped across his chest and his chubby hand up near the opposite side of his face. I call this the ear-scratching position, and it is particularly brutal to push out.
As I slipped the baby onto Jessica's chest, she said "Oh that was horrible!" But everyone laughed and she looked down at her new son and suddenly the exhaustion of two hours and ten minutes of pushing vanished.
The little boy weighed in at nine pounds and four ounces, about a half a pound larger than his older brother. A big OP baby. I congratulated Jessica on her fortitude.
"And I didn't have any drugs," she remembered suddenly. "I don't believe it."
I do. Women are amazing.