Birth Story #424: Getting Back on the Horse

The last Birth Story I wrote described the worst shoulder dystocia I've encountered so far in my working life. It was a seven-minute delay between the birth of the baby's head and his shoulders, and it was the kind of seven-minute event which can change a person's life forever. I've heard of cases of shoulder dystocia in which the infant did not survive, or the mother suffered from significant injury, and I know of a number of doctors who have defended lawsuits after a bad dystocia. The outcomes are potentially bad enough that even when you have a good outcome, as I had, your gratitude may be diluted by fear. Some practitioners give up attending births after a near miss, even more change their practice style to become more conservative--becoming the kind of birth attendant they never wanted to be.

Whenever I've been involved in a scary incident, I remind myself of something I learned my intern year. I'd had a bad couple of nights on Night Float in which I'd attempted intrathecal analgesia twice on two different patients and not been able to get into the intrathecal space. Each time, my supervising third-year had to complete the procedure. So when the next night rolled around and my R3 approached me with a three year-old who needed a lumbar puncture, I hesitated.

"What's the matter?" My R3 asked.
"I've missed the last two spinal procedures I tried," I answered. "I think maybe it's better if you tap this kid, because--"
"Nope," the R3 interrupted. "You've got to get back up on that horse. You've got to do this one."

So we went up to the Pediatric unit, set up for the lumbar puncture, and--with my R3 standing behind me--I got in and did a champagne tap. Smooth and easy as if I'd been doing it all my life.

The moral of this story: If you're having a run of bad luck, keep trying. The worst possible outcome after a scary clinical scenario or a failed procedure is allowing uncertainty to take hold. Far better to try, try again than to hold back and never achieve any competence--or courage.

So, after the events in Birth Story #423, I decided to get back on the horse. Here's the story:

The shoulder dystocia occurred at about 3:23 AM. By 4:30, the baby had recovered and was moving both arms normally. Mother and baby were again rooming-in together, and Labor & Delivery was quiet once more. Then I realized: I had to start rounding on the hospitalist service at 8:00.

It's moments like these that sap the energy out of me, but there is no good solution. You can't call out sick when you're on call or assigned to rounds. I mean, if you become violently ill, your colleagues will take over your responsibilities but doing so means they are canceling clinics or other obligations, so someone is being let down if you don't show up. So, unless you're desperately ill, you buck up and carry on.

I took a nap until about 7:30, and awoke feeling like something pulled up by the roots. I splashed water on my face and brushed my teeth and felt about 25% human, which was an improvement. I was nauseated from hunger and left the call room in search of breakfast and a large cup of coffee.

In the hall, I saw one of my favorite doulas, Naomi. "Hey!" she greeted me. "Are you on call?"

"No, I was last night," I answered.

"Wendy's here," said Naomi. "Come say hi."

I followed Naomi into one of the triage rooms where Wendy and Scott were seated. Wendy was at the end of her first pregnancy and looking beautiful and athletic. She was breathing through contractions but was able to look up at me and smile. I made a joke about the labor-inducing effect of hamburgers, because the last time I'd seen her was outside the local burger joint near our clinic. Wendy winked at me and breathed through her next contraction.

One of my colleagues was on call, but sitting in the room with Wendy and her supporters, and laughing about hamburgers made me want to stay with them. This is why attending birth is wonderful: there is joy to be found even after a long bad night.

Naomi read my mind. "So, are you staying?" she asked slyly.

I looked at Wendy and Scott and decided. "Yes," I said. "I think I will."

Wendy was six centimeters dilated. A birthing tub was set up and filled with warm water while she labored in the shower. I made rounds on the hospitalist service, because she was doing so well and her baby's heart tones looked reassuring whenever we checked them. Even though I was running on fumes, I felt a buzz of anticipation at the birth to come. My instincts told me Wendy would have a beautiful birth.

I was about halfway through rounds when Labor & Delivery called me. "Wendy's in the tub and she sounds grunty," the nurse told me. "Want to come and check?"

Wendy and Scott were in the birthing tub, and Wendy looked truly deep in transition: eyes closed, her body relaxed but intensely focused on the physical experience of labor. I crouched by the side of the tub. When I saw she was in between contractions, I asked, "How are you doing?"

She opened her eyes slightly and smiled at me. "Okay so far."

"Do you feel like you have to push?" I asked.

She thought about it. "Sometimes, sometimes not. Some of these contractions are stronger than others."

I thought about examining Wendy while she reclined in the tub. This is wet work, and it is difficult to get an accurate exam while leaning over the vinyl siding of the tub. I decided not to examine her. Naomi and I suggested she bear down with a contraction if it felt good, but breathe if the urge was not present.

I went back to rounding on Med Surg. One benefit to combining hospitalist and OB responsibilities is keeping me from fretting on Labor & Delivery. Most labors take place wonderfully without my presence. Sometimes I feel the need to be present, if the nursing staff is not strong or the woman doesn't have good support with her, but this was not the case for Wendy.

I actually saw a handful of patients before I looked up and saw almost two hours had passed since I'd checked in with Wendy. As if reading my mind, the nurse called me again. "She's been pushing for just over an hour, and I can see a tiny bit of head when she's pushing."

The energy in the birth room had changed. Instead of the deep, concentrated serenity of transition, Wendy was now working. During contractions, she kneeled at the side of the tub with her hands on her knees and her chin tucked into her chest, bearing down strong. Naomi handed me a flashlight and I tiptoed behind the tub, where the beam of light revealed a nickel-sized bit of head under the water. I gave Scott the thumbs-up. Things were going beautifully.

I was torn between running back to Med Surg to see a few more patients or staying near the birth room. On the one hand, I was full of useful nervous energy and could get some patients seen effectively before I hit the inevitable post-call slump. On the other hand, I felt like a mechanical toy that's been wound too tightly, and realized I might just end up spinning around in a tizzy to no avail. So I compromised and sat down outside the birth room to write notes and listen for when I might be needed.

About thirty minutes later, Naomi stuck her head outside the door and waved me in. Wendy's pushes had developed into long, athletic, sustained efforts. I could see her belly tighten with each push. She'd changed positions and was now reclining back against Scott, who leaned against the wall of the tub. The baby's head stayed down in between contractions, and during  a push I could see a peek of pale scalp the size of a small orange.

My hospital requires that I gown and double-glove for waterbirths, so I did so. Wendy opened her eyes and looked at me. "Ready?" she asked.

"Whenever you are," I replied, and sat down to await the birth.

It wasn't long. A few more pushes, and the baby's head was born. As I do with each waterbirth, I reminded myself to keep my hands off. The baby's heart tones were still strong--we were checking with a waterproof Doppler--and the tub water was nice and warm, so there was no hurry for the body to be born. I knew the progress of birth under water is often thought to be longer than on dry land. Yet it was a test of faith for me to keep my hands off the baby's head, after Nola's tense, dramatic birth the night before. Despite being tested, I didn't feel anxious. The energy was just right, and I had no worries, looking at the baby's face through the distortion of the moving water.

With Wendy's next push, the baby's body was born. I reached into the water and guided the infant to the surface of the tub, bringing only her face to the surface and leaving her body under the water to be kept warm. Babies born underwater don't shriek and splutter, I notice. They take leisurely breaths and look around, beginning to form their own impressions. This is what little Madelyn did, cuddled half-submerged against her mother's body.

I de-gowned gratefully--it's hot in those gowns--and we went about the process of waiting for the placenta, helping Wendy out of the tub, putting Madelyn to breast. All these events took place at a leisurely, unhurried pace, and I said a quiet prayer of gratitude for the gift of plenty of time.

Comments

[Ajlouny]

Great stories. Glad you got right back on that horse!

[Theresa]

Hi everyone, thanks for commenting!

Countrymidwife, we use the cheapo thin plastic vet's gloves = goldfish bags. Maybe if we got some better-quality ones.

doctorjen, I can send you our hospital's waterbirth policy if you email me. Cheers!

[CountryMidwife]

For waterbirths I use vet gloves that come up to my shoulders, and secure them with a rubber band. That way I don't get wet at all.

Had THREE waterbirths yesterday! One had a triple nuchal cord and needed a good resus. That's one thing I don't like about waterbirths - if a baby doesn't respond to stim you have to cut the cord sooner than I'd like to get baby on a stable surface for PPV (this baby I actually gave a few mouth to mouth breaths first).

Lovely birth! So healing for you...

[Dragonfly]

I was so disappointed that I didn't get to see any water births when I was on OBGYN. They sound fantastic.

[doctorjen]

Oh, lovely! How nice to have a birth at which you are unnecessary after a birth that needed all your skills!
I just recently did my first waterbirth. My hospital has tubs in the labor rooms, but does not offer waterbirth. I had a 17 year old first time mom client get in for pain relief, though, and adamently refuse to get out. I probably could have forced the issue, but she looked so much more comfortable in the water and had been so miserable out of the water that I didn't have the heart to argue with her. Watching her very quickly and gently birth her baby in the water was pretty amazing!
I'd love to get an official policy in place for waterbirth at my hospital.

[Rixa]

How nice to have such a smooth, peaceful birth after the rough shoulder dystocia. I'm always glad, too, to hear of hospitals that do water births. It's been hit and miss where I've lived so far; usually you can labor in the tubs (if they even have them) but you are supposed to get out before you start pushing.

[Emily]

A friend just sent me a link to some of your birth stories, and I am loving reading them. You sound like a truly wonderful doctor, and I wish I lived in your town! I'm about two weeks (or so) away from delivering my third child. It is a planned home birth with a midwife, and while I love her, I really wish that I had the benefit of a back-up doctor like you. Unfortunately in my area everyone thinks that c-sections are the way to go and that home births are dreadfully dangerous. I hope that someday the rest of the obstetric/medical field catches on to what you've discovered, and that women everywhere can have peaceful, supported births like this one. God bless you for the work that you're doing!