Seriously, What Do I Know?

Obstetrics is humbling. Just when I think I know enough about OB/GYN that I can predict a patient’s course in labor, I have a patient whose uterus, cervix, or baby does something completely unexpected. It’s as if God himself is reminding me of my limits.

Take patient A. About a week into my stint as new OB 2nd year/labor floor queen, a 28 year old multip (a woman who has delivered more than 1 baby before) was admitted in active labor. When she first arrived in Triage, her cervix was 5cm dilated. This lovely Latina woman was tough as nails, but every contraction shook her to her core with pain. She asked for an epidural as soon as she arrived on the labor floor. The nurses paged the anesthesiologist and began the tasks they do with every new labor admission. Ten minutes later, they called out for me. “The patient is complaining of pressure. Can you check her before anesthesia sets her up for the epidural?” I pulled on a glove onto my right hand and sat on the side of her bed. The patient was writhing in pain. Between contractions, I quickly checked her cervix. I felt the hard surface of the baby’s head. I felt the ¼ centimeter thickness of soft cervix partially covering his head. She was a good 7 centimeters dilated (out of 10). I looked up at the nurse and said, “She’s 7. We’ve got a enough time to place that epidural.” As these words left my mouth, before I had my glove off, the patient started to bear down. That’s right. She was pushing. “Ma’am” I explained in Spanish, “you can’t push yet. You’re not fully dilated.” The pain was unbearable and my words bounced right off her. She was squeezing her legs together and pushing. “Listen, you cannot push yet!” I repeated, “Let’s get you your medicine, and by then, it will be time to push.” At that moment, a guttural moan emanated from deep inside her and her knees parted. I looked down. A baby head was sliding out of her vagina. As I saw this, I threw a glove onto my left hand at lightning speed. I barely had enough time to lay my hands on the baby before it came sliding out onto the bed. I wanted to laugh out loud. This woman had gone from 7cm to baby in literally less than a minute.

Surprise! You know nothing after all!

Now take patient B. She was a 21 year old woman who was pregnant with her first child. She had ruptured her membranes (AKA broken her water) the night before, approximately 24 hours before she came into Triage to be evaluated. Given that these membranes are an important barrier for both mom and baby from the outside world, the risk of infection becomes higher and higher the longer she’s ruptured. Given that she was full term, this patient needed to be delivered. She came to the labor floor with a cervix that was 4cm dilated. We started Pitocin, a drug that works by causing or strengthening uterine contractions. How much Pitocin we give depends on how quickly her cervix responds to the medication. We started at 2 (it is not unusual to get up to 20). As soon as we started the Pitocin, the fetal heart tracing started showing late decelerations (a drop in heart rate - a bad sign the baby is not getting what it needs from the placenta). When we turned down the Pitocin, they went away…along with her contractions. We played this game all morning. Pitocin, then late decels, then no pitocin, then no contractions. We were stuck between a rock and a hard place. We wanted her to deliver vaginally, but if we couldn’t use the pitocin, we weren’t going to get her in labor. And if we used too much, we could prevent adequate blood flow to the baby. The risk of infection was too high to leave her ruptured until she did it on her own.

We finally settled at 1 unit of Pitocin. It was just enough to give her 1 contraction every 5 minutes (contractions are usually every 2 – 3 minutes in active labor). Even at 1 unit of Pit, the baby was having late decels. Everything else about the tracing was reassuring so we decided to hold course. After about five hours of this, her cervix slowly made it to 5cm (we usually expect 1-1.2 cm of change per hour in active labor). I remained doubtful. By this time, she was ruptured almost 30 hours, was still only 5cm dilated, and was not contracting enough by normal standards to have a baby. I was certain this baby was going to end up coming out the abdomen. Our team decided to give her 2 more hours. If she was still 5cm, we’d call it. We’d head to the OR for a cesarean section. If she changed her cervix, we’d keep going. So, for the next 120 minutes, I watched the tracing, and those late decels, on the edge of my seat. What if in one of those decels that heart rate didn't come back up? What if it stayed down and we had to emergently take her to the OR? I am certain I grew three new gray hairs that day.

Finally 2 hours pass. I return for a cervical exam. Based on how infrequent her contractions were, I was doubtful I’d find any change at all and was confident a c-section was in her future. I glove up and start my exam. I immediately feel baby’s head. I feel around for cervix. I can’t find it. I feel around even more. And then it hits me. This primip (or woman having her first baby) had gone from 5cm to fully dilated in two hours with contractions not closer than 5 minutes apart. Another moment of shock in OB land. Literally, 20 minutes later, a beautifully healthy baby boy was born. I swore I saw a mischievous sparkle in his eye when I caught him, saying "decels, what decels?"

Oh, obstetrics, you will forever keep me on my toes...

Delivery by Zen

I got the page for another labor admission. “K.L. 20 y.o. G1 @ 40’0 wks in labor. 8/100/0. GBS negative. Declines epidural”. (Read: 20 year old, first pregnancy, at term, 8cm dilated.)

Now it’s not terribly uncommon for our patients to deliver without an epidural. But the ensuing delivery often entails lots of screaming, crying, and the occasional out-of-control, climbing-up-the-bed-with-a-baby-head-sticking-out episode. I knew from the moment I met this patient, she would be different.

When I walked into her labor room, I found a lovely young Southeast Asian woman, sitting on the hospital bed, eyes closed, calmly breathing through contractions. She was the quintessential picture of Zen. If she wasn’t dressed in a hospital johnny, I could’ve easily mistaken her for practicing prenatal yoga. She was almost fully dilated by the time she came up from Triage. By the looks of her, I would have thought she was 2.

As she progressed in her labor, her contractions became stronger, more difficult to breathe through. She changed positions, moaned, writhed, shook – but through it all, it was clear that she had 100% control of her labor.

In most deliveries, where the patient is numb from epidural anesthesia, a lot of labor coaching is required. The patient often can’t feel much and a good deal of time is spent teaching a woman how to push. This type of birthing is an interactive process, a team effort.

The birthing experience of this young woman, however, was completely different. Because she had no inhibition of pain or feeling, she was completely in tune with her body. She could feel when it was time to push, she could feel how and where to push, and absolutely no coaching was required. In fact, she was so much "in the zone” that anytime I spoke, I felt like I was interrupting her focus. Her process of birthing was beautiful to watch. It wasn’t that she was quiet (she was definitely making noise). It wasn’t that she was still (she was moving around a lot). It was that she was focused and in complete control with what was happening to her body. It was an empowering experience to watch.

A beautiful 5+ lb baby boy was born approximately 20 minutes into pushing. The patient did 99% of the work on her own. The one and only contribution we had was to catch the baby.

What made this patient different from the other non-anesthetized patients I’ve delivered? What was her secret? Was it her expectations? That she knew it was going to be painful and developed great coping strategies for it? Was it a personality thing? A high pain threshold?

Regardless of what her secret was, I left that delivery room inspired. Empowered. And very, very proud of my patient.

See One, Do One...Teach One?

One of the things I love about residency is that the learning curve is just so darn steep. Just when you’ve got one thing down pat, it’s time to learn about something else. The process of self-improvement just doesn’t end.

Example 1: The first half of my intern year was dedicated to learning how to get through the basic steps of a vaginal delivery or cesarean section. I was happy just to get through a delivery without fumbling the baby. If I finished a delivery and the baby wound up in a nice football hold, if I could cut and clamp the cord without dropping the instruments, I was glowing. Same goes for a c-section. If I could hide my intern tremor for the duration of the surgery, I was happy. If I could sew up the uterus and the attending didn’t need to throw in a ton of extra sutures afterwards, I considered it a job well done.

Example 2: The second half of my intern year was dedicated to finesse. It was about maintaining order in a labor room, creating a positive birth experience for my patients, catching a baby with grace, and knowing when and how to intervene if a baby dropped its heart rate or if mom had more bleeding than usual. It was about developing my own style and routine of baby catching. In the operating room, my focus was on doing the c-section start to finish, calling for instruments, delivering the baby without struggling, re-loading my needle driver without touching my needle. It was about a beautiful subcuticular stitch to close the skin. It was about dictating from memory before I walked out of the OR.

Now, a year later, the start of my second year is dedicated to a new learning objecting: teaching. I’m no longer standing at the perineum and coaching a soon-to-be mom with her pushing. I am not catching the baby and handing it off to its waiting mother. I am walking our new interns through it. I am helping with their delivery maneuvers, their laceration repairs, and everything in between. The good is that it’s been extremely rewarding. There is a certain pride you feel when your intern does a beautiful delivery or repair. And with every delivery, they get better and better. As if that weren’t reward enough, their excitement and enthusiasm for these new experiences is incredibly contagious.

The challenge for me in all of this is making the personal transition from the “do-er” to the “teacher”. Struggling with something, be it getting the baby into a good football hold or delivering the placenta, is an important part of the learning process.I know this. Watching it without jumping in, however, is harder. It’s like being the kid in class who actually knows the answer to the teacher’s question but not being able to answer it. It’s like waving your hand in the air saying “Pick me! Pick me!” knowing full well that it’s not your turn to talk. A couple days ago, I hip-checked my intern out of the way when we had a tight cord around the baby’s neck. Afterward, I realized that I had missed a great opportunity to teach my intern how to deal with this situation. What makes me feel even worse about the whole thing is that I remember being in this intern’s shoes. Just a year ago, I remember being so eager to do a delivery, by myself, start to finish. I remember being hip-checked myself and thinking, “Just give me a chance! I can do this!!!”

Reflecting on this experience, I realize that I had panicked in this week’s delivery because, as the next senior person in the room, I felt ultimately responsible for the outcomes of this mom and baby (which is true). Looking back, however, there was plenty of time to walk her through a nice somersault maneuver and still have a happy baby.

Intern year, for me, was about stepping into my role as a doctor. It was about stepping up to the plate and getting my hands dirty. As a second year on the labor floor, I’m learning that my job is to take a step back and teach. It’s to trust my intern with a straightforward delivery. It’s to trust myself that I know when to step in. Like I said earlier, there’s always something to work on in residency.

Babies Having Babies

She was 15 years old. She looked like any other youthful teeny bopper, with her silly band bracelets and hot pink nail polish. She should have been at home, in bed, dreaming about the Jonas Brothers, her high school crush, or what she was going to wear to school in the morning. Instead it was 3:00am and she was in our Triage, alone, and 30 weeks pregnant. She sat tearfully on the hospital gurney as the contractions came and went every 3 minutes. Like clockwork.

Concerned she may have broken her water, I did a speculum exam. Through a dilated cervix and amniotic membrane, I saw a head of hair. It was then that I knew my patient was going to deliver early. By the morning, this baby was going to be a mother.

Explaining the implications of delivering an infant 2 ½ months early to a 15 year old girl was not easy. I’m not sure if it was the fact that she was alone, in pain, or still a baby herself, but nothing I said seemed to sink in.

I explained, in the simplest way I could, that we were going to give her steroids in an effort to mature the baby’s lungs prior to delivery. I talked about the role of tocolytics and its purpose in slowing down the labor long enough to give steroids. I discussed the role of magnesium in protecting the baby from the perils of cerebral palsy. After all was said and done, she looked up at me blankly. Her only response was, “Can I take this off now?” referring to the fetal monitoring system attached to her belly. The next question that followed, “Can I just get a c-section now?”

Her lack of insight was profound. I pulled out my doctoring skills, asked her to tell me what she understood about what was happening. She recited back to me the facts of the situation at hand. Her explanation, brief and without detail, was notably void of any emotion or understanding about the gravity of delivering a 30 week infant.

“Do you have any family with you?” I asked. “Can you call anyone to be with you right now?” Apparently her mother had dropped her off at the Emergency Room and left. Despite several phone calls by both the patient and the resident team, she failed to show up. Our young friend delivered a 2 ½ lb baby girl, alone, at 9:00am the next morning.

Anyone who argues against comprehensive sex education, condom distribution in schools, or unlimited access to family planning for minors needs to meet patients like these. These are young girls with little to no family support or financial resources. Their neurologic development will not be complete until their early 20s. Most of them lack the maturity or understanding it takes to raise a child. Their bodies, underdeveloped for childbearing, put them at risk for severe pregnancy complications like preeclampsia, obstructed labor, and having low birth weight babies. Having a child drastically decreases their likelihood of completing high school and increases their likelihood of relying on public assistance in the long term.

There is also a gender issue here – it takes both a man and a woman to achieve pregnancy. Yet time and time again, it is the young girls who suffer the consequences of pregnancy. It’s their lives that are forever changed, their dreams that are forever shattered. Unfortunately, it is just too easy for boys/men to walk away from their responsibility. When my patient delivered, it was her alone in that delivery room.

The most conservative of parents should know that none of the aforementioned interventions (sex ed, condom distribution, access to family planning) have been shown to promote earlier sexual activity in teens. These teens will start becoming sexually active at the same time as their peers. The difference? They are more likely to use birth control or condoms when they do it.

Of course, we all want our youth to postpone sexual onset. But the fact is, they make mistakes. Are we so dogmatic that we don’t want to give our children room for error? Are we really that strict that we will force our kids to suffer life-altering consequences of unprotected sex? I hope not. For every young girl like this one.

For more info, check out: www.advocatesforyouth.org

CRASH!

OMG! I‘ve officially done my first Crash section! Wow. Wow. Wow. Talk about an adrenaline rush.

It all started with a 30-something year old woman who was 37 weeks into her pregnancy. She walked into Triage with a blood pressure of 200/120 (normal blood pressure is 120/80). The first thought on everyone’s mind was Severe Preeclampsia. Preeclampsia is no joke. It is a hypertensive disease of pregnancy that can have serious consequences for both mom (seizures, liver failure, renal failure, pulmonary edema) and baby (fetal demise, intrauterine growth restriction, placental dysfunction). Given that the “badness” of this disease often happens suddenly, we take it very seriously. We rushed our patient into a room, started an IV, drew her blood for labs, and started blood pressure and anti-seizure medication.

Her physical exam was just as scary as her blood pressure. While she denied any symptoms, her reflexes were abnormally brisk and she had marked clonus (meaning after I flexed her foot, it continued to involuntarily tap) – both signs that the Preeclampsia was affecting her nervous system. The only cure for this disease is delivery. We knew that this woman needed to have her baby ASAP. Orders for induction of labor were written.

While all this was taking place, her baby started to tank on the fetal heart monitor. It began to show prolonged episodes of dropping its heart rate. The variability, or ability of the baby to respond to its environment by increasing and decreasing its heart rate on a beat to beat basis, was minimal. These were all signs that the baby was not getting enough oxygen. We repositioned mom on her side. We put her on an oxygen mask. We increased her IV fluids. The tracing just got worse. At this point, the decision was made: We were not going to have time to induce this woman. We needed to get this baby out NOW.

In less than 3 minutes, the patient is in the operating room. The OR staff worked like a well-oiled machine to get the patient ready for surgery. In the next 3 minutes, my attending and I were gowned and gloved and ready to start. The goal on everyone’s mind, including my own, was to GET THIS BABY OUT. My usual OR anxiety was gone, and I was focused solely on our mission. I made the first incision. In two swipes of my scalpel, we were through the skin and onto the fascia (the last layer of the abdominal wall). A couple of cuts with our scissors and we were on the uterus. I made the uterine incision. The baby’s head was easily delivery, followed by her shoulders and body. She was floppy, did not instantaneously cry, and was not at all the vigorous infant we like to deliver. Once she was out, we clamped and cut her umbilical cord and handed her to the NICU team waiting beside us.

Next we delivered her placenta. A large hand-sized clot came out behind it. Our patient had had a placental abruption. (Her blood pressure had gotten so high that the placenta had started to tear away from the uterine wall, compromising the amount of oxygenated blood that went to the fetus.) We had found our reason for the baby’s poor tracing.

The room breathed a sigh of relief. The baby was out. The rest of the case was like your average c-section. The tension and anticipation in the room dissipated, the anesthesiologist put on his music. We sutured mom back together. And with a little TLC, mom and baby did remarkably well.

By the end of the case, I was on Cloud Nine. I was riding high with the feeling that for the first time, I had just helped to save someone’s life. The rush was indescribable.

Downward Facing Delivery!

Last weekend’s call started out normal enough. I rounded on the postpartum patients. We met in the resident lounge at 7:00am for sign out. I learned there was a patient in LDR 17 who was fully (dilated) and pushing. She was a multip (had had babies before) with a history of bipolar disorder, had been pushing for some time now, and had not been able to get an epidural. After 8 failed attempts, she was placed on IV pain medications instead. My senior resident asked me if I would go check on her and deliver her if she was close. “Of course!” I replied, with my I’m-almost-a-second-year-resident confidence.

As I approach the room, I hear the screaming. A couple steps later and I find the patient in a most unorthodox birthing position. She is on the bed, on her elbows and knees, face planted in the bed, bum in the air – a modified version of child’s pose for you yoga buffs out there. Upon seeing the confusion on my face, the labor nurse explains. “We’ve been pushing for over an hour, this is the only position she has made any progress in.” I take a quick second to assess the room and figure out what my next step is. The patient is writhing in pain, screaming for us to pull this baby out. The nurses look exhausted, both from trying to coach a very belligerent patient and from trying dozens of birthing positions. I make the decision to proceed as is.

As I don my sterile baby catching suit, a dozen thoughts run through my head, namely, HOW THE HELL AM I GOING TO DO THIS??? The woman is upside down compared to the usual lithotomy position (face up, legs in the air). She keeps dropping her bum to the bed - how is this baby going to have room to come out? Is she going to have a tear beyond all tears from this? And how do I figure this out without letting the room know that I have NEVER delivered a baby in this position? Another huge question is on my mind: what in the world am I going to do if I have a shoulder dystocia*? Remembering that my panic will cause the room to panic, I take a deep breath and remain calm. On the outside, that is.

At this moment, my (favorite) senior resident walks in. I explain the situation. She says to me, “Okay, you can do this. It’s the same maneuvers, just upside down.” She says this so confidently that it makes me believe that I really can do this. Then, as if she is reading my mind, she announces to the room, “Everyone, if we have a shoulder, we will quickly flip the patient on her back, okay?” There, she said it. I breathe a sigh of relief.

I don’t know if I could post a blog long enough to describe the insanity that came next. It really was like delivering a baby upside down. The patient was in pain, not following directions very well. One minute her bum would be in the air and I would have plenty of room to catch the kid. The next minute, her bottom was down on the bed. It was like trying to deliver a baby through a drawbridge that kept opening and closing. My coaching tone changed from my usual soothing voice to my loud command voice.

Finally, after an entire team effort, she delivered the baby. There was no shoulder dystocia. Baby was a little floppy from all the IV drugs, but otherwise fine. Mom was fine. The whole room breathed a sigh of relief. Me, most of all. This was just another moment in residency when I walked away after doing something I didn’t know I could do. I left smiling inside.

* A shoulder dystocia is when the infant’s head delivers, but the shoulder is stuck. It is a dangerous situation and can lead to asphyxiation or nerve plexus injuries of the baby. We have a toolbox of maneuvers to deal with this, but they all revolve around mom being on her BACK!

Nine Months

Today was one of those days when everything comes full circle.

I was in Triage this morning scanning the board for a patient to sign up for. A patient whose chief complaint was “labor” was checked in and I signed up to see her. I walked in the room and began to introduce myself. She was a big and beautiful African American woman with her hair tied back in a brightly colored scarf. She looked awfully familiar. “I know I’ve taken care of you before. What did I see you for?” Her partner smiles. “You were the one who told us we were pregnant back in August!” I was blown away. Here she was, 8 months later, full term and in labor. Had that much time really passed since the start of my intern year? Was I really nine months into my career as an Obstetrician?

After the shock wore off, I ran to clinic expecting a long afternoon of prenatal care, annual exams, and gynecology follow-ups. Fortunately, it was one of those rare clinic days where everyone who comes in is straightforward, on time, and in and out. I was done with clinic by 4pm. On my way back to Triage, I stopped by the labor floor to check out the action. I am nearing the end of my second OB Days block and have been working closely with our midwives to get “signed off” on deliveries. Most OB residencies require an intern to do a minimum number of deliveries before they can run the labor room independently. Our program is a little different. Our midwife faculty members evaluate our ability to control the delivery room, monitor fetal well-being, and carry out the delivery prior to letting us loose. Needless to say, I was scoping out the labor floor to see if I was going to be lucky enough to have The Official Sign-Off Delivery.

As I meet up with the labor floor midwife and my 2nd year resident, a nurse comes out of a delivery room. “The patient in here feels rectal pressure. Can you check her?” And of all patients, who could it be? Yes, it was my Triage patient. The one I first saw as a wee, insecure, and intimidated little intern just six weeks into my residency. Now, just a little bit older and wiser, I sat on the edge of the bed to check her cervix. Immediately I feel baby head. And no cervix. She was fully dilated and ready to start pushing.

It was one of those flawless deliveries. The baby’s heart rate remained perfect throughout pushing. He was delivered after maybe 5 minutes of maternal effort, and that’s being generous. The baby was strong and vigorous as he slid into my arms. I placed him immediately onto his mother’s belly for his first dose of maternal affection. The placenta delivered quickly and beautifully. To top it all off, she had no tears to speak of. Like I said. A perfect delivery. One to remind me exactly how far I have come as an OB intern. From the days when the delivery room made me tremble with anxiety, when the cervix felt like mush I couldn't describe...to this. A bit of pride swelled in my chest and I walked out of the delivery room beaming.

By the way, yours truly, is now officially signed off on vaginal deliveries.

Impromptu Baby Catching

I’ve done it. I’m finally reaching a point where I am prepared to catch a baby at any time, at any place. In the wee hours of the morning this week, I was sitting in the Triage (our hospital’s women-centered emergency room) working on a patient note when a nurse runs in. “We need a doctor to check room 12 – she’s uncomfortable and feeling rectal pressure!” Now clearly pregnant women in labor are uncomfortable. But “rectal pressure” in the world of Obstetrics can only mean one thing. The baby is coming.

I ran to the patient room. My co-resident lifted up the sheet to do a cervical exam (which tells us how dilated she is) and lo and behold, what do we find? The top of a big baby head trying to make her way out of her vagina… I throw on a pair of gloves and in a fraction of a second I am prepared to deliver this baby on a hospital stretcher. In the emergency room. As the largest diameter of her head pops out, I am hit with a tsunami of amniotic fluid. My favorite fleece sweater sleeves are soaked, as are every part of my unexposed arms. The baby’s shoulders and body follow easily after. I lay the baby on to the stretcher, clamp and cut the cord, and hand her off to mom with pride.

I gaze down at pink tinged fluid covering my arms and sweater. Even during this breach of universal precautions, I am pumped. True, the baby would’ve come out with or without me there. But being able to jump in there in the nick of time and ease her way into this crazy world was awesome. This is why I love my job.

The Honor

It is the stage in which new life enters the world. Where women overcome the seemingly insurmountable challenge of giving birth. As a new intern, the delivery room is a thrilling place. However, I often wondered – will this ever get old? Routine? You hear time and time again about the OB/GYN who no longer does OB because of the “lifestyle”. Will that ever be me?

It was 4:00am and I was nearing the end of my 24 hour call. I had delivered 6 babies throughout the day and night and the shift was finally winding down. I was at the computer reviewing patient labs and vitals, trying to stay awake for an early morning of postpartum rounding. My pager goes off. It reads: “DELIVERY IN LDR 19”. I jump out of my sleepy stupor and rush upstairs. I gown up for the delivery elated at the opportunity to catch one more baby before the end of my shift. After all, I could use the extra practice with hand skills and suturing technique. I approach the patient and explain what will happen next. She is visibly tired from pushing. Her mother and husband whisper words of encouragement and take turns stroking her hair. This is her first baby. She is both scared and exhausted. We push for about 10 minutes and make little progress. The baby is crowning but at this point, we can only see the top of her head. This continues for another 10 minutes. Our patient starts to lose patience. She starts wailing in pain and threatening to give up. She doesn’t want to do this anymore. “Please, I just want to stop,” she wails “I can’t do this anymore!” Her husband encourages her to keep pushing and opens himself up to her wrath. “Shut up! Just shut up! Don’t touch me!” she screams. The tension in the air is palpable.

I call her name loudly to get her attention. I remind her that she can do this, she will do this. We remind her to breathe… and focus… After several minutes, she calms down and breathes deeply. I feel around the baby’s head and note that there is plenty of room. The nurse pours on some Astroglide to help the baby slide out easier. I hold pressure with my fingers at the base of her vagina. “Push where you feel my fingers,” I tell her, “Push my fingers out.” She closes her eyes to focus on the task at hand. She pushes with all her might. The crown of the infant’s head slowly advances out. Then her forehead. Then her face. With two more pushes the infant is out. For a split second, the room is silent.

I hand the child to her mother and she whispers in the softest of voices, “Oh, my baby.” The patient’s mother and husband burst into audible tears of joy and the three of them embrace around the newborn child. I feel a lump in my throat upon seeing this display of love. My eyes well up. I look to my resident and my attending standing next to me and their eyes are teary as well. We look at each other and without speaking a word, I know we are all thinking the same thing. This is what we signed up for.

I realized then that this experience could never get old or routine. The delivery wasn’t about practice or refining my skills. It was about the immense honor when a woman trusts you with her body during the most intimate of all experiences. It was about the privilege of being the first person in the world to lay hands on a newborn child. This is something I could never, ever take for granted.

Slippery Babies

Babies, and their entrance into the world, are always unpredictable. At this point in my short residency career, I have delivered about 12. By the middle of my weekend on call, I felt pretty darn comfortable with the process. The head is delivered with a little downward pressure, followed by one shoulder, then the next. The rest of the body is delivered quickly after. Then, with a swift move of the hands, you flip the squirrely little neonate into a secure football hold while you suction out his nose and mouth and clamp the umbilical cord. Seems pretty straightforward right?

Ha. Today’s call day reminded me that I am a mere intern with a lot to learn.

Working in triage today, I hear the team call out, “She’s complete (read: fully dilated)! We’re taking her straight to L&D!” Being the team member assigned to vaginal deliveries, I hop out of my seat and follow the patient up to the labor floor. We rush into the room and everyone takes their places. Patient is moved to the bed, nurses pace around frantically setting up for the delivery, and my attending physician, Dr. T, and I gown up in what one patient called our “storm trooper outfits”. It’s true. Baby deliveries are messy! You have virtually every body fluid being thrown your way at any given time. You’ve got to protect yourself! So, we don our face shields, surgical boots, surgical gowns, and sterile gloves. Now the process of pushing to delivery can vary anywhere from a couple of minutes to a couple of hours. As the baby catcher, you generally have a bit of time to get mentally prepared for the upcoming events. Alas, that was not the case today.

One push and the baby’s head slides out easily. Too easily. My hands on either side of the head alternate between applying upward and downward pressure to ease out the baby’s shoulders. All of a sudden, the rest of the baby catapults out. I try clumsily to secure the baby in my football hold but can’t get a grip on her legs – she just comes out way too fast. Before I know it, in painful slow motion, I am fumbling to keep this baby in my grasp. And everyone is watching. After a split second in real time (but eons in my brain) I regain my grip. Like a magician pulling a rabbit out of a hat, a jump up with the baby in my arms. Ta da!!! “Here is your beautiful baby girl!” I quickly clamp and cut the umbilical cord and place the baby in her mother’s waiting arms. A decent recovery but my face still burns with embarrassment. Shaken and struggling to remember what to do next, I undo the clamp on the placental sided umbilical cord to collect a routine cord blood sample. I replace the clamp and hand the specimen off to the nurse. When I look back there is umbilical cord blood spraying all over the place. It’s hosed the floor, the nurses, my boots. Apparently, in my self-conscious stupor, I replaced the clamp but did not secure it shut. Don’t worry, everything that came out was from the placenta, not the patient, so no one was hurt by my debacle. Just my increasingly fragile intern ego. And my happy place with those labor floor nurses.