What it's like to deliver a baby: TMI

First, it's always different. Second, I'm a novice, so I am not necessarily the best source of information. Nonetheless, I have a few reflections on the privilege of being the one to catch.

Laboring women - unmedicated laboring women - can be...let's call it sharp. Nobody cares, least of all me, that a laboring mom has just said, "I'm going to puke, I'm going to puke," then, "Get that out of my face," regarding the emesis basin she just asked for. It's expected. She's very busy. Her brow is furrowed, she's getting in and out of her pushing position, and she's profoundly uncomfortable.

Different women have different laboring affects, different concerns, and different styles. The divisions seem to be somewhat ethnic and somewhat cultural, but very individual. One laboring mom came in the other day smiling - really grinning - through contractions. Her expression bore both a furrowed brow and a look of giddy acceptance of whatever her plight may be. So sweet. We checked her cervix and she was at 6 centimeters - well on her way to the golden 10. Well on her way to adding another baby to the world. Smiling so big. (I took out most of this paragraph)

Speaking of cervical dilation checks, these take some amount of skill. My patient OB/GYN co-interns and upper-level residents have helped me begin to develop my skill in feeling cervical dilation. At first it just feels really mushy and amorphous with maybe some puzzling contours. I had a great 3rd year tell me, "Feel all the way back and you'll feel something that feels like a rubber band. That's it." At first I was utterly lost. No rubber bands presented themselves to my fingertips and I started to feel really awkward with the time I was spending searching for the rubber band. Then, sure enough, the tip of my finger found that rubber band thing (the dilating cervix) and my eyes shot wide open.
     "I found it! 4 cm?"
     "Close - about four and a half," she replied.
Oh, man, that was awesome. Some women have very obvious cervixes and these checks are not at all uncomfortable. Other women's cervixes are angled way backward toward their sit bones. Some amount of forcefulness is necessary to access the "posterior" cervix. Experienced OB docs will sometimes brace themselves against the floor, lean onto the bed, and put all their weight forward into their two fingers as they search for a hiding cervix. This tends to be less comfortable for the check-ee, but necessary to assess how far they are in their labor.

Okay, so labor. Labor rolls in waves. Women will roll along for a while in relative peace, dealing with contractions as they come in whatever way works for them.

When labor progresses further, near the end, the woman changes. You can see the contraction coming as the woman's eyes start to rove side to side and she starts grabbing for things - your hand, a bed rail, the edge of the bed. If she's a sounder, she starts to sound. I worry about high-pitched, squeaky sounds, but I know things are getting good when she starts to make low moans, and then - thank the lord - to GRUNT. Grunting means pushing is absolutely unavoidable. It just does. I've felt it myself. When I hear a low-grunting woman, I practically feel the urge to push again. The first time I heard another woman making these characteristic labor noises - she was behind a closed door in a labor room at Hospital and I never even met her - I cried. I cried because it brought me back viscerally to my own labors with my girls. It's a little like the phantom brake pedal when you want to slam on brakes on the driver's behalf. When a woman is pushing, and I'm wanting her to push so so well, to make the contraction count, I have to stop myself from actually pushing, too. 

Anyway, in labor, sometimes we hold the woman's legs for her. Sometimes the woman needs that counterpressure and wants it; sometimes she doesn't like that. One woman recently wanted to sit on a bed pan the entire time because it felt better. Another wanted to flip over and labor on hands and knees. All this and more is fine. But there's a catch. No thinking happens during a contraction, and between contractions women are so tuckered out that very little can happen between one contraction and the next. So you have to plan and generate courage to make a change during hard labor.

Once pushing gets toward the end, the baby's head starts to emerge into view. A dark little sliver comes into view during the biggest pushes, and quickly vanishes again between contractions. Soon, lo and behold, the head doesn't vanish. Then more of it creeps down, and then slowly even more. This is when the person doing the delivery can begin to help. First you take three fingers and apply downward pressure onto the head as it comes into view. This is to limit tearing and to relieve pressure between pelvic bone and head. Finally, the head pops past the perineum and you check for a cord around the neck - which you loop over if you find - then deliver the top shoulder of the baby by pressing baby down. Then you deliver the bottom shoulder, which is easier, by pulling back up again. Then baby slides out all of a piece, cord trailing behind, along with a gush of liquid.

We put the baby on mom right away, in all its slimy blue glory. We clamp the cord and, Voila, baby is taking its first breaths and going through that miraculous transition from placental breather to air breather. The heart starts switching its circulation, rerouting right away...and this normally happens without any problem and extremely little intervention. It's nothing short of astounding, miraculous. Part of me wants to tell the mom: LOOK THERE! your baby's body just accomplished one of the most amazing physiologic feats known to mammals.

But I restrain myself. Instead I focus on the matter at hand: finishing this thing up without too much bloodshed and NO retained placenta.

The cord is cut by dad, and I start to gently tug the cord, which, deep inside the uterus, holds fast to the placenta. The placenta detaches from the uterine wall sometime in the half-hour following baby's birth, and comes plopping out. We massage the uterus because it helps with the amazing watermelon to grapefruit shrinkage (and hemostasis) of the uterus that happens in the next few minutes and hours. Again, it's truly miraculous. When you think about it, the placenta has just been intimately associated with the mother's circulation. It's had to glean all baby's needs from that association for nine months. Then, in 15-30 minutes, not only does it detach, it also seals up the blood flow so that mom doesn't hemorrhage as she undoubtedly would if the same amount of blood flow as nourished baby continued schlepping on out of her uterus. Anything wrong in the system can be deadly. But usually it all goes fine :).