Finally, A Delivery...

During my last night shift on Sunday I finally got to deliver a baby. I was up all night but didn't complain because it was exactly what I had been hoping for on my shifts the past 2 months that have been so quiet. Well, not necessarily quiet. There has been lots to do - just no babies born while I've been working. It seemed that women were either giving birth just before my shift or were coming in in labor just at the end of my shift. I felt disappointed a few times recently, so I was happy when at 9 pm, just as we were getting another woman and the baby she gave birth to just before I arrived on shift at 7:45 pm settled, a mother arrived in active labor. She was to give birth to her 6th baby. She is 35 years old.

This woman was such a champ. She was clearly in a lot of pain but she had her own way of dealing with it that signaled the staff around her to give her her space. I can tune into that, no problem.

I was impressed with this woman because she didn't change the way she labored to fit the setting of a clinic full of relative strangers. You'd be surprised that the majority of our women seem to find a way (to my dismay) to follow along with what their culture's definition of appropriate ways to handle labor. They try hard not to make noise or show extreme emotion. Numerous times I have observed women in labor being "shooshed" as soon as they start to make a little noise. They are shooshed because their family members are perhaps embarrassed by them. In a culture where saving face and harmony (that is, a surface-level harmony - not harmony from working things out through healthy confrontation) are some of the highest values, I am not surprised by this. Things are to be kept peaceful and calm and happy on the outside and this spills over even in labor.

Our patient moved and squatted and moaned and breathed and walked and spoke, "Ohhhh Ginooo! Ohhh Ginooo!" meaning, Oh God, Oh God. She spoke to her baby as if to plead with him to hurry up and help her out a little. Her contractions were strong and powerful and seemed to be more effective than those of many other women I've seen. At the end of a contraction she would shake it off and say, "Wooh!" and then she'd relax and sit for the 2 or 3 minutes break that was afforded her before the next surge of intensity came.

Her husband told us soon after they arrived that we were to bear with her because she made noise in labor. She herself echoed the same thing to us and said something like, "Forgive me for what I'm about to do." Later on, after it became apparent what she and her husband were preparing us for her husband apologized to us on her behalf. To me, this is very normal and I found it funny that they were so worried about what we would think. Personally, I could care less. As long as it's effective and instinctual, I say go for it lady! Make all the noise you need to or want. You're the one with a small human traveling through your body, not me. Besides, she was doing a great job at breathing and keeping her mouth and face relaxed.

For several reasons it was clear that she was to give birth to a large baby as compared to her size. Her last baby was 7 pounds, 4 ounces and it's shoulder was stuck for 3 minutes (called shoulder dystocia) before it was born at our clinic 3 years ago. As we reviewed her history we learned that she had insisted (successfully) on starting to push while she was still only 7 or 8 centimeters dilated (why they let her do this was a mystery to me). This shouldn't have happened and was likely a contributing factor in the shoulder dystocia since not giving the baby adequate time to rotate and get lined up properly in the birth canal prior to adding the extra pressure of pushing can contribute to this complication.

I was on shift with my boss and preceptor Hilary. We decided we weren't going to let her push until the baby's head was visible or unless she had an uncontrollable urge to do so.

At 9 pm when we admitted her she was 5 centimeters dilated. Three hours later (we usually wait to do exams every 4 hours) after she begged us to check her because she was convinced it was time to push, she was 6-7 cm. Two hours after that she was 8 cm and still pleading with us to let her push. We continued to insist that she couldn't and tried as best we could to explain why it wasn't a good idea. There were numerous times that we caught her pushing anyway and so we really had to watch her closely and keep getting her to breath and relax instead of push. As we stayed with her and helped her focus on breathing during her contractions while rubbing her back, numerous times she apologized to us for keeping us awake all night. Can you believe that? She was apologizing! So unnecessary. I really didn't want her worrying about us. We tried to assure her that it was our job and that we were happy to do it. Clearly she was appreciative and so happy not to have to labor alone like women usually do in the hospitals in the Philippines.

Now at 8 cm, she started to really get tired and run out of energy and seemed to be moving toward despair. We hooked her up to a dextrose IV (we had already inserted a heplock as we do with all women with high parity so that we can be more prepared to manage hemorrhage) and encouraged her to try to lie on her side, continue her breathing, try and rest between contractions and let the baby continue to descend. After two hours of doing as we suggested, I was surprised to still find some cervix remaining. She was 9 cm and the anterior portion of her cervix was very swollen (likely from the premature, prohibited pushing). I learned from Hilary that women who have had a lot of babies can sometimes have a cervix that is very floppy with poor muscle tone and can sometimes have a hard time getting out of the way. At this point we really needed to actively manage the anterior lip of her cervix, otherwise we would have to consider transporting her to hospital care due to the slowing of progress. Besides, her contractions seemed to have slowed and grown less intense which is also consistent with women who have had a lot of babies. Their uteri can get tired out in the middle of labor and stop contracting. This can cause a failure to progress and also predisposes to hemorrhage after the baby and placenta are delivered.

So we had her stand and lean forward onto the bed (we tried squatting at first but this didn't seem to be as effective). If her contractions were to become strong enough again to cause fetal descent while pressure was applied to the anterior lip then we would just encourage her to breath through contractions and still not let her push. Thankfully, once she was vertical again her contractions did intensify and as I supported the cervix, I could really feel the baby's head coming down. It only took 2 contractions before the cervix was gone and she was fully dilated and to our surprise, it was only one more contraction before the head was crowning. And she still wasn't pushing! Her powerful uterus had found it's second wind! That and the fact that gravity is really helpful.

We had to get her to the OB table immediately. (We have a bed and an OB table in our delivery room. For better management of potential shoulder dystocia we decided to have her deliver on the table). Amazingly, with my hand supporting the top of the baby's head and us instructing her not to push and just breath, the impressive mom quickly complying with our instructions to move and she was successfully transferred to the table. At this point she was in between contractions so the baby's head eased out slowly. I reached beyond the head to feel for any cord and found the cord wrapped around the baby's neck but it was loose enough to slip over the head. The baby rotated perfectly and both Hilary and I were happy to see the top edge of the anterior shoulder meaning it wasn't stuck behind the mother's pubic bone. We encouraged the mother to push the rest of her baby out but the baby didn't come easily. He was big compared to his mother's size. So I applied downward traction while supporting the head to try and deliver the anterior shoulder. It wedged out only slightly so I applied upward traction, then again downward. With this and after about 1 minute of wedging the baby out, the anterior shoulder was freed and the baby was delivered.

He was very blue, floppy and not breathing. Hilary had to give 7 puffs of O2 using the ampu-bag while I and the other assistants stimulated the baby and checked his heart rate, which was reassuringly strong and normal. Soon the room was filled with the sounds of a crying baby. Praise God.

I was just so thankful that after the usual signs of placental separation, the mother only had one other gush of blood (pitocin was then added to her IV fluids) and her placenta was delivered normally. I was worried that if she was hemorrhaging that I would have to handle it by myself since Hilary was tied up with the baby. But I did my job and kept a close eye to make sure she wasn't bleeding abnormally. We have seen so many women on the verge of hemorrhaging (500 cc blood loss or more) that we are all extra sensitive to it and every time a woman loses 200cc or less, I feel so relieved. I was also happy to find that she didn't tear at all (not surprising for a women whose body had been through this 5 times already).

Her placenta was lobulated and that was the first one I had seen like that. It was the usual round shape but with an extra lobe off to the side. Very interesting.

Afterwards, once mom and baby were stable, the tired but happy mom looked each of us in the eye and told us, "thank you." She was sincerely grateful. This is one of my favorite moments to experience.

Her baby boy weighed 8 pounds, 1 ounce and his poor little face looked like it had been beat up a little. Being born was a little rough on him, poor baby. He had quite a big head considering the size of his petite mother who I'm sure was shorter than 5 feet tall.

Afterwards when all the staff were goo-goo-ing and gaa-gaa-ing over the new baby one of the midwives commented on how fair and pink the baby's skin was. The father spoke up and told us that this was the case because when they "made it," they left the fluorescent light on. We all laughed so hard. Mom & Dad laughed too but it was clear that they really believed it to be true. So funny.