Yesterday I witnessed my first birth. Not in recent memory have I experienced such rapid emotional cycling. I have a new understanding of the common parlance use of "emotional roller coaster," and have a new respect for the process by which human life begins. We hear in the lay press about the artificial intensiveness that hospital births impose on patients; my experience as a medical student sometimes confirms the believe that kids get put through more than they need to be. This episode pushed me in the other direction. There is a reason why certain procedures are necessary; when medicine occurs at the brink of life and death, I want life to prevail.
As part of my pediatrics core clerkship, I participate in care at the university hospital's newborn nursery. The team of medical residents I join is not the same as the doctors who take care of infants in the neonatal intensive care unit (NICU). The NICU cares for babies that have already been born and need additional care; the nursery team cares for babies immediately after birth. Those of you who have had kids, they are the folks who assign Apgar scores, conduct the baby's first physical exam and look after the babies in the newborn nursery while mom is resting in the wake of her birth. Whenever there is the possibility that the baby will not do well in the minutes after delivery, this team in on hand to revive and restore the infant's vital signs.
Our first call came in the afternoon - about 20 minutes after the other team passed the pager to us. A normal vaginal delivery had failed to progress, so the doctors decided to do an emergency Caesarian section. This was a good choice, because the baby's skull probably would not have fit through the mother's pelvis. When we entered the room, the only sounds I noticed were the beep beep of mom's heartbeat and the constant calm voice of the baby's father. Dad's retelling of their shared memories was a distraction for mom; for me it put into context the significance of what was happening. An epidural anesthetic kept mom from feeling anything but pressure below her belly button. This was important, because a few minutes after our team entered the room, two different doctors were up to their elbows (literally) trying to extract the baby. A normal C-section looks like the picture at right. The baby is removed from a horizontal cut about 8 inches long at the mom's waist. That's not what I saw.
As Dad relayed stories from their honeymoon and spoke of a recent family gathering, I provided a foot-stop so the ob-gyn resident could push the baby back up through the vaginal birth canal. Her body was at about the angle you want to see a second row lock at in a rugby scrum; 30 degrees to the ground is how you get the best forward push without falling on your face. At this point, you can expect there were more sounds in the delivery operating room than the heart rate metronome accompanied nostalgia. I was surprised about the C-section incision, disgusted by the amount of blood and fluids being schlepped about, fascinated by the procedure, and incredulous that mom was not screaming through it all.
Finally, after the longest 6 minutes I can recall, I glimpsed the baby's head and snapped back into my role. In the midst of the joy associated with seeing a new baby, my job was to provide the team with fresh warm towels to clean and stimulate the baby. The cleaning part should be obvious; the neonatal team also uses warm dry towels to stimulate the newborn. Maybe you have heard about smacking the baby to make it cry? I am not aware that this is still done, but there is still plenty of jostling that is done to help the infant take its first breath. Repeated rubdowns with a warm towel is also useful for this purpose.
When the baby was removed, there was no cry, there was no gasp for air, he wasn't even moving his limbs. Furthermore, since mom was under local anesthetic, she didn't know the baby was out until the obstetrical surgeons told her. The parents had decided not to know the gender. This was good, it was about the only positive finding we could report about his first minute of life.
They say the Apgar score at 1 minute describes how well the baby did during delivery, while the Apgar at 5 minutes tells how well the neonatal team did. When he came out, this baby's face, arms and legs were blue, he had a pulse less than 100, he didn't respond to stimulation (with a grimace or cry), there was hardly any muscle tone, and he wasn't breathing. That makes for a score of 2/10. Most births score from 7 to 9 in the first minute. Our baby had a way to go and I was scared.
Every 30 seconds I retrieved a new warm towel from the oven. In between, I watched the team slap the soles of baby's feet, rub his head, belly and flank, suction his lungs, and apply positive pressure ventilation by mask. It looked a lot like the picture at left. We were patting and rubbing him, sticking tubes down his throat, and forcing air into his lungs. All we wanted in return was for him to scream at us. After 4 minutes, he took a breath; 30 seconds later we heard a weak cry. The intern kept imploring him to tell us how angry he was. When he did, I wasn't the only person in the room with wells for eyes. We invited dad to come look. I saw immense relief behind the ob/gyn resident's face mask and noticed blood on her arm above the glove. By the time 10 minutes had come along, Seattle's newest baby boy was screaming his displeasure at us. Being stuck in the birth canal left him with some superficial head injuries, so we ordered some head x-rays just to check in on him.
Usually the pediatrics team is the first to leave the delivery room; later, after showing mom and dad the baby, a nurse transports the high risk kids to the nursery for attentive care. In this case, we were the last to leave. Our team waited for the attending physician to come and examine the baby's skull, and conducted his first physical exam. By then he had a good suck reflex, was pink and screaming and had a heart rate of about 150; his hips were healthy and he even opened his eyes. Before we left the ob/gyn attending came back to tell us this delivery was the most difficult she could remember.
Body fluids and betadine were being mopped from the floor as we carried the babe down the hall to the nursery. In my emotional state, it was all I could do to open the doors for the team. Just as I sat to collect my thoughts in the residents' lounge, the pager rang with its distinctive sing-song. I was on my way to my second birth.
Images from Wikipedia.