Arya’s Difficult Delivery

After 30 hours of labor and 6 hours of pushing, my wife and I were delighted to welcome our daughter Arya into the world this morning. Despite the volume of books on labor and delivery we read over the past months, we were still unprepared for the stress and complications involved in our baby’s birth.

My wife saw a patient on Thursday afternoon and returned home with the same minor complaints she has been experiencing the past few weeks: sore back, bloated feet, and dull cramping throughout her uterus. We went to sleep without incident, but she woke me up a few hours later (with a loud yell) to tell me that her water had broken. I had only a vague idea of what it would look like when my wife’s water broke. Many books describe it as a wet trickle. With our experience, I would describe water breaking as a gush of water running through her clothing and dripping down both legs.

Mommy with Baby CookieGiven our firm belief that we would go to the hospital immediately after her water broke, Lisa and I walked across the street (one of the benefits of living in the city) to Tufts Medical Center. Since the emergency room is the only entrance to the hospital after hours, we went in the ER entrance and were greeted by two tired security guards manning the empty waiting area. I asked the first guard if we could go to the LDR (Labor, Delivery, and Recovery) Ward since my wife’s water had broken. He look befuddled and asked if we had an appointment. I still think it was an odd question. If a pregnant woman and her husband walk into the emergency room at midnight and ask to go to the LDR Ward because her water broke; isn’t the reason obvious?

Nevertheless, he was polite and understanding after I explained that she was going into labor and that we did not have an appointment. He escorted us through the (scary) vacant hospital to the LDR Ward and let us in with his security badge. The overnight staff at the Labor, Delivery, and Recovery Ward seemed a bit surprised to see us when we walked in. I don’t understand why the other guard didn’t call ahead to alert them to our arrival. It would seem that a few minutes of preparation time might help the staff prepare. In our case it was inconsequential, but as a matter of policy it would cost nothing to have the overnight guard make an internal phone call to the LDR Ward and it might make a difference for critical pre-term births.

Despite the awkwardness of our arrival, both the nurse and on-call obstetric resident were fantastic. Within two minutes my wife was on a bed in the intake room and the nurse was providing care. Our OB resident had to scramble to find my wife’s chart. Although Lisa sees an OB/GYN in the same hospital, the LDR unit is on the opposite side of the building from the OB/GYN unit. The resident walked across the building to get Lisa’s chart, presumably looked for it for a few minutes, then returned to tell us that she couldn’t find the chart. Setting aside my discomfort of having vital information in a paper chart stuffed into a flimsy manila folder, I offered my theory as to why she couldn’t find the chart. Since my wife had an OB visit scheduled for later that same day, I assumed the staff had placed the “women who are coming in today” charts in a different place than the “all patients” chart storage location. In addition, my wife has the same first and last name as another pregnant woman who also goes to the same OB/GYN practice and I wanted to make sure that the resident didn’t (as two medical assistants and a medical students had already done) grab the wrong file.

After another 20 minutes, the resident returned with the correct chart. The delay was irrelevant in our specific case, but I still find problems with the entire process. If my wife had been a teenage mother pregnant with multiples rushing into the ER because of a fall inducing <28 weeks labor, not being able to find her chart may have caused a crucial delay. In our case, my wife was only 2cm dilated and the time was inconsequential. Following a quick confirmation that Lisa’s water had indeed broken, the LDR staff admitted her immediately. We now think their decision had as much to do with the liability inherent in sending her home than any concern about imminent delivery.

Hospital Delivery Room Admission TimeThe first hour after Lisa was admitted to the hospital was exhilarating.We repeatedly told each other not to worry while simultaneously being worried. Anticipating action soon to come, I tried to read some last minute tips on helping my wife through delivery. The next seven hours were boring. Dilation barely progressed and since Lisa described her discomfort as a “two” (on the standard ten point pain scale), we only saw our nurse and doctor every other hour. I experienced an odd combination of jumpy anticipation and utter boredom that rendered me unable to sleep, read, or even surf the internet.

Near 6am Friday morning, after Lisa’s pain had moved to a “four” or “five”, she asked for a narcotic to provide some pain relief. As part of our birth plan, she wanted to ask for narcotics initially and only request an epidural if absolutely necessary. In addition to giving her Nubain, the staff also got our approval to being augmenting delivery with Pitocin, a synthetic form of oxytocin designed to speed up the progression of labor.

The next few hours were painful to watch. Lisa’s contractions became more intense and more frequent. Since she was hooked up to a fetal monitoring system, I could see the endless, rolling waves of contractions and her discomfort grew worse every half-hour. Finally after a second, low-pressure sales pitch from the on-call anesthesiologist, Lisa decided to ask for an epidural. Oddly, the delivery of the epidural was the only time during our entire four day stay at the hospital when I was asked to leave the room. I’m not sure whether it was part of a hospital policy designed to eliminate witnesses in the event of malpractice or simple discomfort on the part of the anesthesiologist at being watched.

Fortunately the epidural was problem-free and its effect was gratifying. In addition to the obvious pain relief provided by the epidural, there were also two other benefits which I had not seen widely discussed in any of our numerous pregnancy books. As women in delivery are strongly discouraged from eating, their level of hunger increases with each passing hour. The epidural seemed to numb Lisa’s hunger pangs in addition to her pain from contractions. A more important benefit was that administration of an epidural prohibits a woman from getting up to use the bathroom and forces her to rely on a urinary catheter. This small change meant that my wife no longer had to worry about anything other than successful delivery of our baby. Our nurses became responsible for Lisa’s bladder and she no longer had to worry about any elimination activities.

Mommy Halfway Through DeliveryDespite the administration of ever-larger concentrations of Pitocin, dilation still progressed slowly and it was a full 24 hours from the time we were admitted that her cervix was dilated enough to begin the process of pushing. The most disturbing six hours of our lives started with the commencement of pushing.

During the first two hours Lisa pushed three times during each contraction. With an occasional break when she looked like she was going to pass out, Lisa pushed more than 100 times in the first 120 minutes. For her effort, we got to see a tiny, dime-sized glimpse of baby’s head starting in the third hour.

With the hospital staff keeping a constant eye on baby’s heartbeat for signs of distress, we declined additional delivery assistance and Lisa continued to push for an another two hours. Over this time our delivery room began to grow in size. Whereas we began the process of pushing with a single OB resident and one nurse; the OB attending, an additional nurse, and a medical student (briefly) were in the room by the end of the fourth hour.

By this time we were all stressed and my wife looked like she wanted to give up. It took a heroic pep-talk from our nurse and an odd display of power dynamics between the nurse, OB resident, and OB attending to convince both my wife and all the staff to decline a Caesarean section and continue to attempt a vaginal delivery with an operative vacuum extractor. The process of receiving informed consent was quite strange for both my wife and myself. Although we were relatively sure of which choice we wanted in the event an unassisted vaginal delivery were to be insufficient; given the facts of the case, I am now surprised that the OB attending did not push more strongly for a C-section. However, after skimming additional research on the relative risks of a C-section, vacuum, and forceps, we are further confident we make the right choice. Although the attending had a clear preference for a C-section, he accepted our choice immediately and it appeared to me he would have accepted whatever decision we made (even if it had been to decline all operative assistance).

The vacuum extraction was a gruesome sight to watch. I was positioned next to the bed on my wife’s left leg and tasked with forcing her leg back as far as possible to widen the birth canal during each push. From this perspective, I could clearly see all activity related to the delivery. The OB attending attached the suction end of the vacuum to the small bit of our baby’s skull prior to each contraction. Then, while my wife pushed with all her might, the doctor braced his left foot against the bed, turned 45 degrees, and pulled straight back on the vacuum with all his might. Our baby’s head looked like it was going to be ripped off from her body as both my wife and the doctor had to rest after each contraction. One nurse mirrored my position on Lisa’s opposite leg, a second nurse held her hand and shouted encouragement, the OB resident stabilized her pelvic region in the face of the pressure from the vacuum, and an additional nurse hovered nearby waiting for the baby.

This process continued for two additional hours with multiple adjustments of the vacuum, two of the nurses providing continual emotional support, and the OB resident manually manipulating my baby’s head at every opportunity. Distressingly, the room filled even further. In addition to the same OB attending, OB resident, our initial nurse (who voluntarily stayed past her shift), our second nurse, and the baby nurse; our room also contained a fourth nurse waiting to assist with the baby, a fifth nurse near the fetal monitoring equipment and the door, a pediatric neurology resident, and the hospital’s chief pediatric resident. All of them were present for the entire fifth and sixth hours of pushing (which were the 29th and 30th hours since admission). The packed delivery room was particularly distressing because the hospital had a piece of paper taped to the fetal monitoring system with the heading of “Delivery Risk Teams”. Each level of relative delivery risk was categorized by the staff members who would be present in the room. Whereas we started at what was presumably the lowest risk level with the minimum number of staff, we were now close to the highest risk level and maximum staff.

Near the end of the sixth hour, the OB attending finally suggested an epiosotomy (which we had discussed earlier, but tried to avoid). The extra room created by the incision was just enough to make a difference. Finally, long after I thought my wife was going to pass out, the OB attending yanked enough of our baby out to have the OB resident guide her shoulders around my wife’s pubic bone. With the help of the baby nurse and our second nurse, the four of them managed to finally free our baby’s entire body. Since nobody had warned me not to look, I saw the entire process of my baby’s smashed, pancake face pop back into shape after being violently squeezed through the birth canal. Blood and fluid were flying everywhere and both pediatricians looked distressed as they watched our baby finally being delivered. While the standard delivery room staff (obstetricians and LDR nurses) where proficient at disguising their emotions during the process, both pediatricians–who presumably see far fewer deliveries–were easy for me to read. Upon first entering the room the two pediatricians had been relaxed in the far corner casually discussing a local restaurant in politely soft tones. After the first half-hour they stopped their conversation and started watching intently. After the first hour they had subconsciously moved closer and showed strain on their faces. After ninety minutes they both looked outwardly concerned and were as close as possible to the OB team without causing interference. By the time our baby actually came out one of the pediatricians looked scared while the other looked distressed.

The fifteen minutes after Arya was yanked out of Lisa were a jumbled mix of of concern for my wife, concern for my daughter, and amazement at what I had just witnessed. After a surprisingly difficult time cutting her cord and relief at hearing her Apgar scores (9/9), I finally learned from the pediatric neurologist that although our baby was healthy, the staff was concerned about trauma to her head from the violent delivery. Her skull was visibly bruised and there was a bright red ring of what appeared to be burst blood vessels directly where the vacuum had been applied.

First Family PictureAt the same time, both obstetricians were working feverishly on Lisa. First they had to manually scrape meconium out from my wife and exert substantial (and painful) pressure to deliver the placenta. My wife was still bleeding from the episiotomy and the delivery while my baby was crying loudly. As every member of the staff was busy, they ignored me and left me free to move helplessly back and forth between watching my wife and watching my daughter.

After more than 30 minutes of poking and prodding, the pediatricians decided that our baby had not suffered any internal trauma from the delivery (although they agreed to specifically check her skull during every follow-up throughout our stay). My wife and I got to hold our baby from that point on while the obstetricians sewed her up and wound down the delivery process. It was nearly two hours before we were finally left alone in the room with our baby.

Although I would like to claim that I was happy, joyful, or elated upon holding Arya for the first time, my emotions could best be described as disbelieving relief. I can’t believe something so fragile withstood such an intense delivery. I can’t believe it took four medical doctors and five registered nurses to deliver one baby. I can’t believe women do this at home by themselves. I can’t believe women give birth in places without electricity and indoor plumbing. But most of all, I can’t believe that both mother and baby are doing fine.

St. Patrick's Day Baby

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