JUST A COUPLE MORE PUSHES AND CHERYL, A 31 -YEAR-OLD JAZZ DANCER, WOULD HAVE HER FIRST BABY.
I MET HER THE DAY BEFORE WHEN SHE CAME TO OUR SERVICE AT MARY HITCHCOCK MEDICAL CENTER. SHE WAS ONE DAY LESS THAN THREE WEEKS OVERDUE. IN SEPTEMBER OF 1991, I WAS IN THE THIRD YEAR OF MY RESIDENCY AT THE MAINE DARTMOUTH FAMILY PRACTICE PROGRAM AND GETTING ACCUSTOMED TO THE SLOWER PACE OF A RURAL LIFESTYLE, HAVING GRADUATED FROM THE UC SAN DIEGO SCHOOL OF MEDICINE IN 1989. AT AGE 28, I WAS IN THE MIDDLE OF MY FIRST MONTH AS RESIDENT IN CHARGE OF NEW HAMPSHIRE’S ONLY HIGH-RISK OBSTETRICAL SERVICE. CHERYL’S LAY MIDWIFE REFERRED HER TO US; ONCE A PREGNANCY CONTINUES TWO WEEKS PAST THE DUE DATE, THE RISK FOR COMPLICATIONS RISES.
I remember her thick, long, dark brown hair tied in a ponytail that cascaded down her back. I remember her stocky build and cheerful demeanor. We had a pleasant visit, discussing the risks of continuing to carry the pregnancy, and we decided to induce labor the following morning. My affable attending physician. Bill Young, dropped in and concurred. “At 43 weeks,” he quipped, “it’s pretty much just you and the elephants.” I proceeded to place laminaria, a rolled up seaweed product that expands when moistened, into the os (opening) of her cervix to begin the process of dilation. 1 gave her final instructions where to meet us on the labor and delivery floor the following morning.
As usual, we induced Cheryl’s labor with an intravenous Pitocin infusion. A synthetic analog of oxytocin, a hormone produced in the posterior pituitary gland of the human brain, Pitocin stimulates contraction of the uterine smooth muscle. Her team of friends and lay mid wives took such care of her, with paper fans, massages, relaxation techniques, and encouraging words, that I sat back and watched in admiration. While doing high-risk deliveries, one seldom gets a chance to see a relaxed atmosphere where optimism reigns and the intrusions of technology, medications, and decision making are few. Tamara, a calm, thirtyish, athletic, Birkenstock-wearing nurse with light brown hair, freckles, a biting sarcastic wit, and wonderful clinical judgment, also appreciated this break from our routine. We took notes together between our obligatory assessments of her progress.
Cheryl cruised through her first stage of labor — including the crushing contractions of the transition period late in the first stage when the cervix finishes dilating from five to six centimeters to complete dilation — without requesting any medication. The external fetal heart monitor, a round plastic disk through which a white Velcro belt is threaded so it can be worn around the pregnant abdomen, recorded ideal fetal heart records, showing no signs of fetal distress.
After her cervix finished dilating, Cheryl began to push the baby toward the world. Her physical strength and the motivational skills of her team resulted in awe-inspiring effort, forging the baby’s head through the birth canal until it was visible between the labia of her vagina after 30 minutes of pushing — rapid progress for a woman three weeks past her due date with her first baby.
Tamara and I sat in our positions, charting Cheryl’s progress and enjoying the atmosphere. Dr. Eric Saylor, the attending physician on duty, observed behind us. Tamara and I both wanted to do this delivery as the midwives would have, which meant allowing Cheryl to push the baby’s head as slowly as possible through the vaginal opening so that her skin would stretch with the emergence of the baby’s head. This would avoid the need to cut an episiotomy to prevent her skin from tearing.
I almost never cut episiotomies anyway. Using scissors, I cut the tissues from the bottom of the vaginal opening, where the outside skin meets the gray corrugated mucosal surface of the vaginal lining, inward along the center of the vagina’s bottom wall down to midway between the vagina and the rectum. This gives more room for the baby’s head and shoulders and therefore speeds up delivery, which is why it became so popular among obstetricians. Their justification is that it prevents more serious tears, particularly those that extend down through the wall of the rectum (called “fourth degree” lacerations), which are more painful, more difficult to repair, and more likely to result in complications, such as stool incontinence or wound infection. Recent studies indicate what many of us suspected: cutting episiotomies increases the incidence of severe tears because the episiotomies often extend during delivery.
Cheryl’s dancing led to greater-than-usual development of her perineal muscles, located between the vagina and rectum, slowing the head’s progress just before the vaginal opening. Thirty additional minutes of pushing yielded minimal results, despite positional changes and other helpful maneuvers. But we weren’t in a hurry, the fetal heart tracing still showed a healthy baby. Even Dr. Saylor, a veteran of 25 years of obstetrics and a firm believer in episiotomies, didn't stir. Women giving birth for the first time routinely push for two hours.
With the next contraction, Cheryl pushed again, and for the first time, there was a deceleration of the baby’s heart rate, but it recovered as the contraction receded. Obstetrical practitioners classify decelerations into three categories; early, variable, and late.
Cheryl’s baby had a variable deceleration, the most common of the three types. These start just after the onset of the contraction and last for the duration of the contraction, with the heart rate diminishing as the contraction intensifies and increasing as it fades. On the recording, it looks like a mirror image of the contraction. Diminished blood flow through the baby’s umbilical cord causes variable decelerations. Often the cord is wrapped around the neck. Sometimes other body parts compress the cord. Rarely is there a true knot in the cord. With ultrasound, observers have witnessed babies “playing” with their cord, even squeezing it. It’s incredible most of them make it out alive, given the trouble they can encounter or invent inside the womb and during labor.