July 21st, 2005

Lanslebourg - lamp

Sometimes you cry...

Beautiful girl, young for this to be her third baby. One of those shining pregnant girls who is only belly and cheeks and the glow of youth. Notes on the chart: baby up for adoption.
I am in the tail end of conversations, overheard whispers, words and thoughts and half-completed discussions. The adoptive parents are here, they will be at the delivery. They want to stay with the baby but the hospital will not let them. Something happened in the past; adoptive parents now must obey visitation rules. Night charge head nurse talks to the head head high up and bargains: they will be allowed to go to postpartum and watch the bath through the glass windows in the nursery; they will be able to take the baby to the lobby and bond. Baby will have a security tag.
The adoption is only legal if the mother signs the papers after birth, and if the father does not object within a reasonable amount of time. My patient does not want to see her baby, touch him, do anything to him. She knows that if she looks at him she will love him and not be able to give him up. She cannot afford this child; she is on the verge of putting her life back in order, making something besides a scratched-out living. And the father is an on-again, off-again source of support. Not reliable. She has given this careful thought. She is certain that this is best, for her, for baby, for her daughter with her.

It is a strange tableau.
There am I: staff OB tonight is kind and good and hands-off; he hands me the towel and lets me deliver the baby from crown to placenta. There is she, her sisters holding her feet as she pushes; the epidural is good and she is determined. And there, near her head, in the corner, are the adoptive parents, watching, serious, nervous.
The delivery is good - what makes it good is that she pushes when asked to push, stops when asked to stop. My hands are becoming slowly more certain as they move over the crown of the infant, stretching the perineum, pushing against the contractions to control the head's delivery, turning it into an inexorable slide rather than a sudden tearing pop. Suction. Check for nuchal cord. Mother breathes, pants, waits. Grip the baby's head in two hands, fingers under jaw and occiput, pulling down as mother pushes, and feeling for the subtle give that is a shoulder sliding beneath the pubic bone, then completing the upstroke of a "J" to deliver the posterior shoulder without tearing the perineum. One hand slides down from occiput, fingers finding the arm, pinning it against the body - a baby's arm can lacerate as it pops out, turning a smooth delivery into a necessary repair. And once the shoulders are free, it's a hand at the neck and a hand at the ankle to catch this living thing that nearly falls into my hands. I may take up sitting to deliver; it's easier to hold the babies.
Normally, O Best Beloved, this is the cry of triumph - a proclamation of gender, a passing of a wet, bloody, squirming creature to its mother's belly, wrapping it in blankets, cutting the cord, all the while filled with jubilation. Normally, catching the baby is a glorious moment.

Tonight, I caught an infant boy sliding flawlessly from his mother's womb, by neck and ankle, held him, and said quietly, "I've got him." Dr. said to the mother: "Do you want me to cut the cord?" She flung a towel over her face and began to sob. We clamped and cut the cord. The baby went into the nurse's arms as soon as he was suctioned, whisked away to another room, gone. Where normally I deliver a placenta to the background tableau of outraged wails, cameras, and adoring commentary - tonight the room was silent but for the wracking, bone-deep weeping of the woman on the bed. She could not be comforted; the OB later told me that her reaction was that he had seen in women whose children are born dead.
It was business and nothing more, between her legs: look for lacerations (none), check the placenta, deliver the placenta, catch the placenta. Massage the uterus (oh, that Technicolour blood) until it stops pouring out clots and then clean her. Massage the uterus again; a little atony but not much. Business. The routine helped to quell the festering sense of despair that filled the room, but it could not consume it completely. I doubt that anything could have.

I went, after the delivery note was complete, to see the baby and the adoptive parents. They were awkward - it was awkward. I complimented the baby. The adoptive father said "She did well." The mother nodded.
I did not know what to say, O Best Beloved. We were talking about the delivery; she pushed with fantastic determination and did exactly what she was asked. But I could not erase from my mind that grieving woman in her bed, thighs painted with the blood of birthing a child she could not bear to break her heart by seeing. I could not tie together the tattered ends of pain and call it good. I was, momentarily, inside a hollow emptiness as wide as a Titan's drum, looking up at a black and barren, starless sky; I had no sufficient words and no name but sacrifice for the thing that she had done.
Yes, I said, she did.

Someday, O Best Beloved, I will perhaps be able to tell you whether I spoke truth or falsehood. But perhaps I will never know, in this world a thousand shades of grey. I know only that there is pain and blood to the bringing of life; I know only that there is ending and there is beginning and that sometimes the two are one.
House by the river


silmaril linked this morning's entry in her Livejournal. I have new friends. Perhaps the two are related. Welcome, and buckle in. It's going to be, if nothing else, an interesting three years.

I did not actually sleep last night; I moved from room to room, baby to baby. I caught a nap at four-thirty, when the night nurses scolded me: "Go, sleep. Come back less weird." It had something to do with my decorating my nails with strips of surgical tape, I think. At four-fifty my pager went off again, and I was back on my feat, arguing with a girl much younger than her age, coaxing, commanding. You become, at some point, no longer uncomfortable when talking to a woman who is naked from the waist down, splayed and spreadeagled for the very most possible pelvic room. It is no different than talking to a woman who is clothed. She wanted to give up.
I hear that a lot, in the labor room, usually at about ten centimeters dilation, +2 station, pushing. I hear it wailed more frequently than I would have thought. It is mostly at the stage where the baby's head moves from tucked tidily behind the pubic bone to moving steadily out in front of the pubic bone (see this diagram, if you are confused), and in a first-time mother that stage can be very long. It is long, and it involves active pushing, and that, O Best Beloved, is the formula for complaints. They are almost formulaic: mothers wail with each push, a long exhalation that robs force from the effort of pushing. They give one decent push, one halfhearted effort, and one scream with each contraction. And then, between, come the pleas. "Pull it out. Take me to C-Section. I can't do this any more. I can't push."
Please believe me, O Best Beloved, and if you do not believe me then ask any of the women you might happen to hold dear about childbirth: this is marathon-quality effort. It is a cardiovascular effort the likes of which many human beings would not believe themselves capable of putting forth. Even with an epidural there is pain, and so many times the pain overwhelms the anesthesia. The average baby's head, O Best Beloved, is between 13 and 15 inches around. That's about four to five inches across, on average, and it is squeezing through some of the most delicate and sensitive territory on the female body. A first baby with an epidural can push three hours on the average, and we're asking for every last iota of effort with every push. I am not saying that these women have no right to complain and cry and whine. I am saying that it is my job to turn the energy they are pouring into their tears toward getting the baby delivered.
And so I argue, I cajole, I order. The nurses are far better at it than I, but I am listening and I am learning and I am beginning to understand the tricks of the trade. Once the baby turns the corner of the public bone the pain is not over but things move much faster. If you can get the baby there then it is merely a matter of convincing the patient that one more good push might be the last. Thus far, every woman begging for a C-section or a vacuum or forceps has delivered on her own as long as the baby looked well.
It is hard. It is emotionally exhausting to be in the room, to argue, to keep my voice calm and authoritative and soft and nurturing and soothing and encouraging all at once. It is hard to watch a woman in agony and to tell her that the only thing to do is keep pushing, through and past the pain. It is hard. It can be done. After an hour and a half, it was done, and all of her screaming and crying vanished with the wet
and warm infant on her belly. Better than an opiate.

Yesterday's totals: one urgent C-section, five vaginal deliveries, one laceration I did not have to repair. I have settled the affair of the call I did not have covered and I will pay back the karma I am due in spades. I slept from seven AM to eleven-thirty, went to noon conference, went to the resident meeting and came home. I couldn't sleep any more; I am tired but not able to stay still. My father is out in the garages (we have the single-car garage that came with the house, and a second garage that was added on later) jackhammering a hole in the wall so that we can get from one building to the next without going outside. I have scolded him into wearing earplugs and eye protection. My Angel is at the boys' night out, eating buffalo wings and perhaps going to watch a movie.
I think I will go and watch the destruction.
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