Thursday, December 23, 2010

A Promise is a Promise

Mrs A was 42 years old and in labour with her first child.  She and her husband had tried every fertility treatment available to fall pregnant and all had failed.  To their disbelief, they had found themselves pregnant nearly a full year after finishing their last unsuccessful attempt at IVF.  Mrs A realized this was likely to be her only birthing experience and before I was even able to introduce myself, she began begging me to " Please please, please, help me have a beautiful birth!!" I noticed she had carefully arranged her birthing room with pictures, gentle music, soft cushions from home and curious oddments such as a colourful collection of polished stones.

Between contractions she outlined her desires for this birth.  It was a curious mix of all the birthing stories she had read over the many years of trying to fall pregnant. As she was a private patient I assured her I could help her with most things on her list but when the actual delivery was imminent her private obstetrician would be called.  I was relieved to note her doctor was a favorite of the staff with his combination of excellent obstetric ability and a warm and gentle nature.

It wasn't long before Mrs A's gushing enthusiasm was muted by the hard work of labour.  She stopped talking and began humming.  She paced slowly between contractions only stopping when I checked her or the baby. We dimmed the lights and threw mats and beanbags on the floor which she would periodically rearrange. Once she realized she was not going to have to fight to get what she so badly desired, she relaxed, turning herself inward and slipping into her own world. This is, of course, the perfect lubricant and labour progressed very rapidly. Leaning forward onto her husband as he massaged her back during a particularly long pause between contractions, she suddenly sat up and announced she had to push.

Like magic, her obstetrician arrived, knocking quietly on the door.  I surprised him with the good news and asked if he would like me to turn up the lights and ask Mrs A to get on the bed so he could examine her.  He smiled and declined saying " Let's just wait and see what happens".  He sat himself unobtrusively in a corner of the room and smiled encouragement.

Mrs A stopped her pacing and began to sway, arms around her husband's neck.  With each contraction she would bend her knees, look into her husbands eyes and push.  The scene was curiously intimate.  Mrs A had long since forgotten her long list and was responding innately to her own personal needs.

It soon became apparent that the birth was very close and although loathe to break this magical moment, I was aware that Mrs A would need to move to the bed to deliver.  Dr M was no longer young and asking him to get down onto the floor to deliver the baby was not feasible. I began to set up the delivery trolley and was surprised when Dr M shook his head.  Seeing my confusion he came over.  "Set everything we need on the mat over there".  I couldn't help but blurt out " But you can't "  He smiled again and said " A promise, is a promise. " 

It took a great deal of care to get Dr M down to floor level and comfortable.  He suffered with arthritis in his knees and sitting with them bent was painful. He grabbed one of the beanbags, plumped it up and leaned back.  Mrs A was now on her knees, arms still around her husbands neck while he sat on a birthing ball. Dr M waited patiently, rocking forward with each contraction as Mrs A pushed. The baby arrived calmly,without a sound.  I asked Mrs A to reach down as Dr M was unable to pass him forward.  There was then that familiar moment of suspended time, when the baby opened his eyes, parents and baby made eye contact for the first time. He breathed quietly, curling his fingers around his father's finger. I placed a soft blanket over mother and baby. 

And there we sat, obstetrician, midwife and new family in the semi darkness for a full thirty minutes waiting until Mrs A delivered her placenta. Mrs A suddenly seemed to become aware of her surroundings. She handed her baby to her husband and turned.  " My dream baby, my dream birth, I can't tell you, I know how difficult that was for you doctor, there are no words ..........." and with that, she leaned forward and put her arms around us both. I heard Dr M, clearly moved, mutter, " A promise..... is a promise".

Wednesday, December 15, 2010

The Unkindest Cut

Episiotomy is a surgical incision made at the time of birth to enlarge the vaginal opening.  It was a rarely used procedure restricted mainly to complicated deliveries until 1915 when it was made popular by two prominent obstetricians, Pomeroy and DeLee. De Lee had developed a delivery technique which involved cutting a large episiotomy and delivering the baby with forceps as soon as a woman was found to be fully dilated.  He theorised that his technique prevented tears that could lead to incontinence or a sagging pelvic floor( those muscles which criss-cross between the vagina and anus and keep everything in place).  Without evidence or research the theory was taken as fact and soon became standard practice in many hospitals with most obstetricians incorporating episiotomy into their normal delivery routine. It wasn't until 1983 that the first major study of episiotomy was undertaken. Its conclusion?  Episiotomy disastrously weakens the perineum making it far more likely for a woman to sustain a serious perineal tear ( known as a third degree tear ).