Having discussed pain relief at length, we can rejoin the patient in the labor room. By this time she has probably received Demerol and scopolamine, unless she is a successful candidate for natural childbirth. The husband has been dismissed and sent to the waiting room to join other expectant husbands and their retinues of expectant grandparents and aunts and uncles. The patient is oblivious to all this; she is sleeping soundly between uterine contractions, perhaps snoring. When a contraction comes she wakes, tosses about, moans, and, as soon as it subsides, returns to sleep. Her own doctor, the nurses, and resident physicians are constantly going in and out of the room. It is likely that the sides of her bed are equipped with movable metal guard rails, which are kept raised except during an examination. Analgesia makes one behave as if drunk, and the guard rails protect the patient, restrain her from jumping or falling out of bed if she is momentarily left alone. At frequent intervals a doctor or nurse checks the fetal heart with a stethoscope, noting its rate and regularity. At less frequent intervals a physician determines the extent of labor’s progress by rectal or vaginal examination. Now the pains become longer in duration and more frequent, occurring every three or four minutes, and the ‘show’ b^omes bloody. When examinat’on reveals the cervix fully dilated and the baby descended to the vaginal floor, the patient is transferred to the delivery room.
The Delivery Room
A delivery room looks like a small operating room. It contains a complicated-looking anesthesia machine full of knobs and different-colored cylinders of various anesthetic gases. There is also an instrument table draped with sterile throws. An infant-resuscitation machine is off in one corner. The personnel are capped, masked, and sterilely gowned and gloved. Until recently few patients ever saw all this, but now, in the era of natural childbirth and conduction anesthesia, many patients see not only the room itself but the whole process of birth by means of an adjustable mirror attached either to the wall or to the large, special, shadowless light in the ceiling overhead.
The patient is transferred to the delivery table, a very broad type of operating table equipped with leg holders which, when she lies on her back, hold her legs wide apart. Her wrists are strapped to the sides of the table to prevent her from fingering the sterile drapes when they are applied. If the membranes are intact, the doctor ruptures them with a clamp or hook. Since the membranes are the fetal sac and not connected with the mother, their rupture or puncture is painless. At this stage, unless the patient is under caudal anesthesia, the baby’s head pressing on the tissues of the lower vagina and bowel makes her bear down involuntarily, with a reflex desire to expel the offending mass. With each labor pain, because of the powerful force generated by the contraction of the large, muscular uterus, aided by the mother’s vigorous straining, the baby descends lower and lower, and soon its scalp appears at the entrance to the vagina. The elastic vaginal orifice is further distended with each labor pain, and more and more of the baby’s scalp appears, at first an amount which could be covered by a dime, then by a quarter, and finally fifty cents’ worth.
The Patient Is Anesthetized
At this point, unless the patient is experiencing natural childbirth or is under the effects of a caudal anesthetic, anesthesia is induced. The anesthetized patient is now brought into position at the edge of the table, with knees bent and thighs spread wide asunder by the metal leg rests. The vaginal region, the lower abdomen, and inner parts of the thighs are cleansed. The doctor surrounds the opening of the birth passage so completely with sterile towels, over which he places a large sheet with a perforated eighteen-inch square, mat it appears as though birth is occurring through a window. The bladder is emptied by catheterization, unless the patient has just voided, in order to avoid injury to it that might occur if it were full of urine.
As labor progresses, the baby’s head protrudes farther and farther, and the perineum (the tissue lying between the vagina and the rectum) is stretched to an unbelievable degree. Now the head no longer recedes between pains but continues to bulge through the vaginal opening. Since, because of overdistention, vaginal tears are almost certain to occur in the perineum, most doctors anticipate them at this point (with the patient completely anesthetized) by making an incision in the perineum before the head emerges. The simple operation is called an episiotomy. The episiotomy cut is made with scissors. The arguments favoring episiotomy are: an incision is straighter, less jagged, and simpler to repair than a tear; and an incision made before a tear occurs prevents the vaginal tissues from being overstretched and makes vaginal relaxation less likely following childbirth.
Now the child’s head is pushed out by an assistant who applies pressure on the mother’s abdomen, or the obstetrician makes upward and outward pressure on the chin through the thinned perineum and virtually lifts the head out. The head spontaneously turns to the left or right, depending toward which side of the mother the baby’s shoulders are directed, and is grasped by the doctor, who places one hand beneath each side of the jaw. As the head is guided downward, the front shoulder slips out; then a pull upward brings forth the other shoulder. With continued gentle traction, the chest, trunk, and lower limbs follow easily.
Tending to the Baby
When delivery is completed, the child is held by its heels, head down. Using a rubber bulb or tube, the obstetrician sucks accumulated blood or mucus from the mouth and nose. By now the child begins to breathe regularly and cry. The navel cord is clamped three inches from the abdomen and cut. The child is then handed to a nurse, who blankets and deposits it in a warm.
A clamp resembling a bobby pin is applied to the stump of the umbilical cord, where it remains until the cord dries and drops off.
A drop of a very weak silver-nitrate solution is put in each eye, or the baby is given an injection of 50,000 units of penicillin to eliminate any chance of gonorrheal ophthalmia, eye infection due to the gonococcus bacterium. Since gonococcal infection of the birth passage has become so infrequent and gonorrheal ophthalmia of the newborn so readily treated by penicillin, when and if it should occur, some hospitals have recently omitted all delivery room eye care of the infant.
The infant is immediately marked with the mother’s name to prevent even the remotest chance of a mixup. There are several different methods of identification. At the Mount Sinai Hospital, when the mother is admitted to the labor suite, a bracelet of plastic with a cardboard insert marked with indelible ink is made in triplicate with her name and admission number spelled out. One bracelet is attached around the mother’s left wrist, and she wears it during the complete hospital stay. The other two completed bracelets are kept in reserve. As soon as the baby is born, one is placed around its left wrist and the other around the right ankle.
If the child does not breathe and cry at once, it is given to a trained assistant to resuscitate. Here too there are many methods. Modern delivery rooms are equipped with one of several excellent machines which combine three features: suction to clear mucus and other secretions from the upper air passages, positive pressure to inflate the lungs in order to establish respirations, and a mask with constant oxygen to be put over the baby’s face when its own respirations have begun.
Less satisfactory methods of infant resuscitation are blowing one’s breath into the infant’s mouth, manually compressing and expanding the chest, or putting a tube past the larynx into the trachea and inflating the lungs. Injections of various drugs are advocated by some; others momentarily immerse the baby in ice water; and still others slap it vigorously. Patience, imperturbability, and exquisite gentleness will resuscitate more babies than all radical methods combined.
Delivery of the Placenta
The obstetrician next turns his attention to the delivery of the placenta. It is attached firmly to the uterus over an area about eight inches in diameter. After the child’s birth the elastic uterus retracts and becomes much smaller, since it is no longer ballooned out by the. Soft, its muscle fibers uncontracted, the uterus rests, following the strenuous work. In a variable number of minutes—usually just a few —it begins to contract again. The placenta is spongy, non-contractile tissue; the uterus, pure contracting muscle. With the further contractions of the undistended uterus, the area to which the placenta is attached diminishes marvelously. Since the placenta cannot contract and remains the same size, the flimsy attachment between the two is torn through, leaving the placenta free in the cavity of the uterus. With additional contractions of ever-increasing magnitude, the uterus obliterates its cavity by squeezing the free placenta downward into the capacious vagina. This occurs without the aid of man.
The uterus, after separating the placenta and expelling it into the vagina, assumes a different shape and position. When this occurs the uterus is held through the abdominal wall by a doctor or nurse and pushed downward toward the pelvis. The firm mass of muscle acts as a piston and thrusts the placenta halfway out; then the obstetrician gently pulls and twists the partially extruded afterbirth from the vagina. The membranes, being joined to the placenta, come away with it.
As soon as the placenta is delivered, the obstetrician examines it carefully to be certain it is complete. A placenta is formed by the fusion of twenty or so little placentae (cotyledons) which are more or less separate, but crowded compactly together. It resembles a mosaic of many smooth, even tiles, each tile representing a cotyledon; if the mosaic is complete, the placenta has been delivered intact. If there is a defect, one of the tiles missing, the accoucheur must put his hand in the uterus and remove the retained cotyledon, because otherwise it might cause immediate or late hemorrhage. I have oversimplified the problem; sometimes even the most experienced and meticulous obstetrician remains uncertain whether the placenta is complete, and if so he usually awaits developments.
Occasionally the normal mechanism of placental separation and extrusion does not function, and the placenta has to be peeled away from the wall of the uterus. With the patient anesthetized, the operator follows the navel cord high up into the uterus until he reaches the placenta. He then scratches it loose with his gloved fingers and removes it as he withdraws his hand. Most doctors perform a manual removal if the placenta is not delivered several minutes after the baby; they may do so sooner if hemorrhage occurs with the placenta undelivered.
At the site where the placenta was attached, pencil-thick blood vessels are torn across. The reason women do not ordinarily bleed from this wound is that the uterus is specially constructed to meet the situation. Its muscle fibers run crisscross, that is, they interdigitate, and the blood vessels run in the interstices. It is like fitting the fingers of one hand between the fingers of the other. When the fingers are loosely fitted and held before the window, light comes through the web; but if they are tightly fitted, not even the tiniest beam filters past. In the same way as the light, the blood vessels of the placental site are shut off, the walls of the vessels squeezed together by the tightly contracted, in-terdigitating muscle bundles surrounding them on all sides. It is therefore essential that the uterus remain firmly contracted after the delivery of the placenta. Ordinarily this is accomplished by massaging the uterus off and on for an hour through the abdominal wall in a bread-kneading fashion. The modern obstetrician is greatly aided by two drugs, Pitocin (obtained from the pituitary glands of cattle) and ergot (obtained from a vegetable parasite which grows on rye). Both are now manufactured (synthesized) from chemicals in the laboratory. These drugs have a specific action on uterine muscle, causing it to contract firmly, and, when given in sufficient quantity, cause it to remain contracted. Each is given by injection, either intramuscularly or directly into a vein. The blood lost at delivery averages eight ounces, or half a pint. Since the woman’s blood volume temporarily increases about a quart during pregnancy, she usually tolerates the loss of half a pint, or even several times this amount, with impunity.
Repair of the Episiotomy
The episiotomy—or if perchance one was not done, the perineal tear sustained—is repaired with absorbable catgut sutures, and since they are absorbable they need not be removed. The methods of repair, the length of the sutures, and the type of stitch vary so much from operator to operator that the usual lay question, ‘How many stitches did I have?’ has no meaning. The answer, ‘Just a few,’ is truthful.
The Immediate Post-Delivery Care of the Mother
The patient is either transferred to a recovery room adjacent to the delivery room or kept on the delivery table in the delivery room for one hour or longer, so that she can be carefully observed by doctors and nurses. The consistency of the uterus is constantly checked; if it is firm nothing has to be done, but if it is soft and toneless it must be massaged through the abdominal wall. When this does not harden it, a bottle of a dilute solution of Pitocin in glucose water is fed into a vein over the period of an hour or two. The patient’s blood pressure, pulse, and respirations are observed, as well as any evidence of abnormal vaginal bleeding. If the patient is being cared for in a recovery room, as soon as she is awake and conscious of her surroundings the husband is invited up so they may congratulate each other, and perhaps be introduced to the ‘little bundle from heaven.’
The Immediate Post-Delivery Care of the Baby
As soon as he has finished with the mother, the doctor turns his attention to the infant, which has spent the first few minutes of its earthly existence snuggled in a warm crib. From this it is taken and laid on a table. The doctor examines the child for congenital defects. First he notes whether it has a harelip. Then he sweeps his finger over the roof of the mouth to determine if the hard palate is normally formed; if the child has a cleft palate, its nose and mouth form a single cavity. The doctor looks to see if movement of the child’s tongue is restricted by an excessive length and thickness of the fraenum (Latin: ‘bridle’), a small web of tissue that, when well developed, binds the normally free front portion of the tongue to the floor of the mouth.
If the child is tongue-tied, the doctor simply clips the fraenum with a pair of scissors; no bleeding follows, since the web has no blood vessels. The doctor examines the skull to determine the distance between the bones. The bones on either side and the bones in front and in back are separated from each other by a narrow furrow (suture) covered only by skin. If the separation is abnormally great, it indicates unusual pressure within the skull, commonly caused by hydrocephalus, known to the layman as water on the brain. The doctor inspects the ears, for frequently a small accessory lobe grows like a mushroom from the true lobe. If this is present, a piece of silk thread is tied tightly about its stalk, and in a few days the accessory lobe drops off. He listens to the child’s heart and lungs with a stethoscope. He determines whether the heart sounds are normal, for certain abnormal sounds (murmurs) denote abnormalities of structure. He also determines whether the lungs are expanding properly. He feels the abdomen for tumors. He then puts the child on its belly and examines the bony spinal column for defects. The presence of such a defect (spina bifida—’spine divided in two’) can be determined without X-rays only if a small fluid sac overlies it. He next examines the genitals of the child, in the male paying special attention as to whether or not there is hypospadias, a defect in the underside of the penis which discharges the urine at the base of the penis instead of its tip. The scrotum, the pouch-shaped sac below the penis, is felt to see if both testicles have descended. Often, particularly in premature infants, one or both are still retained within the abdomen. The anus, the external end of the rectum, is observed to see if it is normally patent or imperforate; if the latter, an opening must be made within the next several hours by a surgeon experienced in the procedure. Then the doctor examines the arms and legs. He observes whether the toes or fingers are webbed and if there are any accessory ones. Very often the extra digit is purely rudimentary, hanging by a thin strand of skin. Sometimes, however, it is well developed and as well attached as the other five fingers or toes. If it is of the former type, the doctor ties a silk thread about it and allows it to drop off a few days later. He examines the feet to see if they are clubbed, for remarkable results may be obtained if a club foot is put up in a cast during the first few days of life. Then he rapidly passes his fingers over the whole bony framework to ferret out unsuspected fractures.
Mother Meets Baby
The baby is wrapped in its receiving blanket and, if the mother is awake, taken to her to be loved and held. This is a touching scene, and only a stony heart would not be moved by it. Most mothers, particularly first mothers, are awed, a little strange and frightened. One has to place the baby next to her and guide the mother’s arm to encircle the infant. Opening the blanket and demonstrating the presence of ten toes and ten fingers, and the genitals to corroborate the sex, breaks the ice, and then mother and baby really start getting acquainted. If there is a recovery room and the mother promptly transferred to it, the baby’s introduction may be postponed until the father can join them.
The baby is soon transferred to the nursery, frequently in an electrically heated boxlike structure on wheels, where it is weighed, bathed, and diapered. Its temperature is taken rectally or under the armpit (the axilla). If it is below a certain level the infant is placed in a specially heated crib; otherwise, in a regular bassinet. If the infant has a birth-weight of less than five pounds, it will no doubt be placed in a special nursery for prematures, and perhaps in an incubator with oxygen available.
The Moment of Triumph
After one or two hours, depending on hospital routine, the mother is wheeled in her bed to one of the postpartum floors. Hers is a victorious march; if a woman is ever a queen it is at this triumphant moment of her life.