Monday, April 1, 2013

two minutes

two minutes 

Two minutes is nothing - a wait in the drive-thru line, a skim through an email inbox, the tidying of an unkempt living room (my life with two schoolage kids). A phone call with an expectant woman. The time between two contractions in hard labor.

And yet, two minutes can stretch into eternity; when you have to pee, and the person in the stall is (apparently) spending her jolly-good time methodically counting out the toilet paper squares into a prime number equal to or greater than 167. When it's *almost* time to leave work - but not quite. When it's just about bedtime, and someone, for some strange reason, taught your offspring how to tell time (leaving no chance of tricking --- um, convincing --- them that it really, TRULY is 8 p.m.).


Any midwife, nurse, doula, birthing woman, goddess with a vague idea of the birthing process may have had an involuntary squeeze in the region of their kegels right there (sorry for any men that might have stumbled upon this particular post --- not sure what kind of physical response will be manifested there!). Shoulder dystocia --- or "shoulders" in the lay terms (that is, talk-fast-because-there-is-no-time-for-the-extra-three-syllables-dammit-get-the-stool-and-get-ready-for-suprapubic-pressure-NOW!!!") is one of the most terrifying, unpredictable, ready-or-not-here-I-come complications that may occur during childbirth. Sometimes you can get an inkling that shoulder dystocia may occur --- moms who have had previous deliveries with the complication, babies that are 'known' (* I could argue this "point" on and on, but we'll just leave it!) to be large, whether from serial ultrasounds or hands-on measuring, suspected pelvic anomalies, funky labor patterns --- but in the vast majority of cases, it's not until the bitter "oh meconium!" (midwife joke - hahahaha. sorry...!) moment that you realize just how deep things are going to get.

Backing up a tad, a quick refresher on shoulder dystocia. If you know all of this, go ahead and fast forward through this part. It's a bone-on-bone issue; while the first instinct one may have may be to cut a big ole episiotomy, few shoulder dystocias will be resolved by this. (The only benefit of slicing the vaginal tissue is to allow theoretical "roominess" in an otherwise snug tight area... more on this soon.) So what happens in a shoulder dystocia, for heaven's sake, if it can't be fixed with a big scissors and blood gushing everywhere?!

(Sorry if that sounded overdramatic... I imagined crazed readers, confused with the thought that a 'pis could fix everything, wildly glancing around at each other trying to figure out what the heck was going on here. I may have illusions of grandeur going on here. Also, there are a few people who could attest that though there was no snipping or clipping at any shoulder dystocias I have presided over... they still end up looking like massacres. In fact, all of the births I attend seem to resemble the Battle of 1812 for some reason. Let's pretend it's my own small rebellion at the outdated hospital curtains and furnishings, and little by little, I WILL get them all replaced...)

 Anyway. Woman labors, baby progresses through the cardinal movements (if you aren't familiar with these, I encourage you to do what any sane person would do and google that #&*%! In particular, look for some of the great videos out there, as well as the sites verbally outlining the process. I LOVE the Spinning Babies website - - both in general and for their nice description of the 7 cardinal movements). So, in a nutshell, the baby has to do some funky dance moves during labor and delivery, and so does mama*. Things tend to go okay if both partners are dancing together and to the same music, but if someone's hearing salsa music and the other is into those love ballads I associate with my junior high dances and sequined, cheesy dresses (think "Stairway to Heaven" with a rapid latino underbeat), things aren't going to work as smoothly as you'd like. In this awful analogy, the love-ballad may be a mom who's not coping with the intensity of contractions, or is *too* relaxed with an epidural on board, or whose uterus is putting out wimpy little contractions for whatever reason (an effort to induce before her due date, or what-have-you). So the dance is on, but it -again, oddly reminiscent of that 8th grade homecoming dance - looks like the short kid with pimples and the gawky, tall girl with braces trying to slow dance to "Mambo No. 5". Then, on top of everything you could have a pair of left feet (does it matter if they're mine? Does it? Does it!?! Oh, wait... Back to the present....) --- or a less-than-ideally-designed-pelvis (did you know there are four basic pelvic types, with each one possibly predisposing babe to "fit" a different way? True story.), and things really get fun. Or not fun, depending on your sense of humor.

So, anyway, the dance is on. If you're rockin' out with a first time mama, the first movement (engagement) could happen days or weeks before labor ever kicks in; with moms who've been to the dance before, it might not happen until somewhere after the punch and crackers are served. Not too big of a deal either way, except Mama will need to find the bathroom more often once it happens, so be ready. From then on out, the dance starts to resemble more of a tuck-and-roll kind of craze; the babe needs to curl up in a snug little baby roly-poly bug (but cuter and covered in amniotic fluid yet), chin to chest - this is known as flexion; next the snug little bug head continues pressing down on the vaginal floor (descent) while rotating into the ideal position to pass through the pelvis (internal rotation). Once through the pelvic arch, the babe's neck extends (appropriately called extension!) and within moments her body rotates - or "restitutes" - to face either maternal side (rather than face down as her face had delivered), allowing first one and then the other shoulder, followed by the rest of her lovely body, to slide under the pubic bone (expulsion). Beautiful! Angels sing! The Macarena plays, everyone dances in unison, arms undulating, baby crying but doing so rhythmically to the music. A successful, textbook birth!

Except when it isn't, of course. Sometimes, for whatever reason (see that bad-dance analogy above...) some of us are tone-deaf in relation to music itself, some of us unfortunately get set up for bad labor/delivery/birth experiences, some of us are blessed to be "lucky" when it comes to baby-birthin' - and (I'm a firm believer in this) some of us are just not quite as lucky. For anyone who gets set up with a bad mix of techno and 1970's country, it can get messy fast in the birthing room. Many times labor will progress veeerrrrrrrrry sllloooowwwwwwwly - but not always. Same thing for pushing - it might take hours and hours and hoooours - but not always. Usually it will be a first time mom - but definitely not always! Sometimes after the delivery of a squashed little eggplant head, it will appear to be sucked back in (the ominous "turtle sign") - but not always.

Once in a while, it seems the baby gets messed up in his dance steps somewhere. Maybe that extra "left" shoe of a pelvis coaxes him into rotating before he descends fully, or somewhere along the line something (toss in whatever you can come up with here ---- history of childhood sexual abuse? chronic low back pain? anesthesiologist who is "on the floor but ready to go home now, so if there's any laboring women who want an epidural, now is the time, and I don't care if she's only 2 cm!"? artificially-strong pitocin-augmented contractions for SROM for 24+hours sans any symptoms of infection? etc) led his mama to get an epidural rather early along the line, leading to weaker-than-expected contractions that needed to be kickstarted again after the anesthesiologist left. Wimpy uterus, lax lower abdominal and pelvic floor muscles = no resistance to encourage flexion.... ? Someone encouraging mama to push too soon ("Oh! You're 10 cm and you don't feel a thing? Let's get you pushing!") or staving off the urge to push ("No no no! Oh no you don't ---- you can't deliver here, not without Dr. so-and-so, what if you had a bay-yuh-bee?!?!") for too long?

Once you have a baby head, and no sign of shoulders emerging --- you have trouble. You call for reinforcements - as many nurses as can roll into the room (something akin to the clowns trying to fit into the tiny car, only with fewer airhorns and absolutely zero humor), your back-up provider, a stool, a pediatric/NICU team if you're lucky - and jump into the HELPERR mode. Believe it or not, this does not mean looks at your helpers and then run like crazy from the room --- but rather calmly and systematically roll through a series of steps meant to (hopefully) dislodge one-to-two sticky little shoulders from one stubborn little pelvic ridge.  After getting that extra help, think about that episiotomy (what the whaaa?), legs waaaaay back, and ask a nurse to nudge babe's shoulder from the outside; if still no-go, you have to take things to the inside (which is where the episiotomy may come in handy - the vaginal opening is only so large, and in order to introduce the bulk of your hands into it, along with sufficient room to work with the fetal body.... you may need a bit of extra space. May.), and/or try to slip the posterior arm out. For some reason, many sources list "reposition" as one of the last "R's" in the handy-HELPERR mnemonic --- even though this can often open the pelvic diameters sufficiently to allow the babe to pass without the use of the  more invasive measures, and even women with epidurals (depending on the depth of the anesthetic block) can many times do this with assistance. Anyway. As an afterthought - and I hope that it rarely, rarely happens - mnemonics usually list "replace"... as in, try to hit the "rewind" button and get the baby's head back through the vagina and cervix, and rush to an emergency (like the ultimate, beyond-emergency-emergency) cesarean.

I've got no good answers, and suppose I've rambled on far too long, and far too far from the original point of this post. Suffice it to say, shoulder dystocia is (a) need-a-bath-and-a-good-stiff-drink (except you'll probably still be on-call, so good luck with that) scary, (b) thank the heavens/god/creator/karma/blogspot/nursing directors for nursing staff trained to jump in like they do it *every* day and be amazing when it happens (as well as to switch out non-scrubbable furnishings like nobody's business), and (c) watch out for those sneaky, rotten little roly-poly babes and their shoulders; they'll get you every time! Thankfully - the majority of shoulder dystocias - when handled appropriately (which includes the provider staying cool and calm -*not* anywhere reminiscent of my prepubscent dances - and great teamwork, communication, and dedication) end with a healthy, albeit crying little pink bug (and midwife). What more could you want?

*warning: bad analogy ahead 

**Genetics, biology/anthropology, diet/exercise, knowledge, mind-over-matter, all of these or none of them, whatever - but I do believe that some of us just are "luckier" when it comes to birthing. That being said, those of us who care for birthing women have the largest responsibility in ensuring that we do all that we can to level the playing field --- avoiding unnecessary inductions, minimizing interventions, providing the education and support that's not there.