Swimmer’s position
As a third-year medical student on my first OB-Gyn rotation, I was sent to examine a mother in labor, to see if I had understood my studies of how to correctly perform an exam and gauge the progress of a woman in labor. My job was to perform a gentle vaginal exam and to feel and estimate how far how far the mouth of the womb had opened and how close to the pushing stage of labor the mother might be.
This Mom-to-be had been close to fully dilated less than an hour ago, and she had told the nurses to get the doctor, because “something was definitely happening down there.” Imagine my surprise and alarm when I lifted the sheet from the slightly parted knees of this semi-reclined mother-to-be, and saw a small, perfect hand protruding from her introitus.
This baby was in “swimmer’s position”, with one arm extended above her head, much like a freestyle swimmer, literally reaching for the light of day. It’s not hard to see that an infant cannot be safely delivered vaginally in this attitude. I ran to my the attending, who was sipping coffee at the nursing station, and excitedly announced my findings and offered my opinion that this mother would need to be taken to the OR for a C-section.
“Hmm…” the attending murmured calmly, ”Well, let’s see, shall we?” He confirmed my findings at the bedside, then turned to the table where the instruments for delivery were laid out and ready. He put on gloves, and selected a pair of small sterile forceps—essentially a pair of tweezers about the appropriate size to pluck the eyebrows of an orangutan. Gently, he applied the tweezers to the pad of the fetus’ index finger and gave the finger a small pinch. In a flash the hand was withdrawn from this noxious stimulus, apparently all the way back to the normal position, as a second manual exam revealed only the small round ball of the head presenting to be born. This mother went on to deliver normally, and I was amazed by the “magic trick” I had seen.
Too Tiny
A troubled teen, 15 years old, had always had difficultly learning at school. Overwhelmed, frustrated and shy, she fell in with a bad crowd of older teens, who found her compliant and easily led. After several months of this association, she accompanied her so-called friends to a “party” in a sketchy part of downtown, and never came home.
Her distraught mother, after desperate searching, finally found her daughter three months later in another city. Mother brought daughter home-the young woman was now nearly mute, traumatized, unable to tell her mother anything about what had occurred during her time away from home. Mom barely had time to help her daughter shower (“she was filthy, Doc”) and feed her a first hot meal, before the rescued runaway began complaining of period cramps. The unusual severity of her pain and some leakage of fluid as well as fresh blood led the alarmed Mom to bring her daughter to an Urgent Care, from which we received an urgent call. The attending doc from the free-standing clinic called ahead to our big city Labor & Delivery to apprise us of the situation. As the intern on call, I took all outside communications. The doctor sounded both startled and concerned.
“She’s in labor, about 4 cm dilated, I have no ultrasound, so I can’t tell you much about the fetus’s size, but on examining her abdomen, I would guess she’s about 6 months along. I just now put her in the ambulance to you.”
When the ambulance arrived, there was no time for more than a brief assessment-daughter was already pushing. On exam I felt a tiny head just about to emerge from the birth canal. At that time, (mid-1980’s) the borderline between survivability and demise was from about 27 to 29 weeks gestation and this baby’s head felt smaller than that of the 27-weekers’ I had helped care for during my current day rotation in the Neonatal Intensive Care Unit (NICU).
I tried to explain all this quickly to the shell-shocked grandmother-to-be and the stoically laboring teen mother.
“Mara is having a baby for sure (the Mom had disbelieved the doctor at the Urgent Care), but this baby feels very young and tiny. I must tell you that this baby may be too young to survive even with the best care we can give.”
I thought it was necessary to let the patient and her Mom know that this delivery was dangerously premature, and to voice my honest fears, as Grandmom seemed to expect a full-sized newborn.
Next thing, I held the diminutive infant in my palm. Too tiny. My heart fell. Yet, he filled the room with shrill, enthusiastic mouse-squeak cries and moved all his little limbs. The Neonatal Resuscitation Team hadn’t even had time to get upstairs to the bedside. I tied and cut the cord, administered “blow-by” oxygen, and gently dried the baby as he lay in the warmer.
“Will he be okay?”
Grandmom looked to be on the verge of fainting. The nurses hurriedly sat her in a chair, helped her put her head between her knees and put an ice-pack on the back of her neck. Still, she craned her head to see the newborn boy in the warmer. Her face was lined with worry.
“I am so sorry, he is very, very small and premature. We will do all we can, but I must tell you, he looks too little to live.”
I felt it was imperative not to give false hope, as the infant’s thin, translucent skin thru which veins were visible, sparse black hair (once dried, he had a little cowlick on his crown!) and matchstick thin limbs all bespoke his severe immaturity. Yet the little guy continued squeaking with all his might, as if to put the lie to my words. The NICU team arrived and swarmed him, while I tried my best to comfort the stunned new grandmother and the resolutely silent new mother, as I delivered the afterbirth, and massaged new Mom’s uterus to stop her bleeding.
The Neonatal Intensive Care Unit staff nick-named the little boy Alfalfa, after the Our Gang star of old, for his endearing cowlick. Those spiky hairs persisted, grew, and made him a standout among the rest of the very premature.
In my day rotation I functioned as the NICU intern, so I was assigned to the team that cared for Alfalfa, which bonded me to this family and made me a big fan of and fervent cheerleader for the little guy. Although his prognosis was poor, Alfalfa proved to be made of strong stuff, though he had a rough time. An early small stroke, respiratory distress, worries about oxygen toxicity and infection…it was a harrowing experience for Grandmom and Mom, as well as his invested young intern. Grandmom came nearly every day, in between transporting his young mother to counselling and social work visits.
After about a month, young Mom began to visit as well. Over the weeks, I noticed her blank thousand-yard stare gradually gave way to tender glances at her son and shy smiles. She hung over the medical bassinette and looked at her doll-like, intubated and Saran-wrapped boy, and touched his arm, which sported a blood pressure cuff the size of a Band-Aid.
On the day the Mother-Daughter duo finally were able to bring Alfalfa home, the NICU staff provided cake and punch. Young Mom placed him proudly in a carrier that dwarfed him, and Grandmom anxiously attended them. Alfalfa went on to do well, after everything he’d endured, with no significant sequelae from his early stroke, minimal lung damage and with preserved vision and hearing.
I understand that subsequent advances in care can now save infants born even weeks earlier in gestation than Alfalfa had been, but at the time, Alfalfa truly was a “miracle baby.” We were all astonished and gratified that he survived intact, and I never will forget his persistent and brave cries at birth, even as I told his family he would likely not survive.
“You’re mistaken, Doc! I’m gonna make it!”
This is what I hear now when I remember his birth. I’ve never been more happy to be wrong.
Paula Lyons, MD
5/20/21
As context:
One of the most exciting, rewarding, and occasionally scary of all medical adventures is the birth of a baby. As a medical student I thought I would specialize in Ob-Gyn. I took extra clinical rotations in this specialty during my third and fourth years of medical school and actually began an Ob-Gyn residency after graduation, though I went on to complete my training in Family Practice instead. I’ve been at the bedside assisting or delivering approximately 150 babies via regular vaginal birth or C-section, counting my cumulative experiences as a medical student, resident physician and attending in both Ob-Gyn and Family Practice settings. So, naturally, I’ve collected a series of anecdotes about childbirths I’ve witnessed- and think of these most memorable events as very Special Deliveries. I thought I’d share some with you, a few at a time.
Paula Lyons, MD
12 Responses
How lucky you are to have experienced this magnificent event, the overcoming of all obstacles. It has to balance all those times when the outcome was different.
It does!
Special deliveries. Special stories.
Remarkable! Not for the faint of heart.
I remember when Ethan was born. Her water broke at one of our early birthing classes. A definite “This, class, is what you definitely don’t want to have happen” moment. Upon emergency ultra sound we were informed that he may be as small as 2 1/2 pounds when delivered. Told that the hospital we were in couldn’t handle that, she was whisked off to a hospital in the big city by ambulance. I was not allowed to ride with them and had to follow in my own vehicle. Upon arrival and some crazy hours in between he was delivered. He was actually 3 lbs 14 ounces when they whisking him out of the room after delivery. We were told soon after that he was breathing on his own, and he was soon brought back in for us to see and hold. Soon his mother began to go down hill. The result of a massive blood clot due to a previously unknown medical condition. (Possibly the reason she went into labor so early?) My life began to crash down around me. It became weeks of my wife in intensive care on one side of the hospital, and my small son in the NICU on the other side of the hospital. Splitting time between the two, I neither slept much nor ate much. But I do remember one fateful day, when two things really changed my perspective. First, was a kind NICU staff member, who seeing a scared young father leaning over his son tried to alleviate some of my fear. “Look,” she said. “Your son is breathing on his own. He needs no other medical support other than some help with a feeding tube. He may be small, but he’s strong!” She then took me on a short tour of the NICU, pointing out the fact that of the dozen or so infants there at that time, Ethan was by far the biggest and strongest, needing the least medical support. “He just needs to put on some weight. He’s gonna be fine!” Her gentle words and warm smile immediately eased my worried soul a bit. The second happened as I left the NICU that same evening, I was headed down the elevator en route to the ICU to see my wife, when the doors opened at another floor and a man and his daughter got on the elevator. He was not much older than me I guessed. He smiled slightly at me as he entered saying a quiet “hello.” He had his arm protectively around his young daughter’s shoulders. She was small. I guessed around 6 or 7 years old. She was wearing pajamas, fuzzy slippers, and a hospital gown. From her arm protruded several IV tubes, which snaked up to several fluid filled bags on a tall metal IV stand with wheels. This she held on to and pulled along with her as she walked slowly with her father’s help. The fact that she was completely bald told the story of why she was in the hospital. She looked up at me and gave me a weak smile. I was so taken with the brave strength both she and her father showed on their faces, as I returned their smiles and their greeting. They only went to the next floor where they just as carefully exited the elevator leaving me alone once more. I instantly began to cry. Weeks of stress and worry pouring out of me in a sudden mix of emotions. I remember thanking god that my child was small but strong and mostly healthy. I could only imagine what that other father must be going through. And for some reason I felt guilty that I was so worried about my son, when this other father had so much more reason to fear. I remember exiting the elevator and making a dash for the nearest men’s room where I stayed sobbing until my emotions were in check enough to wash my face and pull myself together. I spent a ragged month going back and forth between those two hospital units, until we were able to finally go home with both mother and son healthy. I was emotionally spent, but I was never as fearful as I was before that day. I hope you don’t mind me sharing such a long post. This is YOUR blog after all. I don’t want you to think that I’m trying to hijack it all the time. I just wanted to tell you what your story made me think of and feel. Love you!
Rich, Thanks for sharing your experience regarding Ethan’s birth. It was harrowing, and you tell it very well. It’s amazing to hear about the cognitive shifts you underwent in a very short, nerve-wracking time. Kudos to that wonderful NICU nurse! They are heroes for sure. So are the daughter/Dad pair you saw, showing the bravery that parents and children display in the face of one of the worst monsters ever, childhood cancers. There have been so many advancements in that field in the last decades that we can hope that she and her father are alive and well.
Rich, thanks so much for sharing that raw emotional rollercoaster of an experience that was Ethan’s birth! Wow! Don’t feel bad about hijacking, i chimed in too! : )
Rich
I never knew about that story when Ethan was born. He made it and is now a great kid getting ready to enter college.
and you’re right. Paula is a great Doctor.
Biggie
Your niece, Hayden Grace, as you remember, was just 4lbs 4oz at her 36-37 week birth. I was told on my 1st appointment with my brand new OB, the day after we moved to Chatt, “this little one has to come out now, you have very little amniotic fluid.” What was left of my “waters” was manually broken and the baby started to have decels on the fetal monitor. They hung a bag of saline, place the fluid line into my womb and let it flow. Magically, the HR evened out as it filled my “bag” back up, a trick i hadn’t even heard of. We knew she was going to be small, so we summoned all of my former PICU RN and Marc’s peds residency buddies who were available when it was time to head to the OR, just in case. My MD said, “Okay, let’s just give a practice push and see how the baby responds. One push and out she came! We had to feed that tiny little mouth by syringe for about 3 days before she coordinated her suckle. I even have a pic of Poppop feeding her with a 10cc syringe : ). Best part? Mom & Lis were already on their way that day, as Lis was about to leave for Germany for 2 years. They came to the hospital to see us, then got to work unpacking the uhaul with Vanessa, my new 14 yr old neighbor’s kid, who would be the only sitter we ever had for all 3 kids and Will’s godmother. Serendipity abound!
Definitely another VERY special delivery! And just look at her now, all grown and beautiful!
Your dad told me I ought to check this post out! Glad I did, Paula! Your story reminds me of a phone call we received over 20 years ago to come to Kosair’s Chidren’s Hospital in Louisville, KY. A very young mother from our church had delivered her baby early, so early that he only weighed one pound! The caller asked us to come and pray for this tiny newborn. We had been in ministry for a while, but believe me, this was a totally new experience for us! After scrubbing up and putting on all the sterile coverings and gloves, we entered the preemie ward. Incubators everywhere with little ones. But nothing quite like this special newborn. He could have been a purple hatchling with his translucent skin as though he came straight out of a cracked open egg! Maybe it would have been a fainting situation for one of us, but no. God was with us. We began stretching out our gloved hands and touching this baby with prayers lifted to heaven. It was honestly one of the most spiritual experiences of my life … The report was that the little baby boy probably wouldn’t survive, and if he did, he would be blind and deaf, mentally challenged. Not this time. Not for this one. He now has grown up to be a normal functioning young man by the grace and goodness of our God. Your story reminded me that more often than not, God shows up. I just want to remember that today. Thanks, Paula!
Thanks for sharing your inspiring experience, so well-described! Yes, the perils these premature babies face are truly frightening. Advances in NICU care have improved their chances of surviving intact as the little guy you describe did. Still, nothing medical technology has discovered is quite as good as the mother’s womb, so well-designed by our Creator. Thanks for reading!