Better (19 page)

The nurse asked if the contractions were five minutes apart and lasted more than a minute. No. Had she broken her water? No. Well, she had a "good start." But she should wait to come in.

During her medical training, Rourke had seen about fifty births and delivered four babies herself. The last birth she had seen was in a hospital parking lot.

"They had called, saying, 'We're delivering! We're coming to the hospital, and she's delivering!'" Rourke says. "So we were in the ER and we went running. It was freezing cold. The car came screeching up to the hospital. The door went flying open. And, sure enough, there the mom was. We could
see the baby's head. The resident running next to me got there a second before I did, and he puts his arms down, and the baby went--
phhhoom
--straight into his arms in the middle of the parking lot. It was freezing cold outside, and I'll never forget the steam pouring off the baby. It's blue and crying and the steam was pouring off of it. Then we put this tiny little baby on this enormous stretcher and raced it back into the hospital."

Rourke didn't want to deliver in a parking lot. She wanted a nice, normal vaginal delivery. She didn't even want an epidural. "I didn't want to be confined to bed," she says. "I didn't want to be dead from the waist down. I didn't want a urinary catheter to have to be put in. Everything about the epidural was totally unappealing to me." She was not afraid of the pain. Having seen how too many deliveries had gone, she was mainly afraid of losing her ability to control what was done to her.

She had considered hiring a doula--a birthing coach--to stay with her through delivery. There are studies showing that having a doula can lower the likelihood a mother will end up with a Cesarean section or an epidural. The more she looked into it, however, the more worried she became about being paired with someone annoying. She thought about delivering with a midwife. But, as a doctor, she felt that she would have more control working with another doctor.

She was not feeling very much in control at the moment, though. By midday, her contractions hadn't really speeded up; they were still coming every seven minutes, maybe every six minutes at most. She was finding it increasingly difficult to get comfortable. "The way it felt best was, strangely enough, to
be on all fours," she recalls. So she just hung around the house like that--on all fours during the contractions, her husband close by, both of them nervous and giddy about their baby being on the way.

Finally, at 4:30 in the afternoon, the contractions began coming five minutes apart, and they set off in their Jetta, with the infant car seat installed in the back, her bag packed with everything that
The Girlfriends' Guide to Pregnancy
said to bring, right down to the lipstick (which she doesn't even wear). When they reached the hospital admissions desk, she was ready. Their baby was on the way, and she was eager to bring it into the world as nature had intended.

"I wanted no intervention, no doctors, no drugs. I didn't want any of that stuff," she says. "In a perfect world, I wanted to have my baby in a forest bower attended by fairy sprites."

H
UMAN BIRTH IS
an astonishing natural phenomenon. Carol Burnett once told Bill Cosby how he could understand what the experience was like. "Take your bottom lip and pull it as far away from your face as you can," she said. "Now pull it over your head." The process is a solution to an evolutionary problem: how a mammal can walk upright, which requires a small, fixed, bony pelvis, and also possess a large brain, which entails a baby whose head is too big to fit through that small pelvis. Part of the solution is that, in a sense, all human mothers give birth prematurely. Other mammals are born mature enough to walk and seek food within hours; our newborns are small and helpless for months. Even so, human birth is a feat involving an intricate sequence of events.

First, a mother's pelvis enlarges. Starting in the first trimester, maternal hormones stretch and loosen the joints holding the four bones of the pelvis together. Almost an inch of space is added. Pregnant women sometimes feel the different parts of their pelvis moving when they walk.

Then, when it's time for delivery, the uterus changes. During gestation, it's a snug, rounded, hermetically sealed pouch; during labor it takes on the shape of a funnel. And each contraction pushes the baby's head down through that funnel, into the pelvis. This happens even in paraplegic women; the mother does not have to do anything.

Meanwhile, the cervix--which is, through pregnancy, a rigid, more-than-inch-thick cylinder of muscle and connective tissue capping the end of the funnel--softens and relaxes. Pressure from the baby's head gradually stretches the tissue until it is paper-thin--a process known as "effacement." A small circular opening appears, and each contraction widens it, like a tight shirt being pulled over a child's head. Until the contractions pull the cervix open about four inches, or ten centimeters--the full temple-to-temple diameter of the child's head--the child cannot get out. So the state of the cervix determines when birth will occur. At two or three centimeters of dilation, a mother is still in "early" labor. Delivery is many hours away. At four to seven centimeters, the contractions grow stronger. "Active" labor has begun. At some point, the amniotic sac surrounding the fetus breaks under the pressure, and the clear fluid gushes out. Contractile force increases further.

At between seven and ten centimeters of cervical dilation, the "transition phase," the contractions reach their greatest intensity. The contractions press the baby's head into the
vagina and the narrowest part of the pelvis's bony ring. The pelvis is usually wider from side to side than front to back, so it's best if the baby emerges with the temples--the widest portion of the head--lined up side to side with the mother's pelvis. The top of the head comes into view. The mother has a mounting urge to push. The head comes out, then the shoulders, and suddenly a breathing, wailing child is born. The umbilical cord is cut. The placenta separates from the uterine lining, and with a slight tug on the cord and a push from the mother, it is extruded. The uterus spontaneously contracts into a clenched ball of muscle, closing off its bleeding sinuses--the expanded veins in the uterine wall. Typically, the mother's breasts immediately let down with colostrum, the first milk, and the newborn can latch on to feed.

That's if all goes well. At almost any step, the process can go wrong. For thousands of years, childbirth was the most common cause of death for young women and infants. There's the risk of hemorrhage. The placenta can tear or separate, or a portion may remain stuck in the uterus after delivery and then bleed torrentially. Or the uterus may not contract after delivery, so that the raw surfaces and sinuses keep bleeding until the mother dies of blood loss. Sometimes the uterus ruptures during labor.

Infection can set in. Once the water breaks, the chances that bacteria will get into the uterus rise with each passing hour. During the nineteenth century, as Semmelweis discovered, doctors often introduced infection, because they examined more infected patients than midwives did and because they failed to wash their contaminated hands. Bacteria
routinely invaded and killed the fetus and, often, the mother with it. Puerperal fever remained the leading cause of maternal death in the era before antibiotics. Even today, if a mother doesn't deliver within twenty-four hours after her water breaks, she has a 40 percent chance of becoming infected.

The most basic problem is "obstruction of labor"--not being able to get the baby out. The baby may be too big, especially when pregnancy continues beyond the fortieth week. The mother's pelvis may be too small, as was frequently the case when lack of vitamin D and calcium made rickets common. The baby might arrive at the birth canal sideways, with nothing but an arm sticking out. It could be a breech, coming butt first and getting stuck with its legs up on its chest. It could be a footling breech, coming feet first but then getting wedged at the chest with the arms above the head. It could come out headfirst but get stuck because its head is turned the wrong way. Sometimes the head makes it out, but the shoulders get stuck behind the pubic bone of the mother's pelvis.

These situations are dangerous. When a baby is stuck, the umbilical cord, the only source of fetal blood and oxygen, eventually becomes trapped or compressed, causing the baby to asphyxiate. Mothers have sometimes labored for astonishing lengths of time, unable to deliver, and died with their child in the process. In 1817, for example, Princess Charlotte of Wales, King George IV's twenty-one-year-old daughter, spent four days in labor. Her nine-pound boy was in a sideways position with a head too large for Charlotte's pelvis. Only after the fiftieth hour of active labor did he finally emerge--stillborn. Six hours later, Charlotte herself died, from hemorrhagic
shock. As she was George's only child, the throne passed to his brother instead of her, then to his niece--which is how Victoria became queen.

Midwives and doctors long sought ways out of such disasters, and the history of ingenuity in obstetrics is the history of these efforts. The first reliably lifesaving invention for mothers was called a crochet, or, in another variation, a cranioclast: a long, sharply pointed instrument, often with clawlike hooks, which birth attendants used in desperate situations to perforate and crush a fetus's skull, extract the fetus, and save, at least, the mother's life.

Many obstetricians and midwives made their names by devising ways to get both a mother and baby through obstructed deliveries. There is, for example, the Lovset maneuver for a breech baby with its arms trapped above the head: you take the baby by the hips and turn it sideways, then reach in, take an upper arm, and sweep it down over the chest and out. If a breech baby's arms are out but the head is trapped, you have the Mariceau-Smellie-Veit maneuver: you place your finger in the baby's mouth, which allows you to pull forcefully while still controlling the head.

The child with its head out but a shoulder stuck--a "shoulder dystocia"--will asphyxiate within five to seven minutes unless it is freed and delivered. Sometimes sharp downward pressure with a fist just above the mother's pubic bone can dislodge the shoulder; if not, there is the Woods corkscrew maneuver, in which you reach in, grab the baby's posterior shoulder, and push it backward to free the child. There's also the Rubin maneuver (you grab the stuck, anterior shoulder and push it forward toward the baby's chest to release it)
and the McRoberts maneuver (sharply flex the mother's legs up onto her abdomen and so lift her pubic bone off the baby's shoulder). Finally, there is the maneuver that no one wanted to put his name to but that has saved many babies' lives through history: you fracture the clavicles--the collar bones--and pull the baby out.

There are dozens of these maneuvers, and, though they have saved the lives of countless babies, each has a significant failure rate. Surgery has been known since ancient times as a way to save an entrapped baby. Roman law in the seventh century b.c. forbade burial of an undelivered woman until the child had been cut out, in the hope that the child would survive. In 1614, Pope Paul V issued a similar edict, ordering that the child be baptized if it was still alive. But Cesarean section on a living mother was considered criminal for much of history, because it almost always killed the mother--through hemorrhage and infection--and her life took precedence over that of the child. (The name "Cesarean" section may have arisen from the tale that Caesar was born of his mother, Aurelia, by an abdominal delivery, but historians regard the story as a myth, since Aurelia lived long after his birth.) Only after the development, in the late nineteenth century, of anesthesia and antisepsis and, in the early twentieth century, of a double-layer suturing technique that could stop an opened uterus from hemorrhaging, did Cesarean section become a real option. Even then, it was held in low repute. And that was because a better option was around: the obstetrical forceps.

The story of the forceps is both extraordinary and disturbing, because it is the story of a lifesaving idea that was kept secret for more than century. The instrument was
developed by Peter Chamberlen (1575-1628), the first of a long line of French Huguenots who delivered babies in London. It looked like a pair of big metal salad tongs, with two blades shaped to fit snugly around a baby's head and handles that locked together with a single screw in the middle. It let doctors more or less yank stuck babies out and, carefully applied, was the first technique that could save both the baby and the mother. The Chamberlens knew they were onto something, and they resolved to keep the device a family secret. Whenever they were called in to help with a mother in obstructed labor, they ushered everyone else out of the room and covered the mother's lower half with a sheet or a blanket so that even she couldn't see what was going on. They kept the secret of the forceps for three generations. In 1670, Hugh Chamberlen, in the third generation, tried and failed to sell the design to the French government. Late in his life, he divulged it to an Amsterdam-based obstetrician, Roger Roonhuysen, who kept the technique within his own family for sixty more years. The secret did not get out until the mid-eighteenth century. Once it did, it gained wide acceptance. At the time of Princess Charlotte's failed delivery in 1817, her obstetrician, Sir Richard Croft, was widely reviled for failing to use forceps to assist. In remorse for her death, he shot himself to death not long afterward.

By the early twentieth century, the problems of human birth seemed to have been largely solved. Doctors could avail themselves of a range of measures to ensure a safe delivery: antiseptics, the forceps, blood transfusions, a drug (ergot) that could induce labor and contract the uterus after delivery to stop bleeding, and even, in desperate situations, Cesarean
section. By the 1930s, most urban mothers had shifted from midwife deliveries at home to physician deliveries in the hospital.

But in 1933 the New York Academy of Medicine published a shocking study of 2,041 maternal deaths in childbirth in New York City. At least two-thirds, the investigators found, were preventable. There had been no improvement in death rates for mothers in the preceding two decades; death rates for newborns had actually increased. Hospital care brought no advantages; mothers were better off delivering at home. The investigators were appalled to find that many physicians simply didn't know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps. The White House followed with a similar national report. Doctors may have had the right tools, but midwives without them did better.