Delivering a baby; the dramatic event that is the culmination of months of waiting, anxiety, and anticipation. The excitement of learning you’re pregnant is exceeded only by the entrance of a new life into the world. It truly is an exciting event. In fact, it’s miraculous!
My first delivery was in the winter of 1968 at Marion County General Hospital in Indianapolis while in med school, and my last was in December, 1986, at St. Francis Hospital in Beech Grove, IN. Over those 18 years, most deliveries were in the first 12 years of private practice. Unfortunately, I did not keep a record of my deliveries, but in that 77 months I estimate I delivered 300-375 babies. Each month I had anywhere from 2-15 pregnant women due. The busiest month was a July when I had 15 patients deliver all in the first two weeks of the month. I lost a lot of sleep that month.
During residency, I was in the delivery room for the birth of quadruplets; the first two delivered vaginally and the last two by C-section. In my private practice, I had a patient with triplets, but I had an obstetrician deliver them. I personally delivered four sets of twins, six breech (feet or bottom first) presentations, and sadly, two stillborns. Many others required emergency C-sections for failure to progress in labor, fetal distress, or various other reasons. The OB part of practice kept me very busy.
The human species has a gestational/reproductive cycle just like every other species in the animal kingdom. But each species has its own unique gestational process. They all require the uniting of a male component with a female component to form the resulting offspring. The male provides his reproductive element (sperm) which finds its way by various means to the female element (the ovum) to form a zygote, a single-celled organism that contains the genetic information of both parents. The single-cell zygote then divides into multiple cells whose development is directed by the genetic information provided in the sperm and ovum.
Over nine months, the zygote progresses into an embryo (the stage of development during the first two months of gestation) followed by the fetus (the stage of development after two months until birth), during which time organ development occurs. When gestation (the period of fetal growth) is complete, an unknown force triggers the onset of labor during which muscular contractions of the womb (uterus) attempt to expel the fetus. This is successful 68-76% of the time. When labor is ineffective, when the mother’s bony pelvis is too small, or signs indicate the fetus is under stress, a Caesarean section is done to surgically remove the fetus. However, the majority of births occur naturally through the female birth canal.
For this blog, I will limit my remarks to the normal vaginal delivery, the event that occurs most of the time. Comments on labor, delivery, and post-delivery phases of birth will be discussed, too.
During the 9 months preceding labor and delivery, there’s a lot of waiting, testing, examining, probing, anxiety and anticipation. The positive home pregnancy test is followed by confirmation at the doctor’s office or a lab. The first prenatal visit with blood and urine tests, an ultrasound, and physical examination, is the chance to meet the obstetrician in whose hands you’re placing the responsibility for a good outcome. Over the next several months, trust is gained through monthly visits to monitor blood pressure and weight gain, check urine for protein and sugar, and ensure the fetus is growing properly. A bond of trust, comfort, and reassurance develops. Trust is very important for success in the delivery process.
At the 32nd week of gestation, visits increase in frequency. Monitoring for pregnancy-induced hypertension, diabetes, and fetal problems become more important. Ultrasounds (sonograms) assess fetal heart beat, gender, growth and organ development. At 36 weeks, weekly visits begin. Internal examination of the vagina and cervix is done to tell the doctor if the patient is readying for delivery. The cervix softens, shortens, and begins to open.
For simplicity sake, we’ll assume everything has gone normally up to this point in the pregnancy. The mother is not diabetic, not pre-eclamptic, and the baby has grown normally. The baby’s size is appropriate for a full term infant. Thus we can discuss what happens when uterine contractions begin, the cervix dilates, and the baby delivers.
It’s 3:00 am. Mrs. X notes a rhythmic tightening of her uterus accompanied by cramping pain every 12-15 minutes. She can still walk around, do her usual home activities, but after several hours, the “contractions” are coming every 3-5 minutes, are more and more painful, and normal activities are difficult. This being her first baby, she calls her doctor who suggests she head to the labor and delivery area of the hospital.
Upon arrival at the hospital, she is undressed, placed in a gown, vital signs and urine are checked, and her contractions are evaluated by an external monitoring device. She is having good contractions so an internal pelvic exam is done. The nurse reports to the doctor details of the previous information and tells him her cervix is 5 centimeters (cm) dilated. Wow! This is getting serious!
There are four stages of labor and delivery.
Stage I: Uterine contractions occur that cause shortening and thinning (effacement) and
widening (dilation) of the opening of the cervix.
Phase 1–The cervix dilates from 0 cm (closed) to 3 cm
Phase 2–The cervix dilates from 3-7 cm
Phase 3–The cervix dilates from 7-10 cm. At 10 cm the cervix is dilated completely.
The Fetus is ready for delivery.
Stage II: Mother begins pushing to prepare the infant to be delivered through the birth canal
(vagina)
Stage III: The placenta (afterbirth) is delivered.
Stage IV: Recovery. Uterus contracts, bleeding stops.
What causes labor to begin? Something, it’s not known exactly what, triggers an area of the brain (the hypothalamus) to produce a hormone in the pituitary gland called OXYTOCIN. Oxytocin (Pitocin, Syntocinon) finds its way to the muscular layer of the uterus (the myometrium) and causes labor contractions. These contractions are what expel the infant from the uterus through the cervix and vagina. When labor is artificially induced, oxytocin is the chemical given IV to make the uterus contract.
Well, since Mrs. X is in active labor and is 5 cm dilated, her labor is progressing, and an epidural anesthetic block is administered. The doctor heads to the hospital. Over the ensuing hours, her amniotic membrane (the barrier between the baby and the outside world) ruptures (her “water breaks”), the doctor checks on Mrs. X’s progress via the fetal monitor, which was applied before the epidural was given, and by periodic vaginal exams. Anticipation builds. Mrs. X has now entered a world where she is on her own. Her uterus is contracting every 3 minutes, she’s experiencing the “pain of childbirth,” and she is praying it will all be over soon. Everyone is watching! She’s being coached and encouraged, but it’s really all up to her.
During this time, the doctor is trying to catch a few winks. The nurses are watching Mrs. X closely, checking her fetal monitor, following the progress of the dilation of the cervix, and on the lookout for sudden unexpected emergencies. The doctor is notified of any changes.
By 10:00 pm, her cervix is completely dilated. It’s time to push. The nurses raise her legs, she grabs her knees, and with the encouragement of everyone in her labor room, she pushes for over an hour. Mrs. X is progressing well, but is given two hours to push before concern is raised. But her baby’s head is now visible. The vaginal area is beginning to bulge. It’s time to go to the delivery room, or if she’s in an LDR (labor, delivery, recovery) room, get ready for delivery there.
In the delivery room, the epidural block is injected again to prepare for delivery. Mrs. X is moved to the delivery table, her legs are placed in stirrups, and sterile drapes are applied. Now it’s the baby’s turn to be the focus of attention. The doctor “scrubs,” quickly dons sterile gown and gloves, and prepares his patient for delivery.
If Mrs. X can still push, she is encouraged to do so. If not, a variety of instruments are available to be attached to, or placed adjacent to, the infants head to apply gentle traction to deliver the child. An incision is then made in the vaginal opening in the direction of the rectum. Called an episiotomy, It widens the vaginal opening enough to permit an infant of any size ample room to pass through to the outside world.
The next event is God’s gift to a man and woman—a new life. The head emerges first. The doctor removes the assistive device, holds the head on both sides, and eases it out. Next, the shoulders deliver; the front shoulder first under the pubic bone, then the back shoulder over the vaginal incision. The doctor is very careful not to pull too hard and damage the neck. Bending the neck too far to either side to deliver the shoulders can damage the nerves that run from the neck into the arms. Amazingly, the shoulders squeeze together just enough to allow passage.
After the shoulders deliver, the doctor has to be alert and ready for the baby to almost squirt out! Suddenly, a wailing, kicking, wiggling, beautiful infant is born. This slippery, active, thrashing little life commands the attention of everyone nearby. All pain is forgotten. All anxiety is calmed. Joy and love fill the delivery room. Happiness and tears of joy flow, as the baby vigorously announces its entry. All attention turns toward this squirming miracle. The baby is placed on mother’s abdomen, the nose and mouth are suctioned of fluid, and the umbilical cord is clamped and cut. The baby handed off to the nurse who places him/her under a radiant warmer, wipes off the skin, wraps him up, and places him in mother’s arms. As far as the parents are concerned, that’s the end of the procedure. Once that infant is in their grasp, that’s all they remember. They are aware of nothing else from then on. A state of near euphoria exists.
For the doctor, there’s work left to be done. Blood from the umbilical cord needs to be collected, the afterbirth (placenta) must be delivered, the uterus inspected internally for retained fragments of the placenta, and the episiotomy repaired by suturing. After delivery, the uterus automatically contracts to stop bleeding, so it’s very important to be sure that happens. The uterus goes from the size of a football to a grapefruit in a matter of seconds. It’s very important to be be sure it stays small and fully contracted to control bleeding.
Mrs. X has forgotten the doctor is there and understandably so. The epidural has allowed the doctor to complete his work with no pain to Mrs. X. Beside that, she has a baby in her arms, and a tidal wave of maternal instincts is immediately unleashed.
Other than paperwork and post-partum care, the doctor’s work is done. His workday may have been extended 6 or 8 hours, his night’s sleep shortened, and his family eaten dinner without him, but he still loves his role in this joyous life event. This is what makes the practice of medicine so rewarding
Before leaving the hospital, the doctor checks on Mrs. X again, congratulates her, and heads for home or the office.
Babies are never born at a convenient time. There are three possibilities: they come during the middle of the night, during office hours, or during leisure time. It’s a certainty one of those will occur.
According to CDC statistics, however, most babies are born between 8:00 am and noon and less than 3% of births are from midnight to 7:00 am. It never seemed that way. I guess you remember those middle-of-the-night babies more than the daytime ones. Saturday and Sunday births more often occur in the late evening hours, and Monday through Friday births in the early morning hours. Interesting.
It is the conception of a fetus and the process of labor and delivery that confirms my belief that God is real. He exists to enrich our lives with children and oversees all of these events. There are just some things for which science doesn’t have a thorough explanation or understanding. We are not supposed to know these answers because only God knows and is in control. What determines which sperm unites with the ovum? How do millions of genes influence fetal growth? What triggers labor? How does an infant survive passage through a very narrow canal,? Why after nine months in a fluid environment is it suddenly able to breathe air? Where does maternal instinct and love originate? I believe it’s because we are all children of God, and He is in control of every human life.
If you disagree, I’m sorry you feel that way. If you have a different explanation, I’ll listen, but my mind is certain there are things man will never be able to explain. God, Himself, cannot be explained, but his handiwork is everywhere for us to see, and the miracle of birth is one of the prime examples. The birth of a baby is one of the happiest moments in the lives of men and women. Doctors are privileged to be able to share in that joy and participate in whatever way is needed.
Yes, it’s true, the last baby I delivered will be 34 years old in December so how can I still remember all of this accurately? It’s like riding a bicycle or swimming; once you’ve done it hundreds of times it becomes second nature. I could do again today if asked to in an emergency situation. A physician isn’t always needed. However, in the event of a complication or a difficult delivery, you want someone there who can handle whatever the crisis is.
Delivering babies is one of the happier and more rewarding moments in a doctor’s practice life. Had my two partners not decided to stop OB, I may have continued for who knows how much longer. Despite the many uncertainties and disruptions possible with delivering babies, I never felt resentment. It was an overwhelmingly positive experience that resulted in many, many loyal, long-term patients.
References: https://www.cdc.gov/nchs/products/data briefs/db200.htm
https://www.americanpregnancy.org/labor-and-birth/what-is-the-first-stage-of-labor/
https://www.wa.kaiserpermanente.org/healthandwellness/index/pregnancy/laborstages
