THE ALMOST DEAD WOMAN
By Martina Nicholson MD
Paraguay
Peace Corps, 1972-74
The almost dead woman came from seven leagues away, on an oxcart, on a Sunday afternoon. Dr. Orihuela came to our house to find me, to ask for my assistance, as all of the nurses were home with their families at farms outside of town that day. He told me she was in obstructed labor for 4 days, and that the baby had died inside, and that she was moribund. He said maybe a cesarean section would save her life; he wasn’t sure. It might be just too late. Still, the family had brought her, and he thought he should try. Of course I said I would help, but since I never had seen or assisted at surgery before, that he would have to tell me what to do. We went to the Centro de Salud, stopping to get the dentista on the way; this fellow had learned the art of dripping ether onto a gauze-covered strainer over the patient’s face— and thus was our anesthesiologist.
Dr. Orihuela had been trained at the Adventist hospital in the capitol, and he had meticulously taught some willing young women to be nurses, and to sterilize and keep the OR things ready for surgery. We had the pink alcohol which was used for lighting lamps, and yards of muslin bandages. All of the instruments were sterilized in an antique but functioning sterilizer. The OR was lit with sunlight, and one bare bulb.
We carried the moaning and glazed-eyed woman into the OR and put her on the table. The anesthesiologist put some ether over her mask. I was told to be careful not to breathe too closely to it. I remember how hard it was to get the uterus clean from the thick pea-soup meconium. The dead baby was removed. I realize now it was a classical uterine incision. Vertically cut into the muscle, at the top the uterus is so thick that it is very difficult to stitch together again, even in healthy tissue. This tissue was inflamed and wooden. The stitches kept tearing through. Dr. Orihuela worked carefully and as quickly as possible. When the anesthesia became too light, I would lean my arm against the patient’s thighs to keep her from writhing off the table. When she fell too deeply asleep, Dr. Orihuela would tell the anesthesiologist to take the mask off and let her breathe for a while, real air. Finally, all the layers were done, the skin was closed and bandaged. Beads of sweat were on my forehead, and my nose itched through the surgical mask. I helped lift the patient and carry her to the post-partum bed. Her urine was red as cranberry juice, and the doctor thought she was going to die of kidney failure or possibly lack-of-blood-clotting problems.
I could not sleep all night; I prayed she would live. The doctor’s wife, Na Irma, told me that one problem is that the patients would wait too long to come; and if they died, other people would believe the hospital was a place for dying, not a place to be saved and to become healthy. They would blame the doctor, instead of understanding that the disease was too advanced. She told me that when a patient is cured, people always thank God; but when a patient dies, they blame the doctor.
I paced in my room, and before dawn, I walked back to the Centro de Salud. The woman had a catheter, and the bag for urine was now full of pale yellow liquid instead of red wine-colored urine. The doctor came in early, too. She was very pale, but he said she would live. He took her in the VW van to the capitol, to get a blood transfusion. He said it would help her not to get a puerperal infection.
Two weeks later, I was giving my morning charla to the waiting patients at the Centro de Salud. A rosy-cheeked young woman walked up to me and said “Hello, doctora Martina!” and looked expectantly at me. I looked blankly, trying to recall ever seeing her before. “Don’t you remember me?” she queried, “I’m the patient whose life you saved! I will never forget you.
Twenty three years later, I am an Ob-Gyn. I have done many cesarean sections since, but none with a clearer sense of its life-saving potential. My desire to become an Obstetrician was born that day, and I have told this story many times to explain why I became a doctor. I have never regretted the long path it took to get me to where I could be able to perform such a service. I have also never forgotten how Dr. Orihuela had diligently and quietly prepared for that day. Without his foresight, there would have been no sterile equipment, no clean and functioning OR, no electrical generator and running water in the Centro de Salud. Almost alone among Peace Corps Volunteers, I was working for a physician who cared deeply about public health and was doing the best he could to be like the Johns Hopkins missionary physician who trained him. One looks back with gratitude to mentors who were truly men of great stature, and I will always be grateful that I worked in Ybycu’i under Dr. Orhuela’s great example.
Wednesday, April 8, 2009
Saturday, April 4, 2009
Women who write
I am finishing the 3rd book of poems, and working hard on the figuring out of the title. I will post it as soon as I am sure of it. Today's Writer's Almanac says that men like women who write. It is probably not true in my case. My husband is not glad that I say anything to anyone about him. He believes in privacy and anonymity, and considers me like a leaky faucet in his life. He is not happy about it, but he has continued to let me live, while he grumbles.
In my AlAnon group, once after a meeting, several women were visiting together. One woman said that she has known married men to "hit on" women in the group, even when it is inappropriate. I said that it is good that we have been sort of encouraged to have same-sex sponsors, so that it will help us to maintain healthy boundaries, when we have not been good at boundary-setting before. I admit, I have been an amoeba to other people's needs. After the conversation, I went on thinking about this issue. I think the men in the group are very privileged to hear women's inner thoughts. We don't talk back, or "cross-talk" or counsel. We simply listen. So some women, working on an issue inside their own minds, are laying out their thinking in a "safe place" for the first time. Many women came from homes with a tremendous amount of emotional abuse, and were completely shut down and unable to allow themselves to communicate beyond a bare survival level. We see this all the time in the places where life is more primitive, and the gender roles more restrictive. The way we have structured the 12 Step meetings, people are encouraged to share their experience, strength and hope. This allows everyone access to our insides. Which is a sort of emotional penetration, which others in the group are privy to, without having to know the person well, or do any connecting work. I realize that there is still some "weight" attached to the issue of gender. The other day we were talking after surgery with some nurses who are like me, with grey hair and a couple of decades of "health care" experiences. I was remembering how it felt to walk into the surgical lounge during the Anita Hill/Clarence Thomas hearings. The guys were incredulous that this should be happening on tv, to someone who was being vetted for the Supreme Court. We still had a few guys who were up until that time telling off-color jokes, or teasing nurses, or flirting a bit too outrageously. That was the beginning of the wake-up call, I think, for a lot of the guys to watch what they were doing, and be more respectful in their manners and speech. Most of the men I have known have been respectful in their thinking, but some of their behavior was a bit rough; and they have learned the necessary lessons for acting more professional and reasonable and respectful in the workplace.
Now, we also have a lot of women writing, and "spilling their guts" in various formats. So it is an interesting thing to think about the question of whether men love women who write, or are alarmed, or just entertained by it. It certainly is a way to talk about the emotional contents of our thoughts, and we are able to give someone an extensive insider's tour of our minds, without having to face us across the breakfast table, or discuss the household tasks, or to undress or touch in any physical way. So there will be voyeurs, and there will be some interested bystanders who go home and understand their own wives and daughters better, and some for whom this is a major form of learning about human nature.
I was thinking about Chekhov. He has always been a wonderful model of a physician to me, although most people think of him as a writer. He is so thoroughly looking at the patient, and the forces acting on the patient, and the milieu in which the patient exists, that one can practically name all the medical diagnoses in the people of his stories. Once I read a fascinating article about writers who are so graphic at describing reality that even a disease which was not yet known at the time of the writing can be inferred from a description by one of these writers.
It remains interesting to me that most of the male writers write about men with more clarity than they do about women. Women are often written more as an "object of affection" or interest, rather than from the inside, in novels from the previous centuries. And also, women had the handicap of less education, so often their thoughts could not be as complex as the thoughts of men, and be believable. It remains to be seen whether there will be a new sort of gain from the women writing now, into the interiors of women's minds, not just as romantic partners, but as independent thinkers and interesting people to know. And sort of a side issue, is whether this "window into the interiors of the womens' minds" will yield a new level of friendship and integration of self and other, and interactions with both men and women.
In my AlAnon group, once after a meeting, several women were visiting together. One woman said that she has known married men to "hit on" women in the group, even when it is inappropriate. I said that it is good that we have been sort of encouraged to have same-sex sponsors, so that it will help us to maintain healthy boundaries, when we have not been good at boundary-setting before. I admit, I have been an amoeba to other people's needs. After the conversation, I went on thinking about this issue. I think the men in the group are very privileged to hear women's inner thoughts. We don't talk back, or "cross-talk" or counsel. We simply listen. So some women, working on an issue inside their own minds, are laying out their thinking in a "safe place" for the first time. Many women came from homes with a tremendous amount of emotional abuse, and were completely shut down and unable to allow themselves to communicate beyond a bare survival level. We see this all the time in the places where life is more primitive, and the gender roles more restrictive. The way we have structured the 12 Step meetings, people are encouraged to share their experience, strength and hope. This allows everyone access to our insides. Which is a sort of emotional penetration, which others in the group are privy to, without having to know the person well, or do any connecting work. I realize that there is still some "weight" attached to the issue of gender. The other day we were talking after surgery with some nurses who are like me, with grey hair and a couple of decades of "health care" experiences. I was remembering how it felt to walk into the surgical lounge during the Anita Hill/Clarence Thomas hearings. The guys were incredulous that this should be happening on tv, to someone who was being vetted for the Supreme Court. We still had a few guys who were up until that time telling off-color jokes, or teasing nurses, or flirting a bit too outrageously. That was the beginning of the wake-up call, I think, for a lot of the guys to watch what they were doing, and be more respectful in their manners and speech. Most of the men I have known have been respectful in their thinking, but some of their behavior was a bit rough; and they have learned the necessary lessons for acting more professional and reasonable and respectful in the workplace.
Now, we also have a lot of women writing, and "spilling their guts" in various formats. So it is an interesting thing to think about the question of whether men love women who write, or are alarmed, or just entertained by it. It certainly is a way to talk about the emotional contents of our thoughts, and we are able to give someone an extensive insider's tour of our minds, without having to face us across the breakfast table, or discuss the household tasks, or to undress or touch in any physical way. So there will be voyeurs, and there will be some interested bystanders who go home and understand their own wives and daughters better, and some for whom this is a major form of learning about human nature.
I was thinking about Chekhov. He has always been a wonderful model of a physician to me, although most people think of him as a writer. He is so thoroughly looking at the patient, and the forces acting on the patient, and the milieu in which the patient exists, that one can practically name all the medical diagnoses in the people of his stories. Once I read a fascinating article about writers who are so graphic at describing reality that even a disease which was not yet known at the time of the writing can be inferred from a description by one of these writers.
It remains interesting to me that most of the male writers write about men with more clarity than they do about women. Women are often written more as an "object of affection" or interest, rather than from the inside, in novels from the previous centuries. And also, women had the handicap of less education, so often their thoughts could not be as complex as the thoughts of men, and be believable. It remains to be seen whether there will be a new sort of gain from the women writing now, into the interiors of women's minds, not just as romantic partners, but as independent thinkers and interesting people to know. And sort of a side issue, is whether this "window into the interiors of the womens' minds" will yield a new level of friendship and integration of self and other, and interactions with both men and women.
Monday, March 30, 2009
Pray 5 times a day
Let us pray five times a day
In Spanglish
And in Frerabic,
Let us pray five times a day:
To the God who is running things,
God Almighty, Yahweh, Allah,
Jesus and Mohammed and Buddha,
And the Holy Spirit,
The God who is letting things flow,
Evolve, bloom, grow,
Alpha and Omega,
Brahma/ Vishnu/ Shiva,
And any other of the million holy names,
Whether you believe or not,
In a higher power—and saving grace,
Pray:
Pray five times a day;
In solidarity
With the known and the unknown,
The great mystery,
Let it be, let it be, let it be, let it be…
With acceptance and actions,
Bliss/ Consciousness/ Energy
Green grass daily rising,
Breath on breath,
Galaxy beyond galaxy,
Singing Psalms, or Om,
With all our alphabets,
Our metaphors and murmurings,
Quintessential praise and thanksgiving;
Five fingers touching,
Five toes dancing,
Five senses playing together,
Five Benedictine and Islamic prayers—
The rhythm moving through life for
At least five centuries,
Five decades of a life,
Five times a day
In Spanglish
And in Frerabic,
Let us pray five times a day:
To the God who is running things,
God Almighty, Yahweh, Allah,
Jesus and Mohammed and Buddha,
And the Holy Spirit,
The God who is letting things flow,
Evolve, bloom, grow,
Alpha and Omega,
Brahma/ Vishnu/ Shiva,
And any other of the million holy names,
Whether you believe or not,
In a higher power—and saving grace,
Pray:
Pray five times a day;
In solidarity
With the known and the unknown,
The great mystery,
Let it be, let it be, let it be, let it be…
With acceptance and actions,
Bliss/ Consciousness/ Energy
Green grass daily rising,
Breath on breath,
Galaxy beyond galaxy,
Singing Psalms, or Om,
With all our alphabets,
Our metaphors and murmurings,
Quintessential praise and thanksgiving;
Five fingers touching,
Five toes dancing,
Five senses playing together,
Five Benedictine and Islamic prayers—
The rhythm moving through life for
At least five centuries,
Five decades of a life,
Five times a day
Monday, March 23, 2009
WILPF
I am a member of the Women's International League of Peace and Freedom. This month the newsletter has a great article on how Linus Pauling, and his wife, Ava Helen Pauling, made such a difference, and helped get the Atmospheric Test Ban treaty of 1963 signed. But also, women all over the country helped by bringing up the issue, having local parties to educate other women about the potential harmful effects of radioactive fallout on children and other humans, and putting together a Women's Strike for Peace. There is also a great article about childrens' books which get the Jane Addams award for violence prevention. This is a deeply conscious way of making people realize that the prevention of violence demands that we keep teaching ways to promote conflict resolution skills, and ways to work toward constructing peace by reducing prejudice and other sources of potential conflict. You can access the toolkit for these books by going to www.janeaddamspeace.org. Click on "about children's book awards" and then click on "building Wilpf". I firmly believe that only when mothers across the country and the world begin to demand peace and safety and better diplomatic solutions will we finally make headway against the culture of perpetuating violence and weapons.
I also deplore the news that the Iraq war has obliterated what was previously one of the best health care systems in the middle east. Besides the loss of clean water and electricity, and all hospital equipment, and medical personnel who fled the country as their lives were endangered, the escalation of PTSD has made increasing demands; and 70% of the victims of violence die because of inadequate resources at the hospitals.
We can do better in helping the world to become a better place. We need to continue to push our government to help build infrastructural support, and peace-making activities.
There is also an article about Rwanda. I am very interested in Rwanda, because Paul Farmer MD and his organization, Partners in Health, have made a commitment to try to build a whole national infrastructure of health care with them, following the model he used in Haiti. One of the crucial issues in any poor country is water, Getting a safe water supply for drinking, and making sure the waste is safely disposed of are the first basic and very important issues of public health. It will be very interesting to see how Rwanda does, with the NGO support; and WILPF is very interested in helping secure local and safe water supply.
I encourage you to join WILPF!
I also deplore the news that the Iraq war has obliterated what was previously one of the best health care systems in the middle east. Besides the loss of clean water and electricity, and all hospital equipment, and medical personnel who fled the country as their lives were endangered, the escalation of PTSD has made increasing demands; and 70% of the victims of violence die because of inadequate resources at the hospitals.
We can do better in helping the world to become a better place. We need to continue to push our government to help build infrastructural support, and peace-making activities.
There is also an article about Rwanda. I am very interested in Rwanda, because Paul Farmer MD and his organization, Partners in Health, have made a commitment to try to build a whole national infrastructure of health care with them, following the model he used in Haiti. One of the crucial issues in any poor country is water, Getting a safe water supply for drinking, and making sure the waste is safely disposed of are the first basic and very important issues of public health. It will be very interesting to see how Rwanda does, with the NGO support; and WILPF is very interested in helping secure local and safe water supply.
I encourage you to join WILPF!
Sunday, March 22, 2009
Mysteries in my world
Yesterday there was a loss of a 21 week fetus, in a family who really wanted the baby and were grief-stricken by the loss. It is always a sad and hard thing, when these miscarriages happen, in the time before a baby is actually big enough to be helped by care in the intensive care unit. This little person, a boy, was so small, and so fragile, that we could not blow air into his lungs sufficiently to help him be able to exist outside the womb. My colleague, the perinatal specialist, had told the parents that we sometimes do not know why babies come too soon, that it may be that they get confused, their timing is off, and they are born too early. Maybe it is about the immune system, but we just don't always have a good answer to that heartbreaking question "why?"
Still, the fact that it happens, as in this family, sometimes makes a couple have a stronger love and devotion to each other, as they have lived through this suffering together, and have comforted and supported each other. So it sometimes happens that I believe I can see an outcome which is a good thing, from such a sad event. For a young couple with their whole life ahead of them, something like this is often the first truly hard thing they have ever had to bear. Still, it is a deep mystery.
Today I had a 16 year old mom, who did a magnificent job of pushing her baby out. She re-confirmed my opinion that being young is just such a big help for the muscle-tone and work of labor. Who knows how her life will go, and I am sure it will not be easy to have had this child so young. But my experience has often been that these young mothers are devoted and good moms, and get their lives "on track" precisely in order to help meet their children's needs. Again, it is a deep mystery, and sometimes very much against the beliefs and the conventional wisdom of our time.
Asking for help, being humble, and just trying to do what is required, one day at a time, are a big part of finding one's way in the world. Spilling blood is part of the work of having babies. Sometimes it seems so beyond-comprehension, and other times as easy as "falling off a log". I just keep hoping that the spilling of blood will not be in vain.
Still, the fact that it happens, as in this family, sometimes makes a couple have a stronger love and devotion to each other, as they have lived through this suffering together, and have comforted and supported each other. So it sometimes happens that I believe I can see an outcome which is a good thing, from such a sad event. For a young couple with their whole life ahead of them, something like this is often the first truly hard thing they have ever had to bear. Still, it is a deep mystery.
Today I had a 16 year old mom, who did a magnificent job of pushing her baby out. She re-confirmed my opinion that being young is just such a big help for the muscle-tone and work of labor. Who knows how her life will go, and I am sure it will not be easy to have had this child so young. But my experience has often been that these young mothers are devoted and good moms, and get their lives "on track" precisely in order to help meet their children's needs. Again, it is a deep mystery, and sometimes very much against the beliefs and the conventional wisdom of our time.
Asking for help, being humble, and just trying to do what is required, one day at a time, are a big part of finding one's way in the world. Spilling blood is part of the work of having babies. Sometimes it seems so beyond-comprehension, and other times as easy as "falling off a log". I just keep hoping that the spilling of blood will not be in vain.
Thursday, March 5, 2009
Santa Clara University
Anyone who knows me knows that I loved being at Santa Clara, and am very proud to be an alumna of this great Jesuit school. I loved studying philosophy, and liberal arts, and especially Humanities, as taught by Christiaan Lievestro. Dr. Lievestro was the first person besides my own father who tried to help me learn to align the history, art, music and literature of a period, and to recognize cross-currents from one author to another, across different languages and cultures. I first fell in love with philosophy by learning from Austin Fagothey SJ, who was by then an SCU institution of higher learning, and awesome self-discipline and clarity. I was graced that the university allowed me to take a course about Teilhard de Chardin taught by Fr. Fagothey in the spring of my sophomore year-- they let me take it because I was going to be away in Vienna for Junior Year, and he would not teach it again till the year after I graduated. Fr. Fagothey had a bit of the old man's falling in love again with God, as he read Teilhard with us. It was a priceless thing, to be in his seminar. I also loved studying under Fr. Timothy Fallon SJ, who taught me metaphysics. In those days, we had to go to the professor and ask to be admitted to their class. So when I asked, I already knew that I would be leaving for the Peace Corps in South America two weeks after graduation in June. And this class was for the last quarter of my time at SCU, in the spring of my senior year. So I asked Fr. Fallon if Metaphysics would be helpful to me in Paraguay. And he answered graciously, with the full force of his leprechaunish humor, "My dear, it's the only thing that will!"
I am very grateful for being taught about Bernard Lonergan, and the metaphysics of Lonergan's "Insight". I took the book with me to Paraguay, and I still think of the basic premise, once in awhile, that "being is the objective of the pure desire to know." And I think of how he presented the way there is a heuristic structure of knowing, and that increased knowledge is pushing back the frontier of the unknown little-by-little, as the data and knowledge pour in.
Today I got the Santa Clara Magazine, and the goodbye note from Fr. Locatelli. He is going to Rome, to be the secretary of higher education for the Jesuits, which is the only organization which currently has a worldwide system of schools and universities. He will begin to coordinate a global structural network. In the weeks ahead, there is going to be a summit among Jesuit educators, addressing some of the themes for faith and justice from within education. The themes Fr. Locatelli says they will address are pretty instructive:
1) migration and refugees
2) faith, understanding and interreligious dialogue
3) religion, science, secularism and the new atheism
4) ethical capitalism and the realities of poverty and inequality
5) eco-justice and sustainability
6) youth and social networking
I am excited to hear about this work, and how those dynamic Jesuits move world education forward. In the same issue of the magazine, there is an article about Leon Panetta, another SCU graduate, and taking on the CIA, and the hope to make the interface with Congress and the world the best possible fit. It pleases me that they also published my letter lauding Sharon Kugler, who is the head chaplain at Yale, for her excellent ministry, and for being a good woman who models "the change we wish to see in the world". The note from Patrick Finley, about Professor William Sheehan was also wonderful.
God bless Santa Clara, God bless America, and God bless the whole world!
I am very grateful for being taught about Bernard Lonergan, and the metaphysics of Lonergan's "Insight". I took the book with me to Paraguay, and I still think of the basic premise, once in awhile, that "being is the objective of the pure desire to know." And I think of how he presented the way there is a heuristic structure of knowing, and that increased knowledge is pushing back the frontier of the unknown little-by-little, as the data and knowledge pour in.
Today I got the Santa Clara Magazine, and the goodbye note from Fr. Locatelli. He is going to Rome, to be the secretary of higher education for the Jesuits, which is the only organization which currently has a worldwide system of schools and universities. He will begin to coordinate a global structural network. In the weeks ahead, there is going to be a summit among Jesuit educators, addressing some of the themes for faith and justice from within education. The themes Fr. Locatelli says they will address are pretty instructive:
1) migration and refugees
2) faith, understanding and interreligious dialogue
3) religion, science, secularism and the new atheism
4) ethical capitalism and the realities of poverty and inequality
5) eco-justice and sustainability
6) youth and social networking
I am excited to hear about this work, and how those dynamic Jesuits move world education forward. In the same issue of the magazine, there is an article about Leon Panetta, another SCU graduate, and taking on the CIA, and the hope to make the interface with Congress and the world the best possible fit. It pleases me that they also published my letter lauding Sharon Kugler, who is the head chaplain at Yale, for her excellent ministry, and for being a good woman who models "the change we wish to see in the world". The note from Patrick Finley, about Professor William Sheehan was also wonderful.
God bless Santa Clara, God bless America, and God bless the whole world!
Wednesday, March 4, 2009
Pregnancy and ripeness
Dear friends,
I have been thinking about what to write, that is not already written, on this vast subject. I am posting this review of cervical ripening and induction, WITH MANY THANKS to Dr. Aaron Caughey, MD, MPP, MPH, PhD, at UCSF, for the expert review of the data and nuances of this topic.
One of the things I have wanted to say is that there is now sufficient data about how long the cookies should stay in the oven, so they will come out golden brown, not underdone or overdone. And the answer is 39-40 weeks. There is the lowest chance of morbidity at that time. So now we are trying to get as many babies as possible to deliver within that window of opportunity.
After the edge of "term" there is more risk of the baby being surrounded by inadequate water, so the cord can become squeezed in labor, as the contractions intensify. The cord brings oxygen to the baby, and if it is too "vulnerable" it will not deliver enough, so that the baby gets stressed, and then distressed". This makes it important to try to get through labor when there is still enough fluid around the baby so that the cord can float freely, and pass oxygen in and carbon dioxide out. The placenta is "breathing" for the baby, until delivery.
Also, the baby can go poop in the water, which is called meconium. If the baby takes deep gasping movements, the fluid in the baby's lungs can be so noxious, covering the insides of the lung surface, that the baby can not breathe air when it comes out. The baby has to make a transition from being in a watery world, to being in air, and learning to breathe, rather than get all its oxygen from the placenta, through the umbilical cord. So it is very important for the baby not to gasp and inhale deeply the meconium. We now know that babies gasp as a reflex, when they are inside and there is not enough oxygen. So we want them not to have long or deep fetal heart beat decelerations, which cause them to feel less oxygen, and gasp. Babies can tolerate some stress, some low-oxygen, for awhile. But labor can be long and hard, and if it is getting harder and harder to get enough oxygen, the baby will become "distressed"-- and need to be bailed out.
So a big part of the work of doctors, in watching labor, is to gauge how much stress the baby is under, and whether the baby is bearing up under it. In a fast, easy labor the water is abundant, the cord is not compressed with contractions, and mother's pushing allows a natural squeezing which may help the lungs be less full of water, and more ready to take in air when the baby first breathes.
In a long hard labor, there is also the risk of infection, which can rise from bacteria which naturally live in the vagina up into the uterus. So it is really important for the mother to be delivered as promptly as possible, to reduce the risk of infection passing to the baby. The mother also can get a deep infection in the walls of the uterus, which is called "chorioamnionitis" (infection in the bag of waters) and later, "endometritis"(infection in the lining of the uterus)--and this causes the walls of the womb to be less capable of contracting efficiently, both in labor, and afterward, to keep from bleeding from the raw site where the placenta was attached.
When a baby is post-dates, and has meconium, and has infection, it is like 3 strikes against them. For this reason, we want to get them delivered when they are ripe but not at risk.
Some women look askance at us, for trying to talk them into being induced at term. They need to understand that this is the underlying reason. For most moms and babies, it is safer, and there is more chance of a successful vaginal delivery, if we don't wait till two weeks overdue.
In general, I try to "let the river flow, rather than trying to push the river". But sometimes we need to nudge someone into labor to get them to deliver in the best window of opportunity for safety.
What stops us? The last process of pregnancy before labor is cervical ripening. If the cervix is like a green apple, it is much harder to get it to open. It needs to be like a ripe peach. The soft, squishy, mushy tissue will more easily begin to open up. So what we now use, to get the "ripeness" we need, is prostaglandins. The medicine Cytotec, or misoprostol, was invented for ulcers, but it was found to be exactly what is needed to make the cervix ripen. This is what does it naturally, in most women. But some women don't make enough. So we can give them this medicine, vaginally or orally, and the cervix will respond by ripening.
After the cervix is ripened, which may take around 24 hours, the uterus can begin to open up the cervix, by contracting. The contractions are like a castle opening a heavy drawbridge. The drawbridge is drawn up and into the castle walls. We sometimes have to use pitocin, a medicine which is dripped into mom through the iv, to help this process of lifting open the cervix.
Another thing that has to happen is the baby has to come down deeper into the pelvis, and make it through the outlet of the bones. Some babies are just too big for the bones of their moms. Others are lying in a position which makes it harder to get through the pelvis. And some have a tight loop of umbilical cord holding them up. Sometimes we can change the mom's position to help get the baby to turn and come through the pelvis. Sometimes we can actually reach in and turn the baby's head a little, to get it to do this.
When the baby is distressed, or there is thick meconium, or the baby has a body which is too big for the mom's bones, we do a Cesarean Section. This surgery has helped millions of babies to be safely born, with lungs which can breathe, and not having severe infections, and so they can stay with their moms and breastfeed, and not need to go to the nursery in exhaustion and need tubes, iv's and oxygen to help them get out of trouble. A lot of people think doctors are making unnecessary interventions, because they do not understand these facts. All our monitoring is to make sure the baby and the mom are both safe through the process of labor. We want to help babies be born safely, and in optimum health, like golden brown cookies!
I have been thinking about what to write, that is not already written, on this vast subject. I am posting this review of cervical ripening and induction, WITH MANY THANKS to Dr. Aaron Caughey, MD, MPP, MPH, PhD, at UCSF, for the expert review of the data and nuances of this topic.
One of the things I have wanted to say is that there is now sufficient data about how long the cookies should stay in the oven, so they will come out golden brown, not underdone or overdone. And the answer is 39-40 weeks. There is the lowest chance of morbidity at that time. So now we are trying to get as many babies as possible to deliver within that window of opportunity.
After the edge of "term" there is more risk of the baby being surrounded by inadequate water, so the cord can become squeezed in labor, as the contractions intensify. The cord brings oxygen to the baby, and if it is too "vulnerable" it will not deliver enough, so that the baby gets stressed, and then distressed". This makes it important to try to get through labor when there is still enough fluid around the baby so that the cord can float freely, and pass oxygen in and carbon dioxide out. The placenta is "breathing" for the baby, until delivery.
Also, the baby can go poop in the water, which is called meconium. If the baby takes deep gasping movements, the fluid in the baby's lungs can be so noxious, covering the insides of the lung surface, that the baby can not breathe air when it comes out. The baby has to make a transition from being in a watery world, to being in air, and learning to breathe, rather than get all its oxygen from the placenta, through the umbilical cord. So it is very important for the baby not to gasp and inhale deeply the meconium. We now know that babies gasp as a reflex, when they are inside and there is not enough oxygen. So we want them not to have long or deep fetal heart beat decelerations, which cause them to feel less oxygen, and gasp. Babies can tolerate some stress, some low-oxygen, for awhile. But labor can be long and hard, and if it is getting harder and harder to get enough oxygen, the baby will become "distressed"-- and need to be bailed out.
So a big part of the work of doctors, in watching labor, is to gauge how much stress the baby is under, and whether the baby is bearing up under it. In a fast, easy labor the water is abundant, the cord is not compressed with contractions, and mother's pushing allows a natural squeezing which may help the lungs be less full of water, and more ready to take in air when the baby first breathes.
In a long hard labor, there is also the risk of infection, which can rise from bacteria which naturally live in the vagina up into the uterus. So it is really important for the mother to be delivered as promptly as possible, to reduce the risk of infection passing to the baby. The mother also can get a deep infection in the walls of the uterus, which is called "chorioamnionitis" (infection in the bag of waters) and later, "endometritis"(infection in the lining of the uterus)--and this causes the walls of the womb to be less capable of contracting efficiently, both in labor, and afterward, to keep from bleeding from the raw site where the placenta was attached.
When a baby is post-dates, and has meconium, and has infection, it is like 3 strikes against them. For this reason, we want to get them delivered when they are ripe but not at risk.
Some women look askance at us, for trying to talk them into being induced at term. They need to understand that this is the underlying reason. For most moms and babies, it is safer, and there is more chance of a successful vaginal delivery, if we don't wait till two weeks overdue.
In general, I try to "let the river flow, rather than trying to push the river". But sometimes we need to nudge someone into labor to get them to deliver in the best window of opportunity for safety.
What stops us? The last process of pregnancy before labor is cervical ripening. If the cervix is like a green apple, it is much harder to get it to open. It needs to be like a ripe peach. The soft, squishy, mushy tissue will more easily begin to open up. So what we now use, to get the "ripeness" we need, is prostaglandins. The medicine Cytotec, or misoprostol, was invented for ulcers, but it was found to be exactly what is needed to make the cervix ripen. This is what does it naturally, in most women. But some women don't make enough. So we can give them this medicine, vaginally or orally, and the cervix will respond by ripening.
After the cervix is ripened, which may take around 24 hours, the uterus can begin to open up the cervix, by contracting. The contractions are like a castle opening a heavy drawbridge. The drawbridge is drawn up and into the castle walls. We sometimes have to use pitocin, a medicine which is dripped into mom through the iv, to help this process of lifting open the cervix.
Another thing that has to happen is the baby has to come down deeper into the pelvis, and make it through the outlet of the bones. Some babies are just too big for the bones of their moms. Others are lying in a position which makes it harder to get through the pelvis. And some have a tight loop of umbilical cord holding them up. Sometimes we can change the mom's position to help get the baby to turn and come through the pelvis. Sometimes we can actually reach in and turn the baby's head a little, to get it to do this.
When the baby is distressed, or there is thick meconium, or the baby has a body which is too big for the mom's bones, we do a Cesarean Section. This surgery has helped millions of babies to be safely born, with lungs which can breathe, and not having severe infections, and so they can stay with their moms and breastfeed, and not need to go to the nursery in exhaustion and need tubes, iv's and oxygen to help them get out of trouble. A lot of people think doctors are making unnecessary interventions, because they do not understand these facts. All our monitoring is to make sure the baby and the mom are both safe through the process of labor. We want to help babies be born safely, and in optimum health, like golden brown cookies!
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