HW #42 - Pregnancy and Birth Culminating Project

            At 10:00 am this morning I arrived at St. Luke's-Roosevelt Hospital to follow Dr. Moritz for the day. I walked into the 12th floor Labor and Delivery ward, and the first thing I noticed was a huge screen on wall opposite the resident doctors' and secretary's desks. One the screen was a color-coded chart listing the names of patients, the patient's doctor, the last time they'd been checked or visited, their laboring progress, their blood type, what sexually transmitted diseases they might have, and their room number. This screen enabled all the doctors and nurses on the floor to keep track of the patients and have a common ground for communication with each-other. When Dr. Moritz found me, he gave me a side hug and said "Come with me!"

                The following 20 minutes entailed a difficult search for scrubs, greeting anyone and everyone Dr. Moritz passed in the hallway, and visiting patients. There were no size small scrubs left in the scrub vending machine, so we trekked to the basement, where stores of supplies are. Moritz joked that he had to "go all the way down to the basement where the riff-raff are" and light-heartedly cursed the lack of scrubs on the 12th floor. He said to his buddy, "Sup, Man. We got no small scrubs in labor and delivery, what's up with that? Hey hook a sister up with a some scrubs man!" His buddy responded with "And WHAT a SISTER!" "Yeahh we got a hottie on our hands; let's find some smalls for her." After obtaining them, Dr. Moritz visited a few of his patients, either pregnant or in some form of labor. He never stopped joking and making people laugh; he seemed to have an inside joke with every nurse and every mother-to-be. I noticed that in every conversation, he looked people in the eye. Throughout the day, he maintained a calm demeanor despite the many duties he had. His swift gate and quick movements revealed his hurry, and yet he hugged and kissed and conversed with those he encountered (especially his patients). I got the sense that he treated every individual like someone who had something to offer and who was valuable to the world around him. When introducing me to laboring women, he said "She's gonna deliver your baby today!" or "After seeing you in action she's never going to have sex again!" After deciding to break one woman's water, his hand gently disappeared inside her and her face crumpled as she moaned through the pain the water-breaking tool caused. He apologized for the pain involved in what he had to do, and then visited his patients in the waiting room. One of them tried to get him to accept tiny bottles of liquor, because "no one smokes cigars anymore." He kindly made fun of her, but I don't think he ever accepted the bottles.

                Dr. Moritz spoke French to many of his patients, even when they showed that they were capable of English communication. I interpreted that he did this so that he wanted his patients to know that he would try to do things on their own terms whenever possible. He did his best to communicate in their original languages, and sometimes he ignored the protocol so he could preserve the convenience of his patients. For example, he gave a sonogram to a woman whose baby was constantly moving, and that was thus often in a breech position. Although a nurse in the room criticized his unorthodox protocol, he did the sonogram while the mother stood up so that she did not have to undress or waste time moving the sonogram machine and lying down. I had trouble identifying anything in the sonogram because it was extremely fuzzy and not still (perhaps because she was standing up). They spoke in French for most of the time, and the only part of it that I understood was when she asked if she should lie down, and he said that it would be unnecessary. She commented in English that she could constantly feel the baby moving around. Moritz diagnosed an acupuncturist that would help to switch the position of the baby.

                We also visited a room full of prematurely born babies. Some weighed only two pounds. I noticed that most of them were dark-skinned and had Hispanic names, and wondered if there was a correlation between certain ethnicities and premature births.

                After making his morning rounds, he "gave" me to his midwife, Sandy, and disappeared into the operating room for a few hours. Sandy, who helps take care of his patients on Tuesdays, visited a few patients with me in tow. She broke one patient's water, and remarked that "today is the day of membranes that do not want to break" because both she and Moritz were having difficulty with it that day. She advised the patient to switch from her laying on her left side to her right side, and to sleep instead of watching television. As we walked out of the room, she muttered, "I have a real problem with visitors that need to be entertained. She needs to get rest while she can, and she can't because the people in her room want to watch television."

                Sandy, a feisty, albeit gentle woman, told me about her life story while we had some down time. She told me of her daughter, who is "smart as a whip and figured out everything on her own." She told me of her education, which included nursing school and then serving the army to help pay for it. She went to an army base in Massachusetts and spent a year in Vietnam. She took care of army wives, but informed me that she only "managed the births. I prided myself on telling the doctor when to be there to catch the baby. He would stay in his chair and say 'two more contractions' then we'd be ready to go." She went to Columbia University for the midwifery program. (She'd decided to stick with that profession because a friend told her she had something to offer in that area.) Now she has been a midwife for 35 years, and is considered one of best in the country. Dr. Moritz sang her praises while we were in the elevator, saying "Sandy is one of the best midwives in the country. She is THE BEST. Sometimes I just sit back and watch her deliver the baby; she is so patient. Her patients want me when they learn that I won't be there, but after Sandy does the birth with them they come to me and rant about her wonderful she was." I found myself making excuses for Sandy to a patient or two ("She's had a long morning", "Oh, another patient had that problem"), because several times in a five-minute check-in she asked "how many centimeters are you dilated?" or "Do you need an epidural?" I felt that Sandy deserved optimal patience and respect from her patients, because she bestowed it so freely throughout the day. Her favorite thing about being a midwife is empowering women to do what they can do with their bodies, and helping them to get in that spot where they believe that they can do anything.

                In the first birth I visited, I initially planned to stand to the side as Sandy and the nurse did their thing. The laboring patient had her husband with her, so I figured he could offer emotional support. Sandy took me to the side and explained that this woman, who had been in labor for a long time, would need a cheer-leading squad in there to make her believe that she COULD do it. I understood what she meant; the overall vibe in the room was one of exhaustion and even boredom. I stood at the end of the bed and faced the mother. With each push, the baby's head came out a little bit more, and then seemed to slide back in. I told her that every push resulted in more progress, and Sandy got a mirror and brought it to the foot of the bed so that the patient could see what her body was doing from the spectacular angle I was in. Her husband stood awkwardly to the side as he looked at her pain as though touching her would burn his hand off or hinder her progress. I moved to her side and supported her neck and head as she leaned forward in a crunch position and pushed through each contraction. Her wet hair stuck to her face, the damp cloth on her forehead went from cool to hot in a minute, she grinded her teeth, her face turned pinkish-purple, and sweat beaded in unexpected places like her chin and ears. I continually wet her forehead with a cool cloth, smoothed her hair, told her how wonderfully she was doing, helped to pull her knees up and to the sides, and brought her ice. Ice is generally the only thing a woman can consume in labor - no water or food. Once the baby was born, it did not cry for a long time; this concerned the parents. Sandy showed no concern throughout the day, but she told the nurse to call the pediatrician. The pediatrician flicked the bottom of the baby's feet and rubbed her whole body to stimulate cries and breathing. As she did so, the little babe looked up at me with squinting, dark eyes. I wondered if I was the first person she looked at with those little eyes that would go on to see so much. She used a little straw that functions as a vacuum to suck the fluid out of the baby's throat, mouth, and nostrils. The newborn never cried loudly, but the worry ended when they were able to nurse her. The new mother had a first-degree vaginal tear, which Sandy repaired with two stitches.

                The second birth I attended was a C-section. It was scheduled because the mother's previous birth had resulted in a miscarriage or still birth (I cannot remember which), and because she was carrying twins. I walked into the operating room wearing a blue hair-net-like sort of hat and a mask for my mouth and nose. Dr. Moritz adjusted my mask and told me that if I felt sick I should leave the room. I watched as the nurses bustled around me to arrange operating tools on a table near a bed, and bring extra bottled sanitized water. Their efficient movements reminded me of my sisters and I when we were little and we had to set the table before dinner time when we were extra hungry and in a hurry to eat. I knew I would not faint or be squeamish, but I realized that even if I unexpectedly did Dr. Moritz would be understanding and even concerned for my well-being rather than cruelly mocking or patronizing. Pediatricians set up two high cribs with warming overhead lights and tools to tackle any hindrance that the babies might encounter after birth. The patient's belly was a huge dome of skin and stretch marks. As I looked upon its size in awe, I saw it ripple from some force under the surface. I imagined a foot or little baby bottom pushing against the walls of the uterus. A doctor began spreading a frothy brown liquid over her stomach, upper legs, and visible crotch. I learned later that it served the purpose of protecting the mother from electrocution when the surgeons operated with electric tools. They cut through many layers of skin, membrane, nerve endings, and spongy tissue to get to the babies. They pulled the babies out one by one. Moritz insisted that the baby be held up over the curtain separating the mother from the surgery so that she could see her newborns, and then the babies were taken to their little cribs. I observed as the nurses suctioned the vast amounts of blood and as the pediatricians took babies' footprints, weighed them (5 lbs. and 5 lbs., 12 ounces), gave them shots of Vitamin K, rubbed antibiotic ointment over their closed eyes, and cleaned out their nostrils and mouths with the little vacuum-like straws. Both babies were boys. I looked at "Baby A" and mused that he would go on to hug and laugh and hold and be held. Although this cries were irritating to some, they reminded me that he had the power to use his voice in the future. I hope he uses it well. Dr. Moritz joked that Baby B had a bigger penis than Baby A and led me out of the room in his brisk manner.

                A nurse gave him an especially hard time for allowing the patient's mother to go in the room without "sterile attire" and she complained to him about her offensive comments to the surgeons. Moritz's attempts to calm her down and explanations that the patient's previous pregnancy had failed only heightened the tension in the room and the muscles of the angry nurse's mouth and forehead. I had some more down-time, this time with Dr. Moritz. He confided his frustration in the strict protocol that has to be followed, and in the focus on doctors' convenience rather than on patients. I suggested that he find a balance and adhere to a few more protocols, such as wearing safe attire in the operating room. He responded with "but I wrote the protocols, and they're good ones. But I follow the protocols I need to follow." That shut me up. Then he offered me chocolate.

                The third birth I attended was vaginal. Again I walked into the room with incorrect expectations. I knew that this patient had a doula with her, so there would probably be no lack for emotional support. When the patient was given an epidural a few hours prior, I asked the doula a few questions. She sweetly explained to me that she couldn't have a conversation just then because if the patient heard her talking to me, she would feel like the doula was not focused on her and not "with" her emotionally. I had high expectations for the doula's ability to take care of the mother to be. However, when contractions came frequently and she started pushing, Dr. Moritz said as he bent over the bed and looked between her legs, "Casey, go in the drawer and get size 6.5 gloves. Put them on." I did not ask why and put them on as fast as I could. He motioned to me to come next to him with one hand as the other hand was cupped around the protruding head. He placed my hands on the baby's fuzzy, dark head. We both pulled the head out. "Wait and see which was the face falls, and then pull the shoulders out accordingly." We eased the tiny shoulders through the astonishing chasm that is between a woman's legs. I was surprised by the color of the head, which was purple in contrast to his nearly white body. We had no trouble getting this baby to cry. After holding it to the mother's chest, Sandy allowed the father to help cut the umbilical chord and the nurse took the newborn boy to his little crib. The new mother commented on how easy this birth 4-hour birth was compared to the last one, which took three days. The patient had a 2nd degree vaginal laceration, which means that some tissue and a little bit of muscle tore in the vagina. I helped Sandy stitch the tear up, and she showed me which parts to avoid sewing so that the mother won't have painful intercourse later. After simply helping to pull that baby out, I felt an attachment to him. I cannot imagine how attached his mother must have been, and how heartbreaking it must be to be separated from him after having carried him around for 9 months and then getting to hold him for the first time. When the mother said "he has such a sweet cry", tears came to my eyes.  The doula told me afterwards, “That’s the first time I saw a 16 year old deliver a baby; it brought tears to my eyes!” When Sandy accidentally dropped a box of scissors with a bang, I could not help but think "that is the first loud noise he has ever heard, and I got to be there for it." The parents insisted on taking a picture with me and everyone else who had been in the room during the delivery. Dr. Moritz disappeared, by the rest of us smiled for the camera as the baby sucked at its mother's nipple. I promised not to put the photo on the internet, so I cannot post it on the blog.

                The fourth birth I attended was also a C-section. It was not scheduled, but Moritz decided upon it because the baby's heartbeat was becoming erratic and labor had stalled for a very long time. He told me to put my hand on the stomach and feel how the baby's head had "set" in the pelvis. In this C-section, I had to scrub my arms with soap and water, and don a mask, hat, lab coat, and gloves. I was told to stand at the operating table and not to "move a muscle". The nurse across from me explained that that meant I wasn't to touch my face or anything else because that would not be sterile. She was clearly not very happy that I was there; I was just a high school student with not surgical or birthing experience to date. I stood next to Dr. Moritz and across from the nurse. Another new doctor stood across from Moritz. He moved slowly because this was one of his first C-sections, and Moritz paused his scolding during the procedure long enough to tell me, "you're lucky that you're not one of my students", to which his student across the table emphatically nodded. At one point during their struggles to open layer after layer of tissue, I was asked to help hold the bottom flap open while they worked on the next. Later on, I was so focused on the uterus and the many layers above it that Moritz worriedly asked me if I was okay. I said "Yeah!" a little too excitedly, and he and the other doctor had to stop their work for a moment to laugh at my response. The nurse across from me basically served as the clean-up crew, suctioning the blood up and passing them scalpels and clamps. After pulling the baby half way out of the section, Moritz let the head and neck flop onto my hands. The nurse across from me scolded, saying "Nononono, you're here to observe, not participate." I found this odd, considering that simply observing in this case would mean letting the baby's head and neck flop about unsupported. While sewing the section up, Dr. Moritz looked at me and said, "Do you know how to sew?" I said "Yes, but not bodies!" He looked back at his work with stooped shoulders and I wondered if a different response from me would have resulted in a needle in my hand and a section to sew up. In hindsight, I'm glad I was never asked to do that.

                After leaving the operating room, Dr. Moritz and I visited a patient who had had a miscarriage in her ninth week of pregnancy. She did not seem very sad about it, though. She said she would try again, and laughed at all of Moritz's jokes. The procedure for a miscarriage is basically the same as the procedure for an abortion; a thin tube is passed up the cervix and hooked up to a machine which sucks the placenta through the tube. The most saddening part of the day was watching pieces of placenta float out of a woman's body, through a tube, and into some machine.

                Next, I visited the birthing center on the floor below the labor and delivery ward. The rooms were much more comfortable and homey rather than cold and white. They had little bath tubs, big exercise balls, and colorful, original art on the walls. When I asked why anyone would rather be born in the hospital, the midwives present simply laughed as if they had been wondering the same thing for years.

                I found that I was not surprised by much I saw at the hospital today, other than the odd coloring of the babies. I was very happy to have seen "The Business of Being Born" and read "Pushed" by Jennifer Block and "Baby Catcher". My extensive reading and education about birth and pregnancy enriched my firsthand experience of it, because I already knew what the doctors and nurses were discussing most of the time. They were surprised by my depth of questions and knowledge coming into Labor and Delivery, but I can attribute it only to my previous learning. I must mention that the ability to follow a doctor or midwife is totally one of a kind and I discourage others from asking Mr. Moritz for the privileges I was honored with, because he is a busy man and explicitly requested no more students. I am very thankful for the opportunity to shadow some of the best nurses, midwives, and doctors in the country. I aspire to learn Dr. Moritz's time-management skills, gregariousness, and intelligence, as well as Sandy's patience, wisdom, and "no nonsense" attitude. I stand in awe of every nurse, obstetrician, midwife, and mother because of what I witnessed today.