*Trigger warning – birth trauma*
My heart in my throat, I paw at my cellphone in the darkness. The piercing, recognizable ring linked to the hospital is startling.
“It’s Dr. Sprague,” I mumble.
“Labour room one. Grandmultip. Just arrived. Fully and pushing,” comes the crisp reply.
Mere moments ago, I had been slumbering like the dead. After three successive nights on-call for our local maternity practice, it had taken me mere seconds that evening to drop heavily into bottomless sleep, fully dressed in a clean pair of my hospital scrubs. My night uniform, ready for action at a moment’s notice.
With no time for even a quick bathroom break, I stumble along the darkened path to the driveway. As always, my brain rests briefly on the image of my husband and children sleeping soundly, unaware my night’s interruption.
Before my eyes are even fully opened, I jam the groaning SUV into reverse and am speeding down Abram Lake Rd. Blake would certainly have had something to say about the rapidly rising speedometer, but I know I have mere minutes before this baby is born. The junior nurse, just barely through her orientation to our busy obstetrical unit would have much to say if she was required to attend the delivery without a physician present.
6 minutes, door to door. I know the route by heart and at 4am, I drive it like a Formula One racer – my body leaning into corners, my leaden foot on the gas. At this time of night, deer are more populous than cars in our remote, northern Ontario community of Sioux Lookout. Not a single traffic light to slow my course. Only the sole stop sign on 7th Ave which I vaguely slow down for at night on my way to the hospital. So ingrained in the habit of optionality, I once was pulled over by an earnest OPP office driving the kids to the school. “You know that you just drove through that stop sign going at least 20km/h, right?” he had questioned me through the driver’s side window. The kids, observing wide-eyed in their matching car seats. I had had to quickly correct myself before I had blurted out that indeed, it was a bad habit of mine, having had repeatedly blasted through this exact stop sign for many years on my way to catching babies at 3 am.
Luckily, no deer or cops to hinder my nighttime commute tonight. In the final 100m, I ready for the closing leg of my journey to the delivery room. I undo my seatbelt and lasso my name badge around my neck, screeching to a halt in the patient drop-off parking in front of the ER doors. Racing on foot now, I sprint past the COVID screeners encased in their clear, acrylic cage, snatching a mask on the way by. Down the long corridor framing the courtyard that by day spills delicious sunlight into the sterile space. Tonight, the lone custodian perched high atop the droning floor waxer nonchalantly nods in my speeding direction. He’s seen this routine many a time.
Wrestling my bedhead into a ponytail, I slow my pace briefly as I pass the medical nursing desk. I certainly don’t want to cause undue alarm to the bevy of night nurses resting their heads on their desks, flannel hospital-issued blankets draped over their shoulders. Then galloping again for the last few meters before hurdling my body at the metal double doors to the Maternity Unit, my fingers still caught in my long tangles.
Inside, I am met with silence. No wailing newborn. Relief in the rapid realization that I have made it in time, I shed my jacket haphazardly at the cluttered nursing desk. The doptone cuts through the stillness, announcing the fetal heartbeat through the partially opened door of the labour room. Thrum, thrum, thrum, thrum, thrum. 160bpm I note, recognizing the cadence of its rhythm. A moment later, the wail of the birthing mother quickly turns to low guttural grunting. 6.5-sized gloves stretch over my sun-wrinkled hands and soon a screaming babe is lifted to his elated mother’s chest.
A new life.
In some capacity, I have always known that I had wanted to do maternity care. Prior to medicine, midwifery had been my path, but the limited scope hadn’t felt like the right fit. I yearned to work remotely and to use my privileged position, my knowledge and skills to serve marginalized families and communities. I wanted a generalist practice with a broad range of skills. I didn’t seek to solely attend to low-risk women through their pregnancies but also wanted to assist with the woman’s older child’s asthma, her partner’s substance use disorder, her infant’s reflux and her own multitude of medical issues. So rural family practice it was. An immediate, lusty love affair.
During medical school, I intentionally spent eight months of my clerkship in the community of Sioux Lookout. A regional hub, striving to serve the health needs of 33 Indigenous communities of the surrounding Anishinabe Treaty 3 and the Nishnawbe Aski Nation (Treaty 9), a combined area spanning West to the Manitoban border and North to the James Bay Coast. Although my growing passion for rural medicine was solidified on the inpatient unit, recognizing the physical exam findings of rheumatic heart disease or in the fly-in nursing station, stabilizing an ATV trauma, what I fell hard and fast for was obstetrics. Dr. Dooley, my then preceptor, now dear colleague, used to amiably grill me for skipping out on ER shifts in order to follow women through their deliveries. I had drank the elixir and was hooked.
In medicine, there are certain specialties that cause a definite polarizing effect. Obstetrics is one of them. There truly is no middle ground – either one loves it or hates it. While to the layperson, delivering babies into the world may superficially seem like an easy, joyous way to spend one’s working life, the truth of it is attending women in the most vulnerable points of their lives brings many dichotomous feelings. Passion and fierce love for the job abutted against the constant interference into one’s personal life. A tether to one’s phone, car and hospital so short that it curtails most all of life’s treats: a glass of wine at dinner, a lengthy ski in the bush, a solo trip to the library with the kids, an uninterrupted night’s sleep. Yet the rush of the privileged access into a woman’s most intimate moments is almost inexplicable. Strange indeed, the devotion to an occupation that induces terror so deep while at the same time bringing tears of relief and joy at the beauty of it all. After hundreds of births, somehow it all still feels just like home.
In the basement home office, files of green pieces of paper are categorically organized by date. Binders upon binders of labelled billing sheets representing each delivery attended over the past seven years. “How many?” Blake wonders. I shrug. I’ve never counted. Hundreds of stories bleed into each other often hastened by sleep deprivation-induced amnesia. Details blur, but inkblots of tragedy, comedy and elation stand out. Pre-pandemic birthing rooms packed to the gills with aunties coaching labouring women in their language, partners steadying iPads connected to family hundreds of kilometres away watching the joyous arrival over FaceTime, toddlers snoozing in strollers or makeshift beds in the corner, unperturbed by the noisy arrival of their newest sibling. A memory of unflappable maternity nurse, Coral, one arm supporting the leg of the birthing mother, while nonchalantly catching an excited sibling as he near tumbled headfirst from his post on the pull-out chair in the corner with the other.
I loved this job. Despite the depth of the personal sacrifices it took, I loved it without reservation and I was good at it. This past year in BC on our family’s East Kootenay adventure away from my medical home has so deeply reinforced these sentiments.
Yet there is one birth that will never erode at the edges with time. One that will remain painfully and nauseatingly clear for the rest of my working days. One that shook my entire being, rocked my confidence and demanded reconsideration of this beloved career. One that so acutely comes to focus as I ready for my return to Sioux Lookout and re-entry into my obstetrical practice. Nearly a year ago, in six minutes, my bond to this job became utterly and immutably frayed.
In obstetrics, there is little that can categorically bring a care provider metaphorically to their knees more swiftly than a shoulder dystocia. An obstetrical emergency, in simplistic terms, a shoulder dystocia is the time-warped space between the delivery of the baby’s head and the body that refuses to follow. When seconds stretch to hours in the provider’s mind as the baby’s shoulders catch stubbornly against the maternal pelvis. Bone upon bone. Desperation mounts with each passing minute of this precarious stalling of time between life and death before life has yet to even begin. Without vital blood flow through the umbilical cord, nor the ability to fully transition to extra-uterine life, generally, the fetus has roughly five precious minutes before asphyxial injury or worse yet, death, ensues.
If this doesn’t induce sweaty palms at the mere description of it, ask any obstetrical provider about their worst experience with shoulder dystocia and watch closely. Even the most hardened midwife, grumpy obstetrician or senior labour room nurse will not be able to mask the cloud of recollected fear that will pass through their eyes at the pained remembrance of it.
In our maternity practice, due to the remoteness, the high volume and acuity of our patients and the lack of specialty providers, our group of family doctors work as a tightly-knit team with each delivery attended by two nurses and two physicians – one for the baby and one for the mom. This system also provides a relative safety net for each other, a sense of security that you will always have a colleague to back you up. Working in a team also safeguards against burnout as feeling alone and unsupported in medicine is a surefire fast-track for the exit sign.
For years, as a newly minted physician, when I was up shit creek without a paddle (a plummeting fetal heart rate, a complicated perineal laceration, a stalling labour..) while attending the woman at the bedside, relief would flood the moment I saw my colleague’s feet at the doorway, peeking under the privacy curtain. Dr. Bollinger’s muddy Blundstones. Dr. Finn’s scuffed and worn red boots. Dr. Dooley’s ironic skater shoes. Help had come.
As time passed and younger graduates were folded into our group, I suddenly found myself as a ‘senior’ colleague providing support and advice to greener colleagues. On the day of that fateful delivery, I was working with a junior colleague, bright and skilled, as her aged and wrinkled advisor.
It was mid-afternoon, the end of a 30-patient clinic nearly insight when I had been called to a delivery that my colleague had been attending throughout the day. I had met the woman in labour many times throughout her pregnancy which had been largely uncomplicated. Without too much forethought, I trotted to the delivery suite, donned my gloves and, as the ‘baby doctor’, went through my routine of checking the resuscitation equipment. A flip of the switch to turn the oxygen on, the suction noisily coming to life, the seal of the bag valve mask tested against my palm, the laryngoscope light blinking brightly. As usual, all was in order.
As I turned away from my post at the neonatal warmer, I took in the scene before me. The woman labouring in the bed, surrounded by nurses who wet her dry lips tenderly, gently wiped the sweat off of her chest and murmured encouragements. My colleague poised at the foot of the bed, attentive, focused. The partner standing between me and the tableau of female care.
The partner, I had realized was someone I had never formally met despite our town’s sparse population. With his back to me, he shifted nervously from side to side. For a brief moment, I mindlessly contemplated his frame: stocky, solid, built like a rugby player. I didn’t have to extrapolate my growing fears of the inevitable before it was urgently a reality before me. With the next push, my colleague gently guided the baby’s head across the perineum.
In obstetrics, the clinician’s first inkling that trouble might lie ahead is called the turtle sign; a retraction of the head against the soft tissues of the woman, a turtle attempting to retreat into its shell. In reality, it appears just as you can imagine it.
I locked eyes with the nurse, our gaze communicating what we did not need to say aloud. She lowered the head of the bed while quickly pulling the woman’s bent knees up and outwards.
45 seconds in and I hover tightly at my colleague’s left shoulder as she tries to negotiate the baby’s shoulders through the birth canal to no avail. I navigate the delicate dance of allowing her to be independent, to learn, and to have the chance to succeed on her own against my pressing urge to micromanage.
60 seconds. Either I push my way through or my colleague steps aside, I cannot recall. As the senior of us two, I know in my gut, it’s now my turn to step in.
In medicine, like pilots in virtual simulation labs, we rehearse emergencies repeatedly to avoid the folly of our own fallible nervous systems. “At a cardiac arrest, the first procedure is to take your own pulse” states the 3rd law of Samuel Shem’s House of God. Stay calm. Detach. Our hands smoothly go through practiced maneuvers while our minds claw at the door in panicked desperation to be anywhere but in charge of the medical emergency before us. It is not uncommon for physicians to retroactively describe total dissociation, an almost apparition-like perspective, watching their bodies run a code or manage a trauma without anybody at the helm. Auto-pilot. A ship on cruise control while the captain jostles for a seat on the lifeboat.
“Suprapubic pressure, to the maternal right,” I hear myself bark. Her hands entwined over each other just above the pubic bone, my colleague forces the weight of her small frame in a rocking motion against the mother’s abdomen, willing the baby’s shoulder to be thrust out of its firm entanglement.
Rubin then Woods screw maneuvers. My hands move through practiced rhythms in an attempt to rotate the entrapped shoulders.
I fight panic as I then fail to gain purchase on the hyperextended posterior arm, the next step in my drilled algorithm.
“All fours,” I hear the command leave my mouth more solidly than I feel. The Gaskin maneuver. So reliable from my midwifery days, never once failing me in coaxing a baby out of the birth canal. My growing confusion and dread when it too, fails.
4 and a half minutes. Sweat now pours between my breasts.
The woman, heaved hastily again to her back by the nurses in our now increasing desperation.
I will my hands to steady as I widen the opening of the birth canal with my scissors and start the sequence of maneuvers once again.
“Call anesthesia”, I shout. I know now that if I can ever extract this child from his mother’s body, he will most definitely require full resuscitation, if not worse.
My arms, strong and toned from years of weight training, feel like lead, elephantine and useless. My rapid breath catches, hiccuping along with my racing heart thrumming in my chest.
5 minutes. I rack my brain. There is no one else to call for help. The colleague who provides c-sections is at least 15 minutes away. At best, we could get to the OR in 30 minutes. It would be too late by then. At seven years into practice, I am the most experienced physician in obstetrics in the hospital.
I am the end of the line.
“I can’t. I can’t,” I hear a voice rasp. I don’t recognize it as my own. My eyes fly wildly about the room. Searching for what, I’m not sure. My hands continue desperately in their efforts. Attempts to break the baby’s collarbone to fold its shoulders into a smaller diameter are to no avail.
In my limited years of practice, whenever I have managed a difficult shoulder dystocia, there is always a small part of my brain that whispers, “Will this be the one? The one where the baby dies on your watch? In your hands?”
6 minutes. I hear the whine louder and louder. This will be the one. This will be the one.
Then for no rhyme or reason, the shoulder finally gives way to my hands’ insistent pleading. After six and a half minutes, just a few grams shy of 5 kilograms, he is born.
Sweat drips into my eyes as I peer down at the silent, flaccid baby between his mother’s legs. My hands shake violently as I silently cut the cord and shuttle his lifeless body to the resuscitation warmer. Pushing breath into his quiet lungs, my anesthetist colleague is suddenly at my side. ‘”Breathe, Celia, breathe,” I hear him say (later, he tells me I was breathing at a rate three times what a normal adult would breathe at rest). We work seamlessly until the babe finally takes his first breath and a mewing attempt at a cry.
I resist the urge to vomit.
Hours later, I watch through the glass of our makeshift mini NICU as the GP-anesthetist adjusts the CPAP breathing mask over the babe’s bruised face. He is breathing spontaneously now, a good sign. An IV line is anchored securely into his plump foot. The nurse takes his vitals. My chin grips the receiver as I run through the case with the nearest pediatrician, over 500km away. As I end my rattling history with the baby’s most recent numbers and bloodwork results, momentary silence ensues. “Six and a half minute shoulders,” the pediatrician repeats. “I’m so sorry.” An unspoken understanding of the terror that I don’t include in my case presentation. He does his best to reassure me, but we both know that the true outcome is still unknown.
Later, for weeks, as I lay in bed, I replay the sequence over and over. What could I have done differently? Why wasn’t I successful initially? What if I am not competent to do this work anymore? What if the babe had died? I contemplate nightly alternative career options. Librarian? Summer camp director? Canoe trip guide?
I don’t want to hold a baby’s life literally in my hands anymore.
I am just human.
Just a human.
As it happens in small towns, in the months that followed that afternoon, I have run into this family numerous times, getting updates about his pediatrician’s visits and watching him grow as a perfect, healthy, beautiful, blue-eyed squish of a baby. In a recent post on his mother’s social media feed, he peers keenly into the camera with a heart-breaking smile, his face smothered in his lunch. ‘To think we ever worried he wouldn’t meet his milestones!’ his mother has captioned the photo. It’s impossible to look away but my vision is clouded in tears. The joy and the pain, terror and relief, death and birth. This job, full of its impossible dichotomies. My medical home. And inexplicably, I can’t wait to get back at it.