New Life Begins At 36

I began my four years of medical school on a military scholarship with my wife and two children at 36 years old. My three-year residency training started as an intern at forty. It was a life choice that has enriched me daily.

My favorite rotation early in medical school was obstetrics at the nearby community hospital.  I found myself one evening under the tutelage of a family medicine resident doing a fellowship in complicated obstetrics.  He was perfecting his surgical Cesarean-section deliveries.

The state would pay his malpractice insurance so he could continue to deliver babies as he had been trained. Most Family Medicine physicians were prohibited from obstetrics following their residency by the huge premium added to their malpractice insurance costs. In a country where suing doctors is a seeming national pastime, the obstetrician near the top of the list.

“OK, Bob, the labor deck is full tonight.  We have eight in active labor.  I plan to deliver every baby that comes out above the waist, and I expect you to deliver the ones that come out below the waist.  Is that OK with you?” he said, smiling.

His home in rural Tennessee had fewer obstetric doctors than were needed, and they were located far apart.  Family medicine doctors in underserved areas often needed to do their own Caesarian-section deliveries.   This evening he was in the operating room, and I was on the labor deck to catch all the vaginal births I could.  There was a board-certified obstetrician somewhere, but I had yet to see her.

“Yes, sir,” I replied expectantly.  This was a medical student’s dream come true.

I wore a clean set of green scrubs and my student white coat with pockets stuffed with the tools of the trade.  I had a stethoscope, reflex hammer, penlight, antibiotic manual, and obstetrics pocketbook.  The coat would come off when we got down to the baby delivery business, but it would not be far away. The information I sometimes needed was not in my brain yet.  It was in the books.

The baby-catching business was usually pretty simple.  But when something went wrong with a delivery, it was often unexpected and critical.   Nature had given women the ability to have children at home, and in the woods, and in the middle of nowhere since time began.  I needed to play catch and wait for the placenta to follow.

Live, healthy births in the United States have always been distressingly fewer than in most of the world.  Mothers and babies still died in childbirth.  I knew that but was unsure why.  Drugs, alcohol, smoking, obesity, sexually transmitted diseases, inadequate prenatal care, teenage pregnancy, and diet all played a part.

Today, all was going well, and I was smiling.

“Ok, Linda,” I crooned to the 14-year-old soon-to-be mother, “let’s have another push when you see the contraction on the monitor.”   She felt nothing because of an epidural line dripping anesthesia into her spinal area.  It made it more comfortable, but also hard to use the muscles needed to push.

Her mother stood at the head of the bed and watched with an anger she had already made clear to me.

“No Anesthesia!”

“Do not give her any anesthesia! She is 14 years old and having a baby!  I want her to feel every damn contraction!”

I nodded and mumbled, “She is not a minor now, under the law.  I will ask her what she wants.”  Epidural it had been.

The head of the baby protruded halfway out, and there was no need to cut an episiotomy to make room.   It would be smaller than the average baby.  She smoked cigarettes, like many of her friends in Winston-Salem, NC, the home of R.J. Reynolds Tobacco Company.  Mr. Bowman Gray, Sr., as past president of Reynolds, had left money in his will that the family used to move the medical school here from Wake Forest, NC.

I placed my hands on the baby’s head and tried to control the progress, as nature pushed the head out.  It emerged through an expanding vaginal canal covered in clear, leaking, amniotic fluid and blood.  Once the head popped out, the rest was automatic.  Out slipped the neck, shoulders, and body into my waiting hands.  I sat on a stool, dressed in a blue paper surgical gown, wearing surgical gloves.  My legs were spread apart in case my slippery bundle was to wriggle past my hands and into my lap.

I cradled the small child in the crook of my left arm and reached for the two clamps that needed to be placed on the blue, pulsing umbilical cord.  Once clamped, the nurse handed me scissors, and I cut the cord, which was trying to slip away from me.

“It’s a girl!” I declared cheerfully.   This was amazing.  I was present as a new life entered the world.  The new mother’s mother scowled, and the young girl gazed down excitedly.  I handed the baby to the nurse and tugged gently on the cord to encourage the placenta to follow.

“Bob, you better hurry over there,” offered my mentor.  He was leaning against the door of another room across the hall and peering in at a woman in labor.

“This one is coming soon, and if you don’t want to watch it hit the floor, you better get here fast,” he chuckled challengingly.

The placenta made its appearance.   I reached inside the newly enlarged vaginal opening, traced the edges of the placenta, and eased it gently out into the stainless-steel bowl held by the smiling, but bored, nurse.  She had seen it a thousand times.  A quick inspection revealed no tears or missing parts.  The placenta appeared completely intact, so I was free to move on.  If a piece of the dark red pancake-shaped placenta, covered on one side by blue bulging veins, was missing, I would need to reach back inside, find it, and remove it.  This would avoid dangerous post-delivery bleeding — not today.

The placenta, umbilical cord, and two pale blue plastic clamps plopped into the bowl.  I stood up, as various fluids dripped down my gown onto the floor and my paper-covered sneakers.  I moved eagerly to the hallway where the resident still leaned casually against the doorjamb.

“Do I have time to change my gown and scrub up?” I asked.

“I wouldn’t if I were you,” he purred in a warning and expectant voice while glancing into the room.  I entered the room where a nurse stood between the legs.   She moved aside and opened a new set of sterile gloves for me to slip on.  I removed my used ones and reached out, one hand at a time, while I watched the bulging area between the soon-to-be mother’s legs present a pale mass of baby.

My new gloves were on, and the nurse moved the stool to where I needed it.  I sat down, excited and hopeful. The senior resident looked bored and moved on.  He thought his job was done.

The monitor registered a big contraction, and the nurse continued to coach.

“Ok, sweetheart.  We are almost done here.  Let’s have another good push,” she encouraged.

A groan came from the woman I had yet to meet, and a baby started to emerge.  I followed protocol and placed my hands on the presenting part to control the descent.  It was soft!  This was not a normal texture, so I scrutinized it suspiciously.  There was a crease in the presenting part.  Oops.  It was not the head I was holding.

Butt First

I gaped with wide, panic-filled eyes at the nurse and said, “Please go get that doctor back here immediately.  We’re going to have a breech delivery here soon,” I directed in distress.

“Ma’am,” I tried to direct calmly, “do not push again.  Your baby is coming out butt first, and I need you to hold on for a minute.”

I had no idea what I was supposed to do next. That was a medical student experience that is hard to forget, and all turned out well. Whew!

Now let’s fast forward five years to my Army residency training as a doctor on active duty. I started my MD career as a Major because I had prior years of commissioned service. Most doctors begin one rank lower as Captains. My rank often made people think I had more experience than I had, and I did not usually correct them since my graying and balding hair seemed to imply wisdom.

The difference between military and civilian medical practice is most notable by the simple fact that insurance companies do not dictate what a doctor can do. Military physicians are insured by the US government, so malpractice coverage is provided for free to doctors who provide free care to their patients. As a result, we deliver our patient’s babies and help them grow up healthy in a system focused on quality care and not on monetary restrictions. Fun.

This next obstetrics experience began in the operating room. I was a resident on active duty, enjoying the managed learning experiences of a resident physician.

Cold Steel on Warm Flesh

I reached out my scrubbed, sterile-glove-covered hand towards the surgical assistant.  She slapped the shiny steel scalpel expertly onto my palm.  The sterile blade flashed in the bright lights.  A soft rubber plop was all we heard.  This was my moment. I would need to cut a deep, smile-shaped incision into the bulging abdomen of a living person.

I planned to dissect and manually tear through the muscles and layers of tissue to the uterus and open that now much-enlarged organ with another smaller incision.  Out of the bleeding set of wounds would emerge a baby covered with whitish grease.  I would lift a squirming child out of the warm wet hole, cut the cord, and announce, “It’s a boy.”  A new life would begin.

As the nurse slapped my palm with the tools of our trade, she watched my hands for a tremor and my eyes for fear.  She knew this was my first time as the primary surgeon.  What she saw was steady hands and a look of awe. But I was shaking inside.

“How have I earned her trust?” I thought.  I glanced over my paper mask at the anxious face of the now pain-free woman.  The epidural anesthesia drip in her back left her numb from the waist down.  In addition, the anesthesiologist was adding a steady flow of anti-anxiety medicine to her IV fluids.  She was aware, chemically calm, and watching.

“We are going to start now,” I announced while looking directly at her shiny blue eyes.  Mine were focused.

“Do she and her husband know how humbled I am by their belief in my newly developing skills?”   If they could hear my thoughts, I wondered, “Would they tell me to stop?”  I was pretty sure they would.

A sterile blue paper drape was placed neatly over her tummy.  The drape had a peel-away piece of waxed paper protecting the clear adhesive window over her abdomen.  The waxed paper was gently removed as we unfolded the drape into place.   We handed the upper edge of the drape to the anesthesiologist.  He attached it to two poles at the head of the bed, creating a sterile paper barrier. He and the dad could stand behind it and listen.  The surgical area was not visible to them.  Watching could be most disturbing to a dad.

I placed the sparkling steel scalpel at the left lower edge of a pumpkin-sized bulge at a prudently planned 90-degree angle.  My hand pressed down until I could see and feel the outer skin layers separate.  The skin was brown from the antiseptic Betadine lotion we had painted her with.  Her bulge protruded through the clear plastic, adhesive window.

The temperature-controlled, frosty room reeked of disinfectant.  Bright lights glared above and glinted off the blade.  With one single deliberate movement, I cut deeply and accurately along the path I had mapped in my head.  The result was a bright red, curved incision, stretching ten inches along the bottom of the abdomen.  Dark red bubbles of blood oozed up along the incision, and the thick liquid turned shiny and more brightly red as it mixed with the oxygen in the air.  The operating room technician dabbed at the incision adroitly.

“Nice job, Doctor,” observed the tech with quiet surprise in her voice.

The wide-eyed husband peeked over the blue paper drape on his tiptoes.  He could not see the procedure underway, but his eyes, peeking over his paper mask, showed confusion and expectation of his son’s imminent arrival.  I remembered how I had experienced the births of my two children long before I decided to go to medical school.  I had been very confused and lost.

I wanted to reassure him, but it was not my operating room.  It belonged to my mentor, and she was concentrating on me.  Four people were watching my every move, and all had looks of alert concentration.

But, this day, in the obstetrics operating room, I gently lifted a newborn, with the umbilical cord still attached, upward for all to see.

“It’s a boy!” I announced proudly.  My voice cracked a bit.

Squashing Sepsis with Silver Suture

Some interesting medical history is worth reviewing here. Until the 1900s, Cesarean section deliveries were only performed as a last-ditch effort to save a baby when the mother died or was dying from childbirth.  Mothers did not survive surgical procedures frequently due to the belief that the physician should leave the uterus open “to drain the evil humors.”  Physicians believed that sutures would cause infections and that the uterus would contract back to normal size and close up by itself.  This erroneous belief led to universal abdominal infections, sepsis, and death.

In the 1870s, surprisingly in the United States, a report came to Harvard medical school from frontier doctors that they had been sewing up the uterus with silver wire after C-section deliveries, and their patients had lived.

Their logic was reasonable.  “Since the mother would certainly die anyway, why not sew up the incision and see what happens?”  The concept was scoffed at and ignored by medical teaching centers.  Almost ten years later, these institutions of learning repeated the experiment to prove that the paper sent to them by these frontier doctors was wrong.  The women lived – and medical practices changed.

Surgical anesthesia using the newly discovered ether came along in 1846 but was seldom used in childbirth.   Midwives sometimes quoted the Bible (Genesis 3:16) as requiring that women must suffer in childbirth to atone for Eve’s sin.

That biblical prohibition lessened when Queen Victoria used chloroform for the births of her two children in 1853 and 1857, and everyone else followed suit.

Thank God – or the stories above would never have happened the way I described.

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** These memories are taken from my book “Swords and Saints – A Doctor’s Journey.” www.swordsandsaints.com