Pregnancy and Awkward Realities

I can’t think of a more awkward social situation for a single, twenty-six-year-old male to be in. A previous experience as the only Jew in a room full of
Catholics singing songs about Jesus didn’t hold a candle to this. I was observing a group of fifteen pregnant women discussing pregnancy and getting
pregnancy screening tests. Nurse practitioners run this group to aid and educate pregnant women who do not have enough money to pay for individual
physician visits or are uninsured or even undocumented. Some of the screening tests, which occur at specified times during pregnancy, include maternal blood pressures and weights, labs to identify low blood counts, tests for sexually transmitted diseases that are a danger both to the
mother and the fetus, ultrasounds of the fetus, dopplers of fetal heartbeats, fundal heights (a measurement of the top of the pelvic bone to the top of the uterus) to assess
fetal growth, and more.

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These tests provide obstetricians with abundant information about the health of the mother and the fetus. For example, a test for gestational diabetes determines whether the pregnant mother may have insulin resistance — a state in which she is unable to store sugar properly, which could cause the fetus to receive excessive sugar and grow too large, resulting in shoulder dystociahyperinsulinemia, and hypoglycemia at birth. Screening tests help
physicians to identify these sorts of problems early enough to prevent complications.

Obstetricians also examine the cervix, which is the lower part of the uterus. It
may be most helpful to think about it as the passageway between the vagina and the uterus. As females progress through childbirth the cervix dilates up to
10 centimeters to allow for passage of the baby from the uterus. The cervix effaces as well; that is, it shortens. Obstetricians check for fetal station, too, an assessment of how far down the fetal head lies in the
pelvis — the range is -3 to +3, where +3 indicates imminent birth. They use monitors with probes to assess the fetal heart rate and uterine contractions.
The fetal heart rate gives the physician a sense of the baby’s health status. If the baby’s heart slows down too much, the baby lacks oxygen, necessitating
immediate delivery.

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The nurse practitioner performed these tests and more for each member of the group over the course of nine months. After some brief screening tests in this
particular session, the women sat in a circle and played games. As the only male in the room, I had a difficult time participating in some of these. One
game consisted of suggesting an object to bring to the hospital when it was time to have the baby and then listing all the objects the previous patients had come up with — one had to propose something new and remember what others had proposed. Some objects included: a fluffy pillow, baby clothes, a stuffed animal, an R&B CD,
a scented candle (cinnamon), and others that I can’t recall. When it came around to being my turn, although I appreciated not being treated as just a fly on the wall I couldn’t help but feel at this moment like a knight in those scenes in Monty Python and the Holy Grail: “Run away! Run away!”
I had the eyes of fifteen pregnant women on me. Some of them giggled, either with anticipation or, more likely, because my face turned red and I sheepishly
grinned, declaring, “I shouldn’t be here.” I blurted out: “I feel like Arnold Schwarzenegger in Junior.” The reference was lost on every single person in that room; too young, I
guess — or too terrible a movie to bother with. So I started to name the objects they had chosen, things that I probably would not take anywhere even if
I did own them. I stumbled a bit but managed, with some help, to claw my way through it. When I then had to suggest an object I would bring if I were
expecting, I said food. This was met with nods of approval. A love of food is one of those things that certain pregnant women and I share in common.

We next took a short break, during which the conversations mostly covered topics I couldn’t relate to: potential baby names (my only reference for that is
this Seinfeld episode but after my previous pop-culture reference fell flat, I knew better than to mention it), pregnancy clothes, car seats, baby clothes, nail polish, and
past episodes of morning sickness. I excused myself to “go to the bathroom,” which really meant “avoid the conversations and wander the halls until the
break was over.” What else is a twenty-six-year-old male to do in this situation? This was so far removed from any of my experiences or thoughts. After the
break, we watched a corny video about the process of giving birth — the acting was so bad that all the actors convinced me that they felt opposite what
they claimed to feel. It was a nice time for me to check out mentally.

As ridiculous as this experience seemed at times, there is a deeper, more serious matter worth thinking about here. Many of these women were young enough to be in high school and needed a doctor’s note to
excuse them from school. Some of them did not know who the baby’s father was; all except for two were unmarried; and many could not rely on anyone but a
single parent for help. Sociologists have thoroughly studied the deleterious effects of these kinds of social situations. As Derek Thompson asserts in The Atlantic:

Among what you might consider “modern families” (e.g. the 61 million people married and living together, both working), there is practically no poverty.
None. Among marriages where one person works and the other doesn’t (another 36 million Americans) the poverty rate is just under 10 percent. But take away
one parent, and the picture changes rather dramatically. There are 62 million single-parent families in America. Forty-one percent of them (26 million
households) don’t have any full-time workers. This is something beyond a wage crisis. It’s a jobs crisis, a participation crisis — and it’s a major driver of
our elevated poverty rate.

Indeed, Kay Hymowitz, the William E. Simon Fellow at the Manhattan Institute, writes in the Wall Street Journal that homes without
married parents put children “at an enormous disadvantage from the very start of life.” Additionally, teen pregnancy itself causes a range of harmful
consequences for both children and their mothers. The National Institutes of Health points out here that teen mothers are more likely to live in poverty, have infants with
developmental problems, have baby girls who grow up to be teen mothers and have baby boys who grow up to be arrested and jailed. Furthermore, teen
pregnancies have higher rates of illness and death for both the mother and the infant. Though the rates of teen pregnancy are dropping, the problem and its
manifestations are evidently very real.

It is difficult to know what exactly the physician’s role should be in this process. How much should physicians encroach on the job of parents, who ought
to address this issue with their children? When there are no stable parental figures in a child’s life, how much paternalism does the physician offer? Will
such paternalism backfire? At what age is it appropriate to start speaking to teenagers (or preteens) about sexuality, reproduction, and parenting? And what is the best
way to do it? Here’s the CDC’s anodyne take on it: “Make your clinic teen-friendly. Provide your adolescent patients with
confidential, private, respectful and culturally competent services, convenient office hours, and complete information.” It’s not that easy, nor is it that
benign.

The medical profession is unusual in that the private lives of patients are relevant to nearly every visit. Consequently, no matter how uncomfortable or
awkward or humorous it may be for physicians, these issues inevitably come up. Undoubtedly, then, medical practitioners will play a role in this deeply
significant sociological quandary — how large that role is depends on the physician and the specialty.

Labor and Delivery

The obstetrics nurses rushed the stretcher through the triage station as the resident tore out of her chair and followed them. I jumped up and ran with
her. It was the second night of my obstetrics rotation and there was no time for triaging this patient, who was on the verge of giving birth. And because
she spoke almost no English we could not get a history from her. If we had been able to, we would ask all about her gynecologic and obstetric history. Most
importantly, we would ask if she had been screened for sexually transmitted diseases (STDs) which can be spread to the baby
leading to horrific consequences including severe developmental disorders and death. The baby, though, came too fast for any kind of serious conversation,
even with a translator. In women who have given birth before, like this particular mother, the birthing process goes much faster. Therefore, when a multigravid woman comes in and claims that the baby is about to come out, obstetricians immediately
rush her into the delivery room.

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We transferred the patient onto a bed, pulled out stirrups for her patient’s legs and detached the bottom part of the bed such that half of the patient’s
derriere hung off its edge. As she opened her legs I saw the tip of the emerging child’s head, mostly covered in dried amniotic fluid, blood, and other
bodily secretions. The resident, attending, and I quickly put on sterile gowns, gloves, and masks and, encroaching on the woman’s privacy (though she didn’t
mind just then as she began to howl in pain with each uterine contraction),
stood in between her open legs at the entrance to the vagina, our hands ready to catch the baby.

With each muscular contraction of the uterus, the baby inched further and further out into the world. The resident coached the mother, imploring her to
push as she continued to scream. In a not-so-surreptitious manner, the father pulled out his iPhone as he stood by his wife’s head and hit “record” to
document the birth of the couple’s third child. He wore an enormous childlike grin as he did so, aware both of his
slight irreverence and of the imminent addition to his family.

After a few contractions, the baby’s full head emerged and the resident and attending supervised as I delivered the baby. My heart rate skyrocketed; I
sweated, trembled, and attempted desperately to remember the childbirth simulation I had been through one week earlier.

The delivery of a baby is not all that complicated when it’s first explained (here’s a proper

YouTube video of it
 — ignore the very corny soundtrack and beware the graphic nature of the video) but try doing it when the time comes and you freeze up very fast. In an
ideal world, as the baby’s head appears, one puts pressure on it so that it does not pop out and tear vaginal tissue. Make sure the head rotates so
that the baby faces the inner thigh of the mother (also known as external rotation). This rotation also allows one of the baby’s shoulders to emerge. Once
that shoulder is out, tip the baby towards the exited shoulder to allow the other emergent shoulder to exit as well. If you try to get both shoulders out
at once there is a danger of shoulder dystocia in the newborn — the shoulder of the infant
sticks behind the maternal pubic bones leading to anything from transient nerve paralysis in the baby’s arm to compression of the umbilical cord cutting
off oxygen supply to the child.

With the resident’s and attending’s hands near mine, I performed the delivery. As I angled the baby’s shoulders and allowed its body to exit the vagina, a
huge amount of fluid gushed out — a combination of amniotic fluid, some blood, liquid mucus, and vaginal discharge — and soaked my shoes and gown. Ignoring
this, I clutched the child to my stomach to prevent her from slipping out of my arms (not very smooth). You’re supposed to hold the baby in the left arm
with the head in the palm and the body resting on your forearm, not clutch the baby to your chest. When babies are born they are frighteningly slippery though.
And, fearful of dropping the baby, I used both arms and my abdomen to cradle the child, praying I would not drop her.

I held the neonate below the level of the vagina to allow the umbilical cord, which has vessels
that carry oxygenated blood to the baby in utero, to drain all the rest of the blood into the child before cutting it. The resident clamped the
umbilical cord on two ends, waited a bit, and then cut it. This prevents the two ends of the cord from bleeding. Simultaneously, the attending suctioned
out the baby’s nose and dried off the baby with a towel. Newborns are prone to temperature changes so we dry them off and then wrap them in a blanket to
keep them warm. The resident took the child from me and handed her over to her mother while the father continued to use his iPhone to record this remarkable moment. The mother bawled and even the father cried as his smile enlarged to one of complete and unreserved joy. Their perfectly healthy, new daughter held their rapt attention
and despite the commotion around them, nothing distracted the parents from this life.

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The pediatricians arrived in the room, examined the baby for any malformations (none were found, thankfully) and placed her in a hospital crib. We continued to deliver the placenta, tissue which attaches to the uterus
and allows for the umbilical vessels to exchange deoxygenated blood from the baby for oxygenated blood from the mother. It is semi-flat and looks very much like an alien organism
nonetheless it is crucial to the survival of the fetus. After the baby is born, if the placenta remains inside the uterus, there is a greater risk of
infection in the mother. I gently tugged on the umbilical cord while I massaged the lower abdomen with my other hand. This helps coax the placenta out of
the uterus and also helps to stem the bleeding from the uterus (uterine contraction is integral to cessation of bleeding postpartum). The placenta slowly
plopped into my hands; warm, squishy, and bloody. I placed it in a plastic tub and began to clean up all the tools, gowns, and gloves when the resident got a
call on her phone: another woman about to give birth two doors down. We rushed out.