The View from the Vue (34 page)

In that day, caesarean section was probably the deadliest of all surgical operations. Every caesarean section performed in Paris between 1787 and 1876 resulted in the death of the mother. It was safer to be delivered via the goring of a bull than by the surgeon’s knife. In New York City in 1887, angry bulls tore open the uteri of nine women; five of the victims survived. Yet only one of the eleven women subjected to caesarean section in that year in that city lived to labor another day. Small wonder that the caesarean operation came to be used only as a desperate last resort, frequently when the patient was moribund.

However, time passed, and as it did, modern obstetrical practice changed. Obstetricians learned how to properly suture a uterine incision, and then they picked up a few timely hints on cleanliness from Dr. Pasteur and Dr. Lister. Suddenly caesarean section gained not only respectability but respect. Therapeutic horizons undreamed of in the ancient days of Braxton Hicks opened up to the most mediocre of early twentieth-century obstetricians.

Now, when a placenta was thoughtless enough to implant low in the uterus, blocking the baby’s path of descent, one had only to cut into the organ from above, extract the child alive, and set matters generally aright. Not only did this mode of therapy have the advantage of expedition, but it also permitted the operator to avoid the risks of uterine rupture or exsanguinating hemorrhage which attended the vaginal manipulations (including Braxton Hicks’s version) formerly necessary in the management of placenta previa. The maternal mortality associated with this complication plunged to one percent, and after blood transfusion became established as a routine procedure, mortality fell even further, approaching one case in 1,000. By the time I began my residency, there wasn’t a modern obstetrician alive who would have been caught dead doing a Braxton Hicks version. The watchword of the faith had become “When in doubt, cut it out.”

Thus the modern obstetrician of 1964 resorted to caesarean section far more readily than did his predecessor. But old customs die hard. There was still a tendency to look upon a section as representing a failure in a sense: a slightly shameful inability to deliver the baby from below. This attitude originated in the days when caesarean section was just beginning to come to the fore. Older obstetricians were proud of their hard-acquired ability to perform all sorts of intrauterine gymnastics.

Thus the advent of caesarean section was gradual, the frequency of use increasing as more young graduates went out into practice, replacing the old-timers being transferred to the Great Labor Room in the Sky. But the criticisms of their professional fathers remained in the ears of the new doctors, causing them to wonder just a bit over the propriety of every section they did. This vague inborn guilt was transmitted to the next generation of obstetricians, and to the one after that. So, even in the early 1960’s the excellence of an obstetrics service was still being judged in part by the number of caesarean sections it had been found necessary to perform. Any figure over 3 percent caused eyebrows to shoot skyward and suggestions to be made that perhaps the doctors were getting a little knife-happy. This lingering suspicion surrounding caesarean section was responsible for some pregnancy outcomes which at the time seemed unfortunate but unavoidable. In retrospect though, they make me squirm much as I suspect Braxton Hicks must have wriggled in his chair in 1861 when he thought about the techniques he had previously used to turn fetuses.

For example, there was the case of Eufemia Montalvo. Mrs. Montalvo was a jolly, smiling Puerto Rican who packed two hundred pounds onto her five-two frame. She came to The Vue in labor one heady spring evening when the perfume from the East River garbage scows was wafting through the open windows of the labor and delivery suite. She told me her pains had begun a few hours earlier, her waters had not yet broken, and volunteered the opinion that this labor seemed just like her previous two. But it wasn’t. A glance at her prenatal-care record told me that her two children had been born, as are most children head-first. This fetus, however, was coming either ass-backward or ass-forward, depending upon how you define your terms. It was presenting by the breech.

In 1965, at The Vue, when a mother was unable to push out a breech baby by dint of her own efforts, the child was usually extracted. This procedure involved reaching up, grabbing the baby’s feet, and then pulling it into the world. The chance to do a breech extraction was an opportunity highly prized by senior residents, so I called Bryan Rollins, my second-year man. He, in turn, called Guillermo Sueza, the third-year resident. Together we reviewed Mrs. Montalvo’s situation.

We all agreed that she had a breech presentation. We differed a little, though, on our estimates of the baby’s weight. Under the best of circumstances, this is difficult to appraise accurately, and Mrs. Montalvo’s more-than-adequate padding made the circumstances anything but the best. Guillermo and I both estimated the weight at around eight and a half pounds, but Bryan said he thought it was more like nine and a half. He shook his head. “Gonna be a tight squeeze,” he said.

Guillermo laughed and shook his head. “Won’t be any problem,” he said. “You just do a good breech extraction, it comes right out. I’ll help you. You do it, and I’ll help you with it.”

Bryan looked dubious. “It’s a mighty big baby,” he said.

Guillermo picked up the prenatal record. “Look,” he said. “Her first baby weighed nine-two, and her second one was nine-five. She delivered both of them without any kind of trouble. Her pelvis must be plenty big.”

Bryan looked only slightly reassured. He scratched his head and mumbled, “Yeah, I guess you’re right.”

“Sure,” said Guillermo, and slipped me a wink. “You just got to do the extraction right, that’s all. You’re always worrying too much.”

Bryan bit his lower lip. “Okay,” he said, and turned to me. “Call us when she’s ready to deliver.”

“You bet,” I said.

Over the next two hours, I gave Mrs. Montalvo the hawk-eye treatment. I knew that if I failed to watch her closely, and didn’t give Bryan and Guillermo sufficient time to get down to the floor, scrub up, and get gowned, they would be more than a little angry with me. And justifiably so.

When at last the two senior residents marched into the delivery room, all ready to extract, I had the patient up in stirrups, with the anesthetist sitting by her head. Both senior residents examined the patient and agreed that her cervix was completely dilated. All that remained was for the baby to be pushed and/or pulled through the birth canal.

I felt the uterus begin to tighten under my hand. “She’s having a contraction,” I called out.

“Push, Mama,” said Bryan, leaning forward from the bottom of the delivery table. “Push as hard as you can. Push, push, push, push, push, push, push, push!”

Mrs. Montalvo strained against the handles on the sides of the table. Her face turned bright red and the veins on her neck stood out like blue worms. Her anus bulged, releasing a large piece of stool which plopped into the bucket at the foot of the table. Finally, her contraction over, her head fell back onto the table, and she panted and gasped for breath.

“Good push,” said Bryan to Guillermo. “But she didn’t move the baby a bit.”

“Okay,” said Guillermo. “Let’s do the extraction, then.” He asked the anesthetist to put her to sleep.

While the anesthesia was being administered, Bryan and Guillermo carefully reviewed the technique of breech extraction; during the procedure, there would be no opportunity to rectify a false move. Then, as soon as the patient had been rendered unconscious, Bryan cautiously inserted his hand into the vagina. “Got both feet,” he muttered. As he pulled downward, the feet appeared at the vulva. They looked big.

Bryan kept pulling, and the baby’s rump came out, followed by the back. A couple of twists and the shoulders were free. Then, Guillermo took hold of the feet as Bryan made ready to deliver the head. The umbilical cord hung down in a loop from the middle of the abdomen.

Bryan put one hand over the nape of the baby’s neck, slipped a finger of the other into the mouth, and began to pull. I leaned over Mrs. Montalvo’s abdomen to watch the head emerge, but nothing happened. Well, not exactly nothing. Bryan’s face turned bright red, and drips of sweat fell from his forehead onto the baby’s back.

“It won’t come,” he said, looking back at Guillermo.

“Wiggle it a little,” said Guillermo.

Bryan wiggled, but the head still didn’t budge. Guillermo felt the umbilical cord to count the Heart rate. “It’s down to sixty,” he said. “Better put on the Pipers.”

I ran across the room and came back with a pair of Piper forceps, an instrument specially designed for the extraction of the aftercoming head of a breech baby. His hands shaking more than a little, Bryan took the forceps, applied them, and pulled downward, at first gingerly, and then with all his might.

“Jesus Christ,” he moaned. “The God-damn thing’s absolutely stuck tight.”

“The cord’s not beating now,” said Guillermo rapidly. “We gotta get the baby out fast. Here, gimme the Pipers.”

He exchanged places with Bryan, took a deep breath, braced his feet against the table, and yanked. I felt sick to my stomach as I heard the unmistakable crunch of breaking bone. With that, the head of the baby flew out of the vagina, sending Guillermo staggering backward a couple of steps. Recovering himself, he began to slap the limp baby’s feet.

“Forget it,” said Bryan dully, rubbing his hand lightly over the crushed, flattened back of the baby’s head.

Guillermo turned pale above his mask as he looked up and saw what Bryan was showing him. Without another word, he clamped and cut the umbilical cord, and placed the baby into the bassinet. When we weighed it later, the scale read ten pounds, six ounces.

Our management of this case constituted good, standard obstetrical practice in 1965, but obstetricians have now come to realize that when large babies present by the breech, it’s much safer to deliver them by caesarean section. In the case of a head presentation, several hours may safely elapse while the head gradually works its way through the mother’s pelvis, but the aftercoming head of a breech baby must descend through the pelvis in just a couple of minutes. And with the rest of the child already born, there can be no turning back when the head hangs up, as occurred in the unfortunate case of Mrs. Montalvo.

As with the Braxton Hicks version, a breech extraction can be a real ego trip for the obstetrician, much more so than a caesarean section. But only when the extraction is successful. Guillermo and Bryan didn’t feel any too good for several days after Mrs. Montalvo’s delivery. As judged by contemporary standards, their actions had given them no reason to feel guilty, but doctors customarily look upon the death of a patient as representing failure, and take the matter very much to heart.

In some respects, Marta Garcia’s case resembled Mrs. Montalvo’s. It would have taken two Martas to make one Eufemia, though. Mrs. Garcia was a slightly-built-nineteen-year-old Puerto Rican who came to The Vue in labor with her first child. As the labor progressed, it became obvious that she had the Puerto Rican problem: a flat pelvis.

Since the Puerto Ricans who emigrated from their sunny isle to the Lower East Side of New York were overwhelmingly from the poorest segment of Caribbean society, their nutrition had been none too good while they were growing up. Consequently, they suffered from a generalized softening of their bones. One consequence of this condition was that the developing pelvic bones became excessively molded so that the pelvis was extremely flattened from front to back. Then, in labor, the short pelvic dimensions would block the passage of the baby.

Thus, Mrs. Garcia labored bravely, but in futility. Her cervix dilated properly, but the baby couldn’t descend through the birth canal. I called the senior resident for the night, Peter Edwards. Pete came down, examined Mrs. Garcia, and rubbed his hands together in eager anticipation. It was a case for the Bartons.

The Barton forceps was an instrument designed to fit into a flat pelvis and extract the baby. Because of the large number of these architecturally deformed birth canals that found their way into The Vue, the Bartons had achieved great popularity there, and the residents were all eager to use it. Like a successful breech extraction, a good Barton delivery was a real ego trip.

When it became apparent that Mrs. Garcia had pushed her baby as far down as she possibly could, we took her to the delivery room, gave her a spinal anesthetic, and put her up in the stirrups for delivery. Pete put on his gown and gloves, did a careful last-minute examination, and applied the Bartons. Then he got down on one knee and began to pull.

I say he pulled. He tugged. He yanked. He towed. He hauled and wrenched. His efforts made Bryan’s attempt with the Pipers seem feeble by comparison. Great torrents of sweat flooded his eyes and his ears and formed lakes on the floor in front of him. What we could see of his face was the color of an overripe tomato, and the veins on his neck bulged frighteningly.

After what seemed like half an hour, but was really more like five minutes, the baby emerged. No one in the room was breathing including the baby. After Barton extractions, not many newborns demonstrated terribly much in the way of spontaneous respiration.

We all set to work resuscitating the infant, while Pete sewed up Mrs. Garcia so that she once again looked as her Creator had intended. After about five minutes of oxygen and other indicated tonics, the baby started to come around. By fifteen minutes, he was breathing on his own, and by half an hour, he was obviously no longer in danger.

So Mrs. Garcia got to take home a live baby. However, by today’s standards, we really may not have done her a favor. We’ve learned that babies who are severely depressed at birth often don’t do as well as expected on IQ tests and neurological examinations later in life. For this reason, difficult forceps extractions, which may cause neonatal depression, have been largely supplanted by caesarean sections which, although less exciting, seem to yield up babies in much better condition.