Thursday, June 7, 2018

Third World Green Daddy 74: Habemus papam, or "Hello Cesarean. How do you do technology?"

"We're going to have to do a Cesarean, right now.  I'll start calling the other doctors, and the nurses will get you ready for surgery."

My wife and I are dumbfounded.  It wasn't supposed to happen this way.  I haven't read anything about Cesareans, hadn't even considered it a possibility.  Yeah, I made a glancing reference to it in our birth plan that we'd drafted, in the same sense that I made provisions for bringing a priest in in case of a stillbirth, or if Caro's life were at risk.  But this was just covering for any unforeseen circumstance.  We didn't really expect any of that to happen.

I have prepared more for this birth than for probably any other, both reading extensively and really thinking about what it meant to be pregnant again, to have another baby.  Weeks later I will still be marveling at the fact that this little person is real, that we can actually interact with a little baby where others (including ourselves) had only dreamed of having one.

Ironically, having read more in preparation for this pregnancy than for any prior one, it makes me feel less prepared relatively.  For the birth of my first two sons, I don't know that I read anything about childbirth.  Ditto for my wife.  We knew the general process, we consulted a lot with the hospital or clinic to understand how everything worked and make sure they'd let me be present for the birth, but I can't say we read any "pregnancy books".  The books we do have now, and that we read preparing for Francisco's birth, we obtained for professional reasons, as my wife trained to become a doula, a decision which was itself inspired by the good care she'd received from doulas during Paulo's birth, my second son.  I had never touched those books before this year--they were Caro's domain, and even with all my pre-birth reading this time, I only got to a book called The Birth Partner in week 37 or so of the pregnancy.  So even this bit of prep I did in a hurry, and felt rushed and unprepared for, hoping that the baby wouldn't come so early that I couldn't read the relevant sections of the book.

I think this happens a lot to us in US culture.  There's this ethic of reading widely, consulting expert advice, for any undertaking, from making a wooden table in your garage workshop to selecting a college with your kid.  This is nowhere more true than for everything surrounding childbirth and childrearing.  But the perverse effect is that all this prep, this desire for a comprehensive, absolute knowledge on a subject, makes us in fact more aware of how little we do know, or how precarious is our grasp of the things we've just read in the past week or two.

So for the past few hours I've been skimming again through the Birth Partner book, reviewing how contractions should progress, which phase follows which.  Something I give the book a lot of credit for is acknowledging its own utility or lack thereof in different scenarios.  A lot of things I've read or heard about labor all my life, especially all that stuff about timing contractions, about weathering each peak and valley using rituals and exercises like rhythmic breathing and the like, really didn't correlate to anything I'd ever seen in my wife's labors.  Basically my wife normally doesn't have too many distinct contractions, just a nagging discomfort, and then the pain gets greater and she sort of silently draws in on herself, until she's ready to push the baby out.  The Birth Partner reassured me by saying that all the other rituals and Lamaze breathing and all that stuff (which we've never done and which Caro has zero interest in exploring personally) are just a means to get to the state of calm concentration that my wife already assumes in her labors.

For this labor, for Francisco's birth, the doctors have tried to induce labor with different drugs since the baby's amniotic fluid is getting perilously low.  So I am for the first time in my life timing Caro's contractions, but to little avail, since they don't seem to progress much.  Around 7:30pm the doctor, who is the mother of one of my son's close friends, expresses her concern that Caro's labor doesn't seem to be progressing.  Little dilation, irregular contractions even after heavy doses of drugs to induce them.  The doctor is very much on our wavelength in terms of allowing the labor to take its course, trying to avoid Cesareans unless medically indicated, etc.  But the baby hasn't been moving much for the past day or so.  His heart rate sounds fine for now, but she advises us that the pediatrician is already urging her to get the baby out.  If his heart rate starts to do anything weird, or if dilation hasn't progressed in the next hour, we will probably have to do a C-section.

My wife and I consult together, and convince the doctor to give us another two hours before proceeding to Cesarean.  But this is soon moot, as her next check-in reveals a racing heart rate for the baby.  We consent to do the C-section.

For all my reading and prep, I have not even looked at anything about Cesareans.  As I mentioned above, for this birth we have actually prepared a birth plan, which is a very American thing we'd never done before, but I thought it was worthwhile to at least lay out our desires and preferences in writing, given that we're in a foreign country and don't know what standard practices are here.  We have multiple laminated copies of this birth plan, in both English and Spanish, and it does in fact stipulate that we wish to be consulted and give our consent before any major procedure like a Cesarean.

But for our actual preparation, personally, we haven't even considered the possibility of a C-section.  I literally skipped over the part on Cesareans and complications during labor in all my books, since Caro had already had 3 complication-free births.  Caro has done the same, considering a book "finished" once she's gotten through the parts about normal labor and small complications.  So in the twenty minutes between our first awareness of the possibility of a Cesarean, and the confirmation that it will be necessary, I've been racing through that chapter in The Birth Partner.

Now the doctors have arrived from their respective abodes, and they wheel Caro off to the sterile surgery room.  I am ushered to a side entry, to the "gray zone" where you take off your clothes and put on scrubs, before stepping over a low barrier (like a bar bench) with your booties, into the clean area.  The first set of scrubs they give me is medium, which in Central American sizes means the shirt is so tight I can get it on but not off, and the pants seem to be part of a forcible family planning program.  Throughout this pregnancy, our doctors have been asking us if we'd like to get Caro's tubes tied.  "Four kids already, you're in your 40s, we can do it no problem!"  This has echoed to some extent the refrain four years ago in Colombia, when the doctors were constantly scolding us for having a third kid, and at the ripe old age of 36, to boot!  This is obviously annoying, but I guess that societies try to promote needed collective action one way or another.  In the case of countries that are in the midst of the demographic transition, trying to lower the population growth rate after a healthy initial surge in numbers, hectoring young mothers is one way of creating a culture of smaller family sizes.  Anyway, until I get off my too-small scrubs (with the help of a nurse to pull off my shirt), I am wondering if these nut-hugging pants are all part of the plan to keep us from popping out any more kids. 



I won't go into too much detail about the surgery.  Hell, maybe I will.  The longest part is getting the epidural in.  Apparently my wife has "tight vertebrae", so it's hard for the anesthesiologist to get purchase with his needles.  He has to take four or five tries before getting where he wants to be, and in the process he punctures the dural layer slightly, leading to migraine headaches for the next few days that will be the most difficult part of Caro's recovery, far more painful than the cut itself.

From there it flies.  The doctors start cutting away, singeing each cut surface with a little zapper to cauterize it.  This immediately makes sense to me, but I'd never thought about it before.  Caro doesn't feel a thing, and I'm able to zip back and forth between Caro on one side of the curtain at her chest level, and the surgery on the other.  Before I know it, we have a baby.  Apparently Francisco's umbilical cord had been smack between his head and the cervix, so it's a good thing that labor didn't progress, and a good thing that the doctors had decided to do surgery to get him out of the womb.  Otherwise his cord could have slipped out and gotten pinched, an urgent, fatal condition called prolapsed cord. 


After a bit of nuzzling with Mom, they put the baby on an adjacent table to give him his vitamin K shots, eye antibiotics, and the like.  As with my first son, I'm able to be with him for these first seconds of life, while Caro is still a few meters away in immediate recovery.  The anesthesiologist, who despite his multiple syringe jabs is a nice guy, puts on a Juan Luis Guerra bachata to mark the moment.  Everyone is festive.  The pediatrician gives one last pitch for tying Caro's tubes while they've got her belly open, but the OB/gyn discourages her, "I've already tried.  Don't even bother with these ones."

Later I take the baby under my shirt (for skin-to-skin contact), to the nursery room, where he'll be weighed, measured, and fed a small syringe of formula, just to tide him over until he gets real breast milk in like two hours.  I get to be with him the whole time, and I feel so honored to have this special space with him.  Sometimes it's surprising how the division of childrearing labor works out.  There are moments like this, immediately after the birth, as this little alien baby gets his first views of the world and hears our unintelligible babbling, all under a heat lamp to keep his naked body warm, where it's me, the dad, who is with him, because his mom can't be.  It seems like he should be with his mom right now, and indeed he'll spend his first months in almost constant contact with her, but for logistical reasons it's I that get to spend these first tender moments with him.





Later Caro will leave the ICU and give Francisco his first real meal.  To the hospital's great credit, they are really serious about early physical contact with the baby, and exclusive breastfeeding, so even after a highly invasive surgery like a Cesarean, my wife is out of there within two hours of the birth, back in her hospital room.

They are worried about jaundice, so they have us put the baby under a fluorescent light unit for a few hours each day afterward.  Decidedly a less natural approach to that of our public hospital in Colombia, which had a covered glass terrace to expose our first son to the equatorial light, 3000 meters up in the Andes.



The next day I bring my other sons to the hospital to visit their new brother, and they are immediately smitten, even to the point of getting in the pediatrician's way during her checkup!




I am amazed at how quick it all was.  My wife entered the surgery room at 8:30pm or so, they started cutting at 8:55pm, and our baby Francisco was born at 9pm!  In this sense, I can really see the attraction of a Cesarean for a lot of people like me who want to control everything, who aren't used to a long lapse between wanting something, deciding to do it, and then actually being able to do it.  I assume a lot of doctors are like this: high-achieving, in-control people, which is probably why Cesarean rates are way higher than they're supposed to be in most countries with a well-developed medical profession and system.  If you've done all this schooling and have access to all this technology, natural birth must be hard, as the doctor's role is more passive, the woman is the star of the show, and it's a long, animal process not much different than what a woman would have gone through any time else in our long human history.  After the fact my wife will assure me that the long, uncertain rhythm of vaginal birth, followed by an almost immediate recovery, is far preferable to the quick, painless Cesarean followed by days and weeks of pain, reduced mobility, and bodily dysfunction.  Our second child was born at midnight, and we walked into our house at 4am that morning, hale and hardy.  It will take three or four weeks for my wife to feel herself again after this Cesarean.

All that said, I'm thankful that we live in the era that we do.  I personally haven't had much recourse to very high-tech medicine (though I am thankful for the wide range of antihistamines and decongestants that keep my allergies at bay when I need them), but my loved ones have benefited greatly from things like MRIs, ultrasound, pap smears and cervical surgery, and now fetal monitoring and sterile Cesarean.  I think my wife is a real pro at gestating and raising children, and until this one, her births have always been low complication.  But if we were doing this in the late 1800s, we could have had a dead baby with a prolapsed cord, stuck in a dead woman's womb that didn't want to dilate and push.  Come to think of it, even our other, zero-hassle births could have resulted badly without the assistance of oxytocin to push the baby along.

I still rail against technology pretty often.  I still don't see the use of iPhones, which are enough like computers to totally distract you during meetings, but not enough like computers for you to get any substantive work done.  In fact, I'm convinced that, in a few years, the idea of having a computer with a 4-inch screen will seem to us like the big brick cellphones or carphones of the 1980s.  Beyond the novelty of having the newest gadget, the bulkiness of a brick phone makes it effectively not much more mobile than your house or office phone.  Beyond the novelty of checking Twitter and Facebook feeds while you're in a meeting, smartphones are a bad hybrid of useful cellphones and useful laptops, with about 30% of the functionality of each.  In short, I think that a lot of what passes for high technology today is just so much Pokemon Go--a total, inescapable phenomenon, the most important thing going on for a few weeks, followed by a collective realization of irrelevance once the novelty wears off.

But I'm realizing that technology as an overall class isn't something to accept or reject.  We can't go back to an era before mobile technology or even landline technology.  Once something is invented, it's impossible to un-invent it, and so even in a future of reduced resources and probably reduced prosperity for most of the world, these technologies will still be around, even if perhaps not as widely disseminated.  You can and should regulate or effectively muzzle technology in certain cases (nuclear proliferation, bump stocks on rifles, many self-propagating nanotechnologies), but humanity in the 21st century is necessarily humanity with 21st-century technology.  The fundamentals of life, love, nourishment, thought, and art don't change, but the technological context in which we seek these things does, for better or for worse.  Even for a very granola-style couple of a doula and an agrarian, the possibility of a safe, sterile C-section was a life saver!

Francisco's birth wouldn't have been possible without some high technology, much of it invented decades ago, but some of it either invented or perfected only recently.  Even in the low-resource context of our Third World home, it was a handheld Doppler heart monitor that allowed us to monitor my fetal son's heartbeat and make the decision to proceed to Cesarean.  The wires were frayed, and we had to switch out one cord for another to get it to work.  But the technology was there, and that has made all the difference.

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