The Urban Dad

writes letters to his children

The Urban Dad

The Urban Dad
Location
Northeastern US,
Birthday
August 23
Bio
Father of two, now expecting twins autumn 2008. My goal is narrative here. Scene, character, story. I imagine my children reading these stories as young adults.

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AUGUST 14, 2008 1:05PM

"She's not breathing."

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When my first child was born, she wasn't breathing. This is one of the things I will never forget.

Sometimes I try to remind myself that nobody is born breathing. That's correct, isn't it? A fetus lives for months in the womb. Heart driving oxygen to all those tiny parts without fail. One hundred and forty beats per minute. Eight thousand times per hour. Two hundred thousand times per day. Six million beats per month. Zero breaths.

Then suddenly, there is an atmosphere. And cold, I imagine. But still there is no need to breathe air, at least not right away. (We're talking moments here. When you're there, the moments can last so long.)

My neighbor had her second child in a wading pool in her living room. She caught the infant girl in her own hands, her partner told me. We were talking at the playground with our toddlers a few days after the birth. I think it was then that he told me about holding the pulsing umbilical cord in his hand. It stopped 10 or 15 minutes later, he said, then they cut it.

I relayed my story about my first daughter. The part about not breathing, which is what I always remember. About how they whisked her away as soon as she emerged. 

Then my friend asked this question... I can't believe it never occured to me to ask. In three years, I never wondered about this.

"Why did they cut the cord if she wasn't breathing?"

It's a good question. Darlin had been breathing for her for months. Why not wait a minute, or five minutes, or ten minutes, until she breathed on her own and then cut the cord?

I'll call my first child Mimi. We celebrated her third birthday recently. She's rambunctious, and likes to tell stories, though she doesn't quite have the 'beginning-middle-end' thing down. She's still uncertain about cause-and-effect, too. "Why are you mad at [best friend] Billy?" I might ask. "Because I hit him," she'll say, when clearly the former preceded the latter. When I lift children of her same age in my arms, they are as light as pillows. Mimi, on the other hand, feels to me like she just ate a bag of cement, and I mean that in a good way. The girl is sturdy. The girl is strong. Her eyes are gray, though I doubted that anyone really had gray eyes before hers turned this clear and bright shade. These eyes are a regular source of mild wonder to me, the dark-eyed grandson of Slavic immigrants to these green hills.

I was at the office when Darlin's water broke. It was late morning, and she was scheduled to work around mid-day. A day shy of 39 weeks gestation, she was at home on the telephone trying to take care of some bills or something. She dropped her pen walking from one room to another. She squatted down to pick it up, and the amniotic sac burst and leaked fluid all over the floor.

My office is halfway between home and the hospital. Darlin said she could drive through the contractions and pull over if she needed to. It was only two miles.

Okay, I said. Call me when you're here. I have to wrap some things up.

I was interviewing someone for a job. He was busy taking a sort of writing test we'd concocted. I told him I wouldn't be around when he finished because my wife was in labor. I told my supervisor. I was in a mild sort of shock, I guess, like I'd been told to evacuate the city and wasn't sure if it was a joke or not. My eyeballs were a bit loose in their sockets as I walked back to my desk. Good luck, everyone said.

Darlin called. She was just a block or two away. I'll see you out front, I said.

I emailed a few colleagues to tie up loose ends. Darlin called. I can't recall her exact words, but "Where the fuck are you?" captures the gist of it.

I found her on the front steps of the building. She was gripping the steel handrail and trying to look like she wasn't having a contraction. One hand was on the small of her back. She gave me a pained smile then put both hands on the handrail in order to snap it in half. She breathed for a moment or two, then said that the construction workers across the street had been looking at her funny.

Lots of things happen between arriving at the hospital and holding your firstborn. I'll try to make it quick: Somebody checks your wife's cervix to see how much it has opened. Ten centimeters is tops and ready to birth. Darlin is somewhere under five. Women who have been exposed to Group B Streptococcus, as my wife had, get an hourlong IV drip of antibiotics and, afterwards, they continute to sport the IV port taped to the forearm so that they can be topped up again later. When the IV drip is finished, we walk the halls. Darlin moves slowly and stops every minute or two to grip the rail that lines the hall. I put both hands on her, usually the small of her back and shoulders. Firm pressure or light massage. She breathes slow and deep, lips pursed like she wants to be a teapot.

We're riding out a contraction on the long wooden rail, when a familiar face appears at a window in a security door. It's Dave, who was in our childbirth class with his wife. Our due dates are about a week apart. "See you at the hospital," we always joked with each other. And here he is. How is Shelly? Going in for a c-section he says. She labored a while, but it ain't working. But everybody will be fine, including their son.

Later, we're exploring the halls of the hospital more, exercising our midwife-assured right to not be confined to a bed just because one of us is in labor. This can go on for hours, maybe even more than a day. There's no sense confining Darlin to a bed, especially when moving the hips might help ready her for pushing. A nurse appears through another security door to find us on a bench. "There you are," she says. "We need you back."

We go to our labor and delivery room. Dim the lights, stow our bag, put a Ladysmith Black Mambazo CD in the player. Darlin wears a fetal monitor strapped around her belly, put there by the nurse staffing this part of the floor. After a good bit of normal heart rate monitoring, I start to help Darlin out of bed. The nurse returns and exclaims, "W-w-w-whoa! What are you doing?"

We just want to move around. The nurse likes her pregnant women in bed and stationary, apparently. We find a way to get what we want. Track down E., the midwife, who assures us the Darlin can stand up and move around if she wants to.

Darlin progresses. She likes to stand next to the bed, bent with her hands on the mattress like she's trying to keep it from levitating. I apply pressure to her lower back, where she feels the contractions. Sometimes I hold a wet icepack wrapped in a towel there. She breathes. She lets out some low animal sounds.

Essentially, she retreats into herself. We don't make eye contact for hours, it seems, because her eyes have turned inward. She knows I'm there because my hands are always on her and I am in her ear.

When she's fully dilated, they tell her she can push if she wants to. She's been feeling the urge to push and now she gives into it on the contractions. She rests between, and I am in her ear telling her she is strong, which is the truth. I call her 'babe,' and tell her she's doing great. We met playing competitive sports, and I feel like I am coaching her through a marathon session of weightlifting and sprinting.

Eventually, we can see the top of a head, which is a dark patch of hair emerging from her. You have no idea how long it takes a woman to push her first child into the world until you see it happen. You see the head when she pushes. When she stops, it retreats. Her tissues are stretching and it takes time and effort. An hour after she started pushing, she is still pushing. Now the head does not disappear completely when she stops pushing. In the room with us are a midwife, a labor nurse, and a nursing student. We tune out the student at first, because she tells Darlin to breathe in when she is clearly breathing out. Eventually, this student and the nurse are holding either of Darlin's fully bent legs as she pushes and things are happening fast. A mirror has been brought so that Darlin can see. The head is out.

A human head protruding from my wife looks to me as outlandish as if she had sprouted a sunflower from her chest. It is time to push the baby all the way out and I am for the first time in hours feeling my attention pulled away from my wife--like i haven't been more four inches from her ear since I don't know when--and now I am drawn down to the end of the bed as she pushes and all at once there is an entire human being, slippery arms and legs and bottom in the hands of the midwife.

And they whisk her away. And I am between Darlin and the turned backs of the midwife and two nurses. But this is not how I imagined it would be. "She's pink, she's perfect, her heart rate is good," says the midwife over her shoulder. "We're just waiting for her to take that big first breath."

And despite the midwife's best efforts to convey this information in the most positive light, I can't help but hear it as, "She's not breathing."

Incidentally, this is also how we find out that we have a girl. We don't get to look at her on Darlin's belly and touch her little head and limbs and then discover, It's a girl! We hear it from the midwife as she tells us, "She is not breathing yet."

We get more assurances just a few seconds later. She's pink. Her heart is beating away. We just want her to take that big lusty first breath and let out a wail, we are told.

Now they are agitating her. They rub her skin, shake her floppy limbs rudely. C'mon baby. Cry.

She lets out a little squawk of mild annoyance. She's doing fine, we are told. They are still a bit puzzled by the lack of a big lusty wail. But perhaps she just has nothing to cry about. The whole 'not breathing' episode probably lasted 10 seconds or less. Darlin will later say that she never worried about anything at that time. She is exhausted, covered in sweat and now suddenly growing cold since she has stopped laboring. The nurses cover Darlin with blankets to her shoulders to keep her from shivering.

After staying by Darlin's side while Mimi, as we'll come to know her, is worked on by the midwife and nurses, I finally get my chance to walk to my little girl lying beneath the warming light. I touch her arms and belly and her little fingers and talk to her. Dry and warm and soft and vaguely chalky from having her skin dry for the first time ever. Head shaped funny from being forced through a too-small passage. Her big dark eyes with their thousand-yard stare turn to my voice beside her.

I say to the nurse, "I know she might not have scored to well on the Apgar test you give at birth. Do you do that again?"

E, the midwife, bless her kind heart, immediately hears the uspoken concern in my voice. She stops what she is doing (which is sewing up a tear that Darlin suffered while pushing this monkey into the world) and turns to me and states unequivocally, "Your daughter is fine. She is absolutely perfect. There is nothing wrong with her."

A neonatologist, summoned as a matter of course when Mimi did not immediately draw breath, soon comes to take a look and tell us exactly the same thing. A few minutes later, a nurse swaddles our baby girl and puts on her little cap. I walk her across the room, two hands beneath this tightly swaddled bundle and introduce her to her mother.

For three years, this is the story I tell. Then someone asks me, "If she wasn't breathing, why did they cut the cord?" And I don't know. I'd like to ask before Darlin delivers our twins. I expect the see the midwife again, too; she may or may not be the midwife who attends the birth of the twins, depending upon who is on the schedule at the time. 

What do you make of the question, those who have been there?

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I don't know the answer to the question. It is a curious one.

When our first one was born, we had a little bit of initial worry. Her heart rate was slowing too much during the pushing stage. There had been meconium. When she emerged the cord was wrapped around her neck three times. (That midwife unraveled that cord faster than the speed of light.) They whisked her to the other side of the room with a team waiting with all sorts of equipment, mostly to suck all the correctly suspected fluid from her upper respiratory region.

During all this, I was dumbfounded. It was my wife, who had gone through 33 hours of labor, that had the presence of mind to ask as her first child is being whisked across the room to ask, "Is it a girl or boy?"

A couple seconds pass. The midwife finishes telling the nurse something. "Oh, it's a girl. You have a girl."

Reminds me of the closing words in this sketch.
"For three years, this is the story I tell. Then someone asks me, "If she wasn't breathing, why did they cut the cord?" And I don't know. I'd like to ask before Darlin delivers our twins. I expect the see the midwife again, too; she may or may not be the midwife who attends the birth of the twins, depending upon who is on the schedule at the time.

What do you make of the question, those who have been there? "

One of the hallmarks of homebirth advocacy is defiance. The classic homebirth prescription is to review the evidence, then ignore it and advocate the opposite. If obstetricians or scientists show that something works, insist that it doesn't. If they show that something doesn't work, insist that it does.

Hence the claim that delaying cutting the cord cures all ills. Obstetricians have generally cut the cord within the first minute. Therefore, homebirth advocates wait until the cord stops pulsating. Is there any benefit to delayed cord cutting? There can be additional blood pumped from the placenta into the baby. For premature babies, who often develop anemia, this can be a benefit. There does not appear to be much benefit for term babies. Indeed, the latest evidence indicates that delayed cord cutting can increase the incidence of jaundice and the need for bili light therapy.

Interestingly, there is no scientific evidence that shows that delayed cord cutting improves oxygenation. That does not stop homebirth advocates from insisting that it does.

Homebirth advocates like to pretend that "nature intended" that the cord not be cut and infants be allowed to start breathing on their own. We know, however, that such an approach leads to the death of thousands of babies every year. According to the World Health Organization Bulletin April 2008 (https://www.who.int/bulletin/volumes/86/4/07-049924/en/):

"Birth asphyxia, defined as the failure to establish breathing at birth, accounts for an estimated 900 000 deaths each year and is one of the primary causes of early neonatal mortality. Guidelines for neonatal resuscitation, such as those endorsed by WHO and the American Academy of Pediatrics, represent a standard practice set that improves outcomes in asphyxiated newborns. These algorithms stress the importance of drying, stimulating and warming babies in distress, as well as clearing their airways. "

The authors describe a typical case that almost ended in the death of the baby:

"Our experience working alongside neonatal care providers in sub-Saharan Africa and India illustrates how resuscitation practices influence stillbirth statistics. In rural Sudan, we have seen a cyanotic, apnoeic newborn with a pulse be set aside following birth and left to herself to initiate the process of spontaneous breathing. After nearly two minutes of non-intervention by the delivery attendants, we were compelled to step outside of our role as observers and act quickly to provide stimulation and positive pressure ventilation. The infant responded to manual breaths and the outcome was good..."

Training traditional birth attendants in simple techniques like stimulating and drying the baby has been shows to cut death rates in half in underdeveloped areas. That represents tens of thousands of lives saved.

Homebirth advocates live under the spell of the naturalistic fallacy. They assume that whatever is "natural" is good, and whatever is "not natural" is bad. In the case of neonatal resuscitation, however, we know that literally hundreds of thousands of babies die "naturally" each year for want of simple resuscitation measures.

It is rather ironic that while the WHO is working mightily to train traditional birth attendants in basic resuscitation measures so that hundreds of thousands of lives can be save, homebirth advocates are busily pretending that no such measures are needed in "nature."
That was a well-told story. You had me on the edge of my seat - - holding my own breath!
I can't answer your question, but I can tell you it was a great read. Glad it had a happy ending, too. Thanks -
I rarely do anything vital for myself when I'm tethered to someone who's doing it for me. Maybe the people caring for your kid knew that she was never going back to the womb, and were willing to flop her around to bring her to a place where she'll cry.

By the way this line, "Incidentally, this is also how we find out that we have a girl," was worth getting out of bed this morning. My daughter:
http://www.flickr.com/photos/davemedia/2651149989/
turned 21 months old this week, and I loved your story
Thanks Amy, but in your eagerness to state your position on homebirths, I think you misunderstood my question. It's like reading a response to a different post.

I'm not wondering why I didn't get to delay cutting the cord for 10 or 15 minutes without worrying about when my daughter was going to take her first breath. I'm just wondering what the rush was. It may be that there's more information none of us here knows. I'll ask the midwife, and she may know important specifics that I do not.

When daughter 2 was born, she lay on Darlin's belly, alert and breathing. I cut the cord myself. It may have been less than 60 seconds after she was born, but there was no rush.

I guess I'm wondering why not lay the baby on my wife's belly, get her to breathe, then cut the cord? Until she starts breathing, isn't an imperfect oxygen delivery mechanism better than none? I'm just a dad, not a doc, so I don't know.
Actually, Amy, I apologize. I did ask why not wait a minute, five, or ten.

Thanks for the kind words, all.
What a harrowing tale! I'm looking forward to reading the impending post about your new twins arrival - hopefully, less eventful, but just as joyous.
You know, I've been thinking about your story and although I don't know why one practitioner would choose to cut a cord earlier rather than later, based on the telling of your story, I think your baby girl was, in fact breathing. My reasons to think this are the fact that she was pink and that her heart was beating. Both of those things go away so quickly when the babies are apneic. Also, there's a lot of commotion when the kiddos don't breath - people start acting all frantic and freaked out until the baby breathes. So maybe she just wasn't crying loudly enough or breathing as deep as they wanted? Or maybe there was a hint of meconium staining and the specialist was protocol/precaution?

Rahul's a pediatrician. Maybe you should fire off an email to him. He might know more about what the neonatologist was thinking.