Unthinkable choices in childbirth emergencies

Firefighters and doctors stand beside you on your worst days. On our best days, we help you sidestep disaster. On our worst days, we make gruesome decisions, so you don’t have to.

Andrea’s family barely survived the pandemic. Her husband lost his job and her beloved grandmother lost her life. But after years of setbacks, today was move-in day.

The seaside bungalow was not as big as she’d hoped, but still perfect. Then her realtor called to say he was delayed. Winds were tossing debris onto the roads and slowing traffic.

The breeze on her face became hotter. Bits of gray ash floated past like zombie confetti.

A yellow firetruck arrived as a wall of flame roared towards the property’s edge. The heavily geared crew ran to Andrea as she fell to her knees.

“Thank you for saving my home!”

A firefighter lifted her beneath both shoulders.

“Ma’am, I’m sorry. We have to go. Your house cannot be saved.”

I’m not a firefighter; I’m an obstetrician. I also manage natural disasters. One of the worst is shoulder dystocia.

Shoulder dystocia occurs when there’s a mismatch between the size of a baby and the mother’s birth canal. It cannot be predicted with certainty. I’ve delivered a 10-pound, 9-ounce baby in three pushes. My worst shoulder dystocia was in a 7-pound baby.

Once a baby’s head delivers, families cheer. Obstetricians do not, because our work isn’t done. The baby’s shoulders need to rotate and slide under the pubic bone. If they don’t, the baby’s life depends on what happens next.

Medical teams rigorously train to perform the steps needed to save a baby. We have a handful of minutes to release the shoulders and thwart death, even fewer to prevent temporary or permanent injury.

For the doctor, sound becomes muffled, but each passing second pounds like a migraine. We attempt one maneuver after the next, praying the baby survives and our youth spent in training was not in vain.

Shoulder dystocia occurs in 0.15 percent to 2 percent of deliveries. The first-line rotational maneuvers work most of the time, often before the family registers there’s an emergency. The second-line maneuvers require intentional harm to the baby. We have to cause injury to prevent death.

Ten years ago, I broke a baby’s arm to allow it to deliver. I can still hear the sound of that crack. It still makes me nauseous.

The last option to resolve a shoulder dystocia is a Zavanelli maneuver. Every obstetrician fears that term. Fortunately, almost all of us will complete our decades-long careers without ever performing one.

By the time a Zavanelli maneuver is attempted, the baby has died. The obstetrician is fighting with every skill and prayer they have to save the mother.

The final, devastating choice is to separate the baby’s head from its body. The head delivers vaginally and the body delivers through the Cesarean section incision.

Beheading is an act usually committed by terrorists. When your baby has died, however, and your (or your partner’s) life is in peril, I hope your obstetrician can make this unthinkable choice and do what’s required.

I don’t know the details of the case in the headline: “Infant was Decapitated During Delivery.” Neither do you.

Neither does anyone else, including the medical staff and family in the room. In a trauma, people remember some details with laser-etched precision, others incorrectly or not at all.

Physicians, nurses and firefighters need to have our actions reviewed honestly but not brutally. A tragic outcome is not proof we made a mistake. A good outcome is not evidence we didn’t.

Right now obstetricians across the country are rethinking their career choices. We feel like firefighters watching 9/11 unfold. That obstetrician could have been us. That obstetrician could be us at our next delivery.

We are also reassuring our patients this won’t happen to their baby. Despite the reminder that we can never say never.

In the past three decades the world has changed. The earth is hotter and more violent weather is causing more deaths. The most vulnerable are often most at risk.

My profession has also changed. When I started practice in the 1990s, the majority of mothers were in their 20s, had a “normal” body weight and babies averaged 6 to 7 pounds. Now, the average age of mothers in the U.S. is 30, 30 percent are obese and babies often weigh 8 to 9 pounds. This rapid change within one generation makes shoulder dystocia more common and more difficult to resolve.

Performing a Cesarean section on every mother could prevent shoulder dystocias. However, Cesarean sections also cause dangerous complications including hemorrhage, infection and blood clots. More frequent Cesarean sections contribute to the disproportionate morbidity and mortality during childbirth of Black women in the U.S.

Like firefighters, obstetricians don’t cause the natural disasters we manage. We use our training to the best of our ability to save everyone we can.

We are haunted by every tragic outcome, every death, even those that were never preventable. We grieve with our patients, but also in isolation due our perfectionism and sense of professional failure. You cannot blame us more than we blame ourselves.

On rare, horrific occasions, obstetricians are required to make unimaginable decisions and take appalling actions. We do what we are trained to do because no one else can. For that, we deserve some grace.

Kim M. Puterbaugh is an obstetrician-gynecologist.


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