Sarita Vendetta

Terry and Jim Eichel with baby. "I decided not to use gloves."

“Don't push!” The command leaped from my lips as it had countless times in the past nine years, but this was different. The perineal skin blanching white just two feet from my face belonged to my wife Terry, and that crowning skull beneath thick, soft locks of warm black hair greased with mineral oil was my son or daughter. The events, problems, and disappointments that had collided with us in our 22-hour journey to this point disappeared from view and memory. In moments, I would know if we were having a Nathan or an Amelia.

We had thought that Terry’s labor would proceed in the smooth fashion of her pregnancy. Two days before our expected due date of June 3, I checked Terry’s cervix in my office. Sliding my gloved, lubricated index and middle fingers inward along the corrugated posterior wall of my wife’s vagina, I was surprised at how quickly my fingertips met her soft, almost buttery cervix. I was able to insert my index finger through the cervical opening, which meant that it was one centimeter dilated, and just behind the opening I met the hard surface of our baby’s skull, smooth under the two-layered amniotic sac resting like a plastic grocery bag between our child’s head and my finger. At that moment, I became the first human being to touch our baby's head. I took a moment to enjoy the warmth and thrill of that realization and then backed my fingers out of the vagina.

Our child’s head had dropped to such a low level and Terry’s cervix had softened so much that I almost felt guilty. Why should we be so lucky to get such a great starting position?

Because if we weren’t, Terry would have had a C-section. But we didn’t know that at the start. She began to have the mild irregular contractions marking the onset of the initial, or prodromal, stage of labor on Tuesday afternoon, a few hours before her appointment with Janet, Terry’s family practitioner. Janet, her associate Audrey, and I are the only family practitioners in Berkeley who do obstetrics, and we therefore share after-hours calls with each other. Janet, Terry, and I had agreed that as long as Terry didn’t have any complications, I would deliver the baby. A male colleague had delivered his own baby during our residency, and he described the experience as sublime and not to be missed, if possible. By the time we arrived at Janet’s office for Terry’s scheduled appointment, Terry’s cervix had opened to two centimeters, had “effaced" 80 percent (meaning that it retained only 20 percent of its original thickness), and the baby's head was at “plus-one” station, or about two and a half inches from the outside world, which was three to four inches closer than it usually is in prodromal labor. “I’ll call you tonight before I go to bed to see how you’re doing." Janet’s voice and smile exuded optimism. “And, of course, if anything happens before then, let me know.”

After dinner, Terry and I played Skip-Bo with her mother, who had flown out from Florida almost two weeks earlier and was staying in our house in Alameda. Terry’s contractions had dosed to eight minutes apart, and they were strong enough to interrupt her concentration on a game that doesn’t require much. She awoke just after midnight feeling greater pressure and intensity, so I checked her cervix, having brought home sterile gloves and lubricating jelly from my office just for this purpose. I could now fit both of my fingers comfortably inside the cervix and spread them a little bit, so she was three centimeters dilated and now 90 percent effaced. She headed to the bathroom for a relaxing shower, and I tried to go back to sleep. Because the baby’s head had dropped so far into Terry’s pelvis and her cervix was responding so well to her contractions, I allowed myself again to think that Terry would have a rapid labor, even though doctors’ wives are notorious for having horrible labors. Two hours later, her cervix had reached four centimeters, and we decided to go to the hospital. I called Janet, and she called the hospital. As sure as I was that I would be free to come back home before long, I let our cat into the house as we left without bringing in the catbox.

My first clue that things might not go as I had imagined came when I checked her again at the hospital at 3:30 a.m. and found that her cervix hadn’t changed at all. In most cases, particularly when a woman is having her first Jabor, the four-centimeter milestone marks the beginning of active labor, with contractions occurring less than five minutes apart and strong enough that the woman cannot talk when they happen. We expect the cervix to dilate at a minimum rate of one-half centimeter every hour. If it does not, we evaluate the situation to determine whether the problem is insufficient contractions (inadequate strength, duration, and/or frequency) or discordance between the size or shape of the pelvis and the size or shape of the part of the baby that is coming out first, usually the head. I assumed it was time to consider such an evaluation, and I would have wanted the nurse to call me at home if I were the doctor managing the case.

But I wasn’t the doctor; I was the husband. Mary, our nurse, had not worked much at our hospital, so I did not have the rapport with her that I have with many of the labor and delivery nurses there. From her perspective, we had checked Terry only that one time; what I had done at home didn’t matter. This was the first time I felt awkward in the doctor-as-husband role. When it became clear to me that the thought of calling Janet had not crossed Mary’s mind, I asked Mary in the kindest, most objective tone I could muster, “Do you, as a rule in a situation such as this, think about calling the obstetrician to discuss the possibility of augmenting labor? Janet might want to come in and rupture her membranes [break the bag of waters].”

“Oh, no,” she said. “She’s just not in labor yet" Not pleased, but not angry, I held to the notion that I was there to support my wife and allow the paid professionals to make the medical decisions. At about that time, Terry’s contractions spaced out to over ten minutes apart, prompting us to take a walk around the hospital floor, hoping to stimulate her labor. It didn’t work; her contractions stopped.

Tired, discouraged, and wanting something to be done, we wandered back to our room. Meanwhile, from her home in San Francisco, Janet wondered about Terry’s progress, and shortly after Terry slumped back onto her bed, Janet was on the phone. She had asked to speak to “Dr. Eichel” instead of Mary, perhaps contributing to the blurring of the distinction between doctor and husband, but I was glad to hear her soothing voice. I offered to rupture Terry’s bag of waters to save Janet the drive over the Bay Bridge, but Janet gave the right answer: “No, I’ll come in.” I would have done the same; she needed to assess Terry’s lack of progress, and you can’t do that over the phone. And since I was not her doctor, it was not my place to do even such a simple procedure.

Not much fluid came out after Janet withdrew the plastic “amni hook,” with its handle that resembles an oversized yellow toothbrush and, at the opposite end, a curved hook terminating in the sharp point that had just shredded Ferry’s amniotic sac. The clock on the wall facing Terry’s bed read 6:15. “I’d call her three centimeters,” she announced to all of us, while she and I noted the slight green tinge in the fluid, indicating that our baby had pooped a small amount, common when labor happens after the due date.

With the cessation of her contractions, Terry’s cervix had regressed, something the textbooks say doesn’t happen, but in reality it docs once in a while, particularly when the lowest (“presenting") part of the baby is not well applied against the cervix. We were losing ground, and Terry was tired from being awake all night, Janet directed Mary to get some pitocin ready. Pitocin is an analogue of oxytocin, a hormone that causes contraction of smooth muscle, the muscle tissue in the body that is not under voluntary control. It thereby increases the strength of uterine contractions and is used to induce or augment labor.

We headed for the hallway again, and this time, with.the added stimulus of her leaking amniotic sack, Terry’s contractions became stronger than they had ever been. Each time she stopped to breathe through a contraction, I felt energized. This was going to work; with the head as low as it was, we were sure to have our baby by that afternoon.

As we approached our room, I noted the infusion pump poised on an IV pole sitting outside our door, ready to give Terry the pitocin that I now thought she might not need.

By 7:50, Terry’s cervix had returned to four centimeters; after a warm shower and another hour of rigorous contractions, she returned to her bed to be checked again. I can’t remember that she had complained even once to this point, but labor and lack of sleep had taken a toll on her countenance. Her fair Maine-bred complexion had paled, and a sullen expression took over her face. I lay next to her at the head of the bed and held her head against my left shoulder while Janet prepared to check her again.

In this position, lying on the bed with my head right next to Terry’s watching Janet’s gloved right hand advance toward Terry, I saw for the first time what my patient sees when I examine her cervix. I studied Janet’s face as she guided her fingers around Terry’s vagina, and I could almost feel those fingers inside of me. Perhaps I had spent too much energy to have any emotional reaction to that part of the experience because I recall nothing other than the sense of fascination that came over me as I recognized this unexpected perspective. That and my disappointment as I noted Janet’s lack of positive expression while she performed a long exam to assess the orientation of the baby’s head and the shape of Terry’s pelvis.

“Still four centimeters’’ was Janet’s grim verdict. The part of our birth plan that mentioned “no drugs if possible” became impossible. Janet’s voice seemed far away as she began to talk of an epidural and pitocin while I focused on Terry, who began to cry. In the seven years I have known her, I can’t remember another instance where she shed tears for herself. I squeezed her.

“Honey, I know this wasn’t what we wanted, but sometimes an epidural is a good thing, and this is one of them,” I said, trying to make her fed the same certainty about the correctness of the decision that I had, while hiding my own frustration. It helped that Terry had heard me say this before; she has heard me advising patients countless times in the middle of the night about many situations, including ones similar to this. An epidural anesthetic relaxes the pelvic muscles, creating more room in the pelvis and facilitating cervical dilation. The pain relief allows the woman to rest, even sleep, during this first stage of labor, which gives her more strength when the time comes to push.

Terry had wanted to avoid an epidural for many reasons. An epidural confines the patient to bed for the rest of her labor and until the anesthetic wears off because it blocks many of the nerves controlling the leg muscles. Many women cannot urinate with an epidural and therefore require a foley catheter to keep their bladders empty during labor. Epidurals decrease the strength and frequency of contractions, a problem that pitocin can usually fix, and diminish the urge to push, which often makes the woman push with less force. Many educated women know about these problems, but most do not know this: epidurals cause significant fevers in over 10 percent of patients. The fevers are not dangerous, but because they also occur when the bag of waters gets infected, doctors often prescribe unnecessary antibiotics and subject mothers and newborns to unneeded tests, as such infections do cause harm to both mother and baby. Always one to be flexible, Terry did not have the dogmatic antagonism toward medical intervention that I some times encounter in Berkeley, but she understood, as everyone who has an epidural should, that this procedure opens the door to a multitude of other possible interventions.

I should also mention that Terry has a Harrington rod next to her spine: that's the biggest reason she didn’t want an epidural. In her teens, she had severe scoliosis, an S-shaped spinal curvature bad enough to cause deformities in her rib cage, which would have led to problems with her heart and lungs. An orthopedic surgeon at Boston’s Children's Hospital straightened her spine and implanted the stainless-steel rod to keep it that way.

The rod imposes a formidable barrier to an anesthesiologist trying to thread a needle into the epidural space, just outside the fluid-filled canal that surrounds the spinal cord.

When Gary, the anesthesiologist, arrived at 9:40, he was honest about his chances. Remarkably, Terry had regained her composure, but her mother, knowing this wasn’t going to be fun to watch, left the room. Four times my wife, sitting on the edge of her bed, tucked her chin forward, slumped her shoulders, and curled her spine like an angry cat. Four times Gary guided his needle between Terry’s vertebral bodies at different levels in the center of her back, his experience allowing him to feel Terry’s tissue layers as though the needle were an extension of his fingertip. Four times Hillarie, the nurse who had taken over at 7:00 a.m. and within moments showed an uncanny ability to anticipate and meet Terry’s needs, rested her head against Terry’s and brought Terry's mind to a place where pain mattered less. Four times the rod obstructed Gary’s path, forcing him to withdraw the needle.

Thirty minutes had passed with these efforts. Gary decided to go for one more approach, this time taking a trickier “paramedian” route from right of the midline in an effort to go around the rod. Because he works full time as an obstetrical anesthesiologist, he has more experience than most with this technique. He had everyone assume their positions again and advanced his needle, behind which he had a syringe filled with air that he would use to locate and expand the epidural space. Facing Gary from Terry’s right side, I watched with hope each time he pressed on the syringe, only to have the plunger recoil with resistance, until the time it emptied.

“Could be a tissue plane (a space between soft tissue layers),” Gary said to avoid raising my hopes, and he was right; when he tried to pass the narrow catheter into the space, it would not go in. But the next time he advanced the needle, he was again able to inject air, and this time he was in the right place. Shortly after he gave Terry her first dose of anesthetic, Hillarie started the pitocin infusion.

Although the procedure had taken 45 minutes instead of the usual 10, we all felt better. Most of Terry’s pain wait away. Hillarie brought in breakfast for Terry’s mother and me. I ate with greed and gratitude, aware all the while that my wife could not eat, but she begrudged me the pleasure without seeming to mind. It helped, of course, that when Hillarie checked Terry’s cervix at 11:20, we had our first news of real progress: 5 to 6 centimeters. Our goal of 10 centimeters, which means complete cervical dilation, still seemed far away, but at least we were on our way.

As the late morning became afternoon, my mother-in-law and I tried at various times to get bits of sleep on the reclining chair and small sofa the hospital provides in each labor room. They weren’t comfortable and we didn’t do well. Terry’s epidural, though a great help, left her with small painful areas because the surgical scars in her epidural space prevented the medication from spreading evenly. Those pains kept her awake except for a few brief periods.

Hillarie offered to check Terry again at 12:45, and we were grateful; we needed everything we could get to keep positive and alert. Instead, the news was dismal: Terry's cervix had not dilated in the past 85 minutes but had swollen on the top side. Cervical swelling delays dilation and suggests the need for a position change because the cervix is trapped between the baby and one of the pelvic bones. Terry’s swelling was anterior, meaning that we had to have her lie flat on her back to tip the baby’s head back away from her symphysis pubis, the “pubic bone” in front.

My frustration and disappointment mirrored Terry’s; the whole thing seemed endless. In ten and a half hours, her cervix had dilated all of 2 centimeters, from 4 to 6. As a rule, it takes a maximum of two hours for each centimeter during the slowest labors. Terry knew this and began to cry. She then showed me a pouting face she must have borrowed from one of her first-grade students and uttered the words of the six-year-old inside both of us at that moment: “I don’t want to play anymore."

But she had to, of course, and did. A little while later, she told Hillarie she needed something to relieve the pain near her rectum, so Hillarie called Gary. When Gary walked in, Terry startled all of us with her playful command: “Fix it, buddy!” “Man, she’s tough,” I thought. It didn't hurt that the drugs were making Terry, who doesn’t drink or use other recreational substances, a little goofy. Gary gave her an additional epidural dose and explained that, to get the medication where it needed to go, she would have to sit up. The dilemma, therefore, was that if she sat up, her cervix would swell but she would be comfortable; if she lay flat on her back, her cervix could dilate but she would be in pain. We decided to have her sit up until she felt better and then have her lie down, which worked well at the time but later did not. Every two to three hours, the pain increased such that she needed an additional epidural dose, and I don’t think she ever got comfortable again.

Four hours later, 4:35 p.m., Ferry’s cervix reached eight centimeters and had thinned out again. A low dose of pitocin had kept her contractions coming every three minutes since the morning, but I had wondered through the afternoon, one time aloud to Janet, whether Terry’s contractions had enough strength. The only way to mea sure their power is via an intrauterine pressure catheter, or I UPC, a long narrow plastic tube with a pressure transducer at the end. The obstetrician, using sterile technique, slides the catheter through the open cervix, along one side of the baby’s presenting part, into the uterine cavity. I use one every time one of my patients is not progressing as she should because they are easy to use, provide valuable information that one cannot get any other way, and almost never cause complications. Not all obstetricians use them as readily, and I did not disagree with Janet when she said that she thought Terry’s labor pattern during the afternoon was fine. Janet believed that the problem lay in the baby’s head’s orientation, and she may have been right. But when Janet checked Terry’s cervix two and a half hours later and found it to be k*ss than 9 centimeters, Janet opted for the IUPC, which showed what we suspected: Terry’s contractions did not have sufficient amplitude. Hillarie increased the pitocin infusion rate to give Terry a larger dose.

Yes, Hillarie was still in there with us. Her shift had ended at three in the afternoon, but she volunteered to work an extra shift, and we will always be grateful for that. In the role of physician, I have observed interactions between women in labor and all kinds of professional support persons, including labor coaches, doulas, midwives, and doctors. Many have been wonderful, but never have I seen one establish the depth of rapport Hillarie did with such speed. She knew what to do with words, pillows, washcloths, or Just the right touch, and when to do it.

Aaron also made an enormous contribution, and he managed to do it in less than three minutes. One of those veteran obstetricians who has seen almost everything during decades of practicing his craft, Aaron happened to be at labor and delivery’s front nurse’s station at 8:00 p.m., about five minutes after Janet had examined Terry and found her cervix to be 9 centimeters, minimally changed from what it had been 70 minutes before. Nine centimeters meant that only a thin rim of cervix remained all the way around the head, which had swollen from squeezing through Terry’s pelvis and now rested just a few centimeters from the outside world. The pitocin had had the desired effect on Terry's contractions, as the monitor recording her intra-uterine pressure traced symmetrical mounds depicting the pressure rising and falling with each contraction. There wasn’t anything else we could do to help. It seemed endless. Terry had been in active labor for almost 18 hours, 6 more than the usual acceptable

maximum for a first baby. Frustrated and exhausted. Terry and I thought we might end up in the operating room for a C-section. The power of her dysphoria hit me hard as I realized what was happening inside her head.

“Are you scared?" I asked.

“Yeah.” Her eyes were moist.

“It’s okay." That was as positive a statement as I could summon. “If we have a C-section, you and the baby will still be all right.”

Janet maintained her clinical perspective and made the right move. Since Aaron happened to be nearby, Janet asked our permission to have him come in to give his objective assessment.

Dressed in surgical greens with his short silver-in-black hair neatly combed back, Aaron walked into the room combining the right mix of concern, experience, and empathy, with a freshness that stood out in contrast to our fatigue. He was in an awkward situation, one I knew well from my experience as a senior resident: he was about to ask a woman he was meeting for the first time if he could put his fingers in her vagina moments after introducing himself. He asked with the appropriate amount of sheepishness. My wife consented with the appropriate reluctance. Aaron confirmed that she was nine centimeters and asked 'Terry to bear down and push; she obeyed. After finishing his task, he withdrew his fingers and said the magic words: “I wouldn’t section this woman in a million years.” The head was so low and she was so close. We all knew this but to hear him say it made an immeasurable impact. Terry’s reaction: “I’d give you my firstborn child, but I’ve worked so hard.”

“I wouldn’t take it,” Aaron replied with a grin. He then told Janet he thought the baby’s head was occiput posterior (“OP”), meaning that the back of the head faced Terry’s posterior, and the face pointed up toward Terry’s abdomen. When the head is OP, labor proceeds more slowly because the head presents a wider diameter than it does when it is lying occiput anterior, or OA. The baby’s head had enough swelling (“caput”) on top that feeling the skull lines to figure out the baby’s head orientation was challenging, and we’ll never know if he was right because the head may have turned before delivery.

Less than 30 minutes later, Terry’s cervix completed its recession, ending her first stage of active labor at 18 and a half hours, longer than any I can remember witnessing. It didn’t matter. Terry’s mother, who had nine births of her own but never had to work this hard, put her diabetes, heart problems, multiple sclerosis, and acute sleep deprivation aside to help Terry lift her head and tip her chin to her chest with each contraction in order to push more efficiently. I held Terry’s legs up, rotated her hips to the

outside, and counted to ten three times with each contraction to encourage her to push longer and harder each time. Before king, we could see the top of our baby’s head with each push. Terry’s mother got excited: “All tliat hair! It must be a girl!” Terry had thick black hair at b'irth.

Our baby had tolerated labor for all these hours without so much as a hint of distress. The external fetal-heart monitor recorded a stable tracing throughout Terry's labor, an unusual but welcome occurrence because it allowed us to be patient. The meconium staining we had noted when Janet ruptured the membranes had cleared, so we would not have to apply suction deep into the baby’s nose and trachea at birth to prevent meconium aspiration and its consequent lung disease. As the babys thick black hair inched closer with Terry’s efforts, we told Terry to touch it. “Hi, sweetie!” Terry blurted out, surprised and relieved at the discovery. Terry’s mother was more reluctant, but when her fingers reached the head, her lips parted with a broad grin.

Terry reached down to touch the head again, to which her mother reacted, “Stop touching yourself down there!” Everyone laughed, as each of us remembered our own mother’s voices. “You’ll go blind.”

“Oh, that’s why she (Terry) wears glasses,” observed Janet.

Touching her baby was strong motivation for Terry, she put forth so much effort we had to remind her at times to direct all her energy toward her rectal area, not into her face, feet, or hands. As the head continued its slow journey under and around Terry’s pubic symphysis, it forced the stool that remained in Terry’s rectum out ahead of it. This always happens and is why obstetricians used to give women enemas during labor to clean out the colon before the baby came down, but there’s no harm in letting the baby do the job instead. The scent of stool thus becomes birth’s most powerful odor, and its physical presence contributes to my belief that the beauty of childbirth is in being there. I don’t understand those who shoot video and rolls of film during labor and delivery.

Having changed into greens when Terry began pushing, I gowned in preparation for the delivery, as Terry and the baby were doing well. Terry had a fever of 100.7 degrees, hut she was working hard and had an epidural, both of which could be responsible for the low-grade fever. Janet would get bacterial cultures of the placenta after birth, but she wasn’t very worried, and I was even less concerned.

I decided not to use gloves.

After all, it was my wife and baby. Hillarie, who explained later that she felt part of the family, didn’t glove up either. At one point, I felt obligated to tell the other medical personnel in the room who came to take care of the newborn that I didn’t act so casually as a rule, but this was my baby. When I brought it up, they told me they hadn’t noticed I wasn’t gloved.

Minutes, which had passed like hours during the day, now felt like minutes. I played with my baby’s hair as it advanced toward me. With each contraction, it edged farther between the lips of Terry's vagina. Hillarie brought me some mineral oil with which I massaged my wife’s perineal (between the vagina and rectum) skin, the elasticity of which delighted me. Her perineum might not tear at all. I also rubbed the oil on my child's head to facilitate a smooth entry into the world.

Delivering a woman’s first vaginal baby requires patience, unless a sudden problem with either the infant or the mother necessitates a rapid birth. To minimize trauma to the vagina, labia (lips), and perineum, the head must come out at a snail’s pace. Any sudden movement will cause cuts or tears. I explain this to my patients in advance so that they expect me to use my voice as a gas pedal, exhorting them to push as hard as they can until the head’s widest diameter approaches the vaginal opening, at which time I have them push at lesser intensities or stop to allow the perineal skin to stretch rather than tear. The intense burning from this stretching frightens women not using anesthesia. If you are a man or have never given birth, try to imagine passing a stool as wide and hard as a softball; that’s how it feels, Terry met “the ring of fire,” but the epidural weakened it, and she handled it with the same grace she had handled everything else.

She followed my instructions flawlessly, which eased our child’s head to the point of no return, where the head slides forward and out on its own. After “Don’t push!” I drew Terry’s perineal skin over our baby’s forehead, eyes, nose, mouth, and chin; the face thus emerged with a blooming flower’s elegance. The faced pointed down, with the occiput anterior, the easiest position to come out.

I did not maintain the same calmness I do with my patients. As I suctioned the mucus out of my baby’s nose and mouth, I once squeezed the bulb too quickly after removing its tip from the mouth, shooting a glob of clear mucus at the face; it landed harmlessly on the baby’s right cheek. As I took a deep breath to maintain my composure, I heard Janet or Hillarie chuckling behind me.

Resuming the delivery routine, I allowed my child to choose to rotate to the right, so that the right shoulder was now on top, or anterior. I checked to see if the umbilical cord was wrapped around the neck; it was not. Telling Terry to push, I exerted downward traction on the baby’s head to bring the anterior shoulder under the pubic symphysis. The baby’s shoulders fit tightly through Terry’s pelvis, and while they never got stuck, they took enough time getting out to make the baby’s father sweat. I had Hillarie pull Terry’s legs way back and called Janet’s name.

“Do you want fundal [at the top of the uterus] or suprapubic (right above the pubic symphysis)?” she asked. She wanted to know in which of these two areas I wanted her or someone else to push down to help force the baby’s shoulder down and out.

“Both.”

I didn't see who did what. I exhorted Terry to push hard, pulled straight down on the baby’s head, avoiding the use of too much force so I wouldn't cause nerve damage, and thereby coaxed out the anterior shoulder. I then pulled straight up to get the posterior shoulder out. Usually, the baby slides out without much effort once the shoulders are out, but mine didn’t. I had to grab under the armpits and pull, as though someone was holding my child in from the other side, but now I had won. I glanced between the legs and announced, “Here’s our baby Amelia,” just before she emptied her bowels on my gown and right leg. She then threw her hands forward, stiffening her arms. The power behind that gesture told me she was fine, although she hadn’t cried yet. Terry had not torn and would not need any stitches.

Because of the difficulties at the end, I knew I could not put her on my wife’s belly, as Terry had hoped, so I reached for the clamps. Janet already had them and immediately clamped and cut the cord. With my daughter in my arms, I hastened to the warmer ten feet to my right and positioned her with her face upward and head toward the advanced practice nurse (APN) so she could give Amelia some supplemental oxygen and make sure she got off to a good start. Moments later, we heard the first of the vigorous cries to which we have since grown so accustomed.

Janet finished the business of getting a blood sample from the umbilical cord and delivering the placenta, freeing me to switch back to being daddy. Exhilarated and tired as I was, I found it difficult to focus, and my mind oscillated between doctor and daddy. I spent about a minute watching Amelia receive supplemental oxygen, first noting her bluish skin tone that was changing to light gray with a touch of pink, then listening to her cries and watching her arms and legs move. I caught myself in the midst of this unmistakably clinical assessment and heard another part of me say, “This isn’t another one of your patients. This is your daughter.”

I struggled for a moment with this concept and then realized I would get to take her home. In retrospect, that was what differentiated the moment most for me as a parent versus that moment as a doctor. I had previously believed what I found at that moment to be true. When I am the pediatrician for a newborn, for as long as I am at the hospital supervising that child’s treatment, I care almost as much about the outcome as I would if the child were my own. But once I leave the situation, I can concentrate on something or someone else. As my daughter lay in the warmer with oxygen flowing from the mask next to her swollen crown, bruised forehead, and sparkling gray-blue eyes, the warm love I felt was similar to what I have known hundreds of times before. Stronger, but familiar, and perhaps diluted by the immense relief that the labor was over. But this wouldn’t end with congratulations, a few hugs or handshakes, and a walk out the door. I would take this home to have forever.