OB/GYN: Bringing Forth Life

In real life, the uterus looks just like it does in picture books. Springing forth from behind a curtain of fat and abdominal muscles in the depths of an incised abdomen, it's a strange, almost whimsical shape which is easily recognized as "uterus!"-- even by the unseasoned medical student. On the inside, the uterus looks just like a blood-soaked sponge, and it's easy to imagine that if you were just to rinse and wring it out, it might be ready for another go on the kitchen counter.

These were my observations today on my first two C-sections. This operation is easily the most unique of the common operations: whereas it is extremely invasive, the patient is awake-- and very aware of what is happening to her body behind the sterile drape.

It all begins with a nervous mother-to-be seated on the operating table with her bare back to the door. Regardless of how fat or thin she may be, and despite the funny shower cap surgical hat she is wearing, I am struck by how beautiful she looks in her nakedness. This is her monologue under the bright OR lights; she is the quiet center of commotion as the OR staff prepare for the procedure.

The operation will involve up to 20 people, from OR staff to anesthesia to OB/GYN to pediatrics, each a perfect gear turning in time with its colleagues. An anesthetist sterilizes and drapes her back, then injects a spinal block. Her legs go numb, then limp; she loses pain sensation from her abdomen down. She is helped to rest on the operating table and draped: she becomes nothing but a vast blue sterile field with a hole on the abdomen. The freshly scrubbed obstetric team enters, dripping, and is gowned and gloved. The OR nurse hurries to set up her arrays of instruments. Pediatrics people shift impatiently from foot to foot next to the empty, expectant incubator. The stage is set.

From here, the plot thickens and becomes free to veer off wildly in unimaginable directions. She may be hugely pregnant and ready to burst with triplets... or barely showing with a 14 week premie who will tip the scale at scarcely more than a pound and make only faint, exasperated movements of the head and arms. The first incision draws superficial blood, some of it squirting skyward in its great eagerness to get out of her body. The underlying connective tissue is carefully dissected. The rectus muscles are revealed, glistening and taut. They are pulled violently aside by the obstetrician and his assistant to widen the sight line into the peritoneum; a maneuver that requires strength remniscent to me of the Army football team playing tug-of-war with Navy.

The uterus appears through the translucent peritoneum, protecting its precious cargo. Inside the soft muscle is a living soul preparing to enter the world. The rest of the operation is a blur because here the emotions begin to run high. After we enter the uterus, a gush of fluid (here I silently thank my lucky stars for choosing the mask with a face shield) signals rupture of membranes, and suddenly a grey, drowned rat is being pulled free from its mother's abdomen. I stand transfixed, shocked: it's almost like a scene from... what's that movie where the aliens take over human bodies and burst forth from their abdomens? The rat mews weakly. Mouth and nose suctioned. Quickly rubbed dry. Cord clamped and cut. Handed to mom. Tears rolling down her face. Her new child. The pediatrics team swarms in.

Our emotions spent, we turn our attention to undoing the hole we've made in mom's abdomen. And what a hole it is... her uterus hanging outside the skin, the muscles separated like a drawn curtain, blood everywhere. So we clean up our mess with what tools we have: sutures here, electrocautery there, more sutures, staples. What intricate handiwork! When we've finished, the neat incisional scar mocks the havoc we wreaked beneath it. We apply the white dressing, just to make further assurance that its tight lips will never divulge her secret.

I look over at the incubator several minutes later, and see that the rat has turned into a plump, pink infant. I can't help but smile behind my mask; it is only fitting that this first chapter of life makes such a traumatic, exuberant, and eloquent preface to all the rest. Happy birthday, kid.