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What happens at birth?

Shieva Ghofrany: [00:00:00] Okay, so it's early in the office. This is gonna be part two. Yesterday we reviewed. Going into labor, what are the signs and symptoms, what might transpire during your labor and what might lead you, for example, to a C-section? So just to review during your labor, if the baby's heart rate drops in a way that makes the doctor's concern that the baby is not necessarily getting enough oxygen. 

Which again sounds so dramatic. It's typically not a drama. It's that we're trying to preemptively make sure we get that little baby out quicker than the baby decides that things aren't okay. Does that make sense? Like it's a hard prediction. It's not an easy position to be in. But again, if the heart rate drops, if your cervix doesn't dilate, or if you get to fully die and you push, the baby just does not wanna come out. 

And that can have to do with the power, the passenger, the pelvis we talked about. If you don't know what I'm talking about, watched yesterday's. . Now, let's assume the baby does come out vaginally. Literally the head will come out and your doctor might say something like I say to every patient, the head's gonna come out and then I'm [00:01:00] gonna tell you to stop and I'm gonna do the rest. 

Meaning the minute the head comes out, we'd love to believe the baby's all just come flying out afterwards. And the majority do. But a couple of percent babies will actually have their head come out and then their shoulder gets stuck. Can we talk, I'm gonna take this off. We talk about it as their anterior shoulders. 

So meaning the baby comes out, their shoulders are up and down, meaning typically one of the shoulders is up towards mom's pubic bone and the other one is down towards mom's sacrum. , not always, but most babies are like that. And so sometimes that anterior shoulder, we call it, the one that's closer to the pubic one can get stuck. 

We're not gonna do a whole video about shoulder dystocia. I will at some point I have, because that's a kind of big dramatic thing. But the, the doctor will help. The head will come out, the doctor will guide out the anterior shoulder, the posterior shoulder. Get the whole baby out. Ideally, the baby comes out pink and crying, assuming the baby is pink, crying vigorous, showing us signs that the baby is happy and healthy. 

Then we try to do delayed cord clamping and different [00:02:00] hospitals are different, but many hospitals throughout the country do this delayed cord clamping, meaning we do not cut the cord immediately like we used to in our hospital. We wait 45 seconds at least, and occasionally if moms want, we'll do it a little bit longer. 

Other hospitals will do anywhere from one to two minutes. So 45 seconds. We do have delayed cord clamping, then we put the baby right on mom's chest. Ideally, sometimes the cord is really short and it's not on the mom's chest. And after that 45 seconds of baby being on mom, yes, slimy, bloody. sometimes with that white cheesy stuff called verex. 

Then we clamp the cord and we allow the partner if they want to, to cut the cord. And sometimes if the partner doesn't wanna, I'll ask, I'll ask mom. Cause they feel like, how amazing. Like you've pushed out a baby and now you get to cut the baby's cord too. Women are amazing. Now, what can transpire in that period of time? 

Maybe the baby's not crying and that can be either because that last couple minutes of the baby's head getting pushed, made the baby a little bit stunned and all the baby needs is a little bit of. Five seconds of kind of being, um, vigorously stimulated [00:03:00] by the nurses. Sometimes it's a longer period of time before the delivery where the baby hasn't necessarily gotten all of the, all of the oxygen that it needed. 

But again, this does not almost ever amount to long-term concern. It's just short-term, immediate. The baby is kind of in a position where the baby's like a little bit floppy and not crying, and in that situation, the nurses will again do their little resuscitative movements where they're vigorously trying to stimulate the baby. 

They'll take the baby over to the bassinet if the baby's really not crying, and sometimes call the neonatologist or the pediatrician. . Sometimes it's because of things like, and we've talked about this in a prior video. If you're taking medications like SSRIs, like Prozac, Lexapro, Zoloft, those things can sometimes make the baby a little bit depressed, meaning respiratory depression, where they're a little bit floppy or like I had alluded to, I've seen a lot of babies who are completely vigorous and pink. 

But they're just not crying. Now, again, that is not a reason to feel bad mom, because if you needed that medication, you did not cause long term harm to your baby, I promise. But in that short term, it's frustrating [00:04:00] for moms and it's nerve-wracking. And it's nerve-wracking for the doctors and nurses because we love that moment, right? 

When the baby comes out, when the baby cries. So yes, the ideal is the baby comes out, the baby cries, but even if the baby doesn't cry immediately, the vast majority of the time it's okay. So then we have the partner cut the cord, and then you get to ideally snuggle with the baby on your chest, mostly skin to skin if you can, because that has been shown to improve the baby's ability to modulate her blood sugar. 

Moderate. I keep trying to figure out when do I use the word moderate versus modulate? I think it's modulate her blood. Also, it can help transfer the good bacteria, the microbiome that you guys know about, like the good bacteria that we all have on our skin. So that's also a benefit to the skin, to skin. 

Plus it helps mom's hormones start to shift so that it really understands. Now what if you can't do skin to skin? First of all, let's say you just think it's gross, or you can't because the baby has to get whisked over to the bassinet, or there's some other. It's okay. I did not do skin to skin with any of my babies for various reasons. 

Not the least of which was, [00:05:00] it just wasn't the thing at the time. But I wouldn't have anyway because I was just in a state with each C, the vaginal delivery that you C-sections, like for various reasons, I would not have been able to do skin to skin. And I have bonded with those babies, I promise. So now let's say you're doing cord blood banking, which is when you have paid a private company, again, I'm not gonna discuss that in detail here. 

We can discuss it at another time. To save the umbilical cord blood for stem cells, then what? What do we do about the delayed clamping versus that, and every doctor's a little bit different. What I try to do is kind of in that moment, I call it the game day decision, right? When the baby comes out, I have to see how is that umbilical cord, is it thick enough and kind of chunky enough where I can get 45 seconds of delayed clamping and still get blood for the umbilical cord for the stem? 

So I make that decision. I'm fairly certain that ACOG has a stand that they say that you should actually do the delayed cord clamping over cord blood banking. But again, that's a decision that you and your doctor can decide together. I I, there are rare circumstances where the cord is so thin [00:06:00] that you can't do any delayed cord clamping if you're actually gonna get, um, cord blood banking. 

The fact is that most of those babies maybe don't come out as vigorous anyway, because that really skinny cord can often mean that they were having some growth issues or. So I have not had a circumstance where I wasn't able to do both, at least to some degree. Maybe not the full 45 seconds. Again, you should talk to your doctor. 

What else can happen in that moment besides the shoulder getting stuck or the baby not crying is right. When the head comes out, the cord can be around the neck, something we call nucle cord, N U C H A L. Nle, it means neck. And that happens, believe it or not, 20. , the literature can go up to like 40% of the time. 

I would say that makes sense with what we see. We see it all the time, like we are not so worried about it because we know it happens. We sometimes know that it happens prior to the baby coming out because the heart rate will show us certain patterns of deceleration where the heart rate drops, where we suspect like, Ah, the cords around the neck or the cord's getting pinched. 

And I kind of try to preemptively tell mom and dad like, you know, it's really common because cord [00:07:00] around the neck sounds so dramatic and I think we're so groomed to believe that it's gonna lead to something really terrible. And again, I want you guys to know 25% at least, Cord around the neck and it's often loose. 

So the head comes out and then we can remove the cord and then we can complete all the other tasks that we have done. Sometimes it's around the neck tight enough that the baby was fine, but that we can't kind of, what we say reduce, but pull it over the head. And instead we have to clamp and cut the cord from around the neck before we get the rest of the baby out. 

And that just means that your partner isn't able to cut the. , I don't wanna say not a big deal cuz of course we've like made this such a big deal, but they can't cut the cord. That's the way it is. But the rest of the cord that's attached to the baby can then be clamped again and then your partner can cut the cord if that's what they want. 

Many dads or moms don't really care if they cut the cord. So I say like, if you wanna, we'll have you do it if you don't wanna, not a big deal. I'm here so early that I don't know if anyone's gonna answer that phone, but that's the private line. I don't know why people are calling. Okay, so what are some other things that [00:08:00] happen? 

Sometimes the, the nurses have to check the baby's sugar. If the baby is over a certain percentile, they're gonna map out the baby's weight and height. But that doesn't happen for usually an hour because we try not to take the baby away for that first hour, because that first hour is the time where mom, and again, the baby can bond skin to skin and have all these changes happen. 

So if it's possible, You try to do the skin to skin, which means you don't get the baby weight until an hour. That's really tough for us sometimes, cuz it's the doctor. I'm like, I wanna know how big that baby was. Terrible. I am terrible at guessing baby's weight. I have delivered babies where I'm like, yep, seven and a half pounds. 

And they're like, yeah, no, let's weigh. It's nine pounds. So I'm terrible at estimating that weight. Okay, so once the baby is born, and let's say everything is okay while you are snuggling with your baby, let's assume everything is calm. Now we need the placenta to. That is the next stage, right? So pushing is what we call second stage labor is what we call first stage. 

And then from after the baby is born to when the the placenta comes out as third stage, we need that placenta to come out. [00:09:00] The majority of placenta come out within a couple minutes, but we can wait up to 30 minutes. Before we consider it a concern, sometimes the placenta will be stuck again. I'll do a separate video on when you have a placenta that does not wanna come out, um, retained placenta we call it, but the doctor's gonna wait. 

The placenta's gonna come out. There's two ways to approach that. One way is more active management of the third stage, which means that they will have the nurse turn on Pitocin. Whether or not you've had Pitocin during your labor, it doesn't matter. Almost everyone, at least in our country, gets Pitocin in their, I. 

If they're birthing in a hospital to help make the uterus contract from when the placenta comes out. So you can either turn on the Pitocin right when the baby comes out so that it helps the uterus contract and push out the placenta, or you wait until the placenta comes out, start the Pitocin to help the uterus contract, so you're snuggling with your baby. 

You're probably not paying attention what's going on, which is a good thing sometimes because sometimes there is blood everywhere, sometimes poops, amniotic fluid, all kinds of stuff that we're used to. You might not be. , the nurse [00:10:00] will turn on the Pitocin. We'll wait for the placenta to come out, assuming the placenta comes out easily. 

We then sometimes just massage. Look at the uterus, look at the cervix, make sure that everything is contracted the way we like, and that the bleeding is not too significant. If it is, then we do a different set of routines that I'll talk about again in another video, and then we look and see are there any tears, what are called lacerations, or did we have to cut an essio? 

Why would we have to cut an app episiotomy? Well, if in that game day moment when the head is about to come out, we either think the baby's head won't come out easily. We need to get the baby out quickly. For example, for a vacuum delivery, if the heart rate has dropped or we feel like the opening to the vagina, the introitus we call it is just so taut, then maybe we can't safely get the baby's head. 

Without causing lacerations in other places like above, near your urethra where you pee out of. So we don't want that. So occasionally, and again, for most doctors, they're a episiotomy rate where we cut. The perineum is less than three to [00:11:00] 5%. Nowadays. We used to routinely do what we stopped, but sometimes we have to make that game day decision that we're gonna make a small cut between the end of the bottom of your vagina and your rectum, because we wanna get the baby out in a space that doesn't kind of tear irregularly, not common, but we sometimes have to do it. 

And the downside is that you don't wanna cut it because in theory it can tear further into your rectum. There's different degrees of tears that we'll review in. video, but you sometimes, again, have to make that game day decision. And this is where I wouldn't say things to your doctor, like you can't do an app episiotomy. 

I would say I'd rather not have one. If you need it, you need to cut it. The fact is you don't even really need to say that cuz that is very standard the nowadays. But if that helps you to understand the process, then talk to your doctor about what her practice is. Um, okay. And then she will sew everything up. 

Then you typically stay on labor and delivery, at least at our hospital, which is fairly standard for an hour or two for. where the nurse has to check your blood pressure at certain intervals. They have to make sure that your bleeding is not too brisk. They have to make sure that you can pee, cuz if you've had an epidural, [00:12:00] sometimes you can't feel your legs very much for about one or two hours and they make sure all your vital signs are okay and they make sure that you're doing okay with the baby. 

At that point, if you want to do, put the baby on your breast and actually get the baby to start attaching and latching on, you can. If you can't do it or you don't. That is okay. Certainly latching on sooner is a great sign that things are gonna progress more easily with nursing, but that's not always the case because it doesn't always progress easily. 

And lack of latching on in that immediate hour doesn't mean you won't be able to. So while I think it's great if you can do it, I also would say don't put so much pressure on yourself that you create angst in that moment, which is really, um, already angst . Then you go to the maternity ward. Different hospitals are different. 

Some hospitals have all private rooms, some do not. That's something you should talk to your doctor about, just so you know the difference. And then if you've had a vaginal delivery, most hospitals in America allow you to stay for two nights, and it's two nights after the baby has been born. Let's say you go in on a Monday to be induced, but you don't deliver until [00:13:00] Wednesday. 

Your first night is considered Wednesday night for delivery. Now, here's the rub with insurance companies. Let's say you deliver at 11:59 PM. that first night is your first night. Let's say you deliver at 12:01 AM Then the, the next night essentially is your next night. So you get two nights if you've had a vaginal delivery. 

Now, let's say during that whole process, you actually had to get whisked in for a C-section. Then you get into the operating room. They will then bring your partner once they know that you are comfortable on the operating room table, meaning that your epidural works, or if you didn't have an epidural, they give you a spinal if they can. 

If it's truly an emergency, they sometimes have to put you to sleep under general anesthesia. Then they get your partner in the room after they have cleaned and draped your belly, meaning cleaned it with the sanitizing solution we use, put up all the, the surgical drapes so that we're sterile and then we do the C-section, getting the baby out. 

If you haven't had any scar tissue, it's actually pretty quick. Most of us can get a baby out and like. Two minutes literally from skin to getting the baby out that's in an emergency. When it's not an emergency, we take our time a little bit more, but it's pretty quick to [00:14:00] get the baby out and we'll often hold the baby up over the drapes that you can see the baby. 

Sometimes we use this clear drape. Your partner can stand up and take pictures. The pediatricians will be the ones to first attend to the baby before you get to, because in a C-section, you wanna make sure that everything is okay with the baby. So we do the delayed cla. We hand the baby to the weight pediatrician, the pediatrician takes care of everything. 

So again, C-sections are not terrible either. Vaginal deliveries are not terrible. They're both good. Tomorrow's video, we'll talk about what happens on the maternity ward and what to expect when you go home. Okay? Like share. See you soon. Bye.