“Wow, you guys (family doctors) sure have patience!” My OBGYN colleague commented in passing on a Sunday afternoon, when she saw me sitting at the hospital nursing station, watching the contraction pattern and fetal heart tracing strips of my patient in labor. She said this because, as the on-call OBGYN surgeon for the weekend, she knew I had been inducing labor for a patient of mine since Friday afternoon. It’s been 2 days, and she is still only just now becoming a 4-5 cm. We had a long way to go yet.

My colleague is right. Family doctors who deliver babies are usually very patient with labor management. Plus, I was trained mostly by the Certified Nurse Midwives in my residency, who are immensely patient practitioners, themselves. When I first started to learn to deliver a baby, I was anxious to see progress. So I would ask my midwife attendings: “Should we do something to speed things up?”

“How does the baby look?” She would ask.

“Well, good. Category I tracing.” I would say.

“How does the mom look?” She would follow up.

“Well. Good, too. She is tolerating pain well, vitals normal, no signs of infection, and her spirits are high.” I kind of knew where this was going.

“Ok. So, what’s the rush?”

What’s the rush? This is exactly the question I ask myself today, as a young attending, practicing medicine on my own. If the answer is about me, for example, I am late for dinner, or I am tired, then that is not the right answer. But if the answer is, something is not going well medically with the labor, then I would act on it. All else, I wait, and let her do her thing. And as it turns out, this minimalistic approach to labor and delivery is not only the safest (less unnecessary intervention, better outcome), but also often the most welcomed by patients. It’s not uncommon for me to push with a first time mother before she delivers for 2 to 3 hours, so long as the mom wants to keep going, and baby looks good, there is no rush.

“Dr. Zha. I really want to try for a vaginal delivery. But I am a little scared my labor will take a long time.” Toni, a young, first-time mom asked me, during our first prenatal visit together. I looked at her, then looked at her partner, and knew that this was a question they had rehearsed and prepared to ask me. She was timid, and frankly, a little unsure about me at this point.

I took a deep breath, straightened my back a little, and said: “Ok. Then we will aim for a vaginal delivery, however long it takes. If you don’t give up, I don’t give up!” Then I saw the timidness fade away from her eyes, and she, too, sat a little straighter.

“Ok.” She smiled, and looked over to her partner, who nodded at her. Nothing feels better than to empower a young woman, who has so much strength and perseverance within her that she hasn’t discovered, yet.

Of course, I explained to her that if it’s medically necessary, we would get a C-section. But it would be a decision she would be a part of.

Toni went on to develop Intrahepatic Cholestasis of Pregnancy, which is a potentially harmful condition for the baby. The recommendations by professional societies usually are to induce labor and deliver the baby early, around 37 weeks (plus or minus a week, depending on how high the lab value is). None of us who deliver babies wish to induce first-time moms, because it’s hard. We have to somehow use different “tricks” to convince her body, which is not ready to go into labor, to go into labor. It’s like working against nature — it can take a long time. Often, days.

I told Toni the dreaded news about having to induce her early due to her lab findings. “But we are still going to try for a vaginal delivery, right?” Worried, Toni asked. “Yes.” I said, without hesitation. She looked unconvinced. “Toni, that is a promise, OK?” Ok, she said with her eyes and an affirmative nod. I went on to mentally prepare her for a very long and sometimes frustrating process, just to set our expectations.

We started the induction process on a Friday afternoon, after I was done with clinic. Of course, her cervix that was not ready at all. After the maximum number of vaginal medicine I could give her, on Sunday morning, Toni’s cervix was still only a 2cm. We were indeed working against nature. It was too premature to start Pitocin, an IV medicine that can bring on contractions. Because if we did, her uterus would be contracting against an unfavorable cervix, and we could tire out the uterus, which can lead to bad outcomes. So I brought up the idea of the Cook catheter.

A Cook catheter is a catheter with two water balloons attached to it (see above). I would slide the catheter into the cervix, put saline water in the balloon that sits in the uterus first. Then I would fill the balloon that sits outside of the uterus, in the vagina. We would progressively fill the two balloons so they can mechanically compress, physically shorten and open the cervix. While people don’t feel much the balloon in the uterus, the one that sits in the vagina could cause pain and discomfort. For this reason, providers don’t like to use them. After all, we don’t like to cause more pain and discomfort to our pregnant patients. But this device works reliably, because it’s simple physics. The cervix has no place to go but away.

And now, this was one of my only options for Toni.

I drew a picture for Toni, and explained to her what I was going to do. I told her that this would not be comfortable, but it would work. “Ok, Dr. Zha, if you think it will work, let’ s do it!” Toni was determined. If she doesn’t give up, I don’t give up. So I inserted the catheter, and progressively put in more water in the balloons every few hours. And Toni was a champion. She didn’t complain. She understood that we needed to have a baby. “Ok Toni, every few hours, your nurse will come in to gently tug on the catheter. When it falls out without much tugging, then we know you are 3-4 cm dilated, and we can start Pitocin! Ok?” I asked Toni, while gently touching her arm. “Ok!”

“Wow Dr. Zha, we don’t see a lot of people use the Cook catheter any more!” The bedside nurse told me, after we came out of the room. The nurse was middle aged, and had 20 years of experience taking care of laboring patients. “Really?” I asked, although I knew the reason why. “But I am impressed you would do this, I’ve never seen some of our older doctors do this even!” She said. “Thank you. Well. The patient wants a vaginal delivery. We are going to give her one, right?” I put my arm around the nurse’s shoulder, who smiled with me. Right.

On Sunday afternoon, 10 hours after the Cook catheter insertion, I was informed by the nurse that the catheter fell out. Excited by this news, I came to the hospital to check on Toni. And sure enough, she was 4-5cm dilated! After almost 48 hours of trying, we finally got her “half way” there! Toni and I were both very pleased at the result. Many people would have gotten frustrated at how slow this was going. But we were not. We were not giving up. I came to the nursing station to order Pitocin on the computer, when my OBGYN colleague happened to pass by.

“How’s your patient doing?” She asked.

“She’s 4-5cm, and we are starting Pitocin!” I said with a grin, proud of the progress we made.

“Wow, you guys (family doctors) have patience!” She commented, indicating that she would have probably offered a C-section. This would have been a totally fine idea, if that was what the patient wanted. But Toni wanted a vaginal birth.

I thought about making some smart comment about “us country doctors”, but I didn’t.

“Yes. Yes, we are.”

Toni went on to deliver a healthy baby girl, after pushing for two-and-half hours, with me at her bedside, on Monday night.

“You did it, Toni.” After examining the baby, I turned around and told her. I could not be more proud of this amazing young woman.

Toni had tears in her eyes. How could she not? She worked so hard, and now they got to hold their baby girl. “We didn’t give up.” Toni said.

No, we didn’t.

*The story of the above patient was based on a true story, but the details and names were significantly altered to protect confidentiality.*