Monday, January 5, 2009

First breath to last.

When I walked into the labor ward this morning, hunting for the primary midwife for the day, I noted a tiny green bundle lying on the resuscitaire, a worn hexagonal plastic box with a tube snaking from the O2 tank beside it through a hole in the top. I figured someone had left it there from the evening shift and I wandered out. I found the midwife, asked what had gone on in the night: three women delivered babies, a fourth delivered at 23 weeks and was then transferred to the surgical wing. She gestured toward the labor ward:

"850g. Too little. He's still in there, gasping." She said simply.

I realized the tiny green bundle on the resuscitaire contained a tiny baby. One about the same size as the one in my belly. I went back in, opened the green, surgical bundle. I was expecting honestly, to find a baby who was dead. Instead, he opened his tiny eyes and began to cry. His tiny mewing sounds caught the attention of the morning midwife, who summoned one of the peds who was in for rounds and somehow the decision was made to support his impossibly slim chances for as long as he was up for the struggle. Support here for such a tiny preterm baby is minimal, but for those babies who take up the fight, they are helped as much as they can. I watched the ped start an IV line, begin him on fluids, and he was tenderly carried to an isolette in the nursery by the male midwife, easily the tallest bloke in the vicinity, where he lay, tiny arms waving occasionally. The contrast of 1lb-something baby in the hands of 6.7ft midwife was striking.

I asked when his mama would be told that her baby was still alive (she was evidently told he was dead). "The pediatrician might tell her sometime today" was the response. He clearly did, because a 1/2 hour later and then every hour after, baby boy's grandpa came up to peer at his tiny grandson through the crackled plastic of the O2 hood in the isolette.

At about 2pm I stepped in to see him. "Him give up" the male midwife reported from across the hall. I went in anyway. His tiny birdlike chest was indeed still, his hands and arms the slightly darker purplish shade which comes with death. I stood there for a while, said a little prayer for him, and his mother (who I never met) and his grandpa. His chest rose and then fell again: an agonal breath. In truth it may not have been his last breath, but in any case his short (almost 8 hours!), brave little life began, and ended today, and I spent some of it with him.

I don't think he was ever held by his mother. His whole family came to collect his body. I think they were to take him to the morgue. It may have been them I heard keening as I walked home.


Today though, about 11 am I admitted a G2P1 in active labor. Was pleased to find her a stretchy 6cm and lovely low head. I broke her bag (protocol) into a bedpan, and 15 minutes later she reported she wanted to push.

To the labor ward we went and about 10 minutes later her son felt my hands first. Wonder of wonders (doesn't happen here a lot) she welcomed him up onto her chest as soon as his cord was cut, and she cuddled him for a few precious seconds before he was whisked away. Don't fret, got him back to mama soon after, latched and nursing.

"How many babies you deliver in Vanuatu?" she asked.
"Yours is the first!" I said. She didn't seem too bothered.


Today was notable also for two misoprostol inductions (also known as cytotec, it's a very inexpensive prostaglandin medication which is placed in tablet form beside the cervix in the vagina to induce labor and treat postpartum hemorrhage). One for a woman whose chart was covered with highlighted instructions. Notes that she was high-risk. of 6 term pregnancies, she's delivered 1 living baby. Two of her babies were stillborn, and two had died within hours of birth. None of these deaths had ever been explained, no autopsies ever done. She presented for induction at 38 weeks, in the hope that we could help her have this baby be ok - her living child was born after induction at 35weeks. for this, her 7th pregnancy, 6 hours after the miso was placed, her baby - who to my eye had had really weird CTG tracings from the word go - began to decel into the 90's (should be between 110 and 160 or thereabouts. Given her history, the decision was made immediately to proceed with cesarean section.

Immediately here translates to the time it takes to call the doc, draw blood, send it to the lab for type and crossmatch, The time the lab takes to type and cross match and then send over the requested two units of blood, place urinary catheter then wheel mama over to the OR, prep for surgery. Scenic detour for me and fresh UK med student as Doc took the time to instruct us on proper hand-washing technique (I wish I was kidding). Then instruction on how to place spinal anesthesia (I KNOW I'm never gonna do that). All with no fetal monitoring going on... I have to tell you my skin was crawling just a little as he talked and 'taught' us through dissecting into the peritoneal cavity, and then the uterus, all the while saying cheerfully "with no indication of fetal distress, there is no need to hurry - I could do this much faster if necessary". I was looking around the room thinking "Dude! We're doing this CS because we had signs of fetal distress and we're not actually monitoring baby presently so we have no idea if this baby is tanking as we speak - not to mention the fact that this woman's lost 4 babies already!!"*

Anyway baby was born alive (good start) and was transitioning poorly. I wasn't actually supposed to be doing anything at this birth, aside from observing, but the baby was looking funky, very blue, low tone, not opening his eyes and I was kinda anxious that he be ok. The ped did an initial suction, but not a whole helluva lot of much else. I was itching to rub on that baby - he just looked too flat. I pulled out my stethoscope from my pocket and gestured to the ped if I could listen. He gestured to me to go ahead. I listened and his HR was 90ish. I busted into full resus mode: rubbed on him, flicked his feet. Bagged him till I got chest rise - he seemed completely disinterested in breathing and his color just sucked. He just wasn't transitioning right at all. But at least with the PPV and stim he started crying a bit and his HR got up over 100. Ultimately he went back to the nursery with blowby keeping him (almost)pink. I popped in to see him on my way home (only 2hrs after my shift was supposed to have ended) and he was still needing 4L O2 but his eyes were open. The word which keeps popping into my head is syndromic, not sure why, but something about the way he looks struck me as a bit 'off'. I hope like hell he's still with us tomorrow morning, and that he continues to do Ok. 1 dead baby is too much for any mama, 5 dead babies (term babies at that) is inconceivable to me.

BBQ for everyone tonight at the place I'm staying. Ate well, but really didn't feel at all like socializing, can hardly walk, my feet are so sore from running around all day, then standing in the OR for a couple of hours. I'm so finishing this post and going to bed.

Oh yeah. Was so tired, my entrance to the BBQ involved me walking through the screen door to my room. In a seriously elegant maneuver (I'm occasionally famous for them) I tore off the screen door completely, and the door and I landed in the bush in front of my room.

A member of my audience: smart arse South African bloke, three beers down, called out: "You're supposed to slide that one, love."

You don't say.

* I should note that I am very grateful for the cool stuff this wonderful doc is teaching me. I mean no disrespect at all to him when I relay my anxiety in this post. It was just stuff that was going through my head. It's just different is all. Cytotec inductions for a grand multip with a history of multiple term stillbirths and neonatal deaths, and lengthy decision to incision times just kinda freak out this student midwife who's used to lovely low risk, healthy gravidas!

1 comment:

Susie said...

I think I have read this post about 3 times already....realizing every time how lucky we are to have the care our babies need when they are born. You have made such an impact already....