Last call night, O Best Beloved, was one of the longest nights of my life.
At 0100 I was not sleeping; I had not been sleeping since I dragged myself out of bed at stupid o'clock in order to make my way into the OB floor for my second-to-last call of the month. I was, instead, preparing to check the cervix of the woman with twins who'd unfortunately ruptured her membranes at 0000 and was now headed for a C-section once the attending could get in. High-risk ward paged me. "We need you."
I am a first-year resident on my first month of OB whose previous experience with OB has been nothing short of brief and relatively happy, sheltered from the unkind truths of Bad Things that sometimes happen to patients and their unborn children. I am rapidly being unsheltered, and I am a little afraid by it. I knew why High-risk needed me, and if it had been twelve hours earlier I might have felt the twisting knot of worry in my stomach, but last night drained me of worry or concern far before 0100. I didn't check the cervix of the twin lady; I excused myself and headed to the floor, where a very nice woman I had met earlier today was in the process of losing her twenty-week baby.
I am ashamed to say, O Best Beloved, that when I heard her story ("I felt something coming. I tried a little push, and felt very strange.") and tried to check her cervix and instead felt a tiny foot or hand clasped between my fingertips, I panicked. I didn't go further to find out what was prolapsed, I didn't examine to see if the baby was lying in the vaginal vault, I did not, in fact, feel her cervix at all. I just pulled my hand back out and asked for them to page her doctor, the OB on call for her group. I don't recall the exact conversation that took place in the wee hours of the morning (after nearly 30 minutes of trying to rouse her via page), but I do recall a few exchanges.
So what you're telling me is that you don't know what you felt, you just put your hand in there, felt something, and ran like hell? Pretty much, yes.
And are you telling me that you need me to come in at one o'clock in the morning because you don't know what to do? I'm saying that I either need a plan I can follow or I need you to come in at one o'clock in the morning, because I don't know what to do, yes. And I can't tell from what you're telling me, so I guess I'll have to come in.
O, Best Beloved, I was not trying to ruin her sleep at home, although I should have seen the warning signs in myself earlier when I made the nurse call her for permission to give Ambien to a post-gallbladder patient who was having trouble sleeping - something I ought to have done, and with some confidence - I was, in fact, on the verge of emotional breakdown. And the subtle jeer and scold of her questioning left me fighting tears, my voice almost breaking over the phone. It had just been that sort of day.
I nearly ran to the twins' C-section, glad that my help was needed urgently to extract two six-pound babies and a monstrous placenta, glad for the time-consuming ordeal of forcing a uterus to contract down when it was exhausted from overstress, glad even that the new surgical prep makes the Ioban stomach drape come unstuck, sending blood rivering off the table, over the abdomen, onto the floor and my boots. I could be angry and disgusted about that, complaining and wrinkling my nose. It was better than trying to face an attending I liked and respected, who until that point had been pleased with my management and triage of her patients, who had come to the hospital at one in the morning because the resident was scared and exhausted and nobody had ever told me what to do or expect.
When I went back, I read her note and talked to the nurses. Just a cord and foot prolapse, sign enough that the baby had most certainly died, but nothing that needed coming in for. "She was very nice about it," they told me, but I heard the subtle jabs even then, when she commented that if I wasn't comfortable placing a second prostin suppository at 0615 that "the next resident" could do it. I can place a prostin suppository, O Best Beloved, I had already done that twice that day at the first dead baby's bedside.
It had just been that sort of day.
We had been discussing a patient, my preceptor and I, faint spotting, UTI by clean catch, and he asked me if her cervix had been closed. I told him I hadn't checked. He asked me please to check before I sent her home, and because my preceptor last night was a teacher by birth he explained to me why he wanted me to check. "Spotting can be a sign of preterm labor or cervical change, and if we sent her home and she came back at 3 cm tomorrow with preterm contractions, wouldn't you feel awful not knowing where she'd been the previous day?" And it made sense. And her cervix was closed, thick, and high.
Not ten minutes later, OB was talking with me about a patient, 20 weeks, with some spotting and UTI symptoms. "Give the vag bleed workup," she said. "She's spotting." And so I slid a speculum in and took a peek and there was something that should not have been. I saw the grey-and-black mosaic of fetal membranes in the opening of my speculum. I saw no other source for the bleeding. I reached in and found a cervix at 3 cm dilation that ought to have been buttoned tightly closed. And I looked at the nurse: 3 cm, bulging bag. She checked after me and agreed.
I saw her face; this was an educated patient who understood what I meant when I said it. She looked at her husband and said, voice surprisingly calm, "That's very bad." We tried to reassure her some. She knew then, though, what was going to happen, and she was adjusting her mind to the fact that her baby was going to die.
So was I.
We do what we can, O Best Beloved; I called the OB and she called the maternal-fetal medicine on-call and we put this poor woman on bed rest in the Trendelenberg position on magnesium for tocolysis (to stop the contractions that she may have been having) and then we settled in to wait. She was 20 weeks and 3 days by good dates and ultrasound; not quite far enough along for her baby to have a fighting chance in the world. And she asked, calmly, for no heroics. We were relieved. She was taking the news well, and when her water broke later in the afternoon it was only a matter of time.
In the meantime, I was running from room to room; we had better than twenty patients come through triage that day and all of them had to be seen and discussed. I was called out of triage at a dead run to catch a baby; she tore right through the episiotomy scar. They paged me out of the repair then - "You have a multip at 9 cm, did you know?" No, I didn't know. Her baby was little, and once she was convinced to push ("I can't." "Yes, you can.") she delivered quickly and neatly. The day was just like that. Forget processing anything; I was too busy to think.
It was probably best that way. After all, in the middle of the day I walked into another room just in time to be responsible for cutting open the amniotic sac of a second woman who'd come in for induction of her dead 20-week baby. A week ago, on ultrasound, baby was doing well, growing, moving. Two days ago, there was no heartbeat in the office. Now, there was a resident doctor, awkward, unsure, and prostin suppositories to draw out the latent contractions and expel the no-longer-living fetus. We had spoken only briefly, mother and I, the awkward niceties of strangers. She was pleasant, distant, withdrawn; liked hot tea and warm blankets and an epidural to block out the events below her waistline. She did not want to see the baby. I wasn't sure I did. But there it was, en sac, a soft, fluctuant bag with the transparency of waxed paper, warm in my hands, the occasional solidity of its contents brushing against my hands as if to remind me of what (who?) was within. I looked at the nurse with the silent "What do I do now" expression that begs for help, and she said "You'll need to cut the bag open and examine the placenta. We can move the baby then."
The baby. This dead infant that the mother did not want to see, encased at the moment in a pretense of safety; I could almost pretend we were going to wrap a shell around it like an egg, incubate it for four and a half more months, hatch forth a living and crying child. I lifted the bag carefully, both hands, trying not to flinch as the child within tapped insistently against my fingers, insisting on being born now, too soon, unalive; settled the bag in the metal pan that lay on the sterile field.
Unsure what to do and unwilling to prolong my time in the room any more than I had to (she didn't want to see it; she was looking up at the ceiling or closing her eyes as we worked) I pulled the scissors from the precipitous delivery tray, slit the bag open, spoke softly. "Grossly bloody amniotic fluid." One begins to intellectualize, rationalize. "Shall I cut the cord?" And clamp, just once, placental side. "Placenta looks fine, intact. I think everything came at once." There was a tiny creature lying in the silver tray, floating in dull red fluid, on its side as if sleeping. I was trying not to look at it and look at it and figure out what to do. Nurse came over with a blanket. "Lay the baby here, I'll wrap it." And she mouthed at me: Boy or girl? I didn't know, I hadn't looked, my fingers were too shocked from the softness, the warmth, the fragility of that tiny dead baby.
I had another chance to look, when we'd moved to the recovery room across the hall, having taken our unbreathing charge with us all wrapped in sterile towels. Baby girl. There was perhaps a fullness to the neck that was not quite right; otherwise my inexpert exam found nothing wrong. The bones like balsa wood, slim and fragile, barely palpable beneath the skin that peeled at my touch, five fingers on each hand, five toes on each foot, infinitesimal . Soft, minuscule, incomplete. Skull plates that flexed at my touch, lined up to flatten wherever the head touched the table, unable to maintain the roundness one would expect. Eyes sealed shut, tiny mouth agape - nostrils, earlobes, everything in miniature and not quite the same as I would have expected in a full-term infant. She was strange. I felt strange.
There wasn't time to process; it was back to the full triage rooms, back to reassurance and medications and for Pete's sake it's 90 degrees out, 4 to 5 glasses of water daily isn't enough for a pregnant lady. All day, all night.
At 0715 when I was updating a family practice doctor over the phone on one of his patients, they came in. "We need a resident in High-risk for a delivery now." I recognized the room number; I'd been there an hour ago placing a prostin suppository and trying to do a cervical exam around a pencil-thin leg and prolapsed cord. I can barely do cervical checks around bulging bags of water. My replacement moved to go, asking what was going on; I waved him back, signed off (I hope politely) with the doctor - "I'll call you back, I need to go right now." He didn't argue. I ran down there.
I was in time, and when I arrived it was worth having stayed to see her smile.
I knew it was coming, and I looked at the clock, she said as I was gloving. And I hoped you hadn't already left. It is a singular, uncomfortable honor to be so welcomed: I'm glad it's you to deliver my dead child. Both feet were prolapsed, the size of my fingernail, toes pointed up. There was no pulse in the umbilical cord; the baby had been counted probably dead when the cord prolapsed out six hours before. We weren't monitoring heart tones, not in a 20-week baby. There was no real purpose, you can't follow them without a mobile Doppler in a baby doing well. I asked her to give a little push; I slid a hand underneath the feet to guide out what I could. It took two pushes - one for the abdomen, the second for the shoulders and head, and then there was the contrast of dull and dying red against sterile blue, a warm limp child making no pretense at life. Boy. This time I looked, as I clamped the cord and disconnected the baby, leaving cord and placenta inside. I had been warned: wait. Do not tug. It will come in time, or it will be retained.
She looked too, craning her neck, dazed from the Nubain and laughing a little, bizarrely. "Bloody mess." Indeed. We wrapped the baby and set it aside, left her to be. I know from the record that she went to the OR for retained placenta later that day. She had been hoping it would not be so.
And so I went home, sleepless, and collapsed into bed. And I woke, drained and empty and sought for words to tell you and found none. It was a day so filled with emotion that I am still beginning to revive my wounded spirit; I can see the two dead infants in front of me still on their blue sterile towels, fragile, without even the rigidity of structure holding them together, looking broken and impossibly bent. I can picture the tiny genitalia that is all that distinguished them one from another, the faces of the mothers, the undignified and hopeless sprawl of death. We studied preserved babies, babies in jars, in medical school. I remembered them, looking down; they were cold and firm and still, leftover reproductions of life - lifeless and without semblance. It is so very different when one is holding the blanket-wrapped body; there is body heat enough to soak through the towels and there is a limp weight that forces the hand, unconsciously, to support head and shoulders as if cradling a living baby. It is a memory I will never lose, I think. A memory I hope I will not have to add to.
It will break your heart sometimes, being a doctor, if you are not careful. It will take the parts of your soul that are alive and hopeful and fragile with joy and it will wrap them around death and despair and strange, sourceless loss. It will rend your unprotected self, decorate you with grief, and cast you aside with the rest of the debris of life's purposeless cruelties. I awoke this morning numb and disconnected, painless and blind.
And then, O Best Beloved, I stepped into the room of my first clinic patient and saw a squealing, laughing six-month-old boy, fat with vitality, trying to eat my stethoscope, reaching out to me. And in the embrace of those chubby arms, in the black reflection of curious eyes, I saw myself stir and wake and come alive. And there is, there has always been, there will always be hope.