Saturday, October 17, 2009

Life and Death.

[Elias] Saturday, October 17, 2009. 0530. This entry contains some pretty explicit details, and a lot of death. Please be warned, and don't read it if these things will disturb you.

The preemie Elias is 13 days old today. Two days ago he stopped breathing for the umpteenth time and I bagged him for 30 minutes, forcing air into his lungs until he started breathing again. He's stopped breathing again countless times since then. We think he has necrotizing enterocolitis. He's on many antibiotics, antifungals, and a combination of naloxone and aminophylline. I'm not sure he'll be able to kick this infection. Every time they feed him he stops breathing again.

The preemie of S was born today. I admitted her a week ago for vaginal bleeding. She'd bled a bit each month she was pregnant and had continued to bleed while inpatient, more and more, until the blood was mixed with amniotic fluid, and we were forced to admit that her membranes had ruptured. They decided to induce her today. Maybe 28 weeks, maybe 32 weeks, hard to tell. Island dates, like island time, is hazy. In my interview she told me that she had attempted to terminate the pregnancy with kustum medicine (local plant medicine) around 9 weeks of gestation. An abusive relationship had forced her back to her parents' household, who didn't want another baby in the house. When the termination failed, she figured she would place the baby with other family members. It was a troubled pregnancy. On admission, she was having rhythmic back pain, a possible sign of preterm labor. They gave steroids to mature the baby's lungs, antibiotics in case it was infection (and then later to reduce the chance of infection with the ruptured membranes). The obstetrician counseled her extensively, that the baby would probably not survive regardless of how he was delivered, and that if he did a c-section, that would greatly increase her risks in future pregnancies. There would be no VBAC on her home island, probably no c-section either. She might have 3 or 4 more babies. It was better to deliver this baby vaginally and preserve her future.

She labored today, Friday, and I caught her baby mid-afternoon, a tiny little guy with a bilateral complete cleft lip and palate. He made no attempt to breath, but his heart rate was good. I bagged him. The pediatrician put naloxone in his umbilican vein. Then aminophylline, and more naloxone, IV. Eventually he began gasping. We argued diplomatically about what should be done. I had been bagging for an hour. Respiration 5 per minute. Gasps, really. The pediatrician wanted to intubate, but the nursery has no ventilator, so it seemed pointless. I held him.

The family wanted to see him. The men first. What happened to his face? I explained that sometimes when the face is forming, it doesn't come together completely. Then the women held him. I walked away, thinking they could hold him as he died. He began to breath more in their arms, so they attempted intubation again. The first couple times they tried, the tube just came up bloody. In retrospect, maybe he had some kind of fistula as well. When we bagged him, the air didn't seem to reach his chest, just the base of his neck. They must have gotten the tube in eventually, because when I came back, he was intubated, with oxygen running through the bag mask, making little grunting noises with every breath.

The naloxone/aminophylline combination can keep a heart/lungs going for 6--10 hours. I was angry then that he wouldn't have the chance to make an easy transition, to come and go in the same block of time, with his family there.

A mom came in today in early labor, but the difficult, back-labor kind. It was her 4th baby. Her 3rd had died at 7 months. Her CTG was flat, with occasional decels. I did a second vaginal exam and managed to wake the baby up with the stimulation, and the trace improved. She labored on, walking up and down the breezeway with her family sitting on a bench nearby. I figured even a posterior baby can make it out of a 4th time mom. Time wore on and still incredibly slow dilation, if at all. Molly delivered a quickie, and I took her to be weighed and immunized, a 2.5 kg baby with incredibly long lashes and plump lips. I took a nap on the bed in the private room. I tried to reconcile what I had felt of the baby's suture with what I palpated in her belly, with the body high and off to the left. I watched a French drama on the New Caledonian channel. I made tea. I repeated her CTG. The Chinese channel was too much static. I made another jug of tea. Back and forth she walked in the breezeway. The student nurse -- we'll call him Adam -- stayed with her, rubbing her back, encouraging her. The 3rd year student nurses 'adopt' a woman as their case study, and attach their name and phone number to her chart and are called when they have visits or go into labor. We worked together, trying to figure out why this labor was progressing so slowly. I explained what we knew about CTGs and drew pictures of the position I thought the baby's head was in. Something wasn't adding up. I was stumped.

Yesterday we found a transverse lie, with the baby lying horizontally in the uterus, neither head nor butt engaged in the pelvis. This baby definitely had a head down in the pelvis. I turned my mental model around and around. This labor is different, she told me. This is not like my other births. I demonstrated all my tricks for turning posterior babies -- somewhere there is a photo of my demonstration last week of open knee chest on a gurney in the hall, my butt up in the air -- and she tried them all, exhausted and clearly in pain. Still she didn't progress. Her cervix was still soft and thick, asymmetrically dilated, 7 cm if I was being generous. She asked if she would have an operation to cut the baby out. You've had babies before, I told her. We know your body can do it. The baby was still tolerated labor in that mildly flat way.

Finally, a little before 3 am, she had an urge to push. We took her into the delivery room and checked her. Same cervix. I tried holding back the cervix, pushing it back and having her push so that the baby's head would come down and slip past it. After a few attempts at pushing, she got the head to advance. I beckoned to Adam and had him take over. The cervix came back. THe midwife held it back. Finally it stayed. Adam gowned up. The head advanced slowly. The baby came out screaming. Adam and I rubbed her down, clamped her cord, and took her to the warmer.

Ey! The midwife cried. A twin! Not funny, I said. My first week I had been convinced that a twin remained in utero. I thought this midwife was joking. She checked for heart tones and didn't find any, but she palpated mor eand was convinced. I checked inside and found a head. I ruptured the second bag of waters. Thick meconium streamed past my hand and the midwife told the mother sternly that she must push, but she was exhausted. Our insistence became more commanding. I held back the cervix again. The head advanced. This baby was born floppy, grey. The cord was dyed green with meconium. He was white, gray, purple. I felt for a heart beat and thought that I felt one, so I did chest compressions. We moved him to the warmer, moving over his calm sister, her lying head up, him lying head down. We sunctioned lots of meconium. He made no attempt to breath, and when we listened, there was no heartbeat. All the hours of resuscitating babies had given me phantom heartbeats in my fingertips. What I thought was muscle tone in his legs was rigor.

The midwife told me that he probably died yesterday, pointing out the features of fresh- but not just now- stillbirth. The other midwife on shift came in and looked at both babies. She said she would call the obstetrician about the stillbirth. Then she told, your baby in the nursery, he is dead. Finis. Fuck, I said.

I turned to the placenta. It was still attached. I waited. It came out reluctantly. Then the bleeding began. Torrents of blood. Metric fucktons of blood. Ey! The midwife cried, reaching across the table to turn up the edges of the waterproof mat so that it wouldn't flood onto my clothes and onto the floor. I looked quickly for a tear. The blood was volleying out, practically leaping. I looked for a pulsatile motion in case she had torn a vessel, maybe in the cervix, from pushing past it. We crammed gauze inside, Adam holding it in. Still she bled. On IV, running wide open, with 40 units of pitocin in it. Another large bore IV in the other arm, in case she went into shock. Exhausted to begin with, she began to shake her. I asked her please to not pass out. I couldn't imagine what it was like, first the long, painful back labor, then being told that you have twins, then that one has died, and then losing blood, a liter already, easily. Fuck, I said. If she has a tear, I couldn't see it. I called the number by the OB's name and waited impatiently for the instructions, first in English, then in French, to finish and give me a chance to leave a message. I called the next number. He answered groggily and said he would come in.

We looked at the bleeding. It appeared to have stopped. I thought there might have been a piece missing from the placenta and searched for a long glove to attempt a manual sweep. First I had to scoop away clots. Lots of clots. Clots all the way up. 500 mL of clots? Then the bleeding began anew. Fundal massage just made it flow harder.

Finally it slowed, just in time for the OB to arrive. All the pitocin appeared to have worked (20 IU in two injections IM, then 40 in the bag). She was still conscious, thankfully, with a good pulse and a decent blood pressure. Adam volunteered to stay with her and clean her up while I took the live baby to be weighed and vaccinated. We weighed the dead one, too. The problem was that the family only brought clothes for one, not two. We used the towel to wrap him. Then the midwife washed him and dressed him with clothes from the hidden stash. Parents here bring everything for their baby. Blankets, diapers, soap, powder, oil. They bring their own toilet paper and plates. They bring their own pads. This baby was dressed completely: diaper, cover, onesie, a knitted sweater, knitted hat, their own towel, and a donated quilt. He was wrapped completely, and his identification slip was taped to the outside. I wrapped the live baby in their blanket and took her back to mom to breastfeed.

Amazingly, the mother was still with it enough to receive her baby, happily even, and put her to breast. Baby nursed eagerly. Her family had gone home in the middle of the night, and she called them to return. (I have no idea where she kept her cell phone during all that. Any illusions readers have about people in 3rd world countries should be shattered by the rapidity by which the cell phone reappears after labor and texting resumes. Everyone has a cell phone here, and it is better than yours.)

After cleaning up a bit, I went into the nursery, expecting to see baby Elias dead, as the midwife had told me. I expected to see his grieving parents. His mother sits in front of his incubator all day. Her breasts are swollen with milk. His father, with whom I ventured to the revival, quit his job on a boat to be closer to the baby and his wife. Instead, I found his bili light still on, and his belly still moving slightly. It was the other baby who had died that morning, between the births of the first and the second twin. The one who was born the prior afternoon, to the mother with the premature preterm rupture of membranes, who had been subjected to the intubation, to the taped tube pulling his mouth way off to the side. He lived just under 12 hours.

People have asked me if I'm still glad I came. All the more so. Death is an amazing thing here. It is not a novelty. It is not an opportunity for blame. It just is. After all that, after all that labor and death and life and bleeding, the mother thanked me. I told her I was sorry the baby had died, and that was it. It was the same with the 28-weeker born earlier with the cleft lip and palate. His family said they were grateful we were doing all we could, and that they loved him. I explained that we couldn't really fix what was wrong with him, that he was very small, and that he might not live. They accepted that. There's no looking for someone to blame. The attempts to evade death don't have the same desperation as they seem to have in the US. The families thank us for doing what we can and make plans for burial.

The reality is that many fewer things are possible here than in the US. A premature baby in the US has a fairly good chance of surviving to a highly functional life, even with disabilities like deafness and blindness. A premature baby here does not have that chance. There's no NICU here. There are incubators but no ventilators. There are some drugs but not the same drugs. The babies are in oxygen-rich headboxes, increasing their risk of oxygen-caused retinopathies, if they survive at all. It's the arbitrary nature of it that I hate. A soul lands on one island instead of another, and that determines so many things about her life.

Baby Elias


saralily13 said...

I can only say how proud and impressed I am with your skills and your ability to continue caring and providing care in the middle of craziness and death. What an amazing midwife you are.

Jessica Loetel said...

Wow Elias - I'm so glad you are there doing the work you are doing and learning what you are learning. I agree with you about death, it is so different elsewhere - but still sad. I'm glad the mom has one baby of two to love, and I'm glad baby Elias is still alive. I hope he makes it.