My eyes open. The blackness of the call room envelopes me. Consciousness sets in with a lingering disorientation. A small green light, is speaking … ringing. “Are you standing up?” The resident on the other end knows her attending too well. She’s right not to risk my falling asleep mid-conversation.
A woman has arrived laboring at 24 weeks gestation. Records aren’t available, but she reports her fetus has a diaphragmatic hernia. Her cervix is dilated 7 centimeters. Tocolytics, antibiotics, betamethasone and neuroprophylaxis have been started.
I move down the hallway. My eyes open intermittently, hoping to adjust to the blinding light before reaching another human. My thoughts move between my blindness and the information I may need. Gone are the days of routine resuscitation. An ever-changing balance of evidenced-based information feeding maternal autonomy has replaced a paternalistic approach to medicine. What’s the estimated fetal weight? The gender? When was the first ultrasound? Are there other anomalies? What about lung volume? Is the liver involved?
The resident scans the patient as I arrive. During our conversation with the parents, I become paranoid about my appearance. What must they think of me? Are my eyes open enough yet? Wait … My hair. I was sleeping. I’m sure that only half the hair on my head is telling the patient to stay calm.
It becomes painfully obvious that there is little apparent lung volume. I try to recall the odds of survival for a neonate in this circumstance, and I admit to myself I am not very good at this type of estimation. We relay our hesitation about resuscitation to the soon-to-be parents, and they seem agreeable to let neonatology make the decision at delivery.
The overwhelming urge to push emerges, and we pass the point of no return. We summon neonatology. The resident decides to deliver with membranes intact. Good thing I put a mask on … Don’t flinch. She’ll think you’re a newbie. During the second push the amnion bursts. I manage to hold still, but the remainder of the team betrays me. The warm fluid stuns the patient’s spouse. “That’s normal. We knew that would happen,” I offer.
“Well, I didn’t,” the spouse rebuts.
Again, my mind wanders. The resident is calm. I think back to when she first started, and recognize how proud I am of her. Emotional experiences with patients and residents have changed me, and I have grown to care for many of my residents. Does her silence come from confidence, fear, or sadness? Has she done this more than I have? The room follows her lead: Sound is lost. The slightest movement rudely interrupts the prayer-like attitude the bystanders have adopted.
The infant swiftly enters the world. You have to be ready with these little ones. The resident hands off the newborn.
The silence of the newborn expands the emptiness of the small room, which shrinks further when several teams work side-by-side. The neonatal team presents the newborn. “You can hold her. She is too small for us to help her.”
I can’t help but wonder if this is self-fulfilling prophecy. We have decided to allow another human to die. Are we playing God? Or are we providing compassion by refusing to prolong suffering? I can only have faith that, by trying to do the right thing, we are.
While the patient holds her daughter, I have no interest in dealing with the placenta. This is the only time she will hold her daughter alive. We cover the crimson that contrasts her pale legs. The parents hold their dying daughter in a perfectly quiet room. We don’t dare leave, nor deliver the placenta, lest they miss the short life of their newborn.
Seeing this has never been the same since having children of my own, or after seeing many of our residents raise newborns. What is the resident thinking now? I wish I could ask her, but we are still with the patient, and to the residents, I am not a human with emotions.
I stare. Absorbing her newborn skin … her hair … her silence. Envisioning the immense joy this child could have experienced is gut-wrenching. We offer to take pictures … you know … something to do … anything to do. The newborn holds her mother’s pinky. As best I can tell, the parents are holding together well. They will never see their daughter smile. I take off my gloves and look away.
After some time, we deliver the placenta. We need her bloody legs out of stirrups to allow her family to see the newborn, which is still alive. “You’re going to feel pressure … a lot more pressure.”
Trailing membranes taunt us. A tug of war ensues over the placenta and they tear. Sh*t. A wave of blood sends a message. I scan as the resident guides a curette. “To the right … No, your right … Her left.” We must look like idiots. We get membranes on the first try, and the bleeding stops. Using adept reasoning we decide to leave the patient alone. The stirrups finally come down.
“Congratulations … and I’m sorry for your loss.” The fact that their little girl is still alive bores through my chest, and I shrink in my shoes. I avoid further attempts at compassion, and mutter something about genetic testing. My emotions are expansive, but I hesitate. I don’t want to belittle this as my experience… But is this experience just theirs?
I remind myself that I am a complete stranger to them.
“What’s her name?”
Devin D. Namaky is a gynecologic surgeon who blogs at Fibroid Answers of Cincinnati. He can be reached on Facebook or on Twitter @devinnamaky. This article was originally published in the American Journal of Obstetrics and Gynecology.