Emergency Deliveries

Darla, one of the emergency room nurses, called me into the gynecology room. We’ve got a woman nine months pregnant, but we can’t find a fetal heartbeat. She says she felt the baby kicking earlier this morning, then the contractions started coming. Now she says there’s nothing but contractions.  A young, frightened-looking woman lay on the examining table. I took the Doppler, a little handheld device that picks up the faint sound of fetal heartbeats. Though I tried a dozen different spots on her belly, I couldn’t find any sound except for the mother’s heartbeat. I put on a pair of sterile gloves to do a pelvic exam.  The patient was a big woman, and I had to slide my hand in past the wrist before I felt anything. But I wasn’t sure what it was. It felt at first like a string of grapes. Then I realized it was toes. The baby was in breech position. Instead of the head presenting first, as in a normal pregnancy, breech babies present their buttocks first. I could feel that one foot had descended.  This is a footling breech, I told the nurses. I turned to the patient. Who is your obstetrician?  The girl looked at me, terrified. I don’t have one.  You never saw a doctor during your pregnancy?  I was supposed to see one next week.  Famous last words. She was a high-risk pregnancy and never knew it. I turned to the unit clerk: Get someone from ob.  The clerk ran back to the desk. I could handle a normal delivery, but er doctors don’t get much practice with difficult breech deliveries.  A moment later, the unit clerk shouted, I’ve got the obstetrician’s wife. She says he’ll be here in about a half hour.  Just then a nurse cried, I’ve got something. We all listened for the sounds of a normal fetal heartbeat. All we heard, though, was a slow swish, slower than the mother’s heartbeat. Everyone counted silently, gazing at their watches. Seventy-eight, half what it should be. Fetal distress.  During normal labor, the baby’s head is delivered first. If it hangs up in the birth canal, you can do a C-section delivery and remove the baby from the uterus. In breech deliveries, however, the rest of the baby is delivered first, and the head comes last. If the head hangs up, you have a child half in and half out of the birth canal. Sometimes you can push the baby back in and perform a C-section. If not, you have to cut down through the uterus and the cervix--the passageway between the uterus and the birth canal. This procedure is far more complicated than a C-section. Only if you are lucky is the baby delivered alive.  Should I wait for the obstetrician or do I try the delivery? If the head hangs up in the birth canal, the baby’s dead and I’m dead. I would be hung out to dry. And it probably wouldn’t matter if the baby would have died because I waited.  Darla counted again. Sixty-six, she announced. A half hour is a long time for a fetus with that slow a heartbeat.  I put my gloved hand back up the birth canal. The leg had descended further. I could now feel the buttocks.  Do something! the mother shrieked.  So close, so close. Another monumental contraction and the baby slipped down another notch. Well, I said. Let’s do it.  The trick is to corkscrew the baby, turning it slowly so that first one hip is delivered, then the other; then one shoulder, then the other. I held the legs gently and the baby began the slow rotation. It didn’t require much traction; this baby was ready to come out.  First one hip slipped free, then the other. I had my hands on the baby’s waist and kept pulling, gently. The baby kept descending with traction. I got my fingers up near a shoulder, hooked it, and eased it down. One shoulder popped out, then the other. Textbook.  When I got my fingers up to the neck, I felt the cord wrapped around the baby’s neck. I couldn’t feel a pulse.  I eased the cord gently back up toward the chin and then beyond, trying to unwrap it from the neck. The cord had become crimped, stopping blood flow--hence the fetal distress.  The lower half of the baby dangled like a doll, blue-black and lifeless. I put my hands over the shoulders and began gently pulling again. I could feel the walls of the cervix give a little, allowing the baby to slide out a bit more. Then the sliding stopped. I tried a little more traction. Nothing. I eased up. At that moment the baby’s head, as if of its own volition, popped out.  We all stared down. It was a normal, if very blue, baby boy. While we scrambled to resuscitate him, the baby took one deep breath and started howling.  My baby! the mother said.  That night I lay in bed, staring at the ceiling. I was relieved the baby was alive, but I was angry at myself for attempting the delivery. If I hadn’t delivered the baby and it was dead at C-section, nobody could really criticize me. After all, how was I going to deliver a breech baby? But if I had attempted the delivery and the baby’s head had hung up in the birth canal, it would have been a medical catastrophe. That night I thanked God from the deepest part of my heart. I thanked him for letting the odds go the patient’s way--for that flicker, that brief glimpse of grace.  Six days later I had another delivery.  A woman, 35 years old and six months pregnant with her first baby, was complaining of abdominal pain. The nurse signed her in. Just then, the bag of water that cushions the fetus broke, and amniotic fluid began leaking onto the floor. The nurse rushed to get me.  I still hadn’t recovered from the previous week’s delivery. I had been dreaming about reaching out and feeling toes, feeling feet. I craved a normal headfirst er delivery, all panic and chaos, climaxing with the delivery of an irate, squalling, and clearly healthy baby. I wanted the expected unexpected--a healthy woman whose labor has proceeded more quickly than foreseen. You slip your sterile glove within the vagina and feel for the cervix. During most of a woman’s life, the cervix is a narrow funnel- like entry to the uterus, but during delivery, as the baby’s head presses against it, the cervix becomes wide and flat like a plate and the os--the opening of the cervix into the vagina--dilates enough to let the baby’s head through.  I pulled on my gloves and began the ritual. You’re going to feel something cold and wet. I slipped my hand into the vaginal canal.  I didn’t know what I felt. There was the cervix and the os, and there was something sticking out from the os. It felt like a piece of wood, like a little tree log extending into the vagina.  What the hell . . . I said. There was a rivulet of fluid and then this thing slithered out onto the cart--its head was a great bubble of membranes with a wrinkled, gray, gelatinous mass under it. Two gigantic bulging eyes, like the eyes of an enormous fly, stared blindly at the ceiling. Long gray folds of flesh draped down to the grinning mouth. All this was attached to a normal baby’s body.  Jesus Holy Christ, the nurse said.  Anencephalic, I said. I could not believe what I was seeing. It’s an anencephalic baby. The gelatinous mass was the brain.  The medical definition of anencephaly is markedly defective development of the brain, together with the absence of the bones of the cranial vault. The cerebral and cerebellar hemispheres are usually wanting, with only a rudimentary brain stem and some traces of basal ganglia present. Colloquially, individuals with this malformation are sometimes called frog-babies. A number of conditions can increase the risk of anencephaly, including malnutrition, folic acid deficiency, and certain medications.  To me the baby’s head looked like the head of a giant housefly. The nurse and I stared down, too stunned to move.  Is the baby alive? the mother asked.  I had been too overwhelmed to check for a pulse. I put my hand down on the umbilical cord. There was a slow pulse.  Scenes of the resuscitation procedure flashed before me: intubating the baby so it could breath (it hadn’t so much as gasped), iv in the umbilical stump, the drugs, the fluids, a helicopter ride to a neonatal intensive care unit, the days, weeks, even month or two in the unit, the hundreds of thousands of dollars, the grim prognosis, the inevitable, heart-wrenching end. I thought about all this.  No, dear, I said. I’m afraid your baby is dead.  Is it a girl?  I looked down. I hadn’t even noticed. No, he’s a boy.  Can I see him?  The nurse and I looked at each other. The nurse shook her head.  No, dear, I said. Later, later.  I cut the cord and delivered the placenta. The pulse was gone within a minute or so. There was never even a hint that the baby took a breath.  That night I went home to bed and as usual stared at the ceiling and reviewed what had happened. I didn’t worry over the ethics of the life- and-death decision I had made. It somehow didn’t bother me, although it should have. What I saw instead was that baby--that inhuman fly-baby. But then I thought about the mother. This woman had tried to conceive for ten years. After the stillbirth, she had wept, saying, It’s all my fault. I’m bad, I’m bad. It’s all my fault, and I wanted that baby so much.  I kept going back and forth between the image of the fly-baby and the weeping mother until finally I got out of bed, sat down by the window, and looked out over the city. A few cars passed, a dog barked, a cat picked its way across the street, otherwise nothing. Except, of course, somewhere in this city, someplace I couldn’t see from my window, that mother was still crying and still blaming herself.  So much for grace.  Some time later a resident was going over a case with me. The patient, a healthy 20-year-old woman, had come in with seizures a week earlier, the first in her life. Her second episode of seizures occurred just as she was being given an antiseizure drug in the er. The er physician referred her to a family practitioner at the hospital. The patient did well, no further seizures, and was sent home 72 hours later. Now she had returned with a low fever, burning pains when she urinated, and some lower abdominal cramps.  The resident drummed the clipboard nervously with his pen. I think she has a urinary tract infection, he said.  I’ll buy that.  A nurse shouted from the patient’s room on the other side of the er, She’s crowning!  Another voice followed, She’s in labor. She’s having a baby!  We rushed to where this young woman lay, moaning, knees drawn up, the dark dome of a baby’s head just visible between the lips of the vagina.  I pulled gloves on and slid my fingers down, beside the baby’s head, under the strained skin of the vaginal opening. This obviously was the girl’s first baby. She needed an episiotomy, an incision to open the edge of the vagina. Episiotomies prevent painful, hard-to-heal tears.  The procedure is usually done with sterile scissors. Most obstetric physicians I have trained under say that the vaginal wall is entirely anesthetized at this point during delivery. That’s not what I’ve seen, and this time was no different. The woman screamed and beat the bed railing while I cut into the flesh. The vagina opened wider and the baby practically popped out into my hands.  It was dead.  It was clear the baby had been dead for several days--at least. The skin was macerated and yellow, and the fingertips and toes were beginning to blacken.  What is it? the girl shouted. What’s the matter with me?  It’s a baby, I said, peeling off my gloves. And I’m sorry, but it’s dead.  A baby! the woman shouted. I’m pregnant? I’ve had my periods! I can’t be pregnant! I would know that, wouldn’t I?  I shut my eyes and pressed my fingers against them. Something was wrong. Wait a minute. I turned to the resident. What was this woman here for last week?  Seizures. First-time seizures.  A week ago?  Six days.  I looked at the baby. It was about six days dead. I looked back at the resident. Eclampsia. I nearly whistled it. She was eclamptic.  I watched this information pass like a pinball inside the resident’s brain before the bell finally rang. Pay dirt. Eclampsia. Oh, my God, he whispered.  This was very bad. Eclampsia, a poorly understood condition, involves a toxic maternal reaction to the fetus, and it usually occurs in the last month of pregnancy. The initial symptoms--called preeclampsia--are elevated blood pressure, leg swelling, and protein in the urine. True eclampsia causes a patient to have seizures, and immediate delivery of the fetus is required. If left untreated, the condition can jeopardize the life of the baby and, sometimes, the mother.  When this woman had come in to the hospital seizing, nobody had thought to do a pregnancy test--and her condition must have been missed during the physical exam. I looked up from the chart to the girl. She wasn’t particularly large, but she was fleshy enough, apparently, to hide a first pregnancy--even at term.  I told someone to put the girl’s parents in the grieving room-- the room where we put families whose relatives have died--and that I would be right out.  Your daughter was pregnant, I told them. We delivered the baby, but I’m afraid the baby is dead.  How is Suzy? the mother asked.  Suzy’s okay. Suzy’s fine.  They sat for a minute, taking this in. The mother cleared her throat. I thought she was puttin’ some weight on, and I asked her one time . . . but . . . she trailed off. She was thinking. How long has the baby been dead?  I don’t know.  She had that seizure last week. Did that seizure have anything to do with the pregnancy?  I’m not sure, I lied.  They thought for a minute more, then the mother nodded. She told me she was still having her periods.  Wishful thinking. Apparently she wasn’t.  Can I see Suzy? the father asked. The mother thought for another minute, then said, Can I see the baby?  Wrongful death. The worst kind of malpractice case. I could imagine the string of accusations that would follow.  The family medicine department, which admitted her into the hospital for observation the week before, would claim it was the er physician’s responsibility to make the diagnosis. The er doctors would counter that family practice had had the patient for two days, so they should have caught it. But I was at risk as well: for not attempting to resuscitate the baby, and for any gynecologic problem the woman might develop.  When the er slowed down, I reviewed my decisions. There was absolutely nothing I would have done differently. There was never a doubt in my mind that the baby was clearly dead. But I could already hear some lawyer at a deposition asking me if it was possible that the baby hadn’t died the week before, during the seizure, but had actually died because I did not attempt resuscitation.  It stayed quiet.  Later that night I flipped through The Healers, a book one of the nurses was reading. The cover blurb read, This is Chandler Medical Center, where contagious scandal stalks the corridors in crisp and spotless uniforms and hides behind a medical mask. I glanced around the desk where we wrote our reports. There were cups of cold coffee, crumpled Coke cans, a two-year-old Physician’s Desk Reference with the cover torn off, The New England Journal of Medicine, Sports Illustrated, Glamour, a half-eaten sandwich, a cheap stethoscope missing an earpiece. Stark fluorescent light, worn linoleum floor.  Reality.