I saw two tiny feet – perfect, but far too small. Then I had to tell the mother
A pregnant midwife on night shift confronts her own worst fears during an emergency delivery of an extremely premature baby.
By Oceane Campbell
Warning: the following article explores sensitive subjects which may be triggering for some readers.
“The next few minutes are a blur of people coming in, calls to NICU ... Amid the commotion, this baby is making her way out. But this birth isn’t straightforward.” Credit: Getty Images
Working night shift still has a particular quality to it, just like when I was a student. Years ago, when I travelled in India, everything seemed extra vivid and vibrant – the smells, colours and sounds all felt borderline psychedelic somehow. Night shift is the antithesis of this.
Everything feels darker, hushed, as if shrouded in a certain mystical energy.
The quietness of the roads when I drive or ride to work plays a role in this. The sight of the already dark houses and the streetlights shining onto empty pavements imprint itself onto me. Once I’m at work, even if there are blaring emergency buzzers or bright theatre lights, that image of the darkness and quiet outside stays with me. I love imagining that those who are awake in the middle of the night are breastfeeding mothers, maybe women who’ve been here in the birth suite.
Tonight, I’ve ticked over to 24 weeks and one day pregnant. I’m loving the regular movements and how my body is feeling, I am full of energy. The gentle curve of my little belly makes me feel sensual and healthy and strong. Although, at this moment – 5am, after a shift that was a touch too quiet to keep me fully awake – I’m feeling exhausted; eyes stinging, slouching posture.
“Hey, sorry to wake you, Oceane …”
Oops, I must have actually had my eyes closed as I was slumped on the desk.
“Can you go prepare Room 6 for a 24-weeker?”
The team leader gives me a brief handover: “She’s coming in on an ambulance. Apparently she’s had a bleed, but hopefully it’s stopped now and she’ll be OK to be transferred to the ward for monitoring. I don’t know anything else about her – but she’ll eventually need to see NICU [neonatal intensive care unit] for counselling in case she does end up having her baby early.
“It won’t hurt to set up the Resuscitaire with the right-sized gear for a tiny baby and to warm up the humidifier – just in case. Although I’m pretty sure she’s only 24 weeks as of midnight, so it’s a bit grey whether this baby would even technically be suitable for resus.”
All straightforward enough, I think. The woman is from out of town and I know it will be about an hour before she arrives. I check that Room 6 is stocked, writing my list for equipment I need to fetch from the larger stockroom. If I don’t keep doing something, I doubt I can keep my eyes open.
To make preparations for a really premature baby, I have to rack my brains. Some time ago, I’d seen an email about “raincoats” which keep extremely premature babies’ skin moist, protected and warm. The other new piece of equipment is the humidifier. It warms the air you use to resuscitate these babies and is said to significantly improve survival rates.
I know where to put the water to heat, but the team leader and I spend 15 minutes figuring out the complex tubes and leads that attach to the Resuscitaire. Once it’s set up and we’ve double-checked it works, I attach the doll-sized mask to the end, thinking, Wow – that’s the size of my baby. This woman is 24 weeks and 0 days. With the proper time to counsel the family, NICU staff would respect their wishes to attempt resuscitating babies from 24 weeks, but would generally consider it unethical and futile to attempt it any earlier.
For all my soapbox moments about women’s rights for autonomy in analysing risks and making decisions, I wouldn’t want to feel the weight of making that decision for myself and my baby.
the author Oceane Campbell, who dealt with a woman’s traumatic birth while at the same stage of pregnancy.
The prognosis and journey ahead for a baby born at 24 weeks aren’t pretty. I’ve seen a few in NICU, and watched a documentary on these extremely premature babies, too. There are high rates of mortality and morbidity, never mind the months and years in and out of hospital. But how could you let go of your baby in that moment?
Eventually, I hear the door chime and the telltale clatter of ambulance trolley wheels entering the unit. At the first sight of this woman, I know this isn’t going to be a straightforward admission. Any trace of sleepy eyes on my part disappears in a spurt of adrenaline. She’s obviously in significant pain. Hmm, even having contractions, I think to myself: her face is pinched as she focuses on her breathing. I lead the way to Room 6. Once inside, the paramedics disclose that, yes, she’s been contracting every two to three minutes since they picked her up a little after 3am and for the entire two-hour drive.
My adrenaline levels surge and for a split second, I can’t think what to do first. The woman is transferred to the bed and one of the paramedics hands me a zip-lock bag containing a blood-soaked pad. “This was what she kept for us. That’s how much blood she lost roughly at home when she called. She woke in the night and went to the loo and found this in her pants.”
Hurriedly, I weigh it: 300 grams. That’s a lot of blood; subtracting the 30 grams weight of a pad doesn’t seem terribly relevant.
‘A whole lot of people are about to run into the room, but just focus on me.’
I know the team leader is already fetching a portable ultrasound machine and the senior registrar, so I carry on information-gathering – I’ll wait till the registrar is here to try listening for the baby’s heart with the ultrasound machine. In 24-week babies, it can be tricky to find and I don’t want to press hard on the woman’s abdomen in case she’s bleeding from an abruption – where the placenta starts to come away.
Throughout this, the woman is having contractions and is highly distressed with anxiety and pain. Her partner, wide-eyed and silent, shifts from foot to foot – unsure what to do or where to stand. I reach for the blood-pressure cuff and take a baseline set of vitals. Reassuringly, all is normal, which means she isn’t haemorrhaging more severely internally than is apparent from the outside. Phew, I think, breathing out a little. The doctor will be here in a minute and will know what is happening and what to do. Then I ask to check her pads to see whether she has been actively bleeding since the ambulance delivered her here.
Noticing her trembling hands, I help her undo her dressing gown. “Can I help you with your undies?” I ask. It always feels strange unclothing someone else.
I gasp.
Two tiny feet. The most petite and perfect things. But far too small. Far too blue. I reach to the wall behind the bed and triple-buzz. “Hey,” I say to the woman, feeling as unprepared as I am sure she feels. “I’m so sorry, but your baby is being born.”
Another contraction.
“A whole lot of people are about to run into the room, but just focus on me. I’m sorry: it’s too late to stop your baby coming.”
The next few minutes are a blur of people coming in, calls to NICU and the doctor grappling with the ultrasound. Amid the commotion, this baby is making her way out. But this birth isn’t straightforward.
As a “footling” breech baby, she slips out easily to her head but then stops. Gently, I support her body, which fits into one hand, racking my brains to remember my rote-learned breech manoeuvres to help birth the head when it isn’t coming with gravity alone. But it’s all scrambled in my head because this baby seems too small and fragile to apply the moves I’ve been taught. In the best of circumstances, it would be a highly experienced midwife or consultant managing a birth like this, not a junior like me. After an eternity passes, I turn to the registrar beside me, who’s still trying to ascertain if the baby has a heartbeat. I all but plead, “Can you take over? It isn’t coming …”
The registrar obliges and soon after, the baby is out. Swiftly, I clamp and cut the cord, then pass this weightless little being to the three senior NICU staff waiting by the Resuscitaire. Gratitude washes over me for the confidence and expertise of the whole team who’d had next to no notice for this emergency.
As two of them start chest compressions and intubating, the third approaches the woman and tries to condense into a minute what’s usually a long and gentle discussion on intervention and survival odds for such a premature baby. They have to know now whether to persist with full-on resuscitation measures or go to palliative care. The NICU practitioners talk her through the risks, seek consent, and respect this woman’s autonomy seamlessly and thoroughly in the face of incredible pressure and stress. Once the mum confirms that she doesn’t want her baby resuscitated, the team extubate and turn to providing comfort to this baby, whose signs of life rapidly fade.
There’s a palpable sigh of relief. The vigour and physicality of chest compressions and intubation felt intrusive and violent on this tiny body that just couldn’t hold on to life. Despite the sadness, it looks more “right” – for want of a better word – to see this baby cradled in her mum’s arms rather than being pummelled back into an uncertain existence.
By this point, it’s past the end of my shift. I garble out the best handover I can to Fiona, the midwife taking over from me; I appreciate her grave and compassionate face, that wordless acknowledgement of how monumental the last few hours have been.
Then, bone-weary now that the levels of adrenaline in my system have dropped, I sit down to write up the notes of all that’s happened. It’s critical, but so difficult, to document amid the turmoil. When I see the registrar and team leader debriefing at the front desk, I wish I could join them, but I have nothing left in the tank. It’s all I can do to gather up my bag and walk out of the birth suite.
Pausing, I poke and prod my belly. After an agonising five minutes of nothing, my 24-week baby rolls and kicks me back, which gives me goosebumps and tears. I can visualise the tiny feet of my baby now after seeing the same-sized feet unexpectedly slide into the world for such a heartbreakingly momentary existence.
At home, the sadness I’d pushed aside in that emergency slowly uncoils as I debrief with Sarah, my wife. I gratefully crawl into bed for the oblivion of sleep.
This is an edited extract from Labour of Love: A Midwife’s Stories of Birth, Life and Speaking Up for Women, by Oceane Campbell (Pantera Press; $37).
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