Tuesday, February 21, 2017

When Pregnancy Doesn't Have a Happy Outcome: Tomorrow I'm scheduled to scrub in for the labor and delivery of a baby who is already known to have passed away in utero

Image result for newborn babies with emotional mothers  in hospitals

     My OBGYN rotation is winding down. So far, the parents and babies and I have all been very lucky, and everything has worked out more or less as it should have. Tomorrow, however, none of us will be so fortunate.  A 26-year-old mother is scheduled for induction in order to deliver her pre-deceased infant. About a week ago, the mother noticed a lack of fetal movement. By then, it was too late. An ultrasound revealed that the umbilical cord had tightly wrapped itself around the baby's lower calf, almost to the ankle. The baby's lifeline was, in effect, cut off. Doctors don't know how much time elapsed between the cord accident itself and the fetal death. Two-and-one-half weeks ago everything was fine at the regular maternal check-up.

     Some mothers of babies who have died in utero like to wait until labor commences on its own, but there is potential for danger to the mother for a variety of reasons if labor doesn't start reasonably quickly. The OBGYN set tomorrow as the cutoff date. The mother will be induced late tomorrow morning. The mother has chosen to be conscious for the birth, though she will feel as little pain as possible -- just enough to know that it was real and that she experienced it.  She wants to hold her baby. The plan is for her to have have an epidural and anything else that she needs. Anesthesia is limited during normal deliveries for the good of the baby. It's too late for this baby, so there's no need for the mother to suffer needlessly with physical pain when a pharmaceutical product will prevent it. 

     I'm dreading this as much as I've ever dreaded anything, but death is a part of any branch of medical care. It's so very difficult to take when it's supposed to be at the beginning if a child's life. In this case, it's all the harder, because as far as anyone knows, this was a perfectly healthy baby boy who happened to get his leg tangled in his umbilical cord. I don't know if going through this experience now with the couple will make it easier to deal with if I'm ever in charge when something like this goes wrong. With OBGYN not being my chosen specialty, the odds of my being the physician of record when something of this nature happens are reduced. Still, in my intern year, I'll be exposed to all sorts of things, and in some cases I will be the one in charge. For that matter, it doesn't matter if being scrubbed in for this birth will be of benefit to me or not.

     I've been told to be there by 2:00 p.m. It's possible that something will have already happened over the long weekend, or even that labor and delivery will proceed so quickly tomorrow that the baby will have been born before I'm even on duty. Such is not likely, though. Deceased fetuses don't have a lot of natural "push" to them -- that innate desire babies have to be born that moves labor along a bit faster than it would otherwise go. Many mothers feel as though their babies aren't doing much to speed things up, but they are. If those babies were not alive, however long the labor seems to be taking, it would take even longer.

     To show that I'm being cooperative, I'll scrub and be ready to enter at 1:00 unless I'm told to keep out.  I would love to stay in the background, but the very last thing this mother and father need is an extra body "observing," so I'll try to conduct myself as a generic member of the medical team. There is a lot I can do that the assigned labor and delivery nurse would normally do -- even more than is customary since we're no longer concerned about the well-being of the baby. (In a standard delivery, an experienced labor and delivery nurse is often all that is standing between the baby and a lifetime with cerebral palsy or worse. The experienced L & D nurse is the one who notices when things are not right and who gets a doctor into the room immediately when such is the case.) In this case, with the baby's outcome already a foregone conclusion,  the nurse just needs to point me in the right direction, and I can do all the things she (or he) would typically do. I've packed a soft pastel-blue blanket that I picked up a a baby store over the weekend. In the even that no one in the family thought to bring anything along, I'll pull it out at the right time, and the mother will have something softer than a standard hospital-issue blanket in which to bundle her baby as she gives him a first-and-last cuddle. (If the mother or someone else in the family has packed a special blanket, I won't even take the one I brought out of its bag. Instead, I'll save it for a child of parents who appear to be economically deprived.) The only person whose physical condition we'll be concerned about is that of the mother. We obviously don't want the father passing out and hitting his head or doing anything else to himself that would make him less able to support his wife, but that is secondary.

     Another procedure besides induction/labor is a possibility, but seems to be rejected by most parents. Known as dilation and evacuation, it involves the mother being put under via general anesthesia, and the baby removed however the medical team needs to get him out with minimal trauma to the mother. It's much like the technique that would be used for a later-term partial-birth abortion. There's absolutely nothing ethically wrong with the procedure -- the baby's already gone -- but most mothers want their baby out in one piece even if it is no longer living. This case is typical in that regard; the mother wants to hold her whole baby. Furthermore, in cases where the cause of fetal death is uncertain, it's more difficult to reach a clear conclusion as to what led to the baby's death following such a procedure. In the particular case of the baby who will be born tomorrow, his cause of death has been determined.  Tests will be run to see if anything else might have contributed to his death, though at this point no one has any reason to believe that it's anything other than a tragic cord accident.

      The good news for this family, if there is any such thing as good news for this family, is that the condition with the cord is very much a freak accident -- not something to which any mother or baby can be predisposed. Many times when a fetal death occurs, it's due to some sort of condition toward which the family's subsequent children will also be inclined. That is not the case for this family. Their next baby -- I presume there will be a next baby for this family -- will have no greater predilection to a cord accident or any other condition that might lead to fetal death than will any other baby.  There was nothing wrong, presumably, with either the cord or with the baby. The little leg just happened to stick out there at precisely the wrong time, and the currents of the amniotic fluid just happened to help to lead the cord in the direction of the baby's leg. Someone could actually try to make this happen (though God knows why anyone would) but would have no way of influencing the course of events that led to the cord tightening around the baby's leg. 

     If there is any silver lining that anyone can take away from this, it's that these parents have statistics working in the favor of their future children. At the moment, I'm not sure how much that or anything else helps.

     I am of little faith these days, but I'll still say a prayer that everything will happen in as non-traumatic a way as possible and that nothing happens to make it worse for this couple than it already is. I hope and pray that going through the birthing process somehow helps this new little family to facilitate making its way through initial stages of grief. And if anyone has the time and a bit of mental energy to expend on my behalf, please pray or send positive thoughts that my words and actions may be directed by a person with greater wisdom than that which I presently possess, so that I, first, do not say or do anything to add to this family's burden, and, if it's not asking too much, that I might actually be, in some small way, a comfort to them, and an instrument of God's peace and grace. And join me, please, in asking that the grief, while temporarily overwhelming, will not, in the long term, be something that is too great for either of the parents or for their marriage to endure.

     Babies die in utero somewhere in the nation every day of the year. We (speaking collectively in including myself as a part of the greater medical profession) have done so very much to make pregnancy and childbirth as safe as it can possibly be. Some things we have learned to prevent, and others we will learn more about and will be able to prevent even though we currently lack the technology and the knowledge of how to use the technology to prevent such tragedy from happening. Still, as long as babies have limbs and are attached to their mothers [and their only sources of oxygen and nutrients] through umbilical cords, while we may ultimately have tools to alert us to such accidents earlier, cords will twist around limbs or necks.  The real conundrum is probably why it or something similarly tragic doesn't happen more frequently than it does. Babies go through so many hazards from conception to birth, one OBGYN shared his thoughts with me after a particularly nail-biting delivery with a nonetheless happy outcome, that he's amazed any of them make it through unscathed. God or anyone else out there who can help, please be with this couple as they make their way through this dire journey no one one in his or her right mind and in possession of  a conscience would wish on his or her worst enemy, much less on himself or herself, and an innocent baby.

     This is not my video. My mom read the book to me a lot. I especially remember her reading it to me when she was in the hospital with pneumonia following her blood marrow transplant, when I, also sick with pneumonia and its after-effects, would fly to southern California from Florida to visit her. The book represents the order all parents probably wish their departures from the earth would be in relation to those of their children. It doesn't always work out that way, though.

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