Fragile Beginnings

by Adam Wolfberg, MD

  “She’s three and a hundred,” he finally said to me, using the shorthand of our field to describe Kelly’s cervix as three centimeters dilated and completely shortened. He looked scared, without the confidence he would have shown if Kelly hadn’t been a colleague’s wife.

  “What does that mean?” Kelly beseeched. The resident looked at me, unsure of how to respond. After a moment, he said to her, “You might be in labor.” I opened my mouth to speak, but no words came out. “I’m going to talk to the nurses,” he blurted on his way out.

  I began to feel the stirrings of a dread so foreign I had no name for it. Carefully, I willed the corners of my mouth to rise into a smile and masked my fear with a loving and reassuring look that belied the alarm bells going off in my head. These were not Braxton Hicks contractions.

  The exam galvanized the nurse taking care of Kelly. She efficiently recruited other nurses, and they formed an expert and well-practiced team. One brought an IV pole to hang a bag that contained magnesium in the hope that this medication would cause Kelly’s labor to abate. Another rolled Kelly onto her side and injected steroids into her buttock to help our baby’s lungs mature more rapidly. A third nurse, a matronly type, hovered, asking how she could help; the nurses were used to teaming up when a patient in preterm labor rolled through the door, and they were particularly attentive when the patient was one of their own.

  I watched the magnesium drip from the IV bag into Kelly’s arm as we kept vigil by the contraction monitor. I counted the minutes between the smooth, round hills and wished that the intervals would increase, signifying a slowing in her contraction pattern.

  “Maybe the magnesium will stop them.”

  “Maybe.” Kelly winced as another contraction began.

  Obstetricians count weeks of pregnancy (the fetus’s gestational age) starting from the first day of the patient’s last period; the due date is set as forty weeks after that. Any baby born before thirty-seven weeks is considered preterm. Until that point, the fetus is not entirely ready to enter the world, and she suffers the consequences of prematurity when she arrives too early. The earlier the baby comes, the greater the risks.

  In the United States, approximately 13 percent of all pregnant women deliver early, usually only a week or two. Only 2 percent of pregnancies end before thirty-two weeks. Kelly was twenty-six weeks into her pregnancy when she arrived at Brigham and Women’s in labor. And as rare as it is, preterm delivery is practically unheard-of in a woman who has carried two children to full term. For Kelly, who had delivered Grace and Hannah within days of their due dates, a preterm delivery seemed an impossible nightmare.

  I could see fear on Kelly’s face—fear of what would happen if our daughter was born prematurely, but mostly fear of what she didn’t know. The fear was interrupted, at predictable intervals, by her uterus, which caused enough pain to wrest her focus away from what might be coming and back to the present situation. In the years since that morning, I have cared for hundreds of women in preterm labor, and I have seen that same look on the faces of my patients and their partners. I always try to reassure them—not that everything will be all right, because I don’t have that kind of influence, but that I will do everything in my power for them and for their child.

  As I sat next to Kelly, my tie began to constrict my throat, and a knot formed in my stomach. I knew specifically what to worry about, and, unlike Kelly, I was not distracted by pain. The terror began to take hold, and I felt the cold run down my torso—the cold reality of Larissa’s unpreparedness to exist outside of Kelly’s womb, and our unpreparedness to deal with that.

  Had Kelly’s doctors tried to reassure us that morning—which they didn’t; perhaps they knew better than to try—I would not have been reassured, because I knew the awful uncertainty about delivery twenty-six weeks into a pregnancy. Over and over I thought, This doesn’t make any sense. I kept waiting for the contractions to space out and then stop, but the black pen in the contraction monitor continued drawing hills. I wanted to shut off the power to the monitor to make the pen stop drawing hills. It was like Kelly and I were in a car that was about to crash, but for some reason I couldn’t stomp on the brakes.

  For an hour, the magnesium dripped in, but hills on the monitor kept coming. Then the contractions became stronger.

  The attending obstetrician came in. She looked at the contraction pattern on the monitor, and then spoke to Kelly. “Would you like to have an epidural? If the contractions space out, we can always take the catheter out of your back.” She didn’t sound like she was optimistic the epidural would be removed anytime soon.

  Before Kelly could respond, a gush of fluid poured out between her legs and soaked the linens. Like a dam giving way, Kelly’s water had broken. In that instant, I knew that my daughter would be here soon. Kelly’s cervix was now dilated to six centimeters. Delivery was inevitable.

  An obstetrician has two patients: the mother and her fetus. When the mother is otherwise healthy but is in preterm labor, the baby becomes the focus of some rather grim calculations.

  Babies that are preterm but born after thirty-two weeks of pregnancy tend to do very well. Occasionally, those children will suffer mild behavioral or learning disabilities that become apparent in elementary or middle school, but the risk of serious complications is relatively low, and almost every baby survives.

  Babies born before twenty-four weeks of pregnancy—the point when a baby weighs about one pound—die more often than they survive. Those babies that do live suffer significant complications, including severe lung injury, cerebral palsy, mental retardation, injury to their intestines, and a host of other, less severe problems. Although doctors will occasionally and reluctantly try to save a twenty-two- or twenty-three-weeker, most of the time a baby born before twenty-four weeks is gently wrapped in a blanket and allowed to die in the parents’ arms.

  Of those babies born between twenty-four and thirty-two weeks of pregnancy, over 80 percent will survive, and with each passing week in the womb, a baby becomes less likely to suffer major complications related to prematurity. Had Kelly gone into labor three weeks earlier, there would have been no hope. We would have waited for her to deliver, and then mourned the inevitable death of our child. If Kelly had gone into labor three weeks later, we would have been cautiously optimistic about our baby’s chances of a speedy recovery and a normal infancy.

  After the epidural was in place, Kelly’s pain abated, and she was able to focus entirely on the imminent delivery of our premature baby.

  “Will she live?”

  “Probably. Survival is eighty percent.”

  “Are you worried?”

  “Yes.”

  “What about?”

  “There may be complications.”

  “I’m so sorry.” Kelly started to cry. “I’m so sorry.”

  “Oh, sweetie, it’s not your fault.” I was up on the bed beside her now. “It’s not anyone’s fault.” As Kelly’s tears fell, I held mine back. I felt like I needed to remain in control. As if somehow, if I could force back my fear, I could prevent this awful event.

  Awful event? This was the birth of my child. A precious little girl who would be the third sister. The one who was supposed to be the minx, the youngest daughter who is so adorable and doted upon that she gets away with murder. How could this be happening?

  Then the tracing of Larissa’s heart rate, which had zigged and zagged in a reassuring jagged line at around 150 beats per minute, showed a dip as one of Kelly’s contractions temporarily squeezed off the supply of blood. The heart rate normalized when the contraction abated, but a few contractions later, we saw another dip of the heart rate. This pattern suggested that several hours into Kelly’s labor, our baby was beginning to get tired, and she might not tolerate the remaining contractions necessary for her to reach delivery.

  The chief resident came into Kelly’s room,
accompanied by the attending obstetrician.

  “We have, um, been watching the, uh, fetal heart rate,” the resident began haltingly, glancing at his supervisor periodically for support, unsure of whether to address Kelly or me.

  His supervisor came to his rescue. “I think the question is whether your baby will tolerate labor.”

  Tiny and ill-prepared to enter the world, Larissa might not live through the delivery process. We decided that her chances for survival would be better if Kelly had a cesarean section.

  I left the labor room. A few steps away, a group of my fellow residents were standing together in the hallway; they looked up at me, and then back at one another, unsure of how to respond to their colleague whose wife had become a patient. One of them left the group and came over to give me a hug. “It will be all right,” she said.

  “Thanks,” I managed, not believing her, and I pulled away to avoid letting her see the tears well up.

  I went upstairs to the locker room and changed into standard-issue blue operative attire as I had dozens of times before scrubbing into similar surgeries. A gray-haired obstetrician, unaware of why I was changing, made small talk.

  “Quite a winter we’re having.”

  “Sure is,” I answered unenthusiastically.

  “You got a case?”

  “C-section,” I answered, then hurried out of the locker room before he could ask me for any details.

  “Have a good case,” he called after me.

  Kelly’s bed was unplugged, the connections to the monitors that had tracked the progress of her labor were removed from her abdomen, her IV bag and her epidural syringe were disconnected from the wall, and she was rolled down the hall past a half a dozen delivery rooms to the operating room, where under the bright lights, she was transferred to the table.

  The attending obstetrician and a senior resident were gowned in blue, their faces mostly obscured by masks. The laser intensity of their eyes conveyed what they didn’t say: This might not end well. Their conversation was sparse.

  “Curved Mayos, please.”

  “Kocher’s.”

  “Metzenbaum scissors.”

  The room was otherwise quiet.

  As they cut through the layers of the abdomen that separate the uterus from the skin, they encountered scar tissue left over from Kelly’s two prior C-sections. Scar tissue also encased the uterus, making the going slow. Finally a vertical incision opened Kelly’s uterus like the first cut into a pear. But our daughter’s head was wedged down into the pelvis, caught in the scar tissue, tight bony pelvic structures, and the dilated cervix. Watching over the blue curtain placed to spare my wife a view of her viscera, I saw the placenta deliver itself through the incision. Without the placenta attached firmly to the uterine wall, our child would have no source of oxygen until she too was delivered and could breathe on her own. Meanwhile, the unattached placenta became a vent for Larissa’s own blood, which began to hemorrhage onto the operating field.

  “What’s going on?” Kelly asked. She could see the horrified expression on my face.

  “They are trying to get her out.”

  “Why is it taking so long?” Kelly asked with genuine panic in her voice.

  “She’s stuck.”

  “Um, I can’t get under the head,” the resident said, looking up briefly to address the attending obstetrician. The resident removed his hand, and the more senior doctor tried to gently insert her hand below Larissa’s head in order to bring it out of the pelvis.

  A minute went by.

  “Forceps,” the surgeon called, and a nurse rushed out of the room and returned seconds later, unwrapping the sterile packaging around the long steel instrument as she came through the door.

  First the resident and then the attending failed to get the forceps past Larissa’s head to the point where they could free her.

  “Could I have a hand from below?” When the attending called for this, her tone was higher. I recognized this elevated octave as desperation. Doctors feel it too. When lives are on the line and outcomes uncertain, the pressure to perform miracles is daunting.

  Knowledgeable enough to understand that a disaster was unfolding but lacking the skills or standing to do anything about it, I buried my head next to Kelly’s, unable to watch. Kelly reached up with the one arm that wasn’t strapped to the table armrest and held on to me.

  A semicircle of nurses had formed around the operating room table, waiting, barely breathing, for the surgeons to free Larissa. Now, one of them darted forward, reached under the sterile blue drapes into Kelly’s vagina, and pushed Larissa’s head up into Kelly’s pelvis.

  Hours later—really just three or four minutes after the placenta delivered through the uterine incision—the chief obstetrician lifted our little girl out of her mother’s pelvis.

  The umbilical cord was briskly clamped in two places and cut, and the obstetrician rushed Larissa over to a corner of the operating room where a team of neonatologists stood huddled around their own equipment. The obstetrician laid Larissa down on her back with her head positioned toward the most doctor-accessible edge of the baby warming table, and she stepped away. The team of specialized pediatricians converged on my daughter.

  There is some evidence that the risk of brain hemorrhage in premature newborns can be reduced by minimizing the shifts in pressure that the baby is subjected to. With this in mind, I had requested that the senior neonatologist personally perform the intubation—the insertion of a breathing tube down Larissa’s trachea—instead of allowing a resident to perform this delicate task.

  “Breath, breath, breath . . .” The attending neonatologist counted them out. “Watch the pressure.” She spoke with authority to the resident at her side while she held a tiny mask over Larissa’s nose and mouth.

  “What’s the pulse?”

  “It’s good. A hundred and fifty,” responded a nurse who had gently pinched the bit of umbilical cord going from Larissa’s abdomen to the clamp so she could feel the pulse in an umbilical artery.

  “Would you like help with the intubation?” a resident asked her attending, euphemistically asking if she could perform the procedure.

  “No. I got it,” the attending responded curtly.

  Several seconds later she put aside the mask, reached for the curved stainless steel laryngoscope, and, in a single practiced maneuver, slid it down to the base of Larissa’s tongue and lifted the instrument up to expose her vocal cords, which formed the top two sides of a narrow triangle that framed the view down Larissa’s trachea.

  “Tube,” she called, and a tiny breathing tube was placed into her outstretched hand. She slid the tube between Larissa’s vocal cords.

  “Breath,” she commanded seconds later. She exchanged the laryngoscope for her stethoscope and confirmed that the tube was correctly situated by listening for the sound of air moving in each lung. Satisfied, she taped the tube in place. Within sixty seconds of being born, Larissa was being dried off and wrapped in warm blankets.

  By the time she was five minutes old, the neonatologists had packaged her into a Plexiglas incubator and were rushing her out the door of the operating room. Before they left, they rolled her to where Kelly could see our little girl, wrapped up in the box with the tube down her throat connected to the enormous purple bulb that one of the doctors kept squeezing. “Hi, Mom,” one of them said in a falsetto voice, and then they rushed her off to the newborn intensive care unit to stabilize her. Their hurry to get back to the unit did not comfort me.

  Chapter 2. Critical Hours

  First, the air had been punctuated by the staccato of surgeons requesting instruments and ordering maneuvers while they struggled to free our child from Kelly’s abdomen. Then, the chatter of the neonatologists coordinating their resuscitation efforts filled the space. Now a hush fell on the operating room. Gr
im in the wake of an imperfect delivery, the obstetricians methodically set about restoring Kelly’s anatomy, layer by layer, in a practiced routine they had done hundreds of times.

  “Zero Monocryl,” one said softly, unhurriedly asking for the deep blue suture to close the uterus.

  “How about something to take the edge off?” the anesthesiologist asked. He had already drawn up a syringe of the antianxiety medication Ativan, and he injected it into Kelly’s IV. She was soon asleep under the kind, sedating influence of the drug.

  I sat quietly by her side, holding—really gripping—her hand. In front of me, the blue curtain rose, protecting the sterility of the operative field and shielding the bloody surgical space from Kelly’s view. I knew what was going on behind the blue curtain; the surgical repair was straightforward, even mundane. I also knew that one floor above us, Larissa was trying to survive. I could imagine what was going on up there too. It wasn’t mundane.

  “Give us a couple of hours to get her settled,” one of the nurses had said as the team of pediatricians left the OR. “If anything unexpected happens, I promise I’ll come and find you.”

  What she meant was, If Larissa’s going to die, we’ll come tell you.

  Outside the operating room, the stocky nurse pushing the wheeled incubator took charge, like an engineer driving through a rail yard. “Excuse us,” she barked loudly to anyone who even threatened to get in the way. The large purple breathing bulb made a whishhh sound when the respiratory therapist squeezed it and a droning vzzzzz sound when he released it.

  The nurse reached for the keycard hung on her ID necklace and jammed it into the slot next to the elevator call button. The door opened within seconds as the key overrode the elevator computer system and summoned the nearest car. “Please step out and wait for the next one,” she commanded to the people in the elevator. An elderly couple on their way to visit their newest grandson hurried to comply.

  The team rode up, and when they got off the elevator, the nurse drove straight to the new-arrival section of the NICU where a station had been hurriedly prepared for Larissa. Nearby, tiny babies lay surrounded by large machines that provided oxygen, intravenous nutrition, antibiotics, fluid—whatever was needed to sustain life. Here, under bright lights, cared for by an army of nurses and doctors, babies who need help spend their first hours, weeks, and sometimes months.