Whatever gets you through today..

I had a tough day today. It started at 5am, which was really 4am (as I forgot about the "fall back" thing), I went into work, did some work and rounded with my resident at 7am. Then, I did a cerclage (stitch to keep a cervix closed, or in this case, "rescue" a pregnancy in which the cervix was open at 19 weeks) on a cervix that was 4 cm dilated with the membranes bulging beyond the cervix. It actually went really well, and I avoided breaking her bag or doing any other damage. The outlook for the pregnancy is still guarded, at best, but at least now there is some hope that she might be able to get a salvagable baby out of it.

Then, there was Ms. X. She is .... well, was, I guess... pregnant with twins. I performed a "selective fetocide" on one of the fetuses (via an intracardiac potassium chloride injection) because it had a lethal anomaly. This was 3 weeks ago, when she was 19 weeks pregnant. The issue with this particular lethal anomaly is that it's one that leads to polyhydramnios (an accumulation of excess amniotic fluid). In twins, if one fetus has polyhydramnios, it puts the whole pregnancy at risk of previable or extremely preterm delivery. We performed the KCl injection in order to attempt to get at least one living baby out of this disaster of a pregnancy. The biggest complication of the KCl injection is the potential loss of the whole pregancy, and the risk of this at 19 weeks is 10-15%.

Ms. X started to contract within hours of the procedure. Some people just go into labor after one baby dies. It has to do with chemical signalling that happens with the death of the fetus. For the last 3 weeks, we've been doing everything we can do to keep her pregnant. We gave her multiple medicines to keep her pregnant (without any evidence that those medicines work before 23-24 weeks). I've sat by her bed, searching for the right words to say as she cried, at least 3 times a week for the past three weeks. We'd come up with a plan to try to keep the normal baby inside if she delivered the dead fetus. I reassured her on a daily basis that we would do everything we could do to save her baby, while explaining that she needed to be 24 weeks for the pediatricians to be able to save the baby if she delivered early.

Today, she delivered. At 22 weeks. 1-2 weeks before the limit of viability, she delivered a perfect little girl. The living baby. On the toilet. Without any warning.

When I was called by the nurse, I went straight to her room. We helped get her back into bed. I confirmed that it was the living baby that had delivered, and tried to find the words to explain this to Ms. X. I've been in this situation many times. I've delivered more dead/dying babies than I can remember or care to count, and I can never seem to find the right words. Usually the best I can manage is, "I'm so sorry". At least I always mean it. Ms. X knew that if she delivered before Nov. 6, there would be nothing that could be done to save her baby. I don't think that she was really prepared for her baby to be born alive, though.

I wrapped the baby in a blanket and handed her to her mother. Ms. X's family lives 2 hours away, and I offered to stay with her until her family came. She took me up on it. We just sat. Ms. X cried. I nearly cried (and I don't cry).

She said to me, "I don't think I can do this"

I said, "Is there anything I can do to help?"

She said, "Please, hold my baby. I can't watch her die, but I don't want her to die alone."

I wasn't exactly sure what to do, but I took the perfect, tiny baby and took her to the nursery. I asked the nurse there where they would want the baby, and I was directed to a warmer in the corner. I thought about Ms. X's request. I couldn't just leave the little baby alone. I sat in the rocking chair by the warmer, in the dark corner of the nursery. I held this perfect, tiny baby for 2 hours while she tried to live and eventually died. I studied her perfect but fused eyes, her delicate nose, the hint of her eyebrows, all of the blood vessels that could be seen through her gelatinous skin, and her perfectly formed tiny hands.

I'm thinking of Baby X tonight, hoping that her mother can recover from the loss of both babies, hoping that Baby X didn't suffer as she tried to live, hoping that we did the right things for this mother, and for Baby X.