Digging Deep

by Jay Hogan

  “Just waiting for this contraction to finish. Okay.” I tried again… and there… I heard it. My first reaction was overwhelming relief, until I saw the numbers. “Ninety, damn.” Way too slow. Foetal distress. Son of a bitch.

  “Shit.” Paul mirrored my concern.

  Another contraction and the baby’s heart rate dropped to eighty-two, then back up. Goddammit. If the baby was to survive, we had to get Prim to a hospital and the little one out of her belly as quickly as possible.

  “Baby’s in foetal distress with significant late decelerations down to eighties,” I fed Paul the information. “And none of this fluid looks intrauterine, so I’m guessing her water is still intact, and this is all Prim’s blood.”

  Paul’s brows peaked at that. He already had Prim intubated and was working on an intravenous line. “Not good. The ambulance was right on my tail so we shouldn’t be here long.”

  He did his best to stabilise Prim while I went to work on my end of the deal, repeating all the foetal assessments and trying to ignore the growing pool of blood on the floor. At this stage I knew Paul was trying to avoid giving anything too major drug-wise to Prim, anything that might affect the baby. But if her condition headed further south, her life would take precedence over the baby’s and all bets would be off.

  “Was she placenta praevia?” Paul asked as he worked.

  It was a good question, and one of the commoner explanations for this kind of situation. When the placenta sat too low in the uterus and covered or partly covered the cervical opening, it could start to peel away too early in labour, or even before labour starts, resulting in dramatic blood loss.

  “No, scans were fine.”

  Paul secured the ET tube in place with Prim still and white as a ghost. I swallowed hard and forced myself to look up from the sea of blood and went back to monitoring the baby.

  “Placenta was high and anterior,” I added. “And neither of her other two labours had any problems apart from being early. I’m thinking abruptio placentae, myself. Timing in the third trimester is about right. With this amount of blood and a prem labour, it all points to a sudden separation of the placenta. It’s only a best guess, though.”

  “One I agree with,” Paul said.

  The ambulance guys arrived and waited in the hall with their gurney. Enough hands in the pie as it was, and the bathroom wouldn’t fit any more.

  I shared another set of recordings with Paul and the news wasn’t good.

  “Heart rate’s stable at ninety with late decelerations to eighty so still bradycardic. Regular contractions every three minutes lasting forty-five seconds, so she’s in active labour,” I told him, grimacing. “I risked a light palpation between contractions, and I’d say the baby’s head is engaged and well down. Pretty sure her waters are still intact, though. So she’s leaking all this blood around the edges. God knows how much might be banked up behind and what’s going to happen when the floodgates open and that pressure’s relieved.”

  “Fuck,” Paul swore loudly. “We’re in trouble, kemosabe.”

  I continued, “I can’t risk a decent vaginal assessment, but from a gentle quick check, she’s fully effaced and about eight centimetres dilated. Another two and it’s showtime.”

  Paul pulled a face. “Then we’ll have to hope that placenta holds and bubs gives us enough time to get her to hospital before she makes her debut.” He sounded a lot less sure of that than I wanted, but unfortunately, I agreed with him.

  A minute or two more and Prim was ready for transport. Paul and the two ambulance guys transferred her to the gurney and headed out, with me in hot pursuit. The two of us would’ve worked on Prim for less than ten minutes all up, but it felt like an hour and nothing had slowed the constant trickle of blood that amplified in volume during the peak of each contraction. There was nothing more we could do outside of hospital.

  “I take it you’re coming with me in back?” Paul asked, as the two ambulance guys secured the gurney in the back and Paul threw in his gear.

  I nodded. “If that’s okay?”

  “Fine. There’s a better than even chance that bubs is gonna need your particular skill set, and I’ll happily hand that job off to you if needed.”

  I nodded again. “Of course.”

  “Right. Noel can follow in my car, right, Noel?” One of the ambulance guys nodded and caught the keys Paul threw his way. “And call it in, Noel. Give them all the stats. And tell them we’re gonna need the neonatal team downstairs to meet and greet, got it?”

  Noel nodded and ran to Paul’s car.

  I called for Mrs D. to tell Prim’s sister we were on our way and also for her to get Prim’s husband in the loop so he could organise flights home if needed. Then I clambered into the back of the crowded ambulance, alongside Paul, and we were off. I left Prim to Paul’s capable hands and focussed on the baby, although it was damned hard to ignore the blood-soaked towel beneath Prim’s hips.

  Reaching to check the baby’s heart rate, my hands shook like jelly. I made a couple of fists to steady them and tried again. No better.

  Paul caught my eye. “Hey, no shame in that, mate. Me? I hate baby call-outs. Way too much to go wrong. Take some deep breaths and nail it.”

  I sent him a grateful smile, and for whatever reason my shakes settled, and I got the Doppler in place and counted. “Shit.”

  Pauls gaze shot to mine.

  “Seventy-five max between contractions. We’re losing her. We need that hospital, Paul.”

  “Lead feet, Lyle,” Paul called out to the driver. “Break out your Michael Schumacher, shit’s about to get real back here.”

  In between checking baby’s vitals and trying to keep my feet in the speeding vehicle, I held Prim’s hand and murmured reassurances, of which I had few to give and could’ve done with myself. A couple of kilometres out and I’d almost convinced myself we were gonna make it when Prim suddenly gave a huge sigh through the ET tube, and a lake of pink-tinged fluid streamed from between her legs. Her waters had broken.

  Shit, shit, shit. Could we not catch a fucking break here? The release of pressure would set up a natural chain reaction that would drop baby’s head more firmly down onto the cervix, increase the contraction strength, speed up the birthing process… and potentially reduce internal pressure on the placenta holding it in place, meaning it could now shear off completely.

  Holy fucking hell. Where was a damn operating theatre when you needed it? I shoved another towel up under Prim’s thighs as several alarms flared simultaneously behind me. Paul’s scowl and stream of expletives said it all. Prim’s monitor lights flashed red, relaying long bursts of ventricular tachycardia interspersed with short runs of bradycardic sinus rhythm.

  “Goddammit, she’s bottoming out.” Paul reached toward a line of predrawn syringes stocked with emergency crash drugs. “How far out, Lyle?”

  “Five minutes, tops” came the shouted reply from the front.

  “Drake, what’s happening your end? I’m gonna have to make a decision here. Nothing to lose now, mate, get in and see.” Paul threw a box of dressings out of the way and hauled the defibrillator close. “Jesus, why can’t they make these vans bigger?”

  I yanked on a fresh pair of gloves, repositioned Prim, and was about to slide my fingers inside when shock of wet black hair slid into view. Fucking hell.

  “It’s all on,” I answered, reaching for my gear. “Crowning as we speak.”

  “Shit.” Paul stilled for a second, clearly weighing his options.

  I knew that farther out from the hospital, he might have pulled over to get an extra pair of hands or two in the mix and focus on getting Prim stable if we could, and the baby out. But with little travel time left, in the time it took to do that, we could be at the hospital, a much safer option.

  “Warn them we’re coming in hot,” he called to the driver. Then he caught my arm and we shared a look that needed no explanation. We were both up shit creek with no guarantee of a happy ending for either of our pa
tients. “We do our best, that’s all we can do,” he said, and I nodded.

  Keeping one eye on the shock of black hair, the only thing as yet visible, I grabbed forceps, scissors, a dry towel, and a space blanket, and set them at the ready along with baby intubation equipment, oxygen, and a few other pieces of emergency equipment I might need if things went further to hell in a handbasket. Then I blinked at the disarray that was the current state of the ambulance, its inside strewn with plastic bags and a megaton of equipment, both Paul’s and mine. Holy shit. I guessed we’d passed the signpost to hell a while back.

  Drenched in Prim’s blood and amniotic fluid, and an assortment of other unmentionables from both her and the baby, I tried my best to create a clean space to work, took a couple of deep calming breaths, and got ready to do my job. I held out my hands. Steady as a rock. Paul caught me and gave me a thumbs-up.

  Keeping one hand on the baby’s head and the other over Prim’s belly to feel for the next contraction, I tried to focus my thinking and run through plans B, C, and D hoping I wouldn’t need any of them. When I flicked my gaze to Paul, the man was doing a good impression of a manic octopus, arms and legs punching in all directions as he piggybacked more fluids into his IV, made corrections on the portable ventilator, and got the rest of his resuscitation equipment ready to go.

  “How’s she doing?” I asked.

  He kept working. “Short runs of VT sandwiched with sinus rhythm, but her blood pressure’s dropped to her boots. Seventy over… shit, who the fuck cares. Too low. I’ve got no choice but to give her some heavy drugs, mate. Can’t wait for bubs.”

  I blew out a sigh. The universe wasn’t gonna cut us a break tonight. “Just do it,” I said. “This baby’s out of there any minute as it is. Nothing you do at this point is gonna have too much effect. Colour’s not good, so I’m guessing that placenta is less than functional.” Which was putting it mildly. The baby’s forehead was a deep shade of blue almost black.

  Prim’s belly tensed under my hand, and with the contraction, the baby’s head was forced down far enough for me to catch a glimpse of her ears and upper eyelids. “Here she comes,” I warned. Paul nodded, not looking up, focussed solely on whatever he was pushing into the IV with one eye on the monitors above.

  As the baby’s face was further exposed, I gently pushed the tight skin away at the margins to expose the nostrils and then the mouth and jaw before the contraction finished. Then I cleared them with suction. This baby desperately needed another source of oxygen, the sooner the better, not that she was showing any urge in that capacity yet. I slid my finger down and checked the neck. No cord. Thank Christ. Finally something in our favour.

  The next contraction came hard on the tail of the last. I tried to guide the shoulders out in a controlled manner as best I could, but there wasn’t a lot of time to play with, and in seconds I held a moist bundle of too-blue, too-still flesh in my hands. A less than ideal start in a new world. No more than a second or two later, a gush of blood filled the space between Prim’s open legs, and my heart sank.

  “Trouble’s coming,” I warned Paul, who looked up and took it all in with a look of despair. Then a stream of curses erupted from his mouth, and all hell broke loose as he tried to get Prim stable. Equipment flew, plastic bags were ripped open and tossed aside, syringes lined up and emptied, but I had no time to worry about him or Prim. I had my own hands full.

  Prim’s much-wished-for little girl might have made it out of her mother’s warm belly, but she wasn’t looking crash hot. Fear and guilt threatened to paralyse me. If I’d only gotten to her sooner. If I’d visited today rather than put it off till tomorrow, I might have seen something.

  But this wasn’t the time…. I bit back the self-recriminations and blocked everything other than the protocol drill in my head. I’d volunteered extra rotations through Neonatal Intensive Care in my training and had even considered a career move. I knew this. I was good at this. But we weren’t in a sanitised hospital with every skill on tap, and that fucking changed everything.

  Fifteen seconds out and Prim’s baby was making no attempt to breathe on her own regardless of all my effort to stimulate something, anything. I’d shifted to the opposite stretcher to give me at least some room to work, but nothing was going my way. She had a heart rate of one-hundred-ten, but it was irregular and thready, and without any oxygen to push around, it wasn’t going to last.

  I’d tied off and cut the cord just in time before the placenta followed baby out the front door. That normally took five to thirty minutes to occur, a clear indication it had already sheared off and been sitting uselessly behind baby. How long the poor wee thing had been without oxygenated blood supply, I couldn’t know, but judging by the baby’s colour and eerie stillness, it had been too long.

  I intubated the wee poppet, connected her to oxygen, threw some electrodes on to monitor her heartbeat, and drew on all my training to keep her alive, but her heart wasn’t happy. Regardless of getting more oxygen, her rhythm shut down and fell into fibrillation, and my heart sank.

  “Fuck. She’s in arrest,” I shouted, beginning CPR. “I’m gonna need you.” Although I was trained to intubate babies, administering paediatric drugs during a complicated cardiac arrest was a whole other ballgame. Of the two of us, Paul was by far the authority on advanced paediatric life support and I had no trouble bowing to his expertise.

  “Okay, just a sec,” he shot back.

  “How’s Prim?”

  “Getting there.” He turned and nudged my arm. “She’s okay for a few seconds. Here….” He handed me two syringes from his paediatric bag. “Get those down her ET tube, and it’ll give them a start when we hand her over.”

  “Thirty seconds” came a voice from up front.

  I did as Paul said and then continued bagging oxygen and giving one finger compressions on that miniscule chest. Please, please, please.

  “You okay there?” Paul checked.

  Not really. I nodded, wholly focussed on that whisper-small body in my hands, willing her to breathe, but for all my prayers, she remained limp and lifeless. Desperation cranked in my gut. Voices outside the ambulance alerted us to the fact we’d arrived in the bay and the cab jerked and rocked as we pulled up, then reversed into position. Doors flew open and someone clambered in behind me to help unload Prim, with Paul issuing instructions and briefing people as they transferred her inside.

  A woman peered over my shoulder.

  “On three I’ll take over from you and run her in,” she said. “Help me get her into my arms and tell me the essentials, no more, then follow me in. Okay?”

  “Okay.” I shuffled sideways to give the woman room. “Hannah, her name’s Hannah.”

  The nurse sent me a brief sad half smile. “Okay…. Hannah, one, two, three….” She slid her hands under the baby, and I passed off the Ambu-bag, continuing compressions till the nurse was set and then handing those over too. She then ran Hannah off to a waiting neonatal resuscitation trolley, and I followed, a neonatal intensivist glued to my side as I gave a brief history and answered his barrage of questions.

  Once inside the ER, we headed for the paediatric resuscitation room while Prim was… who knew where? Likely somewhere close to the shouted instructions being given down the hall. For now, mother and baby would be separated as a tribe of skilled personnel worked on each to keep them alive.

  In the baby’s room, I stood back and let a team of people far more skilled than I do their thing. I needed to hang around for a bit in case they had more questions, but I got myself out of the way and found a wall to prop myself against as the adrenaline in my system crashed and my legs went to jelly.

  “Here.” A nurse shoved a chair my direction and patted me on the shoulder. “Sit. We can do without hauling your butt off the floor as well. You done good getting her here alive. Now let us try and keep her that way.”

  I sat. Not sure I really had a choice the way the room was tilting. Half of me wanted to flee the room and leave them
to it, too damn panicked and nervous to watch. But the rest of me was fixed in place, unable to move a fucking inch from the hard-as-concrete chair I was glued to. If sheer force of will could make a difference to whether Prim’s baby lived or died, I was determined to give it my best shot.

  As it was, I could barely even see her, a tiny bundle of flesh and possibility laid out on a high neonatal resuscitation table, surrounded to the point of invisibility by six staff and a fuck-ton of equipment. It should’ve been noisy, a cacophony of shouted orders and relayed recordings, but the team was a well-oiled machine, and the room was eerily calm. No panic, nothing but composed directions and precise movements, the staff urgent but focussed. But for all that as the minutes passed, my heart grew heavier, eyes glued to the monitors that still reflected little change.

  A nurse blew by on her way out the door and I grabbed her wrist. “Can you check on the mother for me?”

  She nodded. “I’ll see what I can find out.”

  Thirty seconds later she returned with two bags of IV fluids. “Mum’s holding her own,” she said as she passed me by. “They’ve taken her to surgery. Her sister’s gone up to wait. Her husband’s trying to get back to NZ.”

  Thank God for that. Stuck in my chair, I hoped and prayed and fucking begged whoever was listening that Prim’s little girl would live as well, but the level of consternation on the faces of the team, and the desperation in their quiet voices indicated it was gonna be a close-run thing. Like most midwives, I’d had some clients suffer through miscarriages—losing a baby under twenty weeks gestation—but I’d never lost a near-full-term baby, and a large part of me couldn’t believe it was happening.

  Goddammit, why hadn’t I gone to Prim’s this afternoon? Why did I wait? I couldn’t lose Prim’s little girl. I felt trapped in a nightmare. There was no way this was happening. I was good at what I did, I was. And I got her delivered. That had to count for something. She couldn’t have been that long without air. Her heart rate was marginal but survivable just seconds before she was born. It had to be enough.