by Leah Hazard
‘All right, Mother Teresa, you’ve got an admission.’
June, the other midwife on the ward that day, had drawn back the curtain and was now surveying our cosy embrace with undisguised irritation, jaw clenched like a sharp-shooting sheriff in an obstetrically themed spaghetti western. Cuddling a patient? Please. To the most hardened of midwives, walking in on such an emotive scene is far more distasteful than wading through the stream of bodily fluids that winds through our daily work. These world-weary battleaxes have grown a tough, calloused skin during their many hard-fought years of professional practice and, as I was soon to learn, there was a certain wisdom in that grim adaptation. Under June’s withering gaze, I was nothing but a soft-hearted fool, ill-equipped for the demands of the job.
‘Room six, bed two,’ June droned as I pocketed my thank-you card, disentangled myself from Mrs Bhatti, and followed her down the corridor. ‘Crystal, a fifteen-year-old PPROM at twenty-three and three, with Mickey Mouse pyjamas and the face of an eight-year-old. Good luck.’ June shuffled back to her own patients on the other side of the ward as I hovered by the door to room six.
A PPROM – or preterm, prelabour rupture of membranes – is when the protective bag of fluid around a baby starts leaking before thirty-seven weeks (the widely accepted minimum gestation of a fully grown fetus), and well before the onset of labour. Sometimes women with this condition can safely continue their pregnancy for days, or even weeks, with the support of oral antibiotics and regular check-ups. For others, a PPROM can escalate rapidly into a full-on gush of waters, the start of strong, regular contractions and the birth of a baby whose bird-like body, immature lungs and delicate immune system are immensely vulnerable. This situation is even more precarious around twenty-four weeks of pregnancy. Until fairly recently, the majority of babies born prior to this point died soon after birth or succumbed to serious illness in the weeks that followed. As a consequence, most babies born up to this gestational age were not actively resuscitated and were officially classified as a late miscarriage rather than a registrable birth, as callous as that may feel to those who have experienced the sorrow of losing an extremely preterm child. The chances of survival into infancy and beyond have always tended to increase incrementally with every week that passes in utero. Accordingly, any babies born after twenty-four weeks have traditionally been deemed ‘viable’ by British law and have therefore been offered the full catalogue of cutting-edge paediatric treatment, even if that means intubation, ventilation and weeks of uncomfortable but potentially life-saving procedures in the short term, and a myriad of potential disabilities and developmental delays in the long term.
Regardless of one’s personal beliefs about the definition of viability and the value of an early life, doctors who hover over this moral knife edge on a daily basis need to rely on hard-and-fast guidelines to create treatment plans with the best possible chance of a decent outcome. As modern neonatology developed, the twenty-four-week boundary provided medical staff with a clear sense of what could and should be done for babies born too soon, but recent advances in the field have improved survival rates for extremely preterm babies, blurring the line of viability. In spite of the risks of long-term disability, more and more babies born in the increasingly grey zone of twenty-three to twenty-four weeks have been successfully resuscitated and kept alive, defying these tiny creatures’ frailty and their inability to breathe, suck or do very much of anything without major intervention. At twenty-three weeks and three days, Crystal’s baby was right in the middle of this no-man’s land and, if it were born, its survival would depend not only on its own meagre strength, but also on the extremely subjective judgement of the paediatric team on that given day. To make matters even more complex – if such a thing were possible – any decisions Crystal made would be subject to more than the usual amount of scrutiny by the medical team, given that she was legally, if not physically, still a child herself.
I heard Crystal before I saw her. Her curtain was drawn, but she appeared to be having an animated conversation with somebody at her bedside.
‘So I said that her pal’s cousin was a fucking liar, because I saw her up the shops with Danny’s brother last week and she looked like a pure clown, like a fucking riot.’
I pulled the curtain back just enough to see the end of the bed, where Crystal was wiggling her feet back and forth in a pair of pink fluffy slippers. I could see a flash of ankle, and yes, the hem of Mickey Mouse pyjama bottoms. Crystal laughed loudly and, as I drew closer, I saw that she was lying back on a pile of pillows, phone propped up on her knees, FaceTiming a friend who was visible only on the tiny screen of her mobile phone.
‘She’s all sugar or all shite, that Britney,’ said Crystal, sighing. Then, catching sight of me, she sat up in bed and brought the phone back up towards her ear. The phone cover was a giant latex panda with googly eyes. ‘Right, I need to go, the nurse is here. Right, right, OK, bye, bye, see you later.’ Then, to me, ‘Hiya.’ She beamed and her smile was a gleaming, crowded jumble, a few tiny milk teeth still vying for space with their permanent cousins – an orthodontist’s dream.
The face of an eight-year-old may have been a bit of an exaggeration, but not a million miles from the truth. Crystal looked barely old enough to be in secondary school, let alone in the hospital on her own and on the brink of having a preterm delivery. Even in her current condition, I couldn’t imagine her thinking that boys were anything other than gross – in fact, maybe the escapades that brought her to hospital had only reinforced that opinion. She had evidently tried to contour her cheeks in line with the latest make-up trend, but the stripes of bronzer across her face made her look like a child who’d fallen asleep in a bowl of Coco Pops. Something about this misguided attempt at glamour reminded me of my teenage self, although Crystal exuded a kind of easy charisma that I could only have dreamed of at that age. She was a young girl trying on the identity of a ballsy, brazen woman, and the effect was both awkward and compelling.
I wheeled a blood-pressure machine up to the bedside and started with the classic opening line of midwives, nurses and doctors everywhere: ‘So tell me what’s been happening.’ Strangely, this greeting brings me out in a cold sweat when uttered by my own GP, who’s about as threatening as a box of kittens. My hands shake, my voice quivers and the cool, collected midwife suddenly becomes a stammering mess, unable even to request a repeat prescription without apologising at least twelve times for wasting the doctor’s time. Put me in a blue tunic and a pair of beaten-up orthopaedic shoes, though, and I’m back in control, the words of my well-practised script tripping easily off my tongue.
‘Well,’ Crystal began, ‘this girl Britney, she thinks I’m a pure muppet, right, because I saw her with this boy who was messaging me …’
‘Sorry, Crystal –’ it was probably best to clarify my intentions before the Britney saga reached its epic conclusion – ‘I meant, what’s brought you to the hospital?’
‘Aaah, sorry, nurse.’ I ground my teeth. With all the enormous respect due to nurses, who can be extremely skilled and specialised, being called a nurse is something that grates on midwives like nails on a chalkboard. Our role is as different and distinctive as our title, of which each and every one of us is immensely proud. However, I kept my opinions to myself as Crystal continued.
‘I thought I was leaking water in double maths first thing this morning, except technically it wasn’t double maths, ’cause I was dogging it, and I was actually with my pal Tammy getting a McDonald’s, and we were just sitting down with our McMuffins when I was like, holy shit, Tammy, my pants are soaking, I think I’ve just pished myself. And she was like, that’s fucking rank, and I was like, I know but I need to go to the hospital, so we went back to my house to get my bag and feed my rabbits and then Tammy’s brother Dean dropped me off in his van, which is seriously rank, and Tammy had to get back for fourth-period geography, so yeah.’
‘Right.’ Head slightly swimming from Crystal’s exhaustive history, I rem
embered the blood-pressure cuff in my hand and wrapped it round Crystal’s skinny arm, pulling it as tight as it would go. I mentally composed my documentation for this case: Patient began draining liquor in McDonald’s. Unlikely though it may have sounded, I had also recently looked after ‘patient who lost consciousness in the middle aisle of Lidl’ and ‘patient who ruptured her membranes while pushing trolley in Asda’. The worlds of retail and obstetrics collide much more frequently than the general public might imagine.
‘So is the baby coming today, nurse?’ Crystal asked as I went through the usual sequence of checking her blood pressure, pulse, temperature and respirations.
‘Hopefully not,’ I replied. I put my handheld Sonicaid to her tummy and heard the reassuring thump, thump, thump of the baby’s heartbeat. ‘You’re not contracting, but we need you to show us your sanitary pads every time you change them, so that we can see if there’s actually amniotic fluid coming away. Sometimes you can be leaking normal discharge or urine, and it feels pretty much the same.’ Crystal looked at me in shock, as if I had just asked her to turn her vagina inside out. ‘You want to see my fanny pads?’ she gasped, then rolled her eyes. ‘Some job you’ve got, nurse.’
The general public may think that midwifery is all baby-catching and biscuits, but behind the scenes a million midwives are paired off in corners and cupboards, showing each other soiled sanitary pads and comparing their colour, consistency and smell in order to make a correct diagnosis and obstetric plan.
‘We just need to have a look,’ I explained. ‘Only to be sure there’s nothing unusual going on. You let me know if there’s any water or blood, or if you have any pains. There’s a buzzer next to your bed and one in the loo if you need it. You can also come and find me … I’ll never be far away.’ I hesitated as an expression of undisguised adolescent disgust settled on Crystal’s face. It occurred to me that this conversation might be easier if Crystal’s mother, or an auntie or a friend, was here at her side – someone who’d been down this road before and could reassure her that my unusual demands were not so unusual after all. Should I ask? I wondered. I should.
‘Crystal,’ I began, ‘is your mum or … is there someone who can come down here to sit with you? Just, you know, for company?’
She squirmed on the bed and flicked her phone’s screen on and off restlessly – the phone had buzzed about six times while she’d been giving me her story. With my own teenage daughter at home, I had long been oblivious to the constant buzz and ping of a million social media alerts.
‘I texted my mum on the way here but she doesn’t finish work till ten and, even then, she would have to take two buses to get here, so …’ Crystal’s voice trailed off, and the briefest shadow furrowed her brow. ‘What am I even meant to do all day anyway, nurse?’ She tilted her chin up, bold and brash again in an instant. ‘I mean, is there even a WiFi password?’
I hated to break it to Crystal, but in spite of the posters all over the wards with the details of the public WiFi network, the hospital set-up was notoriously glitchy and unreliable. Money was about to be poured into a shiny new IT system that would allegedly enable the hospital to go ‘paper-lite’, if not entirely paper-free, but in the meantime, WiFi, beds, staffing and pretty much every resource going were in need of a major cash infusion. ‘There’s no money in the pot,’ we had been informed with breezy humour at a recent staff meeting; the news hardly came as a surprise.
I left Crystal with a wedge of hospital-issue, boat-like sanitary pads and firm instructions to press the call button if there was anything unusual coming away down below. With a cheery ‘Aye, nurse,’ she tucked the pads under one arm, repositioned her phone on her knees and launched into another FaceTime. As I moved on to the next room, I could still hear Crystal nattering away behind her curtain: ‘Check out the size of these fanny pads, Dean, it’s going to be like wearing fucking Pampers.’ Her laughter echoed at my back, and I couldn’t help but smile. Got to hand it to her, I mused. The girl’s got a way with words.
For the next few hours, the afternoon passed like any other in the antenatal ward. At 2 p.m., a clutch of women arrived for the day’s induction list and were promptly dispersed to various rooms around the ward, trailing wheeled suitcases and anxious partners behind them. Every day, women arrive to have their labours kick-started for any number of reasons, from overdue babies, to babies whose movements have slowed, to babies who have already grown so fearsomely chubby that to postpone vaginal birth much longer would mean certain death for the mother’s pelvic floor, and a lifetime aversion to trampolines. And so, as cool afternoon light cast slanting shadows across the ward, June and I dotted from bed to bed, tagging each patient with a white name band and wrapping blue elastic CTG belts around each ballooning belly. Woman by woman, we recited the familiar Song of Induction: You are here because we need to get you into labour, and we have ways of making you do this, and this is how it goes – pessary, pessary, pessary, broken waters, drip.
June and I glided across the ward like smiling angels of pain, reciting this incantation and popping in Prostin pessaries with a light touch made even lighter by the sachets of lubricant we carried in our tunic pockets, warming them with our body heat (a small but achievable kindness, as anyone who’s felt the shocking splodge of a cold-jellied speculum will attest). As we weaved from woman to woman, Crystal made an occasional appearance in our afternoon ballet, now dancing down the corridor to the toilet with pad in one hand and phone in the other, now returning from a trip to the vending machines with an armful of Quavers and Diet Coke. At five o’clock, as I stood at the midwives’ station in the middle of the ward, writing up my notes, I felt a tap on my shoulder. It was Crystal. She had accessorised her Mickey Mouse pyjamas with a pair of large neon-orange headphones and was bopping her head in time to their tinny beat.
‘All right, Crystal?’ I enquired.
‘Dry as a bone, sister,’ she said a little too loudly and grinned, pointing to her crotch.
‘Good,’ I replied. ‘Let’s keep it that way.’
As Crystal bounced back down the corridor towards her room and I raised my pen to continue scribbling my notes (Patient reports nil further fluid per vaginam, mobilising well around the ward), I saw a familiar figure bustling towards me: five foot one, swamped in scrubs three sizes too big and a navy blue headscarf, gleaming white trainers squeaking along the polished floor at a businesslike clip.
‘Salaam alaikum, girls,’ said the doctor, sighing as she approached the midwives’ station. Soraya, one of the senior obstetric registrars, had come to our hospital from Abu Dhabi the previous year and had already earned widespread respect among the staff for her no-nonsense attitude and razor-sharp clinical judgement. The traditional Arabic greeting was as far as Soraya’s pleasantries went – after that, it was just the facts, ma’am.
‘What have you got for me?’ she asked as she surveyed the piles of notes strewn across the desk. ‘And what is all this?’ she said, rifling through the chaotic pages in front of her. ‘Has there been an explosion?’
June popped her head out of an adjacent room. ‘Nothing from me, doctor. All the afternoon Prostins are done, just one patient niggling and another two on the birth balls. And the placenta praevia in room nine’s nipped out for a smoke.’
Soraya rolled her eyes and turned to me. ‘And you?’ The pager clipped to her waistband let out a series of shrill beeps. ‘Make it quick. I need to scrub for a ruptured ectopic.’
I thought of mentioning Crystal but, as the girl herself had said, she was dry as a bone – no more waters leaking, no contractions, tiny fetus still swimming in its cosy bubble. Maybe the whole thing had been a false alarm. ‘Nothing really, Soraya …’
‘That’s what I like to hear,’ she called over her shoulder as she turned on a squeaky heel and began to speed back towards the lifts, raising a hand in a weary half-wave as she went. ‘Keep it good for me, girls. Keep it good.’
It was half past six, just over an hour until the end o
f my shift, and I clicked smoothly into autopilot as the day began to draw to a close. It was time to tidy those loose notes and do one last tour of the ward to check on my patients, refreshing water jugs, dispensing clean pads and murmuring final words of encouragement as I went. The ward was beginning to thrum with the low, crampy moans of early labour; that afternoon’s inductions were crossing en masse into the seductive shadowlands of pain, and as I passed by each doorway, I could see women rocking in slow circles on big pink birth balls, partners rubbing smaller circles on their backs, faces fixed in watchful anticipation. With any luck, the real dramas would start on the night shift – contractions rippling through the ward room by room, women hurtling towards the desk with hastily tied, hospital-issue gowns flapping behind them, desperate to know why there were six women ahead of them in the queue for labour ward, unaware that there were no empty rooms and no free midwives and hours still to go.
‘NURSE!’ I froze as I cleared a dinner tray from the room next to Crystal’s. There was no mistaking the voice. I rushed into room six to find Crystal standing in the middle of the floor, pyjama bottoms and knickers pulled down to her knees, with a steady trickle of olive-green liquid running down her thighs. It was unmistakeable: amniotic fluid mixed with meconium, the murky, sticky poo that builds up inside the fetus’s gut during pregnancy, sometimes released when the baby is overdue, but also sometimes expelled when the baby is in a state of metabolic distress. In other words: oh, shit.
‘What’s happening, nurse?’ There was a new, brittle edge to her voice and the colour had drained from her face. Terror had replaced bravado. The curtains along the back wall ruffled and sighed with a breeze and as the drab, pale-pistachio fabric settled back into place, I became suddenly aware of the winter chill in the room. Every window had been opened. The whole scene was deeply wrong – a child with the ripe, round belly of a woman, a cold space on a warm ward, muddy drops of fluid raining onto a smooth, polished floor – and my vision swam with the incongruity of it all for one long, seasick moment before my midwife brain took over.