The Midwife's Special Delivery

by Carol Marinelli

  ‘Did you ever see anything more divine?’ Jess asked and it was Rory who answered as he and Rinska came over to admire the babies.

  ‘No,’ Rory said. ‘They would have to be two of the cutest babies I’ve ever seen—and that’s saying something.’

  He wasn’t exaggerating. They were absolutely divine, but, as much as she wanted to stand and gaze for a little longer, that wasn’t what Ally was in here for.

  ‘Could one of you come and see my new admission, sooner rather than later? I haven’t examined her yet, but the contractions are pretty close and I’ve a feeling she may well be the next one to deliver. I just don’t want to put her through two examinations if I can help it.’

  ‘Sure.’ Rinska nodded, tearing her eyes away as Jess and Bella picked up the twins to take them over to Mum for a very well-deserved cuddle. ‘I’ll be right there—just need to write up Louise’s notes.’

  Fiona was in a gown by the time Ally returned, and she guided her onto the delivery bed, checking her patient’s baseline observations before turning her attention to the baby. Feeling Fiona’s stomach, Ally attempted to locate the baby’s position, determinedly not showing her worry as the normally easy examination proved rather difficult.

  ‘Is everything OK?’ Fiona asked anxiously as Ally gently probed her abdomen.

  ‘I’m just checking the baby’s position,’Ally explained. ‘It seems to have moved a bit since the last time you were examined. When did you last have an ultrasound?’

  ‘I only had the one at nineteen weeks,’ Fiona answered. ‘We didn’t want to have too many procedures.’

  ‘OK.’ Ally nodded. ‘I’m going to strap the CTG machine on now. All it does is record baby’s heartbeat and the timing and strength of your contractions so we can see how you and babe are both doing. Have you had a lot of movement?’

  ‘Lots,’ Fiona admitted. ‘I feel as if it’s doing cartwheels inside me sometimes.’

  Fiona could well be right, Ally thought as she left Fiona and found Rinska. ‘I’m not too sure about this baby’s position,’Ally said. ‘I think it could be transverse.’

  ‘I’ll come now,’ Rinska said, leaving the notes she was busily writing. Transverse meant that the baby was lying on its side, and if Ally was right in her assessment, Fiona was going to need some assistance.

  Rinska was incredibly gentle as she examined Fiona’s stomach. ‘Have you done an internal?’

  ‘Not yet.’ Ally shook her head, holding her patient’s hands as Rinska gently performed the procedure.

  ‘What’s the problem?’ Fiona’s voice was more anxious now and Ally listened as Rinska gently explained her findings.

  ‘Your cervix is dilating nicely and your contractions are strong and regular. However, the baby is in a difficult position.’

  ‘Breech?’ Fiona asked, but didn’t wait for a reply. ‘Because if it is, I want to deliver normally. I’ve read up on breech births.’

  ‘The baby isn’t breech.’ Rinska shook her head. At least, I don’t think so. We’ll need an ultrasound to confirm the position, but I think that your baby is lying across your stomach.’

  Ally attempted to explain things further as Rinska again palpated the uterus.

  ‘You know how I explained that babies are generally head down for birth? Well, as Rinska said, it would seem that your baby might be lying in a position that we call transverse…’

  ‘But can I still have a normal delivery?’ Fiona pushed, a vaginal birth the only thing on her mind now.

  ‘Let’s get the ultrasound machine in,’ Rinska said, ‘and I’ll ask Dr Donovan to come and take a look at you. Once we know exactly how the baby is lying, we’ll be able to explore your options, but for now all we would be doing is guessing.’ Rinska gave a firm nod. ‘Let’s wait till we have all the facts. I’ll go and get the ultrasound machine…’ She paused for a moment as Fiona had another contraction, and came over as she saw Ally’s concerned face as she read the CTG tracing.

  ‘I’ll go and get Dr Donovan,’ Rinska said in a low tone, reluctant to press the bell three times and alarm Fiona with half the ward staff arriving. ‘Put her on oxygen.’

  Ally was already onto it. The baby had suddenly started to struggle, its erratic heartbeat showing signs of foetal distress, and Ally focused on keeping her patient calm, instructing her to lie on her side to allow for more effective oxygenation of the baby and placing a mask over Fiona’s terrified face.

  ‘Fiona.’ Ally’s voice was calm as her patient panicked. ‘The baby’s starting to struggle a bit so I want you to take some nice slow deep breaths of the oxygen. I’m just going to put a little needle into the back of your hand in case we need to give you any drugs.’

  ‘I don’t want any drugs,’ Fiona insisted, but Ally carried on with the task, wrapping a tourniquet around her patient’s wrist and swabbing the back of her hand as Rory arrived.

  ‘Hi, Fiona.’ Rory smiled down at his patient as he introduced himself. He had the CTG tracing Rinska had ripped off in his hand, and after the briefest of examinations he pulled over a stool and squirted jelly on Fiona’s stomach, carefully checking the position of the babe with ultrasound. Every movement was controlled, his voice supremely calm as he spoke with his patient, but though Fiona probably couldn’t see it, Ally knew Rory well enough to know he was deeply concerned. The tiny creases around his eyes were deep grooves now, his mouth set in a grim line as he scanned the screen in front of him.

  ‘Fiona.’ He looked up at her anxious husband. ‘Mark, is it?’ Ally listened as he delivered his findings directly to the patient and her partner, her mind racing ahead, pressing on the call bell three times as Rory spoke calmly. ‘Your baby is transverse—has that been explained to you?’

  ‘Sort of,’ Fiona gulped.

  ‘Well, your baby is actually back down—which makes it a very difficult transverse position. If you imagine your uterus as a cup, your baby is lying across it, with its back at the bottom.’ He drew an extremely rudimentary picture but it was enough for Fiona and Mark right now. ‘In this position, a vaginal delivery isn’t possible.’

  As the door opened Ally greeted Jess, giving out her rapid instructions. ‘Tell Theatre we’re coming—transverse lie, foetal distress…’ That was all she needed to say, knowing those words were enough to set the emergency wheels in motion. In a matter of moments the Theatre would be ready, and even by the time Ally had returned to the bedside she could hear the overhead chimes summoning the anaesthetist and the paediatrician to the delivery theatre.’

  ‘You could try turning it…’ Fiona was sobbing, her eyes turning to Ally’s, pleading with her to support her in her quest to have a natural birth. ‘Ally said something about an external version…’

  ‘Not in this case.’ Rory shot an angry look at Ally before continuing. ‘External version sometimes works, but it can only be attempted if we’re happy with the cord position and if the baby is stable. Right now your baby is in distress.’ Rory let the words sink in. ‘We have to go ahead and perform an urgent Caesarean section so that your baby can receive adequate oxygenation. At the moment it’s struggling. I need you to sign a consent form…’

  ‘Well, can I have an epidural?’ Fiona begged. ‘I want to be awake, I have to be awake for this.’

  Ally’s heart went out to her. Fiona’s worst nightmare was ensuing, but every word Rory said was true—this baby had to be born and soon or the consequences would be dire. Thankfully Mark seemed to understand the gravity of the situation.

  ‘Listen to the doctor, Fiona,’ he interrupted her tirade. ‘Sign the consent form and let the doctors look after our baby!’

  Thankfully Mark’s words hit home and Fiona’s shaky pale hand signed the consent form.

  ‘Good girl.’ Rory nodded. ‘Fiona, I’m going to go to Theatre now and get scrubbed. I’ll see you in there.’

  Ally moved the drips and oxygen connections to enable the bed to be wheeled directly into Theatre.

  ‘Go ahead, Ally.’
Jess was taking the brakes off the bed. ‘I’ll wheel Fiona down and you can get ready to receive the babe. You’ll see Fiona in Theatre and when I come back I’ll talk to you, Mark.’

  Ally gave Fiona a quick reassuring squeeze of her hand. ‘I’ll meet you in Theatre.’ Racing down the corridor and into the theatre changing room, Ally quickly pulled off her uniform and dressed in theatre blues, slipping her feet into white clogs and putting on the purple flowered paper cap. Different caps were worn by each staff member to identify them—the scrub nurses’ would be blue, Rory’s would be green. Making her way into Theatre, Ally was instantly soothed by the ordered efficiency of the place. Already the anaesthetist was pulling up his drugs as the nurses pulled open packs and started the routine check of their equipment. Rory had finished scrubbing and was putting his hands into a gown. Over his mask his eyes met hers, and despite the mask Ally knew from his grim expression that he wasn’t smiling behind it.

  ‘Don’t,’ he said, coming as close as he could without disturbing his sterile field, ‘ever do that again.’

  ‘Do what?’ Ally blinked, fixing her own mask now and frowning at his hostile voice.

  ‘Don’t ever confuse one of my patients like that again. Just because you’re so bloody obsessed with natural birth, please, don’t pass it on to the patients. You knew how little time we had, and instead of getting on with the job I had to stand there explaining why we can’t perform an external version while her baby’s heart rate’s dropping by the second!’

  Oh, she’d have loved to have let him have it! Would have loved to have broken his sterile field and marched right up to him with a smart retort, but the theatre doors were opening now and Fiona was being rushed inside, so for now Ally had to settle for a single sentence.

  ‘Don’t—’ Ally glowered ‘—ever judge me without knowing all the facts!’

  ‘It’s OK, Fiona.’Ally held her patient’s hand as she was moved swiftly onto the theatre table. Time was of the essence. Fiona’s abdomen was prepped with solution and she was attached to noisy bleeping monitors as she lay wide-eyed and terrified. Ally knew it was her job to comfort her patient, to be the one familiar face that Fiona could focus on as she gently explained what was going to happen.

  ‘The anaesthetist is just getting things ready, and once you’re attached to all the monitors, he’ll put a mask over your face and put you to sleep. We’re going to have your baby out in just a moment. Everything’s under control.’

  ‘I’m scared!’ Fiona wasn’t crying now. Her face was as pale as the paper hat she was wearing. ‘Is the baby OK?’

  ‘Its heartrate’s slow,’Ally said, glancing over to the monitor and keeping her face impassive, ‘but Rory will have it delivered in no time…’

  ‘It’s a boy.’ Fiona bit down on her lip for a second before continuing. ‘Mark doesn’t know, he doesn’t even know I know, but I sneaked a quick word with the lady who did the ultrasound—I’m going to have a son!’

  ‘In just a couple of minutes,’ Ally smiled, holding Fiona’s hand as the mask was placed over her face. ‘You just think about meeting your son.’

  She only let go of Fiona’s hand when she was well and truly under. The anaesthetist injected powerful drugs that rendered her unconscious and a tube was placed down her throat so the ventilator did the breathing for her. Ally slipped over to the cot warmer and joined the paediatrician, ensuring they had everything ready.

  ‘Come on, come on.’ Hugh, the paediatrician, glanced anxiously at the theatre clock. ‘Let’s get this baby out.’

  ‘Nearly there.’ Rory’s voice was tense but controlled, and Ally listened to the gurgling sound as he suctioned out the amniotic fluid. She picked up a sterile green drape to receive the infant when Rory handed it to her, knowing that now he was in, the baby would be here in a matter of seconds.

  ‘Here’s the head.’ She could see Rory’s wide shoulders, shifted herself just enough to watch the grey head emerging, chewing anxiously on her lips behind her mask as the flaccid body was delivered.

  ‘We’ve got a problem here, Rory.’ It was a voice no one was really expecting to hear, and the only person in the room who didn’t turn to the anaesthetist was Rory, too busy concentrating on delivering the baby to turn his head.

  ‘What?’ His single word was like a bullet.

  ‘Muscle rigidity, tachycardia…’ The anaesthetist was working hard, rapidly pushing drugs into Fiona as he skillfully assessed his patient. Ally felt her heart, which was already racing, go into overdrive as machine alarms started going off. ‘We’ve got an erythematous flush.’ The anaesthetist’s voice was urgent now as he assessed the reddening of his patient’s skin, and Ally could scarcely believe the words she was hearing as he called for more help. ‘Get the MH cart!’

  Rory was handing Ally the baby now, a boy, just as Fiona had predicted. But his body was flaccid, his colour grey, and Ally rushed him over to the resuscitation cot, trying to block out the sounds going on behind her and look after Fiona’s baby as the staff worked on the mother.

  MH, or malignant hyperthermia, was a rare and life-threatening emergency that sometimes occurred during anaesthetic. The drugs used to anaesthetise the patient triggered a major metabolic crisis and though the cause was unknown—in some cases hereditary—the most worrying thing was that, more often than not, especially if they had never had an anaesthetic before, nothing in the patient’s history might indicate that the patient was at risk. And nothing in Fiona’s history had even hinted that she might be one of the patients who was susceptible, yet here she lay, her heart rate erratic, her body failing as the anaesthetist replaced the drugs that were known to trigger the event with others, setting up further lines to enable massive lifesaving treatment to be quickly delivered. More backup was being urgently summoned. Eskys of ice were being wheeled in to pack Fiona’s body and Ally could scarcely believe she was witnessing this nightmare—that just a few moments ago it had seemed like just another busy morning in Maternity.

  So dire was this particular emergency that theatres were stocked with a specific cart containing drugs and necessary equipment, just in case of this rare eventuality, but no one had been expecting to use it—especially today.

  ‘Hyperventilate him.’ Hugh was flicking the baby’s feet to stimulate him and listening to the baby’s chest at the same time as Ally suctioned him and bagged him. Looking down, she could see that even Hugh’s usually steady hands were shaking as the theatre staff raced to save Fiona’s life—losing a mother was not on anyone’s agenda.

  ‘You need to close, Rory.’ Another anaesthetist was on hand now, breathless from his mad dash to the obstetric theatre, shouting his orders to Rory who was working on. ‘We need her incision closed.’

  ‘She’s bleeding out,’ Rory shouted back, and Ally caught Hugh’s eyes. Rory’s finding was ominous. Uncontrollable bleeding was a side effect of MH but in this situation controlling the bleeding was an appalling prospect, with the uterus being so vascular. Packed cells were being put up now, replacing the blood that Fiona was rapidly losing. Clotting agents were being administered, but all of this was occurring in the background. Ally refused to allow herself to dwell on the unfolding drama on the theatre table. She just focused on the tiny life that lay on the resuscitation cot beside her.

  Normally, by now Rory would be calling for an update, wanting to know what was happening with the babe, but he was too busy even for that distraction—everyone was. The newborn let out a small fragile cry. It was smothered by the mask Ally was holding over his face and went unheard and unheeded by the rest of the staff as they focused on the child’s mother.

  ‘We’ve got him.’ Hugh gave a tiny relieved nod as the infant started to pink up, one glimmer of hope in this otherwise black day. Ally removed the mask and instead held oxygen tubing near the baby’s nose and mouth, increasing the oxygen content of the air as he took his first vital unaided breaths. His cries were more lusty now, limbs that had been flaccid were furiously kicking, his l
ittle arms jerking at the wide unfamiliar space that surrounded him. As soon as Hugh had completed his examination, Ally weighed and measured him, then wrapped him firmly in a bunny rug. At this point normally she’d have gone outside, would have taken the newborn infant to meet his father, but how on earth could she now?

  What on earth could she say to Mark?

  So instead she placed the babe in the warmer and quietly observed, offering assistance when she could, running through blood, wheeling a never-ending line of equipment over to the theatre table, and her heart went out to Rory. Sweat was pouring down his brow, his face taut with concentration, huge hands skilful as over and over he tried to close the incision in the uterus and bring the bleeding under control. Finally he gave a small nod, watching for a moment and checking that his sutures were holding in the friable uterus, that blood wasn’t filling the abdominal cavity. ‘OK, I’m closing.’ No neat row of stitches for Fiona. Rory finished the procedure with a rapid line of staples, knowing that Fiona needed this anaesthetic nightmare to be over.

  ‘How’s she doing?’ His gloves were peeled off and he threw them in the general direction of a stainless-steel bucket, heading over to the top of the theatre table and talking with the anaesthetist. Ally could only guess at his anguish. In a matter of fifteen minutes he seemed to have aged a decade, his eyes hollow in his face, his skin pasty as he listened to what the anaesthetist had to say.

  ‘How’s the baby?’ Rory looked over at Hugh, who gave him a thumbs-up. ‘He had a shaky start, but he’s doing fine now. You got him out just in time. I’ll take him down to the nursery now and get him out of everyone’s way.’

  Rory stared around the chaos of the room, the mountain of blood-soaked swabs, empty packets littering every surface, doctors, nurses crowding around his patient, and Fiona somewhere in the middle. Ally watched with tears in her eyes as he went over to the woman and, bending down, said something that was for Fiona’s ears only, before standing up and peeling off his mask. He scanned the room for a moment, his eyes finally resting on Ally’s as he braced himself to face the hardest part of this awful day.