Wednesday, February 23, 2011
The Ironies of Life and Death
On Tuesday morning I found myself once again folding gauze. Doubling the upper edge downward, drawing in the two sides, and then giving a fold-flip maneuver to tuck the wiry threads back in on themselves creating a somewhat misshapen 4x4 square. I tossed each pad of gauze into the open mouth of the stainless steel cylinder, years older than I, as the midwife, a student nurse and I chatted about relationships, episiotomies, and seafood soups. The small radio that sits atop of the Nicaraguan birth records buzzed in the background as soul reggae music washed in and out on the airwaves, accompanied by the hiss of the air conditioner. The three of us sat dressed in our clean scrubs, the student in her hand-sewn mint green top-and-bottom that signified her rank as entering her third year of studies, waiting for what the day had to offer. Occasionally, the entire day can be passed like this, without even a single patient gracing the new labor and delivery ward. We might just sit and stare at the walls, painted burgundy from the midsection down, and ivory up to the top, complaining again and again about how the delivery suite is too small and we run circles around one another. One of us will then make a comment about how difficult it will be to address an emergency in the tight 15x15 foot space where two obstetric tables, one neonatal warmer, two lamps, a table with gauze and D&C supplies, a sink, a cupboard, two nurses, a nursing student, a physician, and a laboring mother may all be crammed into at the same time.
The joy, and sometimes the terror of obstetrics is the unexpected. Just as on this Tuesday, one never knows what the day will bring. So at 11 am without a whisper of a patient, and a maternity ward bereft of patients I started to become bored. Twelve hours is a long time to fold gauze. And then I heard the now familiar clunk-clunk of the two sets of double wooden doors being forced open by a patient’s foot and the clambering wheels of the wheelchair as the driver negotiates the chair around the receptacle full of dirty linens, the yellow trash barrel, and decomposing cardboard box full with random medical supplies in his midst. The physician was driving, clutching a bag of IV fluids with 5 units of oxytocin with one hand, guiding the patient haphazardly with the other.
We helped the patient onto the expulsion table, a bright blue gym mat over a metal base, thick white plastic thigh supports at the practitioner’s end, a metal IV pole by the patient’s head. The young woman, dark circles under her eyes, thin and lackluster, was a first time mother whose baby had passed away, and well before his time. At 26 weeks the woman barely had a pregnancy bump. Her labor had been induced to relieve her of carrying this burden. She arrived in my hands with a fully dilated cervix. I gingerly reached my fingers inside to assess how near the patient was to delivery. My fingers came up against a joint, an arm, and a smooth roll of the shoulder, rather than the most common fetal presentation which is the solid skull. I felt panic rise in me. How would this baby deliver? I voiced my concern to the physician, “The shoulder is presenting, how is this baby going to deliver?” With a push on the patient’s abdomen he reassured me that it would be just fine, contrary to my instincts. But one brave push later the small arm made its way from womb to world, followed by its adjoining shoulder, then back, followed by bottom and legs that effortlessly slid up and out. Lastly, the head emerged as I delivered this shoulder-breech, expired preemie. The cord was cut and clamped. The baby lay limp and discolored on the green surgical drape. He weighed in at 1050g. The placenta slid forth soon after the delivery, small and misshapen by infarcts marking its slow shutdown as the fetus no longer thrived. I once again found myself reflecting on the nature of life and death. The wheel that keeps turning as one leaves this earth and another one is ushered in. For this young mother her birth brought death. Her sorrow profound.
No sooner had I let the placenta slip into the rectangular stainless steel basin at the foot of the patient, when I heard that familiar clang of wheelchair, patient, and practitioner against wooden doors. A frenzy of energy exploded as the nurses shouted in Miskito, and the patient grunted with force. I tore my soiled gloves from my hands, and reached for a new packet, tearing the rough paper open, letting out a spray of white talc. I struggled to pull the gloves on with speed. I don’t think I could describe what the patient looks like in detail to this day. All I saw was the telltale puffed cheeks, moist brow, and white-knuckles clutching the arms of the wheelchair that told me this baby was coming NOW! Right hand covered. I lowered the left glove about half way on to my hand when I witnessed the head and body of a vigorous, pink baby girl slip out from under her mothers black floor length skirt dotted with white flowers, famed by the wooden doorway. The physician gracefully arced his bare left hand from shoulder height to wheelchair height to stay the child as I swept in, less gracefully, with gloved right hand to catch the body. The other midwife scrambled to the side of the wheelchair to place clamps about the umbilical cord. Clamp-clamp-cut, and I was carrying the newborn, fists punching, legs kicking, to the newborn warmer,
This is the irony of birth, life, and death. I felt the wheel of life spinning as within 5 minutes I witnessed the birth of this first time mother’s deceased babe, and then a baby deliver herself from a woman who is a mother many times over.
The joy, and sometimes the terror of obstetrics is the unexpected. Just as on this Tuesday, one never knows what the day will bring. So at 11 am without a whisper of a patient, and a maternity ward bereft of patients I started to become bored. Twelve hours is a long time to fold gauze. And then I heard the now familiar clunk-clunk of the two sets of double wooden doors being forced open by a patient’s foot and the clambering wheels of the wheelchair as the driver negotiates the chair around the receptacle full of dirty linens, the yellow trash barrel, and decomposing cardboard box full with random medical supplies in his midst. The physician was driving, clutching a bag of IV fluids with 5 units of oxytocin with one hand, guiding the patient haphazardly with the other.
We helped the patient onto the expulsion table, a bright blue gym mat over a metal base, thick white plastic thigh supports at the practitioner’s end, a metal IV pole by the patient’s head. The young woman, dark circles under her eyes, thin and lackluster, was a first time mother whose baby had passed away, and well before his time. At 26 weeks the woman barely had a pregnancy bump. Her labor had been induced to relieve her of carrying this burden. She arrived in my hands with a fully dilated cervix. I gingerly reached my fingers inside to assess how near the patient was to delivery. My fingers came up against a joint, an arm, and a smooth roll of the shoulder, rather than the most common fetal presentation which is the solid skull. I felt panic rise in me. How would this baby deliver? I voiced my concern to the physician, “The shoulder is presenting, how is this baby going to deliver?” With a push on the patient’s abdomen he reassured me that it would be just fine, contrary to my instincts. But one brave push later the small arm made its way from womb to world, followed by its adjoining shoulder, then back, followed by bottom and legs that effortlessly slid up and out. Lastly, the head emerged as I delivered this shoulder-breech, expired preemie. The cord was cut and clamped. The baby lay limp and discolored on the green surgical drape. He weighed in at 1050g. The placenta slid forth soon after the delivery, small and misshapen by infarcts marking its slow shutdown as the fetus no longer thrived. I once again found myself reflecting on the nature of life and death. The wheel that keeps turning as one leaves this earth and another one is ushered in. For this young mother her birth brought death. Her sorrow profound.
No sooner had I let the placenta slip into the rectangular stainless steel basin at the foot of the patient, when I heard that familiar clang of wheelchair, patient, and practitioner against wooden doors. A frenzy of energy exploded as the nurses shouted in Miskito, and the patient grunted with force. I tore my soiled gloves from my hands, and reached for a new packet, tearing the rough paper open, letting out a spray of white talc. I struggled to pull the gloves on with speed. I don’t think I could describe what the patient looks like in detail to this day. All I saw was the telltale puffed cheeks, moist brow, and white-knuckles clutching the arms of the wheelchair that told me this baby was coming NOW! Right hand covered. I lowered the left glove about half way on to my hand when I witnessed the head and body of a vigorous, pink baby girl slip out from under her mothers black floor length skirt dotted with white flowers, famed by the wooden doorway. The physician gracefully arced his bare left hand from shoulder height to wheelchair height to stay the child as I swept in, less gracefully, with gloved right hand to catch the body. The other midwife scrambled to the side of the wheelchair to place clamps about the umbilical cord. Clamp-clamp-cut, and I was carrying the newborn, fists punching, legs kicking, to the newborn warmer,
This is the irony of birth, life, and death. I felt the wheel of life spinning as within 5 minutes I witnessed the birth of this first time mother’s deceased babe, and then a baby deliver herself from a woman who is a mother many times over.
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