In the Realm of Hysteria II

There is something that frightens me about Obstetrics.

It is almost expectant in the course of life that women somehow naturally go through childbirth. Perhaps a rite of passage into womanhood. Perhaps the joy and responsibility that accompany bring a new life to earth. But from what I've seen, I would describe it as a trial by fire, through tempting and dancing with fate and death.

And almost certainly, we are talking about two lives simultaneously, mother and child. No one can predict the exact outcome.

At my first afterhours shift, the Birth Suite is ghostly quiet.

"Oh I don't like the feel," says more than one midwife and doctor, "it's like the calm before the storm."

"Let's not worry about later, here," I proffered chocolate that has become public property lying about on the station desk, "have an easter egg."

As we munch on the generosity of perhaps the hospital, perhaps some staff member, perhaps some patient, sure enough we catch wind of a lady coming in with preterm labour. The new senior doctor responds to my naiive questioning and looks up clinical protocols and guidelines on the computer.

Within ten minutes, the ambos arrive with a stretcher bearing a woman in emotional distress. Always dramatic, always effective. Not always delivers, though. You can never tell the severity of a problem when people arrive via ambulance. Well, perhaps if they had someone jumping on their chest, yes, that would be barn-door. Yet that almost never happens.

The woman is in her mid-thirties, with a wild look in her eyes. She pants and grimaces, and occasionally a cry erupts. By dates she is only half-way through her pregnancy, bearing twins through in-vitro fertilisation. She is angry at the situation and wants to keep her babies desperately. We reassure her we will try to stop the labour by giving her medications, but we may not be able to stop it, and she will deliver two extremely premature babies. Babies, unfortunately, have a very low survival rate at 24 weeks, and hers are only 22 weeks old.

The next half hour saw me fail a cannulation amongst her agitated continual questioning of "is there a chance...?" "what if...?" and negotiations of private versus public care. In the meantime, the medications have failed to stop the contractions, and the first examination revealed bulging membranes and outline of the first twin's hair and scalp, even I could see it standing in the back of the room. The babies were coming, despite our efforts, despite our hopes, despite their grim survival.

The boss on call arrived, and attempted a conversation to the woman's unlistening ears. Her husband held onto her hand, hovered in the background, with pain in his eyes and a flushed face. The paediatricians arrived and waited patiently in the corridor with the warmed resusitation cubicles. The private obstetrician arrived, knowing the inevitable, and reinstated what we already said.

"Noooo!" She yelled, "Wait! Don't come now!" Holding her legs and buttocks tight. She was doing everything to fight the contractions. "Nooo!" She yelled with every tightening. There was now a small crowd that gathered in the corridor beyond her door.

"But there is a 5% chance of them surviving, right?" She pleaded to the air in between grunts and yells now, the contractions were becoming closer and closer.

I admired the senior doctor, a general practitioner, in his gentle yet firm manner as he continued to guide her during delivery. The membranes were ruptured, and pale yellow amniotic fluid gushed onto the bed, mostly caught by the midwife's skilled placement of a kidney-shaped dish and slight turn of the face to avoid splash injury. "I'm sorry, I'm sorry, I'm sorry," she said to her partner, who holds her head and shoulders and turns his head away in visible tears.

Eventually, the first baby was delivered. Size of a small kitten, skin so thin and tightly stretched that it appeared a deep pink, tiny configured features, waving his arms and legs in the air in the unfamiliar environment. The cord was cut and baby quickly swathed in warm towels and shipped outside to the waiting clinicians.

And so the second baby came, also a boy, this time feet first. Breathing, animate, just like his brother as he emerged. And then the injection for the uterus to contract down again and the placenta delivered uneventfully. A warm, fleshy, bloodied mass, not unlike soft coral.

By now, the new mother has relented, and asks only that we try everything for the babies to survive. We nod and say they are in good hands, but that she does not keep her hopes too high.

I depart from the room, to look for her blood type on the computer, and lingered to listen in on corridor conversations from the bosses. The event is now over for the obstetric side, it is now a fight on the paediatric side. And perhaps a lifetime, for these two eager parents.

I take my leave as it was now at the end of my shift, having done little aside from feeling overwhelmed by the whole episode. I tried to reflect and cannot conjure up a better solution or communication effort for the night's events. I go to the adjacent ward, where the paediatric special care unit is, and assist the doctor there in placing miniature lines into the baby's umbilical cord, until I was truly tired, and long overdue for rest.

It's a difficult world, and one difficult to navigate in, emotionally and clinically. I used to think that transparency was the only patient communication that was needed. But now it appears so cruel, that we do not allow a shred of hope, even though the reality is a tough one.

Is Hope the only medicine? If so, what are we hoping for?