Four years ago, the Friday before Mother’s Day, a team of Emergency Department nurses barreled through the double doors of my Labor and Delivery Unit with a term-pregnant woman. It was just before dawn and I had been the physician on call overnight. In anticipation of this woman’s arrival, I’d already shed my white coat and removed my wedding rings––prepared to transport her to the operating room. As the gurney clattered across the linoleum floor, the woman twisted her body and clutched the dome of her abdomen gathering the fabric of a blue hospital gown into her fists.
Throughout the night, bleeding, adhesions, and brand-new babies had stolen my sleep. After twelve hours of standing, gravity pulled blood into the veins of my feet, my ankles, my calves. I felt as if there were weights in my shoes––I was tired.
The windows on Labor and Delivery glowed gold. It was a typical Southern California morning––a city with gorgeous yet monotonous weather. Soon, the sun would warm the air, the asphalt, and the enormous seals lethargic on the La Jolla shore. Light would illuminate brilliant fuchsia bougainvillea and the wings of hummingbirds, osprey, and lanky blue heron. All night, I had anticipated the sunrise that would signal the end of my shift and my escape from the hospital.
As the Labor and Delivery nurses rolled the woman into a triage room, the emergency department team explained that her name was Lisa. She was thirty-eight weeks pregnant with two prior cesarean deliveries. Severe pain started at home along with vaginal bleeding.
The week before I met Lisa, I’d promised my five-year-old son, Zachary, and my three-year-old daughter, Esmae, I would attend their school’s “Muffins with Mom” breakfast in celebration of Mother’s Day. I am an obstetrician and Obstetrics is a conspicuous thief. It has stolen weekends, my husband’s birthdays, Sundays at church, family dinners, at least two Christmas mornings, Zachary’s first day of kindergarten, and my grandfather’s funeral.
In truth, missing those events and navigating the interruptions was a nuisance but not a burden. I found meaning in my job and possessed a physician’s arrogance: I served a unique role. I felt necessary in a hospital, which provided instant gratification. A baby delivered, a family consoled, a diagnosis made, all justified my absence from home and validated the story I worked to build around my value as a physician and a person.
But the December before my life intersected with Lisa’s, when I came home from work, Zachary asked, “Where were you? All the mommies and daddies were at the Christmas Party but you. Esmae and I had to sit with Jonathon’s mommy.” I imagined my children in a neat, sparse, yet beautiful Montessori classroom filled with tiny versions of common adult items––china tea cups, a blue metal pitcher, glass bowls, a short countertop with a sink. I pictured them still and sad as they both waited for me to stroll through the classroom door. I imagined Zachary and Esmae sitting beside Jonathon’s mother––a woman I’d never met. But I pictured her lovely like calla lilies, ballerina skirts, ivory cashmere, soufflé, ribbons, and monarch butterflies. She wasn’t a woman who wore a pair of bloody scrubs and missed Christmas parties.
I’d sent a plastic container of store-bought oatmeal cookies with Zachary and Esmae that morning––my children’s contribution to the potluck lunch––price tag stuck to the side. The package of cookies was reflection of my approach toward many traditional maternal tasks. I found little value in baking cookies, cakes, or brownies.
Lisa twisted her body like a fish on a line. She pulled her knees to her abdomen, and shifted her legs right and left. I leaned over the metal rails of her bed and asked if she had any medical problems. Was her pregnancy complicated? Did she have a surgical history? When was her due date? She provided fractured breathless answers. She asked me to save her baby. She called him Jonah.
Nurses held down Lisa’s arms so they could thread needles into her veins, draw labs, and start intravenous lines. An obstetrics resident quickly rolled an ultrasound machine next to Lisa’s bed. I positioned the probe on her abdomen then gazed at the black and white image on the screen.
A baby’s heart pumps twice as fast as an adult’s. In a healthy baby, on ultrasound, the mitral and tricuspid valves, the flaps of tissue that separate the chambers of the heart, open and close in rapid succession like the wings of a starling. Rapidity offers reassurance. But the myocytes, the cells that coordinated the muscle of Jonah’s heart, were starving for oxygen. They had lost the energy and strength to beat, thus they failed to pump blood through his body. His heart contracted then fell open in a slow and labored motion. Jonah was dying.
With the tone and intensity of a drill sergeant, I instructed the charge nurse to call a Code Purple. In our hospital, like a Code Blue, Code Purple meant a life was at risk––that someone, in this case Jonah, may die without immediate intervention. The code alerts anesthesiologists, pediatricians, nurses, and scrub techs, to hustle, run, dash through corridors and up the stairs, toward the operating room.
I maneuvered the foot of Lisa’s gurney out of the triage room toward the operating room. The resident ran next to me and a nurse sprinted ahead of us opening three sets of double doors at various points along the path to our destination. As we rushed through the corridors, I directed the nurse to call the blood bank, call the NICU, explain to them that Lisa was abrupting.
An abruption meant that inside Lisa’s body, the arteries that connected her uterus and her placenta, the source of oxygen, to her baby, were shearing apart. Blood surged from both maternal and fetal vessels and spilled into her uterus, which clamped down like a vice in protest. This contraction was the source in Lisa’s unrelenting pain. Like all pregnant women, a half a liter of blood flowed through Lisa’s uterine vessels per minute. The bleeding was torrential. She and Jonah were hemorrhaging to death.
I had planned to leave the hospital at 8 o’clock that Friday morning. I would get to Esmae and Zachary’s school by 8:30 a.m., when the Mother’s Day celebration would begin. At that time, Zachary and Esmae would be choosing chocolate chip or blueberry muffins, opening their cartons of milk, and taking their seats at short square tables.
Every day that week, my children reminded me of the event and every day I promised them I had not forgotten. They excitedly described the details of all the presents they made for me: popsicle stick picture frames, ceramic necklaces, cards, and painted boxes.
Outside the operating room, the obstetrics resident handed me a surgical cap and mask. As I tugged the gauzy blue bouffant over my hair and tied the mask behind my head and the nape of the neck, I pushed through doors and passed the scrub sinks. Those sinks would remain silent––no hum of the plumbing, no water spraying on steel. We would not wash our hands. In emergent cases, sterility transforms from a necessity to a luxury.
Inside the operating room, a team of anesthesiologists and nurses moved Lisa onto the operating table. The pediatrics team set up equipment needed to resuscitate Jonah. A scrub tech opened a rectangular metal box, removed instruments and laid them on a sterile blue table––a scalpel handle, Kelly and Alice clamps, hemostats, Richardson retractors, bladder blade, Debakey forceps, Ferris-Smith forceps, Russian forceps, Adson forceps, Bovie tip, needle drivers, Metzenbaum and Mayo scissors.
I ignored Lisa’s cries and questions. There was no time to address them and I had no answers. I ran through a surgical checklist in my mind. I asked if we had antibiotics in the room. I positioned huge circular lights over Lisa. Then I picked my surgical gown off the back table, stretched my arms through the sleeves, and pulled gloves over my hands. There was no time to count instruments and no time to scrub Lisa’s abdomen. Lisa and Jonah’s condition forced us to start the case without performing the rehearsed rituals associated with almost every surgery.
A nurse tied the back of my gown. Another nurse opened two bottles of betadine and squeezed them onto Lisa’s abdomen––a crude, rapid, and likely ineffective way of sterilizing her skin before I cut through it. The brown liquid pooled in her umbilicus, spilled over her belly, then dripped down her pale flanks like a massive ink blot. The scrub tech passed me the blue surgical drape. In a synchronous motion the resident and I unfolded it over Lisa’s abdomen.
Then I paused. I could not start the surgery––I could not slice into Lisa’s skin––until medications rendered her unconscious. It took energy to alter the inertia I had set into motion. I shivered because a cold sensation grew and spread across my body––the sort of cold that comes when wind pulls sweat from your skin. I shivered because adrenaline zipped through my blood vessels teasing the muscles I worked to keep still. The commotion in the operating room had ceased. I heard Lisa’s cardiac monitor chirp. I folded my arms across my chest and bent my right leg then my left to the rhythm of her heartbeat––a subtle sway.
The anesthesiologist pushed Propofol, a thick white anesthetic, into intravenous tubing that snaked into Lisa’s arm. When her body relaxed, I peered over the blue surgical drape. He slipped a tube into her throat. “Go,” he said.
The resident pulled a scalpel over Lisa’s skin, cutting down to her fascia with one clean swipe, then handed the instrument back to the scrub tech. We hooked our fingers through two small nicks in the silver and white fibrous tissue that held Lisa’s abdomen together. We leaned back with all of our weight bending at the knees like water skiers. The force ripped open her abdomen. I split Lisa’s rectus muscles then felt the warmth of her abdominal cavity as I pushed my index finger through her peritoneum––a thin glistening membrane that draped over her organs.
The swirling muscle of Lisa’s uterus should have been pink. Instead, like India ink, shades of purple and black spread and diffused across its surface. Blood had seeped from her placenta into the centimeter of muscle that separated Jonah from me. The scrub tech placed a scalpel back into the resident’s open hand. Then he incised the lower portion of Lisa’s uterus entering the space where Jonah had thrived and grown for thirty-eight weeks. A tide of blood tinged amniotic fluid spilled from the incision, over Lisa’s abdomen, splashed onto the floor, soaked the bottom of my scrubs, shoes, and socks. The resident grasped each side of the uterine incision then pulled it open.
A blood clot, the size of a cantaloupe, erupted from Lisa’s uterus. I reached down into her pelvis, wrapped my hand around the top of Jonah’s head and pulled it up to the incision. The remainder of his slippery body followed with ease. Sixty seconds had passed from the time of Lisa’s skin incision to Jonah’s delivery.
Jonah’s dusky arms and chubby legs hung from his body motionless. He did not cry or gasp. His face did not grimace, his mouth remained still, gaping, and blue. I held his flaccid body in my hands. “Oh God,” I thought. “He’s dead.”
The resident clamped Jonah’s thick rubbery umbilical cord with two Kelly clamps and cut it with a pair of heavy scissors. Then I placed Jonah into the arms of the pediatrician. She carried him to the neonatal warmer, rested a stethoscope on his chest, and announced, “No heart beat.” Meanwhile Lisa’s uterus was failing to contract and the thousands of the spiral arterials that supplied her uterine muscle gaped open spilling blood into her pelvis, turning the surgical field into an opaque red lake. The resident sewed and stitched with a swift mechanical motion while I soaked up and swept away blood with white laparotomy sponges. Lisa had already bled enough to consume most of her clotting factors––proteins that achieve hemostasis. The more she bled, the more her body consumed the factors, and the less her blood clotted. In this situation, the only treatment is transfusion. Unless we replaced Lisa blood faster than she lost it, she would never stop hemorrhaging.
In the corner of the room, the pediatricians worked to save Jonah. They pushed epinephrine, performed chest compressions, and announced time, “One minute, no heart rate. Five minutes, no heart rate. Ten minutes, no heart rate. Fifteen minutes, no heart rate. Twenty-five minutes, no heart rate. Time of death, 7:10.”
Lisa continued to hemorrhage. I compressed her uterus in my hands slowing the bleeding while we repleted her blood and clotting factors. With my hands in Lisa’s pelvis, I asked one of the nurses to contact my husband, “Tell him my kids cannot go to school today.” I would not leave the operating room in time to make it to their school. I could not bear the thought of Zachary and Esmae waiting for me.
The morning Jonah died, no one reached my husband. Zachary and Esmae waited in their classroom. They waited with ceramic necklaces, popsicle stick picture frames, handmade cards, and homemade boxes. They each picked a muffin for themselves and they picked one for me. My kids did not know I saved a woman’s life. They did not know that Jonah died. And to them, those truths did not matter.
When I finally finished the case and stabilized Lisa, she woke, then asked about Jonah. I said nothing. Though I knew the inside of her body, though I had worked to keep her alive, though I held her son as he died, I did not know Lisa and she did not know me. We were strangers. She deserved to have someone else, someone closer to her, unveil the devastation.
As the anesthesiologist transferred Lisa to the Intensive Care Unit, I lumbered out of the operating room. My back hurt. My jaws were tired from clenching my teeth. My eyes had grown heavy.
Outside, the morning was ablaze and dust sparkled in the sunlight as it stretched through windows and across the hospital floor. The day-shift obstetrician, a colleague, had taken over the unit. He met me at the nurses’ station. As I approached, he opened his arms to hug me. I rested my forehead on his shoulder, then cried. We were not close friends. We did not confide in each other. We did not eat lunch together. But the pain we experience as obstetricians in the midst of losing a baby is universal.
After I settled, I collapsed in a chair. The rest of the world moved as it would any other Friday morning. Residents managed the laboring patients––flitting in out of rooms. Nurses wove through the unit. Pregnant women waited at the front desk to check into triage. Someone had abandoned a travel mug on the counter next to me. My white coat draped over the back of the chair where I sat. Monitors tweeted as they recorded fetal heart rates. Like a culture shock, I reeled from the contrast of the mundane world outside the operating room with what I had just experienced inside of it.
A social worker called from the Intensive Care Unit and informed me that Lisa knew Jonah had died. I made my way through the corridors of the hospital to Lisa. Through the glass doors of her room, she saw my pink scrubs, and panicked. I heard her say, “Don’t let her in here. She killed my baby.”
I bent over, put my hands on my knees and worked to catch my breath. I neglected my children who waited at an oak table with a muffin at an empty seat intended for me. I failed to keep my promise to them. For what? A dead baby? A critically ill mother? Painful accusations? This was an excruciating trinity. I found no solace or explanation for that morning. I dissolved into despair while Lisa suffered and grieved.
Four years after I delivered Jonah, on Mother’s Day, I wore a bracelet Esmae constructed out of clunky foam geometric beads and a pipe cleaner. She had asked me to promise I’d wear it all day, even to work. With great joy, I wore the bracelet. But after Jonah died, I quit making promises to my children because I break them. They forgive me. But I fail to offer that grace to myself. So, I don’t make promises.
But on that Mother’s Day, with Esmae’s awkward bracelet dangling from my wrist, I opened my laptop. Lisa’s name was in my email inbox. She had found me and sent a message. With reluctance, I opened it.
What waited for me was a great deal of peace. Lisa explained that she now had solace on Mother’s Day. The memories of Jonah were more of a celebration than a source of pain. I have always loved Lisa and Jonah in my own way. I bore witness to Jonah’s life and then death. I knew Lisa in the midst of excruciating pain. But I believed she would never understand how her story affected me as a mother and a physician. Yet, in her message, she acknowledged my pain and thanked me for enduring it so I could continue to take care of women like her. She shared that she only had to face the death of a baby once but knew as long as I practiced obstetrics, the tragedy would not end for me. Then, she wished me a Happy Mother’s Day.
***
Names have been changed.
***
Rumpus original art by Maryam Afaq Ansari.
