The Cord

**While the story below is true, please note that all names, dates, and some details of the below story have been changed to protect the identities of coworkers, patients, and family members.**

A few weeks ago, I had an experience at work that changed the way I saw my profession, my work, my coworkers, and myself.

Now, I’m not a new nurse by any means.  So when I tell you that my experience was so fulfilling that I could hardly fall asleep after my shift was over, I’m not telling you this as a wet-behind-the-ears-noob with a freshly engraved stethoscope and rose-colored glasses glued to her brow.  I tell you this story as a nurse experienced in several different specialties of nursing; as a professional that was so burnt out a few years back that she questioned why she became a nurse in the first place.  I tell you this story as a nurse who has endured those demanding, arrogant, immature, or just plain aggravating family members; those obnoxious, loud, unreasonable, argumentative or just plain vindictive patients; and the painful introspection that those sometimes raw, utterly unpleasant interactions evoke.

I was just coming off lunch.  When I say lunch, I mean a night shifter’s lunch–it was just after midnight.  Everyone was taking turns heading in to eat and coming back out, leaving a few of us on the floor to keep an eye on things.

It was a night full of death, to be quite honest.  We had a record number of demises or pending demises in our facility–babies who had died or were expected to die either before or just shortly after birth.  I was caring for one of these patients, and the night had been a fairly quiet one.  In addition to our demise patients, we also had a good number of early patients–patients whose water had broken preterm, who had symptoms of preeclampsia, or patients who simply needed to be watched over until baby arrived for one reason or another.  At any rate, we had all of one actual labor patient, and being that she was a first-time mom who was being induced, the process was slower than a snail race on a hot July day.  The only thing potentially threatening to increase the activity level of our floor was a transfer who might be coming to our hospital from nearby–also a pending demise.

So as I exited the break room and returned to the main nurse’s station, I was a little surprised to hear a call bell alarm just as I arrived at my computer.  A tech on our floor answered the light, looked back at our assignment board, and promised a nurse would be there shortly.

“What is it?” I asked our tech, a short, quiet woman by the name of Carly.

“It’s the patient in room 20.  She wants her nurse to come see her.  She said she got up to the bathroom and felt pressure and something weird.”  Carly said, her facial expression betraying confusion, as if she wasn’t quite sure how to describe what the patient had told her.  “Tessa just went to lunch, though.  Can you go see her?”

“Yeah, of course.” I said, glancing at my computer, which displayed the unit census.  The patient in room 20 was an early patient, here because her water had broken at 29 weeks.  On her last exam, her cervix was high, thick, and barely dilated to one centimeter.

As I headed down the hall, I pondered what I might find.  Perhaps the patient’s water had broken more and she was feeling amniotic fluid leaking.  Still, that didn’t explain her saying she felt something “weird”.  My mind raced.  Could it be…?  The very idea of a prolapsed cord or fetal part made me walk a little faster.

When the umbilical cord prolapses, that is to say, falls out of the vagina before the baby is born, it is an emergency.  The patient must be transported back to the OR for an immediate C-section.  This is because the weight of the baby against the cord can pinch the cord off, meaning baby is no longer getting oxygenated blood from the placenta.  Brain injury and fetal death are two very real potential risks of cord prolapse, and it is one of the bigger emergencies that we see on L&D.

As I walked into Room 20, I saw the patient, Claire, and her husband, Ron, awaiting my arrival.  Claire sat on the bed, fully clothed. Ron sat on the couch.

“Hi, Claire.  I’m Sophina, one of the nurses working with Tessa tonight.  I hear you have something kinda weird going on tonight?” I said, approaching the bed and opening the drawer below my computer station, pulling out a sterile glove and gel.

Claire nodded. “Yeah, I just got up to the bathroom to pee, and I felt like there was something between my legs.  I don’t know if it’s maybe the baby’s leg or what, but I figured I should call you guys.”

The knot in my stomach was growing.  “OK, Claire.  Let’s take a look at that.  If you could slip off your pants for me, I want to check and make sure everything’s all right.”

As I pulled on my glove and swirled my fingers through the gel, Claire lay back in bed, slipped off her pants and underwear, and opened her legs just as I moved to the edge of the bed.  As her legs parted, I immediately glimpsed one of the scariest sights I’ve seen in all my years of nursing: a distinctly purplish-red umbilical cord lay coiled just outside Claire’s labia.

“Claire, this is going to be a bit cold.” I said as I grabbed the cord with my fingers and slid it back into Claire’s vagina, sitting down on the bed and quickly finding two little feet greeting me as I reached her cervix.  The cord, which had no pulse, was wedged between baby’s feet and mom’s cervix.  I pushed the feet apart, freeing the cord and manually holding the cervix and surrounding tissues open, ensuring blood flow could freely travel the full length from placenta to baby and back again.

By then, my heart was pounding.  I looked up at the wall where the call bell sat, just out of arm’s reach.  I glanced at the fetal heart machine–also out of reach.  It was then that I noticed Ron, who had darted to the door, obviously sensing that something wasn’t right.

“Ron, go out to the nurse’s station.  I need everyone in here now.” I told him firmly but calmly.

Ron nodded. “Oh–Ok!” He stuttered, jolting out the door and down the hall.

I looked down at Claire.  Fear had overtaken her features. “Claire, baby’s umbilical cord has fallen out of your vagina.  I’m holding it in with my fingers, and until we get baby delivered, I have to keep my fingers in there so that baby can still get oxygenated blood.  We’re going to take you back for a C-section.  Hang on–we’ve got help coming.”

Claire nodded. “Is the baby–is she–?”

And just as soon as Claire began to ask the question, I felt one of those little feet kick against my fingers.

I smiled, heaving a breath of relief. “She just kicked me, Claire.  She’s still with us.” I said, noting more movement of those feet on my hand.

Claire nodded. “OK. OK.”  Tears welled in her eyes.

“What’s her name?” I asked.

“Gemma.”  Claire said as her eyes overflowed and her nose began to run.

“Take some deep breaths, Claire.  Keep that oxygen coming to baby.  Good job.  You’re doing just great.”  I said calmly as Claire began to follow my instruction, her eyes locked into mine.

I had no sooner finished speaking than my charge nurse, a thin, tall, self-assured woman named Amanda, zipped into the room, with yet another of my fellow nurses, Shelly, on her heels.  Carly was on Amanda’s other side and Ron was running steadily behind them.

“It’s a prolapse?” Amanda turned on the fetal heart machine and looked to me.

“It is.  I’ve got baby off the cord.  We need Dr. Daniels and Dr. Patel.” I said, referencing the OBGYN and anesthesiologist on call.

Amanda, while calling the front desk with one hand, was squeezing gel onto the fetal heart monitor with the other.  Shelly and Carly were rapidly preparing the bed for transport to the OR.  I picked my feet up off the floor, shifting to a kneeling position on the bed while keeping constant pressure on baby’s feet and Claire’s cervix.

Gemma’s tiny feet kept moving, and it took my constant attention to ensure that those little feet didn’t move into a new position and become wedged against the cord.  It occurred to me that in a constantly changing environment like the one inside Claire, any change–especially a subtle one that might perhaps go unnoticed by me in an environment I could only feel and couldn’t see–could be fatal.  Until Gemma was delivered, she needed my rapt attention.  With every move of baby’s feet and every minute change in position that Claire made, I had to make sure that cord remained untrapped.

“Do you have a pulse?” Amanda asked.

“No, but baby is moving.” I relayed.

Seconds later, Amanda scanned Claire’s abdomen, and the faint but steady pound of a fetal heart greeted our ears.  Baby was chugging away in the 90-100 beats per minute range, a full 30 beats per minute where she should have been at very least, but it was objective confirmation that she was still with us.

“OK, we’re good.”  Shelly said as she finished unplugging the bed and monitors.

“Let’s move!” Amanda said, turning off the machine, dropping the monitor and pulling a blanket over Claire and myself as the bed began to move for the hallway.

We dashed out of the room and into the hall, the crowd of four that pushed the bed steadily growing as we went.  We picked up Dr. Daniels and Dr. Patel somewhere along the way, and then a cluster of NICU nurses who were coming downstairs for our section.  Amanda was updating the physicians on the status of both patients and the course of events that led to the urgent stampede for the OR at all of one in the morning.

But as for me, my attention never fully left Claire and Gemma.  Claire was crying and I was giving her moment by moment updates–every kick, every nudge–while carefully monitoring what I was feeling on the inside and moving my fingers accordingly.  The two of us communicated quietly and sometimes silently, but as we rolled, I suddenly felt pulsation in that thick cord that lay between my fingers.

“I’ve got a pulse in the cord!” I exclaimed for all to hear as we rounded the corner to the OR.

“Get me a heart rate when you can!” Dr. Daniels, a tall, somewhat scruffy, but genuinely kind and highly competent OBGYN called as we crashed through the double doors into the OR.

Together, Claire and I moved in a closely coordinated effort from her bed to the OR table, my fingers steadfastly guarding that cord.  “Fetal heart rate is 90-110.” I called as Claire settled in on the OR table and I slid off the other side, standing to Claire’s right.  All had been well in the move; the cord was still free.

Everything was happening at once.  Amanda and Shelly positioned Claire on the table.  Dr. Patel started a second IV.  Jerry, our surgical tech, had the instruments set up within a minute.  Dr. Daniels inserted a urinary catheter just above my fingers, and Amanda prepped Claire’s abdomen.  In the meantime, Gemma’s heart rate was anywhere from 90 to 140.  With all the movement associated with preparing for surgery and the gymnastic effort of inserting a catheter above my fingers while still allowing me to maintain pressure on the vaginal canal and fetal feet, I focused all of my attention solely on the situation just inside Claire’s uterus, chasing Gemma’s feet and keeping Claire’s cervix off the cord.

I knelt next to the OR table on the floor as the sterile drapes came down over Claire’s lower body and my head.  Dr. Daniels stood in front of me; Jerry stood behind me.  From my new position, I realized I had lost my leverage for holding Claire’s cervix and vaginal canal open as well as for keeping Gemma’s feet pushed off the cord.  I was working against gravity and from a clear disadvantage.

“OK, she’s under! Go!” Dr. Patel sounded the shot that began the race.

Claire’s unconscious body began to move as Dr. Daniels swiftly cut down through the abdominal tissue, making a beeline for the uterus.  I struggled to keep my fingers positioned around the cord, my motivation to maintain and hold my position the same as it had been in Claire’s room and in the hallway.  There was simply no time for excuses or mistakes or fatigue, despite my cramping shoulder and aching arm.  One false move from me, one instance where I allowed something to escape my notice, one episode of inattention, and the baby whose feet I had been chasing for the past 18 minutes could die.

“How ya doin’ down there, Soph?” Dr. Daniels asked.

“Oh, I’m good.  How close are you?” I asked from under the drape.

“Almost there, Soph.  Hang in there.”  He replied.

“No worries.  We’re doing all right.”

And perhaps 30 seconds later, I felt those little feet lift off of my fingers, the cord slipping up and away.

“I got her!” Dr. Daniels exclaimed.

I was about to ask how the baby was doing when I heard a loud, rather vigorous cry.

The OR erupted in laughter and relief as the NICU nurses and respiratory therapist welcomed their new patient into the world.

Slowly, I moved out from under the drape, careful not to brush the sterile instruments as I made my way for the OR door.  I held my jacket over my mouth, having not had the opportunity to get a mask on the way in.  And as I exited, I saw a small, pink, squalling little life amidst the receiving blankets, and two little feet, still kicking.

I returned to the OR and recovered Claire in the PACU when the surgery was over.  I brought Ron and Claire’s mother into the room as Claire woke up.  I explained how things had gone, that Gemma was in the capable hands of our NICU personnel, and that her transfer was only precautionary–she was doing so incredibly great, despite the circumstances.  And as Claire woke up more fully, she suddenly recognized me, took my hand, looked to her mother, and said, “Mom, this is the woman who saved Gemma’s life.”

That was the first instance of the copious thanks that came my way that night.  Before leaving Claire and Ron with their new nurse on postpartum, Claire’s mother approached me for a fiercely grateful hug.  Claire then called me over for a hug herself, both of us nearly in tears.  And despite the death that had surrounded us that night, I left work that morning knowing that one baby was alive–for 20 minutes and for the rest of her life, she was alive in no small part because of me.

So when I awoke the next evening and took note of a soreness in my shoulder and an ache in my arm, I stopped, perplexed but for a moment until I remembered Claire, Ron, Claire’s mother, and little Gemma with those kicking feet.

I don’t think a sore arm has ever felt better.