A Rude Awakening

If you happen to be friends with, live with or spend enough time around nurses, you’ll likely be privy to a discussion about our work.  A common need amongst nurses is to vent after a long or stressful shift, and often times, that vent falls on the ears of the family and friends who are nearby.

However, while airing the mishaps of our most recent disaster may do us a world of good, most of us don’t realize how much information–be it technical medical terminology or slang–our family members and friends pick up in passing conversation–that is, until it’s used against us…

It's A Shoulder! 1

It's A Shoulder! 2

It's A Shoulder! 3

It's A Shoulder! 4

It's A Shoulder! 5

It's A Shoulder! 6

Reference for the noobs/non-medical:
http://www.aafp.org/afp/2004/0401/p1707.html

No One Likes A Purple Baby

You can’t always tell a “bad” baby by the fetal heart strip.

That is to say, some babies look fantastic during labor and all the way through pushing, but when kiddo is born and the big moment comes, they just can’t seem to get the hang of “life on the outside”.

The majority of babies transition well.  When L&D nurses talk about babies “transitioning”, we mean the process that takes place immediately after birth where baby goes from being in-utero and fully dependent on mom’s body to breathe, feed, and remove waste to suddenly having to do all of that for himself.

Like I said, most babies figure it out on their own within moments of being born.  They take a surprised breath, and with a bit of drying and physical stimulation, they start to cry, their skin turns pink, and wa la!  Life doesn’t really begin as much as it just continues.

Still, my hospital requires that at all births, there is a nurse present for mom and a second nurse present for baby.  This ensures that if there is an emergency with either, both have their own dedicated staff member present and fully in-tune with their history and their treatment. The last night I worked, I got a great reminder of just why we require two RNs to be present at all births.

The Scenario

The nurse who had the patient in room 2, Barb, was an experienced L&D nurse who had an orientee, Marcy, working with her.  When one of my other coworkers mentioned that Barb and Marcy’s patient was about to deliver, I took a look at the strip and started heading down the hall.  As I was “up”–patient-less and waiting for an assignment–I was ideally free to help in the meantime.

“Well, I dunno, Sophie.  She should be good.  She has Marcy in there with her, and she’s almost off orientation.”  Breanna called from the desk.

“Oh, it’s no problem.” I replied, keeping in mind the happy FHR strip I had just seen on the monitor.  “You never know, after all.”

“True.”  Breanna agreed plainly.

As I arrived in the room with the doctor and the surgical tech, I prepared the bassinet, laying out the blankets, placing a blanket on mom’s chest, and making sure that suction, oxygen and my emergency equipment was functioning and turned on.

Barb and Marcy were helping their patient push, which was taking longer than they had expected for the first-time mom, but baby was clearly at about a +2 station and making progress with each push.  About five minutes later, baby’s head emerged, followed by the rest of his body with one last push.

As the doctor cut the cord, I stepped up at the bedside, drying and stimulating the baby as he was placed on mom’s chest.  APGARs are a little low on this one, I noted as I realized the baby wasn’t crying, had central cyanosis, and he wasn’t moving much.  Moments later, I heard the distinct sound of grunting on the end of each breath and retractions appeared around baby’s sternum.

Seconds into meeting this new little boy, it became obvious that he would require a little extra attention.  I kicked my assessment skills into high gear as I reached for my stethoscope to take a closer look.

Drying, Stimulating and Crying

Drying a baby is important as babies have difficulty maintaining their own temperatures, so the longer baby stays wet, the more likely it is for him to get cold and potentially experience some of the consequences thereof: dropping blood sugar, lethargy, and low blood oxygen to name a few.  While some of the “goop” (AKA: vernix) that baby is born in has been shown to protect baby against infection and help regulate baby’s temperature, making sure baby is dry is of paramount importance immediately after birth.  It is important to note that while some of the vernix will come off with drying, enough will stay on the newborn to provide the benefits associated with delayed bathing (which is a topic for another post!).

A natural result of drying baby is the stimulation that occurs when the blanket makes contact with his skin, and this stimulation usually causes babies to cry.  Crying will naturally help to clear any fluids that baby might have gulped on his way out, therefore opening his lungs and getting him used to the idea of breathing on his own.

Skin Color

Cyanosis is a general term that refers to a bluish coloring of the skin due to a lack of blood flow or poor oxygenation.  A little cyanosis of the hands and feet actually isn’t uncommon in newborns and is called acrocyanosis.  Acrocyanosis occurs normally as baby transitions from being in-utero to having to breathe on his own after birth: slower or decreased blood circulation to the extremities is normal as baby’s body learns to support itself through breathing.

Central cyanosis means that a baby looks purple or blue in his or her trunk.  When the infant’s chest, abdomen or face appear purple, it can be a sign that baby isn’t getting enough oxygen all around.  Though central cyanosis isn’t in and of itself indicative of decreased oxygenation, it is an indication to place an SPO2 monitor on baby’s right hand and make sure that the discoloration you’re seeing isn’t from low O2 levels.

Muscle Tone and Startle

Decreased movement is another potential sign of trouble.  When babies cry, they naturally tense their legs and arms.  In general, crying is a whole-body experience for a newborn.  Also, in addition to the stimulation of having been born, the noise and light associated with birth often triggers baby’s startle reflexes, and if baby doesn’t have good muscle tone and good reflexes pretty quickly after birth, this can point to trouble.

Of note: this can be a sticking point for babies born by C-section.  Vaginal birth and the process of emerging from the birth canal–and all the squeezing that entails–can naturally stimulate a baby as he’s being born and also force fluid out of baby’s lungs.  C-section babies aren’t privy to this particular set of benefits, however, and as a result, sometimes babies born by C-section require a little extra attention to get them to perk up after birth.

Retractions and Grunting

Retractions are a fancy term for when the skin pulls in around baby’s ribs and sternum as he tries to breathe.  The direct result of a baby working extra hard to pull in air, retractions are a sign of respiratory distress in newborns.

The same goes for grunting, which initially sounds like baby is humming a song.  As baby exhales, he closes his glottis (which normally covers the airway when you’re swallowing food or fluids), which causes a distinctive “ah-ah-ah-ah-ah” sound.  In doing so, he causes a change in pressure in his chest that helps improve his oxygenation.  If a baby is resorting to grunting, chances are, he will need some assistance in the breathing department, whether that be suctioning, oxygen administration, chest percussion, or a combination of all three.  Grunting can be a last-ditch effort to open baby’s lungs before things go south, and I’ve seen grunting babies decline from grunting to assisted ventilations (bagging) to intubation (ventilator) depending on the source of their respiratory compromise.

*Of note: breathing is a big deal.  I know that sounds like a given, but in most babies who require resuscitation, breathing is the culprit of their distress.  Say you have a baby who’s born at term with central cyanosis and a no heart rate.  Even before you consider starting chest compressions–even if baby didn’t have a heartbeat at all–per Neonatal Resuscitation Guidelines (NRP), you must give adequate assisted ventilations (bagging) before starting chest compressions.  Most of the time, correcting problems with baby’s breathing will correct everything else.

APGAR Scores

At one minute, five minutes and ten minutes after birth, nurses assess something called an APGAR score.  This quick, objective assessment looks at five categories: skin color, heart rate, breathing effort, muscle tone, and reflex irritability.  At most, baby can get a “2” in each category.  At the least, he can get a “0”.  So on a scale from 0 to 10, an APGAR score tells a provider quickly how a baby is transitioning.

At one minute, my baby scored as follows:
Breathing: 1 -irregular, discoordinated breathing efforts
Heart rate: 2 -pulse is 150bpm, normal range
Muscle tone: 1 -baby has some muscle tone present, but less than normal
Reflex irritability: 2 -baby’s reflexes are normal
Skin color: 0 -baby has central cyanosis

Total APGAR: 6
(As a reference, most babies are born with APGAR scores of 8-9.  A score of less than 7 indicates a need for medical attention).

Back to the Scenario

With baby’s physical assessment looking borderline, I took the baby to the warmer with his mother’s enthusiastic permission.  I placed an SPO2 (blood oxygen) monitor on baby’s right hand and looked for a baseline.  Heart rate was in the 170’s–up from when I had listened to him on mom–and his blood oxygen was lower than normal.

With audible gurgling and coarse lung sounds, suction was in order.  I suctioned baby’s nose and mouth quickly, immediately pulling out some thick, clear secretions.  Suctioning can be an irritating process to a baby which can have the added benefit of making baby cry.  My baby did just that.  He cried immediately after I suctioned him, producing more fluid from his mouth and nose.  A few suctions later, baby’s heart rate came down, his O2 went up, his retractions stopped and grunting significantly decreased, and we were looking at a much happier boy.

In the end, this baby did well.  He was brought back to his mother and monitored for the rest of his time in L&D, but he transferred to postpartum without issues and was discharged normally with his mom a few days after he was born.

However, this scenario just goes to show: a happy strip doesn’t mean a happy baby, and it pays to stay on your toes at all times!

That Awkward Moment When…

I know.  There are a lot of awkward moments in my job.  So I’ll be quick to clarify.

That awkward moment when…you save someone’s life and no one else* knows it.
(This does not include the responding nurses/physician!)

I had my first postpartum hemorrhage the other day.  It was terrifying.  Again, I don’t tell you that as a new nurse whose experience barely extends beyond the imaginative, scenario-based world of training.  And while the scene was unforgettable–arguably, indescribable, as after several edits, I still don’t feel I’ve captured the full chaos of the situation–one thing will always stick with me.

I was the only one who realized what was going on.

I’ll set the stage for you.  I’m about at the end of a recovery after a fairly difficult vaginal delivery.  The patient is doing fine.  Baby is doing fine.  The mom has some visitors in her room and they’re casually chatting while I’m giving her some pain medication.  However, as I’m pushing the med, the patient starts to feel sick.  I hand her a bucket and she is very clearly nauseated, retching but unable to produce anything.  I think to myself, perhaps she’s simply naïve to narcotics.  That could be the case.  Some folks are extremely sensitive to narcs and will become sick quickly after an IV push.  However, it was just as I was starting to think that this was pretty intense to be a reaction to a narcotic, it happened–

A loud splash, as if someone had thrown a bucket of water on the floor.  I look down to see the biggest puddle of red I’ve ever seen creeping rapidly toward my shoes.  And then, a family member’s reaction so misplaced, I can barely believe what I’m hearing…

Hemorrhage 1

Now, let me pause here to explain to you how delivery beds are made.  They have a bucket underneath them that is specifically designed to catch blood during a delivery.  That bucket was in the path of this gush.  Delivery beds aren’t thin, either, meaning there is a lot of distance, including mattress and metal pieces, to travel through in order to reach the floor.  That’s a lot of stuff between the patient and the floor–plenty of material to slow down a fluid spill.  For blood to have hit the floor hard enough to splash…wow.  That’s a lot of blood.

All of this crossed my mind in the span of a few milliseconds before I reached for my poor patient’s boggy uterus and hit the emergency bells.

Hemorrhage 2

If, by some strange coincidence, you realize as you read this that you were among the family members who were sitting in the room when this happened, I really didn’t mean to be rude.  Let’s just say I was stunned–flabbergast–appalled at the thought that you were sitting at bedside during a massive postpartum hemorrhage and laughing as your family member was bleeding to death.

Don’t get me wrong: I don’t expect those guests to be medical experts.  But there is something strange and unsettling about people who laugh at of a volume of blood that is rarely shown in appropriate circumstances on TV, much less seen in a real-life situation involving a loved one.  I argue not for the medical proficiency of her guests, as this was not necessary to deduce that serious trouble was amiss.  Rather, there was a sickening lack of basic concern for the crimson pool that grew by the second and the simultaneously dwindling consciousness of the woman in bed.

At any rate, after an initial moment of stunned silence, the family members left the room, and in a matter of seconds, the cavalry arrived.  The patient was barely conscious, her blood pressure so low that the machine couldn’t read it.  I had pulled back the blankets to reveal a pool of blood in the bed, soaking the mattress and sheets from foot to waist.  One nurse was starting a large bore IV while another opened up the pitocin and fluids that were already running, infusing them in at full blast.  Another nurse put an oxygen mask over my patient just as the doc came running in, slid a hand into my patient’s uterus and pulled out some of the biggest clots I’ve ever seen.

In all, we estimated somewhere around 2.5 liters of blood lost in less than a minute.  Really, 2.5 liters.  Consider that te average human adult has somewhere in the neighborhood of 5 liters of blood circulating.  Approximately half of my patient’s blood had exsanguinated and now lay in the bed or on the floor.

After stabilizing my patient and cleaning up the veritable mess that remained, we let the visitors back in at her request.  I felt bad for the poor girl.  She had been up for over 24 hours, had gone through hell in labor, and now looked like death warmed over (and that is no exaggeration).  Her blood levels, even on the CBC immediately after the bleed, were low.  I expected she’d receive a blood transfusion before my shift was up.

But when her visitors came marching back in, to my amazement, they seemed to have forgotten the events that led to their abrupt eviction and instead, peppered my patient with comments like this:

Hemorrhage 3

Hemorrhage 4

I know what you’re thinking.  They’re probably just being nice, you’ll say.  They’re probably trying to make her feel better, you reason.

No.

Simply put, no.

I only wish their reaction could be attributed to some benevolent desire to make this patient feel like less of a train wreck than she was.  In fact, I made every effort to believe they were only being nice until I was eventually confronted by the uncomfortable facts: they were nothing short of completely sincere.

To boot, even my patient didn’t seem to understand the fact that she had done the Texas two-step with death that night and come out on top, even when I explained to her the extent of her bleeding, the meaning of her CBC results, and the fact that she might get blood to prevent spontaneous bleeds that could result from extremely low blood counts.

So it was an odd night to say the least.  I headed home feeling a bit off, knowing that I had done something incredible, but with very little acknowledgement.  It’s happened before, and I know it will happen again.  It’s just strange to be the one who experiences it in full: the crash in vital signs, the blood, the near-fatality, the incredible response of the staff…

…and to go from all that adrenaline, action and real-life heroism to a patient and family whose biggest concern is…when the mom can have something to eat.

However, as one of my more thoughtful coworkers pointed out, maybe it’s better that way.

The Catch

**Names in the following story have been changed to protect the privacy of patients and coworkers**

I’m proud to say that I recently found myself in my first precipitous birth–that is, it happened so fast that I had to catch the baby myself.

In some ways, doing a “precip”, as it is commonly called, is a rite of passage for night shift L&D nurses.  With many doctors in my hospital opting to head home and trust us to call them in time to deliver versus camping out in the call rooms just down the hall, this sets us up for precips, especially when you have a grand multip (a lady who has delivered 7 or more babies) come huffing and puffing into triage screaming, “The baby’s coming now!”  If you want to see an entire floor of L&D nurses run, be a fly on the wall when that scenario repeats itself.

My experience wasn’t quite as dramatic, but it was a surprise nonetheless.  It was Alana’s second baby–those dastardly, sneaky second babies!–and she had been admitted at 1800 for an elective induction.  The previous shift had started her Pitocin just before I arrived, and by the time I took over, she was well on her way into labor.

Things progressed nicely, and soon, Alana was getting her epidural as contractions kicked out every 2-3 minutes.  Dr. Donaldson, Alana’s OB, had stopped by after her epidural was placed and broke her water, telling me to give her a call when Alana was complete and it was time to push.  Alana had had a long labor with her first baby and on our cervical exams, this baby’s head was still high, so we figured it would probably be a little while until Alana would deliver.  As I checked Alana’s cervix through the night, it was clear that she was making steady progress, going from a 2 to a 7 from the time she was admitted to the time of my last check just before midnight.

It was right as the hour hand was edging past the 12 when I asked my charge nurse, Erin, if I could head down for some dinner. “I don’t think my patient is going to last long enough for me to eat a normal meal from the cafeteria,” I had told her.  Two AM was when the cafeteria opened its full selection of the overnight meal, and being that it was a little over halfway through a 12-hour shift, most of us night shifters held out for 0200 with surprising tenacity.

Erin nodded. “Sure, we’ll keep an eye on things while you’re gone!” She said.

As planned, I headed to the cafeteria, scarfed down some lunch and headed back to my floor.  One of my coworkers had looked in on Alana while I was eating, and Alana was starting to feel lots of pressure with contractions–a good sign that things were moving along well.

I headed straight in to see Alana after lunch and noticed during a contraction that she certainly was having increased pain.  Suspecting that she might be making a quick move for delivery, I headed to the supply room for a straight cath kit (used to catheterize moms with epidurals who cannot empty their own bladders due to the anesthesia) and returned to Alana’s side.

A common trick of the smart L&D nurse is to check a patient’s dilation immediately after straight cathing her.  She is in the right position for a check (lying down nearly flat on the bed, legs apart and knees out) and if you keep the sterile glove on your dominant hand sterile during the cath procedure, you already have the glove and gel necessary to perform a cervical exam.

That had been my plan as I gelled up the catheter, slipped it into Alana’s urethra, and glanced at the clock.  It was just before 0115.  Making a note of the time for charting purposes, I glanced down at my cath tray to make sure I had enough gel for a cervical exam and looked back to Alana.

Alana’s perineum was bulging under my fingers, the distinct and growing form of a fetal head peering out between her labia.  I was so surprised, I had to look twice.  Sure enough, that was a head crowning.

“OK, I’m feeling a lot of pressure all of a sudden.” Alana said, her breathing suddenly labored.

I’ll bet you are! My mind exclaimed. “I’m not too surprised to hear that.  It looks like the baby is coming right now.” I said, pulling out the straight cath, throwing away the kit, ripping off my dirty gloves and grabbing a new set of sterile gloves as I pulled the emergency cord out of the wall.

“Right now?” Alana exclaimed.

I was hurriedly pulling on sterile gloves as the baby’s head pushed further and further out of Alana’s vagina.  “Yep, right now!” I replied. “It’s OK, Alana.  Baby’s almost out on her own.  Take nice, deep breaths for me and hang on while I get the cavalry in here.” I said, placing a hand on the baby’s head and supporting Alana’s perineum as I watched the baby wiggle her emerging noggin between contractions, working to help her mom push her out.

The door burst open. “You OK, Sophie?” Shelly, one of my favorite coworkers, asked as she entered the room.  As her eyes fell on the bed, they widened into saucers. “What do you need?” She blurted.

“A delivery cart, a tech and a charge nurse!” I said, keeping gentle pressure on the baby’s head as another contraction pushed the baby against Alana’s perineum.

“Oh, man, there’s so much pressure!” Alana grimaced.

“Breathe through it, Alana.  You’re almost there!” I coached.

“You got it!” Shelly said, ducking out of the room just as Erin, two other nurses and Jerry, the surgical tech, burst into the room.

“I’ve got a precip!” I called, now holding half of the baby’s face in my hand as Alana’s contractions involuntarily squeezed the head out.

“Oh, well!” Erin said, slapping on sterile gloves and zipping over to Alana’s side.  Shelly came running through the door with a delivery cart a few seconds later and I heard a sterile gown rustle just as Alana’s body kicked off another contraction.

“Here comes another one!” Alana shrieked.

Erin reached over Alana’s leg and slipped one hand around the baby’s neck, checking for a  cord.  “Push, Alana, push that baby out!  We’re here now–you can do it!”  Erin commanded, her voice full of reassurance and encouragement.

Alana needed no further invitation.  I moved my right hand to hold the baby’s head and held up Alana’s perineum with my left hand, guiding the slippery, wiggly little body gently out of her mother as Alana delivered her baby girl with minimal voluntary effort.  Even as the rest of the baby delivered, I noticed to my surprise that the newborn already had her eyes open.  A scream of indignation arose from the bloody, sticky little bundle in my hands and two dark brown eyes gazed up at me.  I don’t think I was able to hide my sigh of relief as I looked over the kicking, pink little baby and realized she had come out perfectly.

“Great job, Alana!  You did it!” Erin was congratulating the beaming new mom.

I was watching the baby, whose squinting eyes searched the room with a level of alertness I had never seen in a newborn.  Shortly after she was born, those eyes met mine and paused, her forehead creasing as if to say, “You’re not the doctor!”

Another nurse placed a delivery blanket on Alana’s belly.

Yeah, well, you’re not supposed to be here yet, you stinker! I replied mentally, placing the baby on Alana’s abdomen and drying her off with the delivery blanket as those beautiful cries filled the room.

“Nice job, Soph.”  Erin said quietly, joining me at the end of the bed. “Was that your first precip?”

“Sure was.” I replied, my heart still racing with the thrill of the moment.

“Way to keep your cool, girl!” She gave me a pat on the back and headed to the warmer for more blankets.

Jerry clamped and cut the cord, stepping into my place to check Alana for tears as Erin and I tended to mom and baby.  About fifteen minutes later, Dr. Donaldson arrived and confirmed that Alana had no tears–we were good to clean her up.  For about the tenth time, I told the story of how the baby was nearly born during a straight cath attempt.  Dr. Donaldson, a (thankfully) very laid-back physician, smiled and congratulated me, heading back home for some sleep.

L&D is by its very nature an unpredictable work environment–you never know what will happen from second to second.  And although that can often encompass a number of traumatic and terrifying experiences, I learned that night that not all surprises are bad.  Some of them are pink, kicking and crying with big brown eyes.

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.