Yesterday, like every November 17th was World Prematurity Day. I decided to share this beautiful experience and hope you get inspired. Enjoy
August 2nd, 1992. I was the duty house officer assigned to the labor and delivery unit of the Lagos University Teaching Hospital. I was doing a one-month neonatology stint as part of my three-month pediatric rotation, and I was on a 24-hour call shift.
I loved working in labor and delivery. Unlike many other parts of the hospital, it was, for the most part, a happy place.
The majority of the women who came in to have babies were relatively young and healthy, with a record of perfect attendance at the antenatal clinic. They arrived in the early stages of labor with their small, neatly packed suitcases of baby clothes, anxious about the impending pain, but excited at the prospect that in just a few hours, the baby they had carried in the womb for nine months would be placed in their arms.
Having recently borne a child myself, I felt a deep sense of connection with these women. I felt honored to be a part of one of the most momentous events of their lives. Despite having attended almost a hundred deliveries, I never ceased to feel an unspeakable joy and sense of awe at that moment when new life came forth and the cry of a newly-born child filled the delivery room.
Just before midnight, Mrs. A was wheeled in from the prenatal ward, where she had spent the last three weeks on admission. Pregnant with her first child, she had started having contractions at just 28 weeks of gestation, 12 weeks before the baby was due to be born.
She had been placed on strict bed rest, tocolytics (drugs that inhibit contraction of the uterus or womb), and low doses of steroids to help the baby’s lungs mature in case a premature delivery became inevitable. At 31 weeks of gestation, her membranes ruptured and the contractions began to get stronger. She was now dilating steadily and delivery was imminent. The neonatal team, comprising two residents and myself, were alerted to stand by to resuscitate the baby.
Baby A slithered out from the safety of his mother’s womb at about 3.00am, still and silent, but red and warm. He was tiny, perhaps 20cm from crown to heel, with arms the circumference of my little finger and legs only marginally thicker. His skin was thin and wrinkled, his spidery veins showing clearly beneath the surface.
He could easily have fit in the palm of my hand. The senior resident clamped and cut the cord, and whisked him off to the resuscitation room where she placed him beneath a radiant warmer to keep his body temperature from dropping. She suctioned his airway for a few seconds, then placed a tiny breathing mask over his face and proceeded to ‘bag’ him. His little chest began to rise and fall as Dr. O lightly compressed and released the Ambu bag attached to the mask, sending little puffs of life-giving oxygen into the tiny motionless form.
The junior resident swiftly inserted a miniscule cannula into a vein on Baby A’s ankle and started a slow drip infusion of glucose and water. I stood by watching, anxiously willing the baby to move, cry, breathe; give us a sign that he intended to live. One minute passed. Two minutes. Baby A stayed red, a sign that his lungs were sufficiently mature to absorb oxygen into his bloodstream. We were hopeful.
Dr. O lifted the mask off his face and watched him closely for about five seconds. Nothing. He didn’t move. She replaced the mask and continued to bag him. I started to pray. After three endless minutes of bagging, Baby A twitched, jerked his arms slightly, and opened his mouth. Dr. O lifted the mask off his face and a faint mewing sound ensued. Baby A cried! Hallelujah!
We stood by as Baby A took one rapid shallow breath after the other, mewing intermittently. Dr. O held the mask close to his face without actually covering it so that he could inhale the oxygen-rich mix. Our joy was shortlived.
After about a minute of taking struggling breaths, interspersed with intervals in which his chest was still, Baby A’s bright red skin began to darken. He was not getting enough oxygen. Dr. O put the breathing mask back over his face and bagged him again for about a minute. He reddened up. She took the mask off, and he breathed on his own again for a couple of minutes, but then stopped and started to turn blue. He simply was not strong enough to keep breathing on his own. He needed a respirator, and there was none. The only one LUTH owned at the time had been faulty for several months.
After about ten cycles of bagging Baby A, letting him breathe on his own until he ran out of strength, and then bagging him again, Dr. O handed the Ambu bag to me and pulled up a stool. “Sit here and bag him. I’ll go and talk to the relatives. Maybe we can take him to St Nicholas. I think they have a neonatal respirator there. Let me find out first, then I will come back and insert a breathing tube.”
She left the room, the junior resident in tow. I sat there with Baby A, gently squeezing the bag at one-second intervals. Every now and again he would move his tiny limbs or let out a few faint cries. I put my finger in his tiny hand and felt the beginning of a grasp reflex as his fingers tried to curl around mine. My heart constricted. I was in love. Minutes passed, then hours. The nurses came and went, asking me each time if he was now able to breathe on his own. “No, not yet. But if we can get him to a respirator, I am sure he will live”.
I bagged Baby A for four hours. Dr. O never came back to tell me if there would be a respirator for him or not.
In the morning, the matron came in. Without saying anything, she walked over to me and took hold of the mask and Ambu bag. I looked at her through bleary eyes, unable to voice the question that was swelling like a lump in my throat. She pulled the apparatus from my hands. “Go and rest Dr”, she said. “I will bag him.”
I knew in my heart what she was going to do. She would stop bagging the baby and let him die. There would be no respirator. And we could not bag Baby A indefinitely.
I wanted to protest but I was too tired and emotionally exhausted to say anything. I walked out of the resuscitation room with a heavy heart and tears gathering behind my eyes.
Later that day, Dr. O found me in the NICU (neonatal intensive care unit) filing test results as I prepared to round up my call shift. “You know Dr”, she said, “in medicine, there is sometimes nothing you can do to save the patient. But it is good that you still try. I am sorry. There was no respirator available at St Nicholas. They only have one, and there is a preemie on it already”.
As I went home to my baby daughter that day, I thought about Mrs. A, who would soon be going home to nothing, her suitcase of baby clothes still neatly packed.
Today, on World Prematurity Day, I remember Baby A, whom I knew and loved for a few fleeting hours all those years ago. He would have been 24 now, filled with the handsomeness and energy of young men, maybe doing all sorts of awesome things with his life. Some would say it was God’s will that his life would be over before it had started. I don’t really believe that.
He was just unlucky to be born so premature, in a sad excuse of a tertiary hospital, in a corrupt, low-income country that has no value for human life. In another clime he might have survived. I do not know if NICUs in our tertiary hospitals are better equipped now. I would hope so, but I doubt it. Maybe some, but probably not the majority. Our health system needs a lot of improvement if these tiniest members of society are to be given a chance to live.
But there are happy preemie stories too. Stories like that of Baby R, who was born at 29 weeks and left for dead until a vigilant nurse noticed that she was still breathing. What followed was weeks in an incubator, months in the hospital, and years of follow-up appointments and medical procedures. And medical bills too, lots of them.
But, to the glory of God, Baby R is with us today, seven years and counting, happy, and healthy and smart, the pride and joy of her parents.
Her mother Petra has established Tiny Beating Heart (TBHI), an organization that raises awareness about the causes of premature births and what expectant parents can do to reduce the risk of their baby being born too soon. Tiny Beating Heart also supports parents of preemies as they go through the trials of nursing a baby that requires up to ten times as much care and emotional strength and financial expense as a full-term infant.
Most who are reading this may not be able to do much about the systemic ills that plague our health system, but you can, if you care, reach out to a preemie parent though TBHI. Head over to TBHI’s Facebook page or website to find out how. (http://www.tinybeatinghearts.org/)
RIP, all the Baby As who did not make it.
First written by Dr. Joanna Nwosu on November 17, 2016.