Of Life and Death
Updated: Aug 11, 2020
The time is 15:00.
I walk into the shift. We are now deep into the second wave. There was a few weeks of reprieve where we thought maybe, just maybe, it was gone for good.
The women have been coming in droves. Some are asymptomatic and we discover, well into the birth or after (due to screening), that they are positive, while others are very sick and present with fevers, coughs, shortness of breath, and general malaise.
I am asked to go to the Corona ward to meet a woman who is on her way with painful contractions wanting an epidural. The patient is in her second pregnancy with a fetus that has died in utero (unrelated to COVID-19) in labor and in pain. I grab the supplies and run.
I arrive at the Corona ward to find my patient sitting in room 1 on a wheelchair waiting for me. She is in pain and scared. I quickly get dressed while staying outside of the room, and saying to her (in Hebrew through an intercom), "Hi! I'm Gila Zarbiv your midwife! Don't be afraid! You're not alone! I'm right here outside getting dressed! You just can't see me!" She continues to look around agitated and I can't hear or understand what she is saying. A few minutes later I am gowned, gloved, protected, and I run into the room. It is then that I realize she is saying over and over in question form "amalia!?", which means surgery in Arabic, while indicating to her stomach. She is asking if we were going to be performing a cesarean section on her.
The Corona labor and delivery ward was built in seperate hospital building from the mother and baby center, in an old, and currently less used, operating ward. The bed sits in the middle of a large operating room with operating lights on the ceiling and a clear operating vibe all around. As I was getting dressed this woman was sitting there, for however many minutes it took me to gown up, worrying that she was going to have a cesarean section. She was agitated, confused, and scared. What to me took just a few minutes must have seemed to her an eternity. My heart broke for her fear. I shook my head emphatically and smiled (though of course she couldn't see). I explained to her (now realizing she spoke English) that this was simply the Corona ward and she was going to have a normal vaginal birth and I anticipated no complications. She immediately relaxed.
I realized that from now on I needed to request that the women be informed, before they arrive at the ward, that the birth will take place in an old OR suite and not to be alarmed. Hopefully that would prevent unnecessary concern and confusion in what is already a very difficult time.
The time is 17:00.
I quickly get her organized.
She receives an epidural (with an anesthesiologist that was able to speak to her in Arabic). I put in a urinary catheter, rupture her waters, start pitocin (a drug for inducing labor), and call her sister on video chat. Together, with the help of her sister translating, I explain the process of labor, birth, and final goodbye from her tiny baby girl. We walk through the paperwork of her wishes and desires for the baby's body, tests, and burial, hug, and cry. I bring her a cup of tea, turn out the lights, and leave her to rest.
Due to the fact that she is my only patient and the regular labor and delivery ward is swamped I tell them that I am fine on my own and there is no need to bring another midwife to help me.
The time is 18:00.
I sit and wait.
The time is 19:15.
I receive a call from the head midwife on the regular labor and delivery ward that there is a positive COVID-19 patient on the way in active labor. She was given no other information. I get dressed, get the birthing kit open and ready, check the baby warmer, and run to greet them.
The time is 19:20.
Another midwife comes, gowned, gloved, and breathless, to help me.
The time is 19:24.
The ambulance brings in a woman well into labor, breathing heavily, and pushing. I introduce myself and smile underneath my mask and face shield, "Shalom! My name is Gila Zarbiv! I'm your midwife!". "The head is coming!" the woman responds. "OK! Lets get on to this bed" I answer her.
She is brought into room 2, climbs on to the bed, and I put the fetal monitor on her lower abdomen. I hear a normal fetal pulse. "Can I check you?" I ask. "Yes! Please! The head is here!" She answers. I examine her and find a bulging membrane sac and head almost crowning. Suddenly I hear a fetal heart deceleration on the monitor indicating that her baby may be in distress. "Let's get this baby out now" I tell her. She pushes.
The time is 19:25.
A baby boy is born in thick meconium (a baby's first poop in the uterus), with the smell of death, not breathing or crying, with a very low pulse. I tell the birthing mother that she did an incredible job and her baby is having a little trouble. I tell her that, with her permission, I am going to take her baby to the baby warmer in the other room in order to help him breathe better. She consents and lays her head back in exhaustion.
I cut the umbilical cord, send the second midwife to inform the pediatrician, and begin to resuscitate the newborn baby. As I am resuscitating I hold the door open with my foot so the birthing mother can see and hear everything that I am doing, while at the same time taking her history. "What is your name? What birth is this? Are you healthy?" I ask while pumping air into her tiny newborn's lungs.
The time is 19:27.
Her baby slowly comes back to life. In an instant he is crying and starts to recover but is still struggling. Despite his crying he is showing signs of difficulty breathing and his saturation is still low. While I am resuscitating and taking a history the woman informs me that she has a tendency to bleed heavily after birth. Her placenta has not yet delivered. I suction the baby, remove thick meconium, and continue helping him to breathe, all the while holding the door open, updating the mother, taking a history, and monitoring her bleeding.
The time is 19:29.
The pediatrician arrives and takes over treating the baby. I run back into the room to deliver the placenta, massage the uterus, give her pitocin to prevent bleeding, and check for tears. The midwife outside brings me new sheets, clothes, and towels to clean and make the woman feel warm and comfortable. The pediatrician reports to the NICU that we are stabilizing a suspected meconium aspiration (when the baby inhales the meconium into the lungs and has trouble breathing), and requests an incubator. Throughout all the phone calls the other midwife and I switch off between making phone calls, helping with resuscitation, and monitoring the woman. We are also always checking on the woman in room 1 to make sure she is comfortable, not in pain, and not alone.
The time is 19:56.
The baby is stable enough to be taken to the NICU. The pediatrician updates the mother on everything that was done, explains the next steps, takes her number in order to be in touch with the birthing mother, and goes up to the NICU.
The time is 19:59.
Room 1 informs me that she feels pressure. I check her. The amniotic sac is bulging and tiny feet are starting to come. I explain to her that she is ready to deliver.
The time is 20:00.
She pushes one push and delivers her tiny lifeless baby girl. She has requested not to see the baby (despite our recommendation that mothers hold, kiss, and say goodbye to their babies). I ask her again if she is sure she does not want to see her baby and she emphatically responds that she does not. I cut the cord, take the body to a different room, and come back to the mother. She is devastated. She keeps saying, "I wish she was alive. I wish I could bring her back". I hug her tightly and we cry together. She delivers the placenta and we continue to hold each other crying.
The time is 20:04.
Room 2 informs me that she thinks she is bleeding. I call rooms 1's mother and sister on a video call so she is not alone. She cries and wails into the phone.
The time is 20:05.
Room 2 is not bleeding. She is stable with a contracted uterus, good vitals, and feels fine. I run back to room 1 to finish all the paperwork, organize the baby, take a skin sample for genetic testing, prepare the placenta for pathology, and sit with the woman to help her grieve. The second midwife disinfects and runs back to the regular labor and delivery ward who need all hands on deck.
The time is 20:32
I return to room 2, check that she is stable, bring her tea and cookies, take a full history and admission, write up the birth, and connect her with the NICU. I return to room 1 do the same and make sure she is stable. She feels better and is resting.
The time is 22:30.
I organize and finish all the paperwork, contact the postpartum Corona ward, and bring up the women one by one.
The time is 23:00.
My shift is over. Another midwife comes to switch me. I am sitting and waiting for the lab and morgue to be ready to take the baby, the placenta, and the skin sample. I tell the other midwife to go back to the regular ward. I know they are full and need all the help they can get. I can watch the baby for the time being.
The time is 23:30.
Everything is organized. The baby is taken to the morgue, the paperwork is organized, the skin sample and placenta are sent to the labs.
The time is 00:18.
I walk out the door after showering, changing scrubs, drinking water, and updating the night staff. I see a pregnant woman sobbing in the hall of admissions. She is having her first baby and is anxious about Corona, the process, and the new regulations. I sit down next to her to discuss her concerns, fears, and anxieties. Together we make a birth plan.
The time is 01:08.
I get to my car. I put my head on the steering wheel. I breathe.