Some things can only be learned on the job: an apology to two new parents.

I was a “senior” resident when it happened.  And by senior, I mean I’d had about 18 months of anesthesia training so when a woman came to the OR with an “emergency” C-section, my staff supervisor left me alone even before I`d topped up the epidural.

I can’t remember anything about the case.  I don’t know why she needed the C-section.  I do know it wasn’t one of those crash down the hall and barrel into the OR kind of emergency c-sections.

But you know what is burned into my brain?  The look in the dad’s eyes just after his baby was born.  The sound of his voice.

The baby came out completely flat.  Floppy.  I don’t remember why.  I remember the OB quickly handing it off to the neonatal resuscitation team.  She didn’t hold it up over the drape to show it off to the parents.  There was no, “congratulations you have a _____.”

There was a glance at me and a, “we’ve got a lot of bleeding.”

There was no sound of a baby crying.

The mom was staring off into space with a glazed look in her eyes that caused icy fingers of dread to wrap around my heart.  The dad had stood up and was looking at his son.  I was fumbling around drawing up the oxytocin and trying to get it into the IV and wondering just how much bleeding was “a lot” and how I could possibly get to the phone on the other side of the room to call for help from my staff person if “a lot” turned out to really be “a lot.”

The circulating nurse was running around opening stuff that the OB was calling for.  Sponges.  Instruments.

The dad said, “What’s wrong with my son?”

I was surreptitiously looking at the mom’s arm wondering where I could slip in another, larger, IV, but I was jolted back to the present by the anguish in his voice.

I looked at the OB.

She was sewing up the uterus.  She looked up at me.

And that’s when I realized it.

That everyone thought that looking after the dad was my job.

Never mind that my primary patient, the mother, might be hemorrhaging.  Never mind that I’m busy with resuscitation measures…replacing blood loss with IV fluid, giving uterotonics, keeping an eye on suctions and sponges, still trying to capture the attention of the single distracted circulating nurse so that I can get some help…

Never mind that I have absolutely no idea how to distill what I know about neonatal resuscitation into non-medicalese.  Never mind that I don’t know how to phrase what is happening to his son in a way that is hopeful and helpful without false optimism.  Never mind that in a minute I might have to tell him his wife is bleeding badly and he needs to leave the OR now.

I took a moment to gather my thoughts while the dad angrily pleaded, “Please, someone tell me what is happening to my son!”

At exactly the same moment, the OB said, “Its firming up now, I think we’ll be okay.”

And I said to both the parents, “Your son was stressed and when he was born he wasn’t breathing.  They are breathing for him and giving him oxygen.  But they aren’t doing chest compressions which means his heart is beating at a good rate.  In a minute or so, he’ll either start to take over and maybe even cry, or he will need more help and they will need to put in a breathing tube.  They are doing a good job.”

And then I had to force my attention back to the mother.  Make sure her vitals were okay.  Count sponges, look at the suction canisters and estimate the blood loss.  Tally up the IV fluid she’d received and think about if it was enough.  Decide if she needed blood drawn…or blood given.  Think about the uterotonics she’d had and the condition of her uterus.  Think about her pain management.

It’s completely callous…but I had a job to do and I couldn’t get too distracted by the baby.

Both the mom and the baby were okay.  Her uterus clamped down and she stopped bleeding.  He started breathing then crying.  I’m pretty sure his second APGAR was a 9.  His parents got to hold him in the OR, even though he ended up going to the NICU for a few hours of observation.

I wasn’t okay though.  I felt like a complete failure.

Still do.  I’m sure the parents of that little boy have all kinds of scary memories of his birth…including one of the callous OR staff, especially the anesthesiologist, who didn’t even have the heart to explain to them what was going on.  I’m sure neither the mom nor the dad caught wind of the fact that she had a significant hemorrhage during her c-section.  I’m sure neither of them was cutting me any slack for having to deal with that.

No, I’m sure what they remember is their little boy…grey, floppy, not crying.  Surrounded by staff working on him and surrounded by a cold silence.

Now that I’ve gone through the experience of birth myself, now that I’ve been a patient myself, I wish that I had visited them a day later to apologize and to thank them for teaching me.

Teaching me to be quicker.  With words.  With comfort.  With multitasking.  With empathy.

 

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17 comments

  1. I have often thought about what the medical professionals in the room thought during my traumatic birth experience. The lack of empathy I felt was astounding. You have done a great job explaining the other side. I just wish that all medical professionals could be as introspective after a situation like this. Apologizing and showing empathy goes a long way in helping those with traumatic births heal. Thank you for your insight. Although you were not one of the seven medical professionals working with me, I can only hope that they think about my delivery as a learning experience.
    -Lauren
    peaceoutofpieces.com

  2. Wow, this is a perspective I’d never considered before. Thank you so much for sharing it!!

  3. Fantastic post!

  4. I’m so glad you shared with us. So often people think the medical community is just calculating what will be the next procedure they can “do to” us that we fail to stop and remember that the GOAL is safety and it is backed by pure concern. ❤

  5. What an amazing reflection on a horrible experience (for them and you). Thank you for sharing, your story will stay with me and I hope help me deal better when similar situations arise. (New RN and student midwife)

  6. Kudos to you for learning to do better under similar circumstances should they arise.

    Now if only parents were better prepared for birth when “it doesn’t go as expected” – because many parents find a vast difference between what they expected and what they experienced.

  7. Absolutely beautiful and heartwarming. Thank you for sharing the depth of your understanding and growth.

  8. It was interesting to read this perspective. I was fortunate that during my cesarean birth (under general at 23 weeks gestation) the staff was truly incredible – I am so, so grateful for their medical care, but also for their emotional care during such a terrifying situation.

    I’m curious your thoughts – I’m a doula and was in the OR this week with a client. A doula isn’t the one to explain what is happening medically, of course, but is this a situation in which having a doula with parents would help for the emotional support and reassurance?

    1. Wow…emergency GA at 23 weeks gestation. I can’t know what that feels like as a mom but I’m so glad that those caring for you were able to support you so well.

      It’s only been recently that doulas have been welcomed into the OR and it’s not a universal policy. Many ORs will only allow one support person to be with the mom while others have a looser policy that depends more on the anesthesiologist (since the support people take up real estate in the anesthetic area and can make it difficult for us to look after the patient). Most mom’s chose their partner to be their person in the OR. I have had both the mom’s partner and doula in the OR many times and it seems to work well although those were all straightforward cases.

      I could see in a tense situation a doula could either be very helpful or not helpful. On one hand, you are a person that the parents know and trust and having someone provide support to the parents when I have to do medical stuff quickly can only be very beneficial. On the other hand, you might not have had much exposure to critical medical situations and may, yourself, have difficulty processing what is going on (intellectually and emotionally) which may limit your effectiveness. If you find yourself in a tense situation, I think the most helpful things you can do are (and this is my opinion):

      – continue to support the mom, stay where she can see you. Before the baby is born, distraction works great for nerves…as does visualization. But you will know what works best for that woman cos you’ve spent more time with them.
      – after the baby is born, if he or she needs help/ resusc, stick to descriptors. Often the mom can’t see the baby or the doctors working on the baby. Someone needs to tell her what is going on. “They have a mask on his face and are squeezing a breathing bag” is good. Comments like, “It’s going to be okay…I think it’s getting better” are not good because they may not be true. Since the parents know and trust you they will hang on your words in a situation like that as if they are gospel. “We’ll get through this together” is also good.
      – When things go wrong, when life is touch and go, it’s time to let go of the birth plan (temporarily). Once the ABCs are established and things settle down, the birth plan can be revisited. I don’t mean to be harsh, but items like delayed cord clamping or skin to skin are completely inappropriate when a newborn needs resuscitation. A long discussion afterwards where the health care providers talk about why those wishes couldn’t be honoured in that moment is entirely appropriate (and I would argue, neccessary).
      – know your limits. If you find the situation is stressful and emotionally disturbing so that you can’t offer effective support to the parents…bow out. make your apologies, or blame me (ie I need to leave now, I’m in the way of the anesthesiologist taking care of you).
      – when you are asked to leave the OR, as will happen if the mom has a critical complication…leave. No questions, no delays.

      1. Thank you for that reply!

        Re: my 23 week preemie – fortunately we were in a hospital that was clearly well rehearsed and they seamlessly passed our preemie off to the NICU team. He was an “easy” intubation despite his size and age and after 109 days in the NICU he came home (on oxygen) – he’s seven now, and amazing us still!

        And as a new doula, I appreciate so much your detailed and candid response – I know it will help me better serve families. I’m linking to your site to share it with other doulas.

        1. Thanks for the link. Of course, I had to go and poke around your site. Your photography is beautiful! My husband and I didn’t have anyone with us when our son was born and he was so overwhelmed by the experience that he forgot to take the camera out. Next time, I’m hoping for more pictures. I wish you all the best with your doula practice.

          1. Thank you!! It was after our cesarean birth (with no photos, of course) that I realized how much I wanted pictures. We’ve had a photographer at three of our six births and the photos are such a beautiful reminder of the experience. I love that I can now capture photos for parents wherever they’re birthing – even in the OR! 🙂

  9. I really enjoyed reading this, I know that when I attended my friend’s home birth after having had one myself, I was struck by how every tiny little detail can affect their experience profoundly. That is a huge responsibility. It strikes me that doctors and medical people are people too.

    I also agreed with what you said about doulas in an emergency situation, such as explaining the practicalities of what is going on to the parents.

    I appreciate your sensitivity too on the subject of the birth plan, but in regards to things like skin to skin and delayed cord clamping not being appropriate, I have to disagree. I can see how this would be a major issue in conventional birthing rooms. The cord causes the cord to clamp down almost instantly. Resuscitation implements may be on the other side of the room and need fast access. However, the body naturally aids with helping a baby to breathe and preventing blood loss in the mother. Ideally both could be practised. I remember reading about an Ob in NZ who found a way to bring the resusc. gear over to the mother/baby. The baby was held lower than the placenta, so gravity could pulse every last drop of oxygenated blood to the baby. Skin to skin contact with the mother helps the baby to warm up so any energy is not being wasted on being kept warm. The baby went 17mins without breathing on it’s own and had no brain damage.

    1. I wholeheartedly disagree.

      ORs are kept quite chilly, both for the comfort of gowned and masked surgeons who are often asked to work under hot lights and because the air is exchanged through a filtration syst upwards of 20 times an hour. That degree of air exchange reduces the incidence of surgical site infection which is one of the biggest threats to the mother after a c/s but also causes a significant amount of cooling via convection. Moms under neuraxial anesthesia can become hypothermic under those conditions. How do you envision skin to skin in the OR to occur with a baby that needs NRP which requires at least two people? Remember we are talking about a floppy apneic baby that needs both bag mask ventilation and potentially chest compressions…where chest compressions are ineffectual with the baby on a surface that is not both firm and flat!

      In addition the cord pulses because of the baby’s heartbeat. Pulsation does not mean oxygenated blood is flowing from the placenta. The placenta could have completely detached and the cord will still pulse. The cord has two arteries which carry blood away from the baby – those pulse, and one vein which carries blood to the baby. Misunderstanding fetal-neonatal-placental physiology and applying it to birth in the way you are suggesting in my mind is malpractice. 17 minutes without breathing is NOT standard of care and nothing on gawd’s green earth would convince me to neglect my patients in that manner.

      Delayed cord clamping is a “nice to have” that may result in a higher ferritin at 6 months but it is not a substitution for prompt neonatal resuscitation. Skin to skin is also nice to have but it’s benefits are best obtained after the critical first resuscitation events are completed and the baby has achieved spontaneous independent respirations.

      17 minutes without air moving in or out? Come on. Not my child. Not my patients’ children, and, I would wager, when it came down to it, not your child either.

  10. Sorry, typo. The “cold” in the room causes the cord to clamp down almost instantly.

  11. tiffany · · Reply

    a good reason to allow doulas to come back to OR. They can explain, calm and buy you that time while also talking with mom.

  12. Stacey Jw · · Reply

    You mean, you aren’t evilly looking around to decide how to make a quick buck?
    /snark

    I love every post, and wish every NCB advocate would read it. I think it would help them to reconcile what goes on in the hospital with their ideas of what’s in the mind of the staff.

    And 17 min? I hope that baby is OK. I think your explanation was thorough, but I wonder if it is believed….

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