“Dr. Bender on line two for you, Dr. Eichel.”
My mouth replied, “Thank you.” My mind thought, “Oh, no." An unsolicited, unexpected call from a radiologist never means good news. I went through my mental Rolodex of patients I had sent for X-rays or ultrasounds and thought of Tina, whom I knew would be getting her second trimester obstetrical ultrasound any day now, so I was not caught completely off guard when he gave me the report: “She has a demise.” That is our medical euphemism for a dead baby in the uterus. The fetus looked to be about 16 weeks old, which meant it had been dead for about one to three weeks, based on the date of her last menstrual period.
“I have gone over this with her and she understands,” Dr. Bender continued. “What do you want me to do with her?”
“Send her right over to my Berkeley office.” A glance at my watch reminded me that now, 11:30 a.m. on Friday, was not the best time for a tragedy. Tina and I would want to deliver her dead baby as soon as possible, and Friday, as a rule, poses a formidable opponent to rapid resolution of any crisis.
Fetal demises in the second trimester, the middle third of a pregnancy, are not common; it has happened to two of my patients in my five years of private practice. A lethal anomaly in the fetus is the usual cause, most often the result of a chromosomal surplus or deletion. Unlike fetal deaths in the first trimester, which usually result in miscarriages and often do not require any medical treatment, second trimester deaths require intervention, either through surgery or labor induction.
The surgical option is a “D and E” — dilatation and evacuation. When possible, this procedure is much easier for the patient. It is done under general anesthesia, so it means getting on the operating table, going to sleep under the influence of sodium pentothal and some anesthetic gases, and waking up with the procedure finished. You can go home that day and get on with the healing process.
The surgeon/obstetrician, however, has a different view: D and E’s are tricky. The bigger the fetus, the tougher it is to get it out through the dilated cervix. That’s the reason most obstetricians will not do abortions more than 12 weeks after the first day of the patient’s last menstrual period. Getting a larger fetus out involves breaking and extracting the fetus in parts, and most obstetricians don’t do enough of these procedures to feel comfortable nor confident doing them. For Tina’s 16-week-size fetus, we had only one obstetrician in town willing and qualified to remove it.
For the medical profession, the easier technical option is induction. You bring the patient into the hospital, place a white waxy suppository containing 20 milligrams of prostaglandin E2 in the vagina every three to five hours, and wait until the patient has the one or two severe pelvic cramps that herald the deceased fetus’s delivery.
Technical considerations aside, however, most of us hate these inductions. Prostaglandin E2 makes patients sick. Most get fever, vomiting, and headaches; many get diarrhea. To us who make a career out of trying to relieve suffering, this procedure breaks our vow to “first do no harm” and just doesn’t feel like the right thing to do. Having a dead baby is bad enough; having a rotten flulike illness along with it makes for a dreadful experience. And after the fetus comes out, about 40 percent of these patients need a “D and C” (dilatation and currettage) to extract the placenta. This happened to my first patient with a demise; she chose the induction because she did not want to break the baby’s bones in the process. When the placenta did not come out, the obstetrician whom I brought in to do the D and C made many references to her ticking biological clock (she was 41), a theme that was neither timely nor appropriate for a physically and spiritually ill patient.
I have my own bias against vaginal prostaglandin inductions. In October of 1991, my third year as a family practice resident, I did four of them on four consecutive mornings during my high-risk obstetrics rotation at Dartmouth’s Mary Hitchcock Medical Center in Hanover, New Hampshire. All of the state’s high-risk pregnant patients came to us for care, giving us residents great experience managing difficult obstetrical problems. But I have never known anyone else who had the misfortune of having to do so many of these procedures in such a short time. Two of the babies were dead prior to the procedure. The others had lethal anomalies: one had anencephaly (no head), and I don’t remember what was wrong with the other one.
That was the worst week of my life, and I remember almost nothing of the four inductions, except that by the end of the last one, the nursing staff and I had overdrawn our emotion accounts. Naomi, a sweet, genuine jewel of a nurse, had lost her 13-month-old daughter a few weeks earlier in a drowning accident, adding to the excess of death in a place where we normally celebrated new life.
It turned out my week was far from over. That fourth afternoon, Amy, one of my fellow third-year residents and a close friend, called from Augusta, Maine, the home of our residency, to tell me about Miriam. A resident in the class ahead of us who had graduated three months earlier and was planning to start up her own practice the next week, Miriam had strong opinions, a firm commitment to spiritual fulfillment, and a volatile relationship with me. Four months after I arrived
in 1989 to start my residency, she anointed me with the responsibility of taking care of her little wooden house on Jimmy Pond while she spent a month doing hospital pediatrics on the Navajo reservation in Gallup, New Mexico, a rotation we all did during our second year. A California native who had limited familiarity with wood stoves, I emptied some 24-hour-old ashes into a plastic pail near her stove a few nights after she left. I never thought those ashes would be hot enough to melt through the bottom of the pail and ignite a stack of newspapers Miriam kept near the stove (while I took full responsibility and paid for all the damage, I still felt somewhat the victim of a setup), so I was confused and startled when the smoke alarm crashed through my dreams.
A few buckets of water doused the flames, but the smoke damaged some of her artwork and her television, and I fell out of her high favor.
Amy explained that a wasp had stung Miriam and caused an anaphylactic reaction. Few people know how to get to Jimmy Pond, so it took the ambulance too long to find her, she was unconscious for over ten minutes before they arrived and resuscitated her heart. “She’s in the ICU in a coma,” Amy told me. I decided to drive back to Augusta that weekend to see her in the hospital.
Moments after I hung up the phone, an ambulance brought in a 40-year-old woman from a rural hospital. Two years before, she had finished chemotherapy treatments for Hodgkin’s disease and was told she would never have children. By some miracle, she had proven her doctors wrong, but within the past week, the 27th of her pregnancy, she had an ultrasound showing that her baby had a cystadenomatoid malformation, meaning that its lungs would never develop properly. Tonight she was developing the classic triad of signs of pre-eclampsia (toxemia): high blood pressure, protein in her urine, and swelling of her legs. through that night and into the next day, while several neonatologists pored over her ultrasounds trying to decide whether her baby would have any chance of survival, she got sicker with headaches and abdominal pain as her brain and liver swelled from pre-eclampsia. By the time the experts reached a consensus that her baby would die, we had almost finished her Cesarean section: my daily delivery of death to a suffering mother, the fifth of the week.
I finished the day’s work, packed a few things, and got in my car to drive home.
It was not until then that I realized what Amy had said: Miriam had been down over ten minutes. A week of too many deaths had fueled my denial such that I had thought I was going home to watch Miriam recover, but like a heavy blow to my temple, my brain unleashed the news of Miriam's impending, inevitable end. I came back to Augusta in time to say a few words in Swahili (her favorite language), including kwa heri (good-bye); in fact, I left for Dartmouth before she died and went wherever she is now. Karen, a mutual friend, later told me that Miriam had forgiven me and was still fond of me. To this day, I feel connected to her; she shared my love of Africa, dance, and art, and we have both worked politically toward trying to achieve a single-payor insurance system in this country to help correct the injustices of our present health-care system. She remains my only good friend who has died young.
So I had personal and professional reasons for not wanting Tina to have an induction.
I called the one obstetrician in our region who does D and E’s, but he was out of town until Monday. Poor Tina wanted to get her dead fetus out as soon as it could happen, but I persuaded her that the induction involved too much misery. On Monday, the obstetrician called me back and said he wasn’t going to be able to do her procedure until eight days later. I knew I wouldn’t be able to persuade Tina to wait that long.
I met her at the hospital Tuesday morning. Not wanting to surround her with pregnant women brimming with the joy of bringing new life into the world, the nursing staff gave her the last room in the back of the hallway. As she lay in her hospital bed, Tina’s long, clean black hair enveloped a quiet, determined 22-year-old face. Married with two children at home, she had a confident maturity of someone ten years older. After I explained that I would be pre-medicating her with Tylenol for fever and Phenergan for nausea, she said, "Let’s get this over with.”
She lay back on the pillow, brought her heels up toward her buttocks, and let her knees drop to the sides, a position she knew well from her two prior labors. I greased my gloved index and middle fingers with K-Y jelly, positioned the white cylindrical suppository between my fingers, and slid it between her labia and up underneath her cervix near the back wall of her vagina, all the while hoping that the prostaglandin released from within this object would not cause her too much suffering. After removing my glove, I grasped her hand, wished her well, and went back to my office to see my patients for the day.
Right hours later, after some low-grade fevers but no vomiting or diarrhea, she had the big cramp, and out came her son and placenta as one intact unit. “He’s cute,” Tina offered through a few tears with as much pride as any mother would. And she was right. Although his gray color and swollen head made it obvious he had been dead for over a week, his five-inch-long body remained intact with ten fingers, ten toes, and no apparent deformities. His placenta, round and six inches in diameter with the usual three-vessel (two umbilical arteries and one umbilical vein) umbilical cord linking it to the fetus, also looked perfect. We’ll never know what happened to him; his tissues had been dead for too long to allow chromosomal analysis, and he was four weeks too young for an autopsy to tell us anything.
After the chaplain came and performed a short Catholic ceremony, Tina felt relieved and overall much better, so I sent her home from the hospital. As for me, without any doubt, this was a big victory: my first vaginal induction from which I walked away with a good feeling. I had taken an arrow in hand and slain a demon from my past, and I must confess I felt proud.