The Children's Doctor and the Single Mum. Lilian Darcy
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a jarring process, even for a healthy baby at full term.
Laird watched, standing at the resuscitaire so that he’d be ready to work on the first baby as soon as he was freed from his mother’s womb. The latest scan suggested this would be the smaller and frailer of the two—the so-called donor twin.
The Parrys understood the terminology by now. Laird had seen them in his office last week after it had become clear that the amniotic fluid reduction procedures weren’t doing enough to help the babies.
They seemed like a pretty sensible couple. They knew that roughly fifteen per cent of identical twins developed TTTs, with varying degrees of severity, and that it occurred when the webbing of blood vessels in the babies’ shard placents grew unevenly, creating a circulation system that favoured one twin at the expense of the other.
They’d asked him a whole lot of questions, which he’d done his best to answer. Unfortunately there’d been a couple of factors, including a badly positioned placenta, that had made laser surgery on the placental blood vessels a very risky option. This had meant that any treatment, including the amnio reductions and steroids to develop the twins’lungs, had only been an attempt to head off worsening problems, and had done nothing to deal with the underlying condition.
Scans showed that the donor twin—the one sending too much of his own blood into his brother—was undersized and passing too little urine, while the recipient twin’s heart was enlarged and working way too hard as it attempted to deal with the excess fluid.
The Parrys already knew that their boys were lucky to have survived this far, and that one or both of the babies could still die.
‘OK, here we go,’ Tim said. ‘Yes, this is the donor twin.’
‘Adam,’ said Chris Parry firmly. ‘His name is Adam, for heaven’s sake, not The Donor Twin.’
‘Adam,’ Tim echoed at once.
Parents were sensitive at a time like this. Laird had seen the racking emotions they went through over and over again, and it kept him humble. He wasn’t a father himself. Not yet. Or not ever? Insufficient evidence to reach a conclusion on that one.
From what he regularly saw in the NICU, parenthood seemed to him like the dramatic, uncharted territory of an undiscovered island—alluring and frightening at the same time. He wondered if he’d have the same strength he saw over and over in the parents of ill babies.
‘Nice. Look at that movement!’ Tim said. It was feeble, but it was there. The baby was very pale. ‘Hey, Adam, going to breathe for us?’
He wasn’t.
No surprise.
He was blue and so small, well under a kilogram at a guess.
‘What’s our other one’s name?’ Tim was asking. After the dad’s moment of anger and Tim’s own carelessness, he’d recovered his sensitivity. These parents needed everyone to treat these tiny, fragile creatures as beloved human beings right from the start.
‘Max,’ Fran Parry said.
‘Here comes Max.’
Laird didn’t waste time waiting to see whether Adam’s breathing would happen on its own. The NICU nurse took the tiny baby from the obstetrician’s gloved hands into the dry, pre-warmed towel she had waiting, then laid him in the heated resuscitaire and folded the nest of plastic wrap over him, leaving his head and umbilical cord exposed. Laird decided he didn’t need to suction the tiny nose and mouth. There was no evidence of meconium staining in the waters or blood visible at the baby’s mouth.
In the resuscitaire, baby Adam seemed lost in a wasteland of white mattress. The nurse dried his head and covered it with blue tubular bandage, while Laird began the resuscitation process. He found a pulse at the umbilical artery—roughly sixty beats per minute—and said after a moment, ‘We have a nice heartbeat.’ He heard tearful sounds of relief from Fran Parry. ‘We’re going to get some oxygen into you right now, little guy.’
He found the heart-breakingly small premmie intubation equipment ready for him right at the moment he needed it and took it from the nurse. He had already forgotten her name. Something a bit odd and comical, which belied her wonderful competence.
‘That’s nice. That’s good,’ he said, just to reassure the parents.
OK, here we go, tube going down. Such a tiny distance, seven centimetres, and the tube was only 2.5 millimetres wide. Gently…gently…
The nurse—Plummy, he was going to have to call her for the moment, in his head, even though he knew it wasn’t quite right—clamped and cut the cord, leaving several centimetres intact to allow umbilical line placement.
‘Max is going to need some help here…’ Tim was saying.
One of the theatre nurses took the recipient twin into a second warmed towel, laid him in the resuscitaire and wrapped him, while Sam Lutze checked his responsiveness on the Apgar scale. At a quick glance, Laird expected the one-minute score to come in at two or less. Adam’s had squeaked to three, and he wanted it higher soon. His colour had begun to improve, some pink radiating outwards towards his little limbs.
‘Swap,’ Sam muttered to Laird, about Max. The one-syllable request acknowledged Laird’s extra year of experience and his reputation for superhero skills at resuscitating the sickest babies. ‘Look at him, it’s his heart. And he’s floppy, no reflex. Give me Adam, he’s almost ready for transfer. Tammy, you’ll stay with Max and Dr Burchell.’
She nodded, finished what she was doing at Adam’s resuscitaire and switched straight to Max, wrapping the plastic, slipping the tubular bandage onto his tiny head with a couple of soft movements.
Laird devoted a critical few moments to repeating Tammy, Tammy, Tammy, over and over in his head, as he moved to the unresponsive baby. Max was a darker red than he should have been, filled with the excess of blood he’d innocently robbed from his much smaller brother. Thick blood, they often called it, because a baby’s tiny liver couldn’t process it and remove the waste. His heart had been struggling, and even without the TTTS the simple fact of prematurity could often present its own cardiac issues.
‘Right, let’s do this,’ Laird muttered. He understood the junior doctor’s reluctance. Max was going to be much harder.
He looked down at the baby, willing it to show some strength and fight, willing the parents’ love to make a difference, to have some power over life and death. Later on it would. Premature babies responded wonderfully to the familiar voice of their mother or father, and to the right kind of touch. Now, though, it was more about medicine than hope.
‘What’s happening? Is he OK?’ Chris Parry had sensed the increase of tension in the medical personnel, and he could probably see for himself that the second baby, although larger, wasn’t looking as good as his twin.
His wife moaned. ‘Max?’ she said. ‘Hang in there. Mummy’s here, and Daddy. We love you so much.’ Her voice cracked and she couldn’t speak any more.
‘Is he going to be OK?’ Chris asked again.
‘We’re going to do everything we can,’ Laird said. Terrible words. Yet false promises were even worse, he considered. ‘Tammy, start cardiac massage while I tube him.’
He hoped she’d sense when he needed her to get out of the way and that she wouldn’t need to be talked through it.
‘Adam’s looking good,’ Sam said, after a moment. ‘I’m getting 85 bpm, his chest’s moving. I’ll get an umbilical line into him now. Then you can go for a ride, little man.’
Laird heard more sounds from the Parrys. Relief and anguish. Then from Tim a suspiciously calm ‘All right, we’re going to have to pack this. Do we have some blood, Helen?’
Mrs Parry had begun to bleed too much, a reasonably common side effect following the procedures she’d had over the past few weeks to reduce her amniotic fluid. ‘What’s happening?