Monsters

They are among us...Be not one.

Sid had seen all the pictures in medical school. Black and white images in books they made him buy. The book of monsters. But he’d never delivered a baby himself, like this. In this small town you can feel all on your own. But he had his training.

He had been on weekend duty in residency when that one young mom had her monster.

Sid was on his OB rotation, every other night on call and every other weekend. He’d rounded on this little woman multiple times. She’d been sent there from her small town. That was the nature of high-risk pregnancies. Try to identify them early and get them to where the care is best. The docs in her small town knew she was an insulin dependent diabetic, high risk right there. But the ultrasound images raised the alarms, so she got shipped to the center where he was training. So he cared for her.

She was young, pregnant and carrying a baby with holoprosencephaly. Sid’s training with fetal development in the monster book included lots of big names he could not always sort out. He learned, monsters don’t always have big names.

She had diabetes and also was developing preeclampsia. She was 28 weeks along. That was considered beyond the cusp, in those days for an abortion. But she didn’t, would never have wanted that. Sid didn’t know if her local docs had discussed his with her. But he knew her religious fervor. He knew her convictions.

Sid was on the team that watched her at bed rest for about two weeks. Sid looked up holoprosencephaly, though the attendings had told him on the rounds about the cyclops. This baby inside her had one central eye. It would not breathe on its own.

Sid was in charge of adjusting her insulin and blood pressure meds.

On this weekend, her blood pressure spiked, she had hyperactive reflexes, and her urine protein was 3+. The very sober attending told Sid to move her to the delivery suite and get her into labor.

So he did the work. And she started contracting, and her blood sugars and blood pressure stayed OK. And the baby’s heart rate stayed steady.

What do you do if you are trying to deliver a baby that will not survive and it shows intrauterine distress? Think about that for a moment.

It’s going to get worse.

She progressed. Sid checked her cervix. It was dilating, the baby’s head was coming down, her blood pressure and blood sugars were okay. But then it stopped.

No further progress. The attending came in. He agreed. This poor woman needed a surgery to deliver a non-viable baby. Despite the trauma, for Sid, this was exciting. He’d get to do something he’d never done. Cut open a uterus top to bottom, instead of the usual down low across cut.

The attending was a serious, South African man with a British accent and many stories to tell. He looked at Sid, shaking his head. Classical incisions greatly increase the risk for uterine rupture in future pregnancies. But that’s what we have to do.

Sid understood his torment. We would do the right thing here, to deliver this baby that would not survive, but it would give this woman future risk. She agreed to it, even if we thought it unwise. She is the boss. Not the monster.

This baby was alive inside her, kept alive by her body, her uterus, the placenta.. It would not breathe, live on its own after delivery. It was in the book of monsters. But the young woman wanted everything done to deliver the baby alive. So the attending and Sid put her future childbearing at risk and cut.

It had just the one eye in the middle of a pale, wrinkled forehead, and it didn’t breathe.

Sid learned.

But then, here he was, on his own. With her.

This young mother’s predicament didn’t make it easier. She had come into his examining room in a big overcoat in late spring. It wasn’t cold outside. She had finally decided to seek medical care for her pregnancy she had hidden for months. Sid had an opening. So here she was.

Sid tried to understand. But the young woman, bright and competent, repulsed any attempt he made to understand or generalize her predicament.

Family? Father? She forcefully shook her head and almost walked out.

Sid knew she needed care. He could see her big belly beneath the overcoat. He felt her conflict, so he backed off.

Let’s just see what we’ve got here.

She remembered her last menstrual period. She was bright. That gave Sid a ballpark idea. He asked more questions, prior pregnancies, blood transfusions. General health questions. She was a solid patient. As she answered, Sid sensed her deep pain. She had not planned or welcomed what was growing, had grown inside her. But now it was pretty big, and she was facing the coming issue.

When Sid got to her big pregnant belly and touched and measured it was way too big. It was very round. It was hard for him to feel the baby in there.

He did the office doppler. Normal heart tones he and she heard. Sid even scanned around, thinking there might be another, a twin, but he couldn’t find another. Just one he could find. But her dates didn’t fit with her size. She was due to deliver in a few weeks by her dates, but the belly was bigger. Twins that he couldn’t find?

Sid didn’t want to run up the bill, but in this case, he wanted an ultrasound. You’re telling me you should be due in a few weeks, but by my examination your belly is bigger than it should be.

Sid said she needed an ultrasound. He convinced her to go across the street and get this done. All while he was fearing she would just walk away. Sid knew her fear. She was on the edge.

But she went.

The radiologist called him in about 30 minutes. That’s never good.

Hey Sid, this lady you sent over has an anencephalic. Plus she’s got big time polyhydramnios, they often go together. Or oligohydramnios. You know, when it’s a monster, the system is messed up. Do you want us to send her back to you?

Have you talked to her?

Heck no, that’s your job. He chuckled.

Please ask her to come back so I can talk to her.

Will do.

As he hung up, Sid knew this radiologist was paid three times what Sid was as a family doctor. Not only was this poor young woman about to hear some tragic news, but Sid also understood, he was in a fatally flawed health care system. But that’s for another day.

Sid looked at his morning schedule and told his nurse what was going to happen. She understood.

Sid had never had to do this before. He hadn’t practiced. No doctors are good at this. It is rare, monsters. But it does happen, and so the medical school classes, pictures, causes, prevention, all that shit, like they want to prepare you for the horrible shit you will have to do.

Sid stood in the hallway between patients and reviewed in is mind what he knew about anencephaly. It took a second for his mind to recall the enfolding process of the developing neural tube. Ectoderm, endoderm, neural tissue, developmental folding, all that shit just settled back through his young, bright brain. And of course, when it doesn’t happen like it should…Here we are.

She was beautiful. Sid thought all pregnant women were beautiful. Her curly hair and round face and tall stature sat up there on the exam table, looking down on him on his low rolling stool.

You have a baby that cannot survive birth. The brain has not developed through some twisted developmental thing. Your baby does not have a brain. It has grown inside you because it doesn’t need a brain as your body gives it safety and nourishment. But it will not live once it leaves your body.

She didn’t cry. Maybe her moist eyes were that. She just stared her sharp piercing eyes at him and asked him about what was next.

So Sid told her. We have to get you delivered. We have to get this baby out. Sooner or later.

When?

Sid looked at the industrial carpet his rolling stool slid over. It depends on your cervix. I need to see if your cervix is ripe. That means ready to let this baby out. So I need you to take off your clothes and I need to do a vaginal exam to assess the cervix.

Sid gave her a paper drape and left the room.

He saw another patient. He told his nurse what was happening. Then they went into the room for the vaginal exam.

Sid found the beautiful pregnant woman sitting on the exam table naked holding the paper drape in her hand by her side. She was actually radiant. Sid found most pregnant women were radiant, even if not naked.

Her breasts were full and warm, her skin almost glowing. Her big round belly held the infant, the monster. Her eyes sharp, met his and followed him.

Here, hold this across you while I examine you.

She blushed as he put the thin paper drape across her breasts. So I was not to take my clothes off?

You did fine. But we offer these for modesty.

She laughed. Modesty as you are going to probe my vagina?

Sid laughed too. It’s the trick of the profession. That we can keep our distance.

Distance? You’re going inside me.

She didn’t seem the shrouded unexpected young mother here. But Sid had just met her. And he had told her the news and now needed to go up inside her. And deliver this monster.

Sid felt his nurse behind him as he had this intimate conversation. This too was part of the trick of the profession. Doctors need assistance for the intimate things they do. And two sets of eyes and ears maybe give credibility.

Yes, I need to examine your cervix. If it has softened, maybe even dilated, we can induce your delivery. So lay back down and put your feet here. Sid did the hand to the shoulder, laying her back and pulling out the little shelf to hold her legs. Then he pulled out the arms that held the stirrups. He moved her warm feet there, one to one.

Sid had his male patients who decided for vasectomies put their feet in the stirrups while he operated down there between their legs on his rolling stool. Such symmetry gave him some small measure of joy.

Sid gloved and lubed his gloved fingers and found the introitus with his right hand. That’s the medical term for the vaginal opening, “introitus”. Now you know.

Sid kept his left hand above, on the fundus. That’s the medical term for the big round belly she had below her full glowing breasts. He had to go up under the false paper sheet he had offered. Her laughter at his sham echoed as he felt for the opening.

Sid knew that what he was doing was trying to squeeze this infant, this baby, this monster between his hands, to get a sense of it. But he couldn’t.

Sid only raised his own daughters. But he had delivered hundreds into this world. And this feeling the baby, the mother’s birth canal, the cervix, the position, it was what he needed to do to predict, to prepare.

He pushed his fingers in and found the cervix soft; in fact she was dilated to two cm. His trained fingers knew this. His index finger within the glove could feel the water filled membrane, right there, delicately floating. Sid pressed down with his left hand to see if he could feel the presenting part. He could not. The ultrasound had said it was head down, but there was so much fluid.

Maybe because there was so much fluid inside the membranes, maybe because there wasn’t a skull to feel. Sid could not know.

All while he was probing, feeling inside this woman, pressing on her belly, she was staring at him. Sid felt it but didn’t look at her. He had to get this monster out of her. Then she had to live her life.

Sid would also have to live his.

Sid scheduled it for the next morning. He called his mentors. They advised. Since the cervix was ripe, just needle the membranes. Maybe it will progress. Have you checked your state laws?

Sid was taken aback. What do you mean? Sid’s mentor was in another state, and Sid knew there were differences.

His kind of British accent was soft, not really British. Some states do not allow intervention to deliver a nonviable fetus.

So this might be illegal?

I don’t know. You should check.

Then what?

I don’t know. Maybe wait. She might go into labor on her own.

All that fluid? Rupture, walking around?

His South African chuckle told Sid he understood. Well, God Speed to you and this poor woman. Let me know how it goes.

Sid thought it went fine, all things considered. He was able to see the membranes, poked a 16-gauge needle in, she leaked, then gushed, then went into sweating, bearing down labor and the monster came out.

The nurses swaddled it, covering the absent skull so she could hold it, though she didn’t really want to. She kept sobbing. It was over.

And Sid never got arrested. No deputies he knew from all the coroner calls showed up in the waiting room to cuff him. No charges were filed that he ever knew about in the county courthouse. Though Sid had actually broken his states laws.

So he just kept being a small-town family doctor. He delivered babies. And he often wondered just who the monsters were.