Yeah. Don't read this one if you are pregnant, anxious, or anxious about being pregnant.

Do you like the new design?  I'm not sure I totally love it, but it was fun to play around with colors and fonts. Much easier than, say, writing.

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Thank you, Kate and Chaya for your emails. I always appreciate writing ideas; I hope to get to yours soon. And Chaya - don't worry! I really don't think it's you that's messing up my stats and I appreciate your loyal readership.

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Patient in the SICU, very ill, 18 weeks pregnant. We are in the midst of trying to decide whether her pregnancy is the source of her infection, when she breaks her water and that decides for us. The pregnancy is, at this point, clearly the source of her sepsis. She needs to be delivered. But she is too sick to be moved out of the ICU; we will induce her here. The ICU is, to put it mildly, freaked out by the thought of delivering this pregnancy here. (I have always found this terror so strange and almost humorous - people routinely die on this unit; why is this what puts them over the edge? But we're all scared of what we don't do.)

"What will we do with the baby?", one nurse asks. "The baby is either dead or going to die." I said. "I will wrap it up and we will grieve." I think I spoke too sharply, or this was too much for her to bear, because her face crumples.

I run upstairs, foolishly in street clothes, and change into scrubs. The nurse manager loads me up with everything I need to be a roving obstetrical unit: medications to induce labor, medications to stop bleeding, delivery instruments, drapes, paperwork. She'll send down a nurse in an hour when she has someone coming in.

I go back downstairs, forgetting to take a cart, and so balancing the metal instruments on top of the draping kit, with the tiny infant hat and blanket above it all; medications in packets and sterile gloves and death certificate papers weighing down my various pockets. I get  back to the ICU and start to prepare to place cytotec*, but the patient has become extremely uncomfortable while I was gone.  I call for morphine, do a quick exam, and find that she's 4 centimeters dilated; at 18 weeks, she probably does not need much more before the pregnancy will come. Her husband, who I've talked to over the phone, has made it in; he looks young and sleepy; I send him to the head of the bed to hold her hand. I ask the patient if she wants morphine - it may make her sleepy, she may remember less - and she does, so we give it. I have explained to her, to him, that the baby may show signs of life, but at this age, it is not able to stay in this world for long.

Less than 10 minutes later, she feels the urge to bear down, and does so; a small fetus, together with placenta delivers, all at once, onto the clean sheets I've brought. The fetus looks raw, as they do, with skin too thin to really hide the blood vessels underneath; he is silky, and small, and a bit alien, with eyes that are fused close and a head that is too large. Because of course, it didn't have time to grow into its body. There's no heartbeat at delivery, and the baby looks bruised; I think there probably has been no heartbeat for several hours now.

After cutting the cord, I announce this in a loud voice, I say: the baby's heart is not beating. I want the parents to know what to expect. I show them the baby, and then say: I'm just going to take him over and get him ready for you. I clean him off, and put on a hat, and wrap him up. I'm trying to make him look more like a baby, like something they can recognize, like he didn't have a rough entrance into this world as he exited from it.

I ask the patient if she'd like to hold the baby, and she says yes. I hand him over, and busy myself with other things.The ICU nurse draws up the oxytocin I brought. There's very little bleeding.  Fifteen minutes later, the father calls me:  I saw the baby move! I think his heart is beating. I very carefully unwrap the baby in the father's arms, and look at the body with the father. I feel the umbilical cord again for a heartbeat, though it would be impossible. I touch the tiny chest for a flutter, and feel nothing. I tell the father what I am doing, show him what I am feeling. "I'm sorry, sir." Then as I hand the baby back to the father, I notice; the father's hands are shaking, and it makes it look, just a bit, like the baby has a beating heart.




*a medication that can be used to induce labor