NONFICTION  |
OCTOBER 2006 – NO. 9 |
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The Twins
Sylvia, a mother who was half way through her pregnancy with twins, was gazing up at the ceiling when I walked into the room. Quietly, fixedly, she looked at the ceiling tiles that repeated themselves over and over in a pattern of lines and squares. Her wavy, gold hair and tired eyes were just visible beyond a hill of white linens. Her upturned chin created a smooth white triangle above her throat. The foot of the bed had been raised higher than the head, placing her long, skinny feet in full view, as if on a pedestal. A surreal light from the late afternoon sun shone on them, making them glow translucent and pink, like delicate ivory carvings.
"How are you feeling today?" I asked. "Are you contracting at all?"
Her disembodied voice rose from below.
"No contractions at all, but I'm feeling disoriented from looking at the world upside-down."
Sylvia had been admitted to the hospital a week before. Twin "A", the lowest baby in the uterus, had ruptured her bag of amniotic fluid. Sylvia had felt a warm trickle of fluid run down her leg and pool inside her shoe. Panicked, and assuming it was blood, she had pulled down her pants and caught the warm, salty scent of the sea.
It was very bad news, to say the least. Like deep-sea creatures, fetuses require an underwater world in which to develop. Although they are kept alive by the blood flowing to them from the placenta, their delicate membranous bodies need the gentle support of a mother-made ocean to grow in. The buoyancy of this saline pool keeps their fragile heads from collapsing onto their developing brains inside. It is what keeps their chests expanded, allowing room for the lungs to grow into. In fact, fetuses are 99% water. They are like spirits that grow ever more solid and dense each day, until they are sturdy enough to enter the world outside.
Sylvia and her husband had been counseled to let these babies deliver and die, since the chance that their lungs would be able to develop fully were very slim. They had said no, they would hang on to these babies, no matter what it took. So, here she was in bed, upside-down, hoping to coax this tiny girl baby away from her cervix; trying to change the direction of the tides within her womb.
Twin "B" was at great risk of delivering also, in spite of the fact that his watery world remained intact. He floated there, above his sister, curled up inside his amniotic sac, growing larger with each day. Did he know of his sister's dilemma? Having seen pairs of twins on ultrasound, I know that they are very aware of each other. They push and poke each other. Sometimes, they rest against the membrane that separates them, back to back, or curled like spoons together. I have seen identical twins floating face to face inside the same sac, sucking each other's thumbs.
"You know, I just worry if it's right to keep on with this pregnancy," Sylvia says suddenly. She knits her hands together and looks off into space.
"I mean, is it fair to keep going if they end up damaged and maybe nonfunctional?" she continues.
Her husband, Tim, puts his arms around her, and whispers, "Shhh, one day at a time."
Sylvia works with disabled children and knows firsthand what it is to wait years for a child to speak a simple sentence or hold a pencil. There is a side of her that meets life with the unblinking realism of personal experience.
It was a different side of her, however, that had come this far with this pregnancy. Almost 50 years old, this was her third in-vitro fertilization attempt. These twins were from two donor eggs that survived implantation into Sylvia's uterus. For a woman over 40, it is estimated that the rate of successful implantation for in vitro eggs is only 6-10%. Of those who do become pregnant, 20-25% will have multiple fetuses, which increases the chance of pregnancy related risks, including miscarriage. Her dream of motherhood had taken her deep into a world of modern science and hope. Used to caring for other people's children, she had taken these two into her very womb with a fierce protectiveness.
"Can we listen to their heartbeats?" Sylvia asks shyly. "Sometimes I just need to check in with them".
"Of course" I answer, pulling two fetal monitors out of the machine next to her bed. She lifts her hospital gown to show a belly that barely swells from her long torso.
Twin "A" is always easy to find, as she lies underneath her twin brother, pressed up against her mother's pubic bone. There is nowhere for her to move to; no pool of amniotic fluid to swim away in.
I can feel her whole length under my two hands, and as the tips of my fingers press against her, I flash on an image of a tiny, translucent baby who is laughing; enjoying what may be only a brief transit through this world. She lets me know that she is aware of me by pushing back against my hand with a skinny, pointy knee or foot. Her spirit is so strong and joyous, and yet I can somehow feel that she will not make it into this life.
"That's Ann Louise," Sylvia says, as if sensing she's on my mind. I look quickly at her. She is smiling broadly and gently caressing the sides of Ann's little body through her skin.
"She is so strong. I almost feel as if she could speak," Sylvia continues dreamily.
"Do you hear her?" I ask. "Does she speak to you?"
"Well," Sylvia answers shyly, "It feels like that sometimes, but I'm not sure if that's really possible".
"Well, you've made her whole world. She's surrounded by your cells, and your blood feeds her." I say. "The fluid that she's growing in — it's all a part of you. That's a lot of physical connection to speak through. Think about how dolphins speak to each other under water.
" At this point, Ann Louise begins to kick furiously against the monitor, which makes it tap, tap, tap against Sylvia's body like Morse code.
The heartbeats from both twins sound clearly from the monitor, but Ann Louise's heart is beating faster than her brother's. She is a wild thing, a shooting star streaking across the night sky, destined to disappear again once we've seen her.
Twin "B" sits solidly above Ann Louise. His heartbeat cannot be immediately located since he has the luxury of a full warm orb of fluid to float in. Today, he is resting with his head towards Sylvia's left kidney, and his feet poking out on her right side. He is big for such a young fetus, and long. His movements are slow and slumberous. I have no sense of playful connection to this baby. When he moves, it is to turn away from the monitor or hand that touches him, just as a sleeping child might in his bed. He always feels dreamy to me; unconcerned with the outside world since his world remains intact "
The boy's name is Daniel," Sylvia says, moving one of her hands up to the top of her belly. "He seems so different in personality from his sister."
We listen to both babies for a while. Sylvia lays flat against the white hospital sheets, the swirling pattern in the heavy cotton cover and the way her hair flows out above her face on the bed, make her look as if she is swimming in a foamy tide pool.
*
It must be strange to be inside that in-between place, alive and yet not part of the world. The change is so gradual. They started out as tiny specks, really only part of a larger pool of fluid, and then they became bigger and heavier by increments, until the pool surrounded and supported them. Just as their bodies became more visible with every new layer added, so too did they become more and more conscious and aware. It may be like being enveloped in a cloud, hearing people all around but not seeing them.
Ann Louise was reaching for the limits of her amniotic sac the day it broke. Kicking her legs out and down and pointing her toes, she had been able to glide to one end of the pool and push off of it again to bounce off the other end. Suddenly, instead of feeling the soft, warm wall of the sac, her foot tore through, and her fluid became a whirlpool that sucked her through the tear in the wall.
Her feet fell into a tight band of soft tissue, and then through that, until she felt a temperature change and a rougher surface over her skidding soles. She hung on though, even as the sac collapsed around her like a deflated balloon. She could feel her brother rocking in the wake and reaching his hand down towards her until it rested on her head. They had always been together on this journey, from the Petri dish through the long needle into their mother's womb.
The twins both come from different mothers' bodies. The memories and information in Sylvia's cells are new to them. The longer they are filled with her blood, the more familiar she becomes. Her blood flows into them, and they release some it into the amniotic fluid as urine, so they are filled and surrounded by a mix of her and them. It is how new people are made and sensitized to family.
Already, in this short time, Daniel has moved on. He has grown, and developed, whereas Ann Louise, without this life fluid all around her, has stopped growing. They have been in the hospital for three weeks now, and although Ann Louise is leaning away from the opening to the womb now and the opening seems to have closed up again, Sylvia's body is undergoing subtle changes. Since Ann Louise doesn't have enough fluid around her now to grow, the uterus is starting to see her as a contaminant. There is less blood flow through the placenta, and soon, something will start an immune response to her presence, and Sylvia will get sick.
Hopeful voices surround the twins everyday, 24 weeks now with Daniel especially having a chance to make it into this world. Without her knowing it, Sylvia's body has been unconsciously saying goodbye these last few days.
*
As soon as all of the nurses are seated, the change of shift report begins. Glancing down at the list of patients on our list, I check for Sylvia's name. She is still here, more than half way to 40 weeks, or full term. Every time I have several days off in a row, I wonder how she is doing, and if she will still be pregnant when I return to work.
"First thing," the day charge nurse begins, "Sylvia might be getting sick. She's had a low grade temp for the last two hours, and said she felt that something was off, different."
Without realizing it, a moment of silence falls over us. Although some of the nurses do not like caring for Sylvia ("too flighty; "neurotic"), all of us worry for her. It is in the nature of any healer to both feel the illness in another person, and to then work on regaining their balance and health. In my many years as a nurse, I have found that nurses, in spite of their stereotype as pill pushing physician assistants, usually have a deep empathetic quality to them. When you "stand at the bedside," you develop a keen insight into the very subtle nuances of another person's health.
"I'll take her," I said.
"Good, thanks," the charge nurse said. "Why don't you just go to the floor now and see what's up."
By the time I reached Sylvia's room, she was shaking with a fever of over 102 degrees. She had the blankets pulled up to her face, and had her eyes squeezed shut.
"We were so close!" she wept "So close."
Placing cool cloths over her face, I gently pulled the blankets down and palpated her abdomen. Ann Louise was very still, moving only once in a while. I didn't monitor their hearts, because I knew that she could already be dead, and didn't want to add to the stress of the moment.
"Is this tender? Does this hurt?" I asked. "Are you contracting at all?"
"No, I'm not contracting, and nothing specific hurts, it's just my whole belly feels weird — kind of sore all over".
"I'm guessing that there's an infection around Ann Louise, Sylvia, but that doesn't mean that the other baby is infected as well," I told her. "I'm going to call the doctor, and have her come in and see you".
"Will antibiotics help? Will that buy them any time — maybe another week?" Sylvia asked. "This is exactly where we didn't want to be. At 24 and a half weeks, we can't just let them go, and yet there's so little chance that they'll be OK".
"Sylvia, let's see what the doctor says. I need to get something to bring your fever down first." I put my hand over hers. "You're not contracting, so we do have some time to make a plan."
We would all spend hours in Sylvia's room that night — her husband, me, the doctor, and the neonatologist, who would be the one to resuscitate and care for the twins when they were delivered. Sylvia and her husband could not decide whether they wanted all measures taken to save either twin, even the boy. The prognosis was poor at this gestation, but there was still hope for Daniel. Ann Louise had let us know that.
Medical policy and law has not kept up with the rapidly advancing field of fertility science. There are large gray areas, especially concerning the viability of very premature infants. The line between prolonging life and postponing death can be very fine and difficult to agree on, and the decisions made are as variable as are the people making them.
Doctors and nurses are ethically bound to counsel patients with the facts, in order to allow them to make their own decisions, but when the facts are ill-defined, counseling becomes a balance between the hopes and dreams of a parent and the unknown. The course of treatment can be affected by the ability of the care-giver to empathize with and relate to the patient.
Once alone in her room, I approached Sylvia. I felt I knew her well enough to know what she was too afraid to ask for.
"Sylvia, I think that this pregnancy is ending, but I think that Daniel has a chance. Ann Louise hung in there for a long time, even though she wasn't growing anymore, and I think she did that to give her brother some more time in the womb. What do you think?"
"I just don't want a severely damaged baby. I'm so afraid that that is what we'll get," she answered. She clutched her blankets tightly, and turned away towards the wall.
They had come this far. Two donor eggs artificially implanted in her uterus, which had not been fertile to begin with. It surely didn't make sense now, to suddenly worry about the consequences of manipulating nature. It left me wondering about the importance of how a life begins and develops, and what hidden exchanges take place in the womb that we cannot yet imagine.
I understood Sylvia's grief and guilt. She was a conduit of life, and tonight there were such serious choices to be made, choices that she hadn't fully realized would come up when she began this long journey.
We listened to the baby's heartbeats once more. In the silence of the labor room, Sylvia, Tim, and I sat quietly and heard Daniel sound out his usual steady, strong beat. As I nervously placed the monitor over Ann Louise's spot, I found myself silently asking,
Are you still there?
A slow but steady heartbeat immediately picked up through the monitor over Sylvia's pubic bone. The baby didn't move, but she was still alive. I could sense that she was slowing down; that she was tired. She didn't kick at the monitor this time.
My eyes met Sylvia's. I could see the fear in them, but I knew that she was a person who would want to know that she had done everything to help these babies, even if neither one of them lived after tonight. I also felt that Ann Louise was counting on me to help her complete her task here.
"Sylvia, I know the thought of Ann Louise dying and Daniel having medical problems is scary, but I think you should take some time and think about how far you've been willing to go to get to this point." Looking over at Tim, I said, "Even if neither one of them makes it, you will need to know that you really did everything possible for them before you say goodbye."
I could already feel the loss of Ann Louise in the pit of my own stomach. I knew that for Sylvia, it brought out the fierce, instinctual protectiveness that all mothers feel for their children. It is painful when these feelings need to be redirected towards saying goodbye, and letting go.
Inside of me, a place that had already accepted the dying of both of my parents and more than a few close friends opened up once more, to receive this baby. The mother in me stood tall and cradled this tiny child away from death. In my mind's eye, I looked down and saw Ann Louise become first my oldest, then my youngest child, and I could not let her go.
"I think we both knew all along that we would have to make this decision, and I think we also knew that we would do everything possible to help them live," I heard Sylvia say sadly. "Can you turn off the monitors, and give us a while to be alone?"
"Of course," I said, as I turned the monitor away from her bed and shut it off. "Whenever you're ready, let me know and I'll get things going."
Leaving the room, I walked slowly around the unit, trying to ground myself. Not only would I have to let Ann Louise go, I would have to support Sylvia as she watched her children move on to an unknown end. My role here would be to keep Sylvia safe, both physically and emotionally, while she passed through this transition with Ann Louise and Daniel.
They spent an hour alone, listening to a beautiful CD of classic choral music. It was as if they were calling in their spirit guides to help them through this journey. Re-centered, and somber, Sylvia entered the surgery room for her cesarean. Tim kept meeting my eye, and when I could, I'd take his hand. Sylvia looked inward, focused on maintaining an inner calm.
Tense silence filled the room as the last incision through Sylvia's uterus was made. The two teams of nurses, pediatricians, respiratory therapists and assistants stood to the side of the delivery bed, hands folded in front of them. Once the womb was opened, Daniel would have to be delivered also. My eyes kept welling up at the thought of seeing Ann Louise in person. Both Tim and Sylvia had their faces turned towards the team, waiting for that first glimpse of their babies.
Ann Louise was lifted out first, contained inside of the surgeon's two cupped hands. She was curled up with her knees to her chest, and didn't move when the pediatrician took her into the open warmed blankets and lay her down on the resuscitation table. I saw a glimpse of her long, thin arms and legs, and her translucent, shiny skin before the team closed around her. Sylvia and Tim watched silently. This is what they had prepared themselves for.
To the sounds of suction and oxygen, and the murmurings of the doctors working on his sister, the surgeons pierced Daniel's amniotic sac, and gently reached in and lifted him up. He cried, softly at first, and then more vigorously, lifting up his arms and legs as if to ward off the sterile, cold air of the operating room. A collective gasp filled the room. Sylvia and Tim followed Daniel to the baby warmer with their eyes, hope suddenly on their faces.
Daniel kept crying in between the suctioning, the sound slightly muffled by the tiny oxygen mask over his face. He was just barely fully formed, tiny, but with a small layer of subcutaneous fat under his skin that made him look more baby-like than Ann Louise did.
Ann Louise never cried. Her lungs were not fully developed, and so she could not take that first crucial breath that would transition her to breathing air. As she was wheeled by to the intensive care nursery, I saw her transparent skin with the blood vessels showing through it. Her tiny body was no more than 11 inches long, and she was still only fragile bones and just-formed organs. Her lungs were like tiny un-inflated balloons, and her face like an artist's delicate, initial carving in wax.
*
Sylvia recovered within hours, the infection and fever gone with the pregnancy. She and Tim spent that night in the nursery, hands on both babies, in spite of the wires and tubes that they were attached to. As Daniel rallied, letting the machines breathe for him and keep him warm, Ann Louise faded. By early morning, before dawn, the machines had been turned off, and her heart had stopped beating while she was held by her parents.
I said goodbye to her a few hours later, when a nurse brought her down for one last visit with her parents. In an empty utility room, I up-wrapped her one blanket and studied her. Her eyebrows were arched and colorless, and as fragile as the powder from a moth's wing. Beneath, her eyelids were still fused shut, not ready to see light. She had a long straight nose, with pearly little nostrils to each side, and thin lips that were set in a satisfied smile. Her body was exquisitely perfect and looked to be made from the same tissue as a jellyfish, or a sea anemone.
"You did it. You watched out for everyone," I said to her.
After making prints of her long, pianist's hands, and her little skinny feet, I rewrapped her in a tiny flannel nightgown that snapped at the neck, and two blankets from the warmer. Over her fragile, lemon-sized head I placed a tiny pink hat, knitted especially for babies born too early.
Sylvia and Tim held out their arms to hold her when I brought her into the room. Leaving them to their privacy, I realized I also needed some time alone. Sitting in the window of an empty labor room, I looked out at the orange rays of the sunrise bouncing off of the deep blue of the mountains. How is it that I could feel the loss of someone so acutely when she had only just become visible? How could this child have been so present until she was born?
Before I left for home that day, I wrapped Ann Louise up for her journey to the morgue. She was to be picked up that morning and delivered to her cremation. Preparing Ann Louise for her final journey, I set the wraps down on the counter in a diamond position, with one corner pointing towards me and another away from me. I placed Ann Louise's body on top, and taking the left corner, folded the wrap over her body and tucked it underneath her right hip. I then did the opposite with the other corner. This is the same way that live babies are swaddled in their blankets. It makes them feel safe and contained again in something warm and close.
The elliptical line of this wrap is the same one that insects take when they make cocoons or a chrysalis. Childhood memories of sitting for hours under a branch to watch a butterfly slowly open it's chrysalis layer by layer came back to me suddenly. When you wrap the person tightly in it, the natural line of an adult death shroud also takes this same shape, and it occurred to me that this tapering, arrow shape may have something to do with holding the residual energy of life close to the discarded physical body after death. An insect, which enters a death-like phase before emerging as a new life, would also need to keep this energy close.
I realized also, with a start, that I was praying over Ann Louise as I carefully moved her wraps into place. It didn't sound like the praying I had heard in church growing up. It sounded, instead, like the roaring of waterfalls and the singing of the wind inside my head. To acknowledge the passing of a spirit is to pray. As I stood alone in the utility room of the hospital saying goodbye to this child, I felt the presence of many other spirits, both present and already passed, who had already opened their hearts to take her in.
Original art courtesy Rob Grom.
