The power of presence

2013
Chaput, Genevieve

It had already been a very busy call when Mrs. M was brought to room 10 of the Obstetrics unit.  The assigned nurse informed me this was Mrs. M’s first pregnancy, and she had come in with abdominal pain as a chief complaint.  I greeted Mrs. M and her husband, and began to gather a history while I waited for her chart.  Mrs. M reported an insidious onset of diffuse abdominal pain late last evening, with no loss of fluids or blood per vagina, and no contractions.  It was now 3h15 AM, and the pain had not subsided: “Doctor, I am worried about my baby”, an anxious looking Mrs. M said.  I placed the ultrasound Doppler on her lower abdomen, and easily found a strong fetal heartbeat.  

The nurse returned to the room and handed me the patient’s chart: Mrs. M appeared to have had an uncomplicated pregnancy course to date, and all of her routine screening tests were normal.  A fetal ultrasound was scheduled in a handful of days from today.  Based on the date of her last menses, Mrs. M was at approximately 19 weeks of gestation.  As the institutions protocol requires all women under 25 weeks’ gestation to be assessed by the Obstetrics team, I immediately paged the senior resident on duty.   Brian, the Obstetrics fellow, rapidly joined me at Mrs. M’s bedside, who was now feeling nauseous.   The fellow completed the history, and examined her: her vitals were within normal limits, and she was afebrile.  On abdominal palpation, she accused generalized tenderness, which was slightly more pronounced in the right lower quadrant.  The pelvic exam revealed a long and closed cervix.  Continuous maternal-fetal monitoring showed a reassuring fetal heartbeat in the absence of uterine contractions. “Mrs. M, from what I’ve gathered so far, your baby seems to be doing well. I am going to do an ultrasound to get more information ok?” the fellow said in a reassuring tone. Mrs. M’s face expressed relief. 

In the middle of the bedside ultrasound, the patient felt more nauseated, and began to vomit.  The fellow suspected a gastro-enteritis, but an appendicitis should be ruled out.  He started her on intravenous fluids, ordered an extensive work-up, and I notified the general surgery team. 

The events that unfolded in the next hour were indescribably sad.  The surgery resident had seen Mrs. M, and she was expected to go down to radiology momentarily.  I was in another room carrying out a reassessment when a terrifying scream was heard from room 10.  Both the fellow and I rushed to Mrs. M’s bedside: she had gone to the bathroom, and lost a large bloody mucus plug.  The nurse promptly re-attached the maternal-fetal monitoring devices, and the senior reevaluated her:  her cervix was now open, and trickling of fluid was abundant.   Mild but regular contractions were now obvious on the monitoring screen.  The fellow and I looked at each other: words were not spoken, but we both knew an imminent delivery was inevitable. 

The senior, visibly distraught, compassionately explained to Mrs. M and her husband that she was in active labor, and that we needed to get ready for the delivery.  I kneeled beside her, and further explained that this meant the delivery of a premature baby unlikely to survive more than a few minutes…  Mrs. M began to cry uncontrollably: “No, no, no… My baby… No…” Over and over… Sadness was palpable in room 10.  The senior had but his sterile gloves on, and was now gently instructing the patient to push.  Mrs. M was in a visibly panicked state, and pleaded with me: “Doctor, please don’t leave me. Please stay with me, please stay…” I stayed by her bedside, in a kneeled down position such that I was at the same eye level as her and her husband, and didn’t let go of her hands.   Mrs. M’s eyes and I were nearly locked during the labor, which seemed never-ending.  There she lay, her husband’s arms wrapped around her neck, weeping loudly as the labor went on, reluctantly obliging to the fellow’s gentle encouragements to push with each contraction.  During this entire time, my soul was submersed in sadness, and I felt overwhelmingly helpless for the patient… I seemingly could not come up with a single compassionate word or sentence that seemed appropriate to say… And so I just stayed beside her as she had asked, and held her hands in silence, hoping my eyes were communicating the extent of my grief for her and her husband… I did not let go of her hands, and found myself squeezing them, wanting them to serve as comforting words that did not seem to exist, wanting them to feel like arms wrapped around her… In the early morning hours, Mrs. M and her husband finally delivered a tiny, precious little girl, whom lived just a couple of minutes.  Many more tears were shed in room 10, and as per the parents wishes, they took turns holding their lifeless daughter, and prayed together.  Mrs. M’s mother arrived, and took part of their religious ceremony.  For the next two hours or so, room 10 was filled with family members and friends whom came to offer support and condolences. I regularly returned to Mrs. M’s room in between my other duties, to “check in” on her and her loved ones. Here again, I felt at a loss of words to offer, and found myself serving mainly as an empathetic listener, and also as a paper tissue provider…

In planning Mrs. M’s discharge, given the sorrowful circumstances, ensuring a prompt follow-up with her doctor was essential. In reviewing her chart, I noticed the physician who had been following her was a resident colleague of mine. I was overcome with a sense of relief, as I personally knew this resident to be a very knowledgeable and caring one: I felt confident Mrs. M was going to receive good post-partum care.  Back into room 10, I told Mrs. M I had organized an appointment for her to see her doctor, who was a friend of mine, for early next week.  Mrs. M replied: “Yes, I know you know my doctor, because my husband and I saw you in the clinic a few weeks ago remember?  You came and helped our doctor find our baby’s heartbeat” Indeed, I now remembered going into my colleague’s office to help him find their baby’s heartbeat.  Mrs. M continued on: “Doctor, you were the one who found our daughter’s first heartbeat, and also our daughter’s last heartbeat. Thank you for everything you did for us, we could not have gone through this without you” Those words of gratitude left me speechless, to say the least.  While I doubted the quality of my care given, the near-absence of my words, Mrs. M expressed feeling otherwise… It might have just been that there were indeed no words to say, and that being present was what had been needed.

Theme: Birth | Naissance
Theme: Death and Dying | Décès et le mourir
Theme: Family | Famille
Theme: Relationships | Relations

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.

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