Joy Cometh in the Morning--Part 2B

******
The following morning, Harm arrived by 08:00 with two bagels, a cup of coffee for him and herbal tea for Mac. As he handed Mac her breakfast, he greeted her with a kiss and settled into the chair. “How was your night…is your blood pressure down…how’s the swelling…did Dr. Abrahms come by yet…is Sally working today, because I didn’t care for the nurse from yesterday…what time is your procedure…did they say when…”

“Good morning, I love you, too,” Mac interrupted with a smile.

“What?” Harm stopped in his tracks.

“Remember calm, in control, relaxed, patience, toning it down…any of these ring a bell?”

“Oh yeah, I forgot…I’ll try, I promise,” he slyly replied. “You can answer any of the above questions at your leisure…by the way, I have a list of questions for the neonatologist…I was on the internet until 0200…”

“Harm!!!”

“Stopping now…Eat your breakfast, Marine.”

***

Mac was taken to a procedure room, to have the amniocentesis performed, at 10:00. As Dr. Abrahms finished the procedure, he smiled, “Well that wasn’t so bad was it?”

Mac responded, “Not really, the needle stung a bit, but overall it was nothing compared to everything else I’ve had to go through.”

The doctor turned towards Harm who was sitting in a chair in the corner, still looking somewhat pale, “Captain, how are you doing? I know that needle is really long, but Sarah did great. Based on your response, I’d say it’s a good thing Sarah is having this baby instead of you.”

“You can say that again,” laughed Mac.

“Hey, no ganging up on the Dad here…I just didn’t like seeing my girls put through that,” grumped Harm. “Beside I think I’ll do just fine with the delivery.”

“We’ll see,” said Mac. “I promise not to share the fact that you nearly fainted with everyone in JAG ops, if you bring me something good for lunch…and it better not be a salad or Bud and Sturgis will hear the whole story of how the big brave naval fighter pilot almost hit the floor at the sight of a little needle.”
“I didn’t almost hit the floor…I just needed to sit down really fast…and that little needle was at least 6 inches long…and you are not to even hint to Bud and Sturgis about that fact, or else…”

“Or else what…are you going to ground me…limit my privileges or food choices…Harm, I’m already held captive on bedrest and the food in this joint just stinks. Besides how am I going to talk to Bud or Sturgis…unless…I think Harriet was going to visit this evening….”

“Mac, I’m warning you,” menaced Harm

“All right you two, I’m beginning to understand the admiral’s comment about ‘patience of a saint.’ I’ll see you two after lunch; I should have the lung maturity results by then,” Dr. Abrahms noted as he left the room.

***

Dr. Abrahms found the couple playing cards when he returned that afternoon. “Who’s winning?”

Mac smirked, “Me has usual, poker is his forte. Did you get the lab results?”

“Yes I did, unfortunately they showed that Sophie’s lungs haven’t matured yet…although, that’s not uncommon at this stage in pregnancy. I had just hoped that if we had to deliver we could take that one concern out of the equation.”

“Is there anything else you can do to speed up the maturation?” questioned Harm. “Maybe you could give another dose of the steroids?”

“I really don’t want to expose Sophie to any more steroids at this point. The literature doesn’t support giving repetitive doses. In fact, it can do more harm than good by causing growth failure of both weight and head size. Taking into account that Sophie already has significant growth failure, I really don’t want to exacerbate the situation.”

“So what do we do?” asked Harm.

“We’ll just sit and wait. As long as we can keep Sarah’s blood pressure down with the magnesium and bedrest, we have the luxury of giving Sophie time to get stronger. I’ve asked on of my neonatal colleagues to speak with you this afternoon. Her name is Dr. Catherine Williams. She should be able to explain some of the problems that Sophie might have after delivery. Relax you two, I’ll touch base again this evening before I leave.”

***

Two hours later a tall female naval commander entered the room, “Hello Sir, Ma’am, I’m Dr. Catherine Williams, the neonatologist or newborn intensive doctor. Dr. Abrahms asked that I speak with you about preterm infants. Colonel, I see from your medical record that you’ve had quite a difficult pregnancy. May I ask if you know if the baby will be a boy or a girl?”
“A girl,” responded Mac, “and her name will be Sophia Elizabeth Rabb, but we plan to call her Sophie.”

“What a beautiful name. Before I begin, please feel free to interrupt me at anytime to ask questions. I will describe for you what might happen if Sophie were to be delivered today…but that doesn’t mean that I know anything,” the doctor replied with a smile, “it just allows me to explain what might happen should that occur. Do you mind if I sit down?”

“Not at all,” smiled Harm. “In fact, it might be a good idea…I have lots of questions!”

The doctor smiled back, “that’s great I love having a family who is involved in their child’s care. Shall we begin?” At the couple’s affirmative nod, she continued, “I usually start at the top of the head and work my way down, that way we don’t forget to discuss anything. You are now 29 weeks into your pregnancy, is that correct?”

“Yes that’s correct,” confirmed Mac. “I’m sure that you’ve read that despite the gestational age of 29 weeks, that Sophie is very small for her age. Dr. Abrahms said that that could cause additional problems especially with her lungs.”

“Yes, I did note that Sophie does have intrauterine growth restriction.” At Harm’s questioning look, she continued, “That just means that she is small for her age. At 29 weeks the usual chance for survival is well over 95%, but in Sophie’s case that survival chance is likely lower due to possible pulmonary hypoplasia.”

“You mean the chance for undergrown lungs?” questioned Harm. “Dr. Abrahms said that could affect her chances to survive. Taking that into account, what are her chances?”

“Well, that’s hard to predict until after she’s born.” At the couple’s frustrated gaze, she explained further, “We can’t really tell whether Sophie’s lungs are too small yet. If we had other stigmata of restriction from low fluid, such as, contractures of her arms and legs, or a flat face or ears, I could confirm that her lungs would probably also be affected. However, Sophie doesn’t have those findings as best we can tell by ultrasound. The fact that she doesn’t have those physical findings is encouraging because it tells us there was enough fluid to allow movement and growth of those body parts. We’re getting ahead of ourselves though, maybe we better go back to our original plan and start at the top. I know that you have been most focused on the lungs, but a lot things can affect survival and long term outcomes.”

Harm and Mac both shifted to get more comfortable and nodded for the doctor to continue.

“Starting at the head, when babies are born early they are at risk for bleeding into the fluid spaces of the brain or the brain tissue itself.” At the couples panicked look, she quickly noted, “Now the risk for an intraventricular hemorrhage, or IVH, is actually relatively low at this stage. You’ll have to excuse my medical terminology, in the NICU we live in ‘alphabet soup land,’ so if you don’t understand our abbreviations just ask. You’ll get use to them after awhile. As I was saying, the risk for a brain bleed at 29 weeks is approximately 20-30%, but the risk for a severe bleed is only about 10%. The risk decreases markedly between 30 to 32 weeks gestation, and is close to zero after 32 weeks.

“Dr. Abrahms said that he wanted to get Mac past 32 weeks if at all possible…is 32 weeks a critical stage for most problems,” asked Harm.

“In many ways 32 weeks is a critical stage for a lot of the complications that can develop. Ideally we would like to get to at least 35 to 36 weeks, because than there is a chance that the baby wouldn’t even need the NICU.”

“Dr. Abrahms did say that that was his original goal, but he now thinks that is unlikely to occur,” noted Mac.

“Yes with all that is going on with your pregnancy, I seriously doubt that you’ll get to 36 weeks. Getting back to our discussion…we look for an IVH by doing an ultrasound through the baby’s soft spot. The ultrasound won’t hurt Sophie, but it does allow us to evaluate for bleeding. We usually do the first ultrasound at a week of age.”

“So if the ultrasound is normal then Sophie won’t have any neurological problems,” stated Harm with a pleading voice.

“Well, I can’t actually say that. Premature infants are at risk for learning problems; although, that risk also decreases the further along in pregnancy you get. The additional factor for Sophie is again her small size. Her poor growth may have also affected her brain growth, so she is going to need close follow-up of her development throughout her first few years.” Harm heaved a heavy sigh and nodded understanding. “The next problem related to the brain is having periods where babies forget to breathe.” Harm and Mac’s eyes again widened. “The portion of the brain that controls breathing is again not fully developed in prematures. Hence, Sophie may have periods where she forgets to breath, we call that apnea, and when that happens her heart rate may slow down, we call that bradycardia…or in alphabet soup land, those are ‘A’s and B’s.’ Most preemies have these events and I just wanted to warn you before Sophie scares you to death. She will outgrow the events before she goes home. If she is having frequent events then we can start a medication to help remind her to breathe…we actually use caffeine as a stimulant.”

Harm started to laugh, “I knew she was you daughter, only a marine would want coffee after birth.” Mac rolled her eyes and smacked him on the arm.

“The next topic to discuss is the lungs. Now I know that Sophie’s lung studies were still immature when checked this morning. Let me explain what that means…when babies are born early they don’t make enough of a chemical called surfactant…to explain what surfactant does…You know how when you blow up a balloon, it’s hard to get it started, but once you do it’s easy to blow up?” Harm and Mac both nodded ‘yes.’ “Well, surfactant helps hold Sophie’s airways open so she can breathe easily…without it her airways want to collapse making it harder for Sophie to take a breath. If her lungs are immature then we will need to place a breathing tube through her vocal cords and into her windpipe in order to put her on a ventilator. Once we place the breathing tube we can actually put the surfactant chemical down the breathing tube to help her breath. Hopefully she would only need to stay on the ventilator a few days, but might still need oxygen much longer.

With tears in her eyes, Mac asked, “Does it hurt her to be on the ventilator?”

“We would give her pain meds to keep her comfortable so she can remain relaxed and allow her lungs to heal.”

“What about if her lungs are undergrown,” queried Harm, while grabbing for Mac’s hand to soothe her.

“In that case, Sophie may need to remain on the ventilator for a much longer period of time or we may need to try a more aggressive ventilator, called an oscillator to assist her with her breathing. Worse case scenario, neither ventilator would work and Sophie would not survive.” At that remark, Mac began to quietly cry and Harm pulled her closer into a hug.

Dr. Williams gave them a few minutes to compose themselves then continued. “The other problems that we may encounter can include blood infections, anemia, jaundice, eye problems, feeding and intestinal complications. Would you like me to explain these now or come back another time?”

“No…,” Harm’s voice cracked. “No, please continue, we need to know what Sophie is up against.”

“Of course, I know this is all a bit overwhelming…and while all of these problems are a potential risk, the odds of many of them happening are quite low. The potential for a blood infection is about 20%. Babies don’t fight infections as well as you or I…and all of the IV lines and ventilator tubes that we place, put the babies at risk for even normal skin bacteria to cause an infection. Initially most sick preemies are placed on antibiotics until we confirm that the blood work shows no sign of infection. The antibiotics are stopped after a couple of days if everything is negative. We will then watch Sophie very closely for signs of infection. The signs are similar to things that preemies do anyways, such as an increase in the ‘forget to breathe’ spells or not tolerating feedings or worsening breathing status. If any of these were to occur then we would draw blood to evaluate for an infection and start antibiotics again.”

“Wouldn’t it be better to just keep her on antibiotics to protect her,” came Mac’s tearful reply.

“No, actually that would put her at risk for infections from resistant bacteria. Our goal is to get her off antibiotics and make sure we’re careful about not exposing her to extra bacteria. That means careful handwashing, getting all the IV lines and breathing tubes out as soon as possible, and utilizing breast milk to help her fight infection.”

“You mentioned anemia, should I donate blood now for Sophie to use?” asked Harm.
“It’s a bit to early for that just yet. We try to be careful about how much blood we draw from the babies. However when you only weigh a pound or two, it doesn’t take much to drop your blood count. We often start a medication when the blood count starts to get low to help the babies increase their own blood production. And if we need blood, I feel very safe utilizing the blood from the blood bank, it’s carefully screened and comes from reliable long term blood donors.”

“Ok, just let me know if I can donate. I’d like to do something to help,” sighed Harm.

“I understand, it is very frustrating to stand by and watch, but just being there for Sophie day-in and day-out is often therapy enough,” smiled the doctor. “Colonel, do plan to breast feed?”

“I really wanted to breast feed, but is that even possible given how sick Sophie is likely to be?”

“Absolutely…initially Sophie will be fed through her IV with a solution that contains sugars, fats and proteins… but once she is ready to begin feedings into her gut, we prefer to use breast milk.”

“How is that possible, won’t she be too little?”

“To start with, we’ll feed Sophie through a tube inserted into her nose and down into her stomach…once she is a little older then we will begin allowing her to try feeding by mouth. Babies don’t really know how to feed by mouth until at least 32 weeks, and don’t do it well until 34 to 36 weeks. Feeding is usually what keeps them in the hospital the longest and is the most frustrating for parents.”

“But if she can’t feed by mouth, then how do I breast feed her?”

“We will have you start pumping your breasts after delivery. It takes 3-4 days for your milk to come in so don’t get discouraged. We will feed Sophie what you provide. Breast milk is the one medication that only you can give your baby and it is one of the most important since preemies tolerate it best. It also helps to prevent blood and intestinal infections. One of the ways to help with your milk supply is do something called ‘kangaroo care.’ Once Sophie’s breathing has stabilized, we’ll let you hold her skin-to-skin. We’ll place the baby on your chest under your clothes. Your body temperature helps to keep her warm and the bonding helps Sophie to get better and grow quicker. If she happens to find your breast while she’s there…you and she can have a ‘good time.’”

“I know I would,” laughed Harm. Mac turned into Harm and blushed feverishly.

The doctor chuckled, “You don’t get out of this Dad…we allow fathers to ‘kangaroo’ too. You just don’t have to breast feed.” Harm blushed in return, while it was Mac’s turn to laugh.

“Most of the rest of the problems are pretty routine baby issues, such as jaundice. If you’ve ever been around a newborn, you’ve noticed that their skin gets yellow…that’s jaundice. All babies get jaundiced, preemies are just a little slower at clearing it…so Sophie will get to sunbathe under some special lights…that should take care of the problem. Because she will be small and not have a lot of fat to keep her warm, she’ll be placed in an incubator to keep her temperature up and help her grow. I would expect her to be in the hospital at least 7 to 8 weeks, maybe longer depending on how she does. Do you have any other questions?”

“Will she be OK long term after she comes home or can we expect her to have significant problems?” asked Harm.

“When a baby is born this early they are at risk for long term problems. These might include asthma, learning disabilities, cerebral palsy, or vision and hearing problems. In most instances, we don’t know if these are going to occur when a baby leaves the hospital. Certain things can increase the risk of these complications; such as asthma after being on a ventilator, or cerebral palsy and learning disabilities with a brain bleed. But even if these problems occur in the NICU, Sophie may still do well long term. She will just needs to be followed closely by her pediatrician for developmental milestones. In addition, we run a follow-up clinic here at Bethesda. We like to follow all the small preemies born at less than 3 pounds-5 ounces, to ensure that their development is progressing appropriately. If we see delays, then we refer the babies for therapies as indicated. Therapy won’t make the problems go away, but it will help both you and Sophie learn how best to deal with them.”

“Any other questions?” At the couple’s negative reply, the doctor rose from the chair. “At this point I like to give the parents a tour of the NICU. It’s kind of nice to see all the equipment before it’s actually on your baby…less scary that way. Colonel, since you’re on bedrest I’m afraid you won’t be able to come. Captain, are you interested in a tour?”

“Sure,” sighed Harm with a nervous voice. “Mac, do you care if I go?”

“Not at all, you can come back and give me a report,” she smiled.

Harm started for the door, but then turned back to give Mac a quick kiss. “I love you…I’ll be right back…sure you’re OK?”

“Go ahead Dad, I’ll be waiting…Love you, too.”

***

Harm came back 20 minutes later, pensive and quiet. “Hey, how was the tour?” asked Mac.

“Scary,” was his overwhelmed reply as he slid onto the bed and pulled her into a hug. “The babies are so small, and they’re hooked up to all kinds of monitors and equipment. There are alarms going off constantly. Mac, do you think Sophie can survive all this…because I don’t know if I can. I was terrified in there…the doctors and nurses just go about their business as if everything’s normal…but I…”

“I know Harm…but we’ll get through this together. We have to for Sophie’s sake. We’re not giving up on our ‘princess,’ remember.”

“Yeah, I do…thanks, sweetheart,” he murmured into her hair as he kissed the top of her head. Mac cuddled in close as they both contemplated the events of their stressful day.


***End of Flashback***


Harm was again jostled from his reminiscing by the same petty officer. “Sir, thank you for the use of the chair,” he nodded as he placed it back under Harm’s table.

“Heading home, Petty Officer,” smiled Harm.

“Yes Sir, the tribe is getting restless. I need to get them home to bed…thankfully the cafeteria is still standing. Thank you again, Sir…have a nice evening.”

Harm nodded back, “Same to you, Petty Officer.”

Harm glanced at his watch and noted that he had now been gone for an hour. Mac was going kill him. He got up quickly to get the requested ice cream and headed upstairs. He passed Sally at the nurse’s station on the way to Mac’s room, “You’re here late tonight.”

“Yes Sir, we were short staffed and the paperwork never seems to end. Have a nice evening, Captain.”

Harm breezed into the room exclaiming, “Mac, I got chocolate ice cream with chocolate fudge sauce and chocolate sprinkles. That should be enough chocolate to send even you into sugar overload…” the comment died on his lips as he noticed that Mac appeared to be sleeping. As he quietly approached the bed, he whispered, “Mac, are you asleep?”

“Haaarm,” came Mac slurred response. “I don’t…feel…very…good.”

“What’s wrong, sweetheart? Should I get the nurse?” The words were barely out of his mouth, when Mac’s monitor began to alarm for a low breathing rate. To his horror, Mac’s arms and legs began to jerk rhythmically as her body thrashed around in the bed. As he ran closer to the bed, the fetal monitor that assessed Sophie’s heart rate began to blare as the audible signal for the heart rate began to slow. He momentarily froze at the scene before him, ‘how could this be happening now…what else could possibly go wrong.’ As he reached for the call button to summon the nurse, Sally came running into the room.

“Captain, what’s going on…” Sally began but instantly stopped when she noted the look of panic on his face. She quickly ran to the bed and maneuvered it flat as she pulled the oxygen mask from the wall.
Sally yelled into the call remote, “Call a code and get anesthesia and Dr. Abrahms in here stat…the colonel’s seizing, I need Dilantin and the code cart in here now…Call the OR and set-up for an emergency C-section!”

Harm backed away from the bed in shock as medical personnel rushed into the room. Words began to blur, “Seizure…fetal distress…oxygen…intubate…need to move now…crash section….” One of the staff ushered him quickly from the room to wait in the hall, “I’m sorry Sir, but you’ll need to stay out of the way. Someone will be with you shortly.”

“Wha…What’s…happening…are they going to be OK?” he whispered aghast.

“Sir, I really can’t answer your questions. You’ll have to wait for Dr. Abrahms.”

At that moment, Dr Abrahms hurried to Harm’s side. “Harm we’re going to have to perform an emergency C-section. Someone will be out in a minute with a consent to sign.”

“But…what’s going on…I…I don’t understand…I…I…didn’t think you wanted…to deliver Sophie yet.”

“Harm, listen I don’t have a lot of time to explain. Sarah is having a seizure due to the preeclampsia. I need to deliver the baby to get the preeclampsia under control…and Sophie’s heart rate is dangerously low…if we don’t get her out we might lose both of them…I’m sorry, but I have to go!”

Harm nodded his assent and gaped as he watched Mac being rushed from the room to the surgical suites. She had a breathing tube in place in her mouth and medical staff surrounding the bed as orders were barked at a furious pace.

Sally appeared moments later with a surgical consent for him to sign. He scribbled his barely legible name to the form at the indicated line and then slowly backed up into the hallway and slid down the nearest wall. With tears in his eyes he looked down into the ice cream cup that he still clutched in his hand and with shaking breaths began to sob.

Sally had grabbed Mac’s hospital chart and started down the hall when she looked up to see Harm collapse. She quickly opened the chart to locate the contact number and dialed. “Admiral Sir, you need to come to the hospital immediately…the Captain is going to need you.”