In Honor of Twin B – Part 2

If you didn’t read my initial post, In Honor of Twin B, about 6 weeks ago, please go back and read it first (https://secretlifeofobgyn.wordpress.com/2017/03/19/in-honor-of-twin-b/). This is the end of the story –

 

The day after I published In Honor of Twin B on my blog, I saw my patient for her weekly visit. I had been following her each week with ultrasounds so that I knew for sure I was seeing each baby’s heartbeat. With the way these babies were lying, it was tricky just listening with the doppler and knowing I was hearing two different heartbeats. This day, Twin B no longer had a heartbeat – his life lasted only 32 weeks. He lay still by his brother’s side.

As much as I anticipated this, it was still shocking. I found my eyes tearing, and for a moment, had no words. Fortunately, the room was dark and I had a second to collect myself. I looked up at my patient and her husband and simply said, “Twin B has died.” They both nodded. “The other baby is okay though, right?” her husband spoke with urgency. I reassured them Twin A was fine, but would need close monitoring. There was not much information in the medical literature about how the healthy twin would be affected by the demise of the other. It was a rare occurrence this late in pregnancy. Potentially, as the baby decomposed, toxins could be released that may affect the other baby.

In the remaining 6 weeks, I had them come weekly for a nonstress test on Twin A and monthly ultrasounds to monitor his growth. Because he was breech, we planned a c-section at 38 weeks, the typical time twins would be delivered. As the delivery drew near, the husband had many questions, most often “you are going to be at the delivery, right?” Her parents came from India and began coming to the appointments. I wasn’t sure how much they understood me, as they were always quiet – the mom would respond to my greeting with a smile and small bow, the dad, a nod. Sometimes, in the busyness of the room, the many questions from the husband and the quietness of my patient, I would forget to ask how my patient was feeling. Once I finally returned my attention to her, she would only smile and say “I’m fine.”

Eventually, the big day arrived. My patient and her family were squeezed into the smallest pre-op room. When I pulled the curtain to greet them, I immediately bumped into a nurse. The nurses had been great all morning, asking me how to best meet the needs of my patient, her husband and the dead baby. “Does your patient want to see Twin B? We will have the bereavement counselor see them. Do they want an autopsy? Their own burial?” In my preoccupation to make sure Twin A was doing well, I had not entertained these questions with my patient and was relieved the nurses did. My patient did not want to see Twin B, but her husband did. I wasn’t sure what Twin B would look like after being dead for 6 weeks, but the nurses reassured me they would wrap him in a blanket so that not much of the baby would show.

As we gathered the patient and walked her into the delivery room, I found myself more anxious than usual. This c-section needed to go smoothly and Twin A needed to be alright. I didn’t anticipate any surgical issues, she had never had surgery before. I had no idea what Twin B would look like after being dead for 6 weeks – it was the first time I had ever come across this situation.

I held my patient’s hand and quietly spoke to her as she received her spinal anesthesia. The only question she had was “when will my husband come in?” “Once the spinal is in and we know it is working, we will call your husband in. It should only be another 5 minutes,” I reassured her. Once she was draped and we knew the spinal was working, her husband came in and we started.

Proceeding with the c-section was routine and we dissected down to the uterus without any issues.  We made the uterine incision with the scalpel, the amniotic sac popped out through the incision and we broke Twin A’s water. His butt was presenting and I could see the resident was struggling to bring the baby’s bottom into the incision. “Feel for the legs and bring them out first,” I instructed her. She was easily able to bring down one leg. “Now rotate the baby to bring out the other leg.” Once she did this, we used a wet towel to hold the baby’s hips and gradually rotated the baby back and forth while also gently pulling him out. When we got to the level of the shoulders, we rotated far enough to bring one arm through the incision and then fully rotated the other way to deliver the other arm. “Bring the baby up to deliver the head.”  In one fell swoop, the baby was out. He was a bit stunned and didn’t cry immediately, but once we rubbed his back a little, he responded. Off to the warmer he was taken, wiggling in the nurse’s arms. My heart was full.

We turned back to the uterus and Twin B. The resident seemed hesitant what to do next. “Break the water and then we’ll see how the baby presents,” I told her. He had been lying sideways in the ultrasound, but being only one pound and now without his brother sharing the space with him, he could easily turn. Instead of clear amniotic fluid, it was cloudy and thick. The resident reached in and the baby easily came floating through the incision, his tiny body floppy and folded in two. We laid him on the blue drape gently as if he could easily fall apart. His head was flattened sideways, probably having been compressed by his growing brother. HIs skin was translucent and I noticed the skin starting to slough off on his legs. There were a few strands of long dark hair on his head – I found that very strange to see. Instead of the cord being gelatinous with the 3 vessels easily visible, it had an opaque pinkish hue throughout its thickness with no obvious blood vessels seen. We clamped and cut the cord. The resident again seemed lost and at this point, my attention was on the gaping hole in the uterus that was bleeding and needed suturing. “Hand the baby to the nurse behind you,” I told the resident. Then “Alis clamp,“ to the scrub nurse with my hand open for her to put the instrument in.

The rest of the c-section went smoothly. As we were suturing, I saw the husband being led to the warmer with Twin B. He looked at him, touched his blanket, then walked back to his wife. As he passed, our eyes met briefly and I nodded. A few minutes later, a nurse placed Twin A in his arms and my patient could finally see her son.

After the c-section was done, I took off my gown and gloves and walked over to my patient. “Do you want to hold the baby?” her husband asked immediately. “Of course!” Both were glowing as he handed me their son, their relief and happiness palpable.

I walked away thinking about the past few months. For the mom, housing a dead baby for 6 weeks in order to save her other son. For the dad, the weight of responsibility he felt trying to protect his wife and children the best he could. For both of them, having to balance the joy of a new son and the sadness of a dead one. And for me, coming full circle with this couple – helping them become pregnant, navigating through an emotional pregnancy, and holding their healthy son and their dead son. Life can be so complex, so unpredictable, so mysterious. But in this moment, for this couple, life was full and for me, simultaneously settling and unsettling.

 

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