life. breath. breathe.

Life is fragile.  Nowhere, perhaps, is that more apparent than obstetrics.  We so closely monitor these tiny lives dependent on their mother from months before viability up to and after delivery where we marvel at tiny fingers and toes complete with nails, the rosebud mouth, the blinking eyes, the soft spot. 

I'm on nursery this month, and I've seen a lot of newborns.  I also hear the OB signout in the morning since knowing what is going on with laboring moms will mean I know what to look for in the babies.  We've had a rash of high-risk, sad cases, though, and the fact that I never see the moms I hear about in signout reinforces my feeling of helplessness in the face of the tragedy down the hallway and yet completely out of my reach even to comfort. 

Perhaps the most dramatic example was a patient that came in with headaches and high blood pressure.  She didn't know she was pregnant despite being about 20 weeks and carrying (surprise!) twins.  Her severe and worsening preeclampsia, however, meant that it was a choice between losing three lives and losing two.  So a C-section was performed, and mom was closely monitored afterwards for her dangerously high blood pressures and risk of seizures, liver damage, and kidney damage.  Her babies died two hours after birth, unable to survive outside the womb at such severe prematurity.  I can't imagine the rollercoaster of emotions she has been on - feeling sick to discovering she is pregnant to learning she will lose the babies to watching the babies die to dangerously ill herself.  It makes me remember, too, the 19-week infant I held in my hands and watched die after a mother miscarried in Zambia. 

Another patient came in having broken her water ("ruptured membranes," as we say) at 20 weeks, nearly a month before viability when her baby could survive outside the womb.  She is at risk for infections without the membranes to keep bacteria out of the uterus, and the baby is at risk for separation of the placenta from the uterus without the fluid to keep it pushed up against and keep the uterus inflated, so to speak.  Her cervix is partially dilated, and the ultrasound showed the baby's feet moving in and out of the cervix with movements.  So close.  So close to life.  So close to death.  A few more weeks, and he or she might have a chance.  She was offered the possibility of delivery now since she has less than 1-3% chance of reaching 24 weeks without spontaneously delivering or getting an infection, but she chose to wait.  So here she is in the hospital, waiting. 

A similar patient who broke her water at 32 weeks waited for a week and a half before starting labor spontaneously and still ended up with a C-section when the baby wasn't doing well.  Her baby is still in the NICU a few weeks later.  She comes in to see him and is attempting to breastfeed.

But it's not just large things, dramatic cases that tear at my heart when I hear the details.  It's little things, too.  A baby's hearing screen comes up abnormal, and I feel for the parent who suddenly faces the possibility of life with a disabled child.  The baby looks perfect, but so much of this whole parenting and doctoring thing is beyond what we can see and control.  (A repeat hearing test ended up being normal, so fears were alleviated this time.)  Another infant has a low temperature overnight, prompting a workup for infection.  Again, the baby looks fine, has been feeding well and is active and vigorous, but I worry.  Am I missing something?  The stakes are so high.  These little lives are so fragile, and I know from the stories that things can go downhill quickly.

There are good experiences, too.  I went in a C-section and got to suction the (crying - yay! never are we so happy to hear a crying baby as at delivery) baby and learned to remove the placenta.  I am doing circumcisions under supervision and feeling more comfortable doing this relatively simple procedure and feeling happy with the results.  One of our babies was crying in the nursery one time when I was there waiting for something.  I picked him up, and he instantly stopped crying.  Gratifying - but again a reminder of how dependent these tiny people are on us older ones. 

The Bible connects the idea of life and breath, starting way back in Genesis when God breathes his breath into us, the breath of life, and humankind lives first in Adam and then also in Eve.  The promised new life as the people of God in the New Testament is also connected with breath, with God's Breath, his Spirit (same word in Greek pneuma and Hebrew ruah).  It makes sense; the last thing you see someone do when they die (naturally) is to breathe out. 

It reminds me of another image, that of vapor.  In Ecclesiastes, the writer reports that life is "meaningless."  I remember learning in my college Old Testament class that the word translated "meaningless" is hevel.  This is a word used to describe vapors, such as the early morning fog that would cover Jerusalem that would disappear nearly before the eyes of those who lived there as the sun rose.  As such, it communicates transience, the ephemeral nature of life. 

But the word has another meaning.  It is also used of breath, this invisible movement of air that enables us to live our lives, to laugh, to cry, to speak, to love, to worship.  The truth, I think - and what I am sensing in the vulnerable small lives I hold in my hands each morning as I round - is in this tension.  Life is temporary and fragile and yet it is beautiful and meaningful, full of significance and closer to its end than we like to think, as close as your next breath or mine.  I am relieved to remember that the balance is not in my faulty hands but in the love-marked hands on which our names are engraved so that we know he will never forget us.

                                      morning mist in modern-day Jerusalem