The Honourable Midwife

They had overhead lights switched on, trays of shiny, sterile equipment lined up, and their patient ready to be wheeled in. The pace had picked up in Labour and Delivery, too. The recently delivered mum had been moved across to the post-partum ward, but they had a new admission to take her place—a young woman of nineteen, who’d had only sporadic prenatal care and no second-trimester sonogram, and was uncertain of her dates. Around eight, eight and a half months gone, she thought.

Thirty-six or thirty-seven weeks? Apparently Bronwyn Jackson wasn’t convinced of this after a manual examination.

‘She feels too small,’ the midwife reported to Pete. ‘By the height of the fundus, I’d say thirty-five weeks, maybe even thirty-four.’

‘Can we try to stop the labour?’ Pete asked.

‘No chance. Fully effaced, half-dilated, contractions every few minutes. This baby’s coming today, and we’ve got the resus trolley on hand.’

‘I’ll get there for the delivery if I can.’

‘The joint is jumping all of a sudden.’

‘Better phone Alison Cairns and tell her she might be needed, too.’ Dr Cairns was good with fragile babies.

The new admission, Rebecca Childer, had been put down as Pete’s patient, although her family was fairly new to Glenfallon, and he’d only ever seen her mother, Susan, for a couple of routine things. He didn’t like having this new, questionable labour hanging over his head when Patsy and her baby were uppermost in his mind.

The baby obviously didn’t want to stay in Patsy’s tumour-filled uterus any longer. He only hoped the little girl would be safe out of there, and in their hands. Should he have sent Patsy to a bigger facility before this? She’d argued against the idea very strongly, but he could have presented it in starker terms.

If we lose this baby, came the insistent thought, how much will I question my own decisions? And where’s Rebecca Childer going to be up to in her labour when I get out of Theatre?

‘Dr Croft looks terrible,’ Emma said quietly to Nell Cassidy.

Although Emma was over a year younger than the A and E specialist, she and Nell had been friends since their school days. More specifically, since the Glenfallon Ladies’ College Senior A netball team’s memorable trip to Sydney about seventeen years ago, for a round of competitions.

Teenage giggles and confessions during the long bus ride had gradually evolved into the more considered honesty and support of adult friendship, and had survived divergent career paths and life experiences, long periods of living in different places and even some significant criticisms of each other’s choices.

Nell knew that Emma considered her too cool and too uncompromising in her approach to her work. Emma knew that Nell would have ‘thrown that parasitical stepmother of yours out months ago’, instead of putting up with the situation until Beryl had left in a huff to go and live with her own daughter earlier that year.

Somehow, however, these differences of opinion didn’t matter. This same honesty now made it possible for the two of them to have a serious, if snatched conversation on an unrelated subject while they waited for their own role in safeguarding the McNichol baby’s first minutes of life.

‘Terrible is a bit harsh,’ Nell said in response to Emma’s comment. ‘He looks tired, definitely. And stressed.’

‘That’s what I meant, Nell. It was sympathetic. I wasn’t accusing him of having a bad hair day and tacky clothes. Is he tired and stressed?’

‘Most people are when their marriage is in the process of doing a slow-motion shatter.’

‘I thought his marriage was over. In his e-mails, he always…Well, in his e-mails, he sounded better than he looks.’

‘These things take time, Emma. But I expect if he’s been talking about his divorce in his e-mails, you know a lot more about it than I do.’

‘I know hardly anything,’ Emma said quickly.

She was sorry she’d made the initial comment to Nell now. She hadn’t meant this to turn into an analysis or a catechism. Having thought of Pete Croft as a kind of penfriend for the past three months, she’d been concerned to see the evidence of stress and problems in his face—problems he’d mentioned to her only in the most oblique way.

Something changed in him when they began the surgery, however. She saw him blink and work the muscles in his face, as if trying to wake them up, and there was a new alertness in his expression, a determination and focus that stripped away the signs of weariness and emotional preoccupation she’d first seen.

Pete was a good-looking man. Somehow, she’d never seen it before. Maybe because he didn’t fit the tall-dark-and-handsome model that most women wanted. He was tall enough, yes, but he wasn’t a giant—just under six feet, nicely built in an athletic way. He wasn’t dark. He did have brown eyes, but they weren’t for drowning in. They were too focused, too intelligent, too ready to be amused and too casually kind.

His skin was typically Australian—fair, a little roughened by the power of the sun, and uneven in tone. On a woman, it would have been disastrous skin, but on a man it was…very male. Rugged and strong and casually attractive.

As Nell had pointed out, he hadn’t been near a razor that morning, and his beard was growing in fast, a red-gold sheen of stubble surrounding firm lips which looked thin when he was absorbed in his work and fuller when he smiled his generous smile.

His hair was cut so you could see that it started as a very dark, rusty gold and went blonder as it grew out, until it settled on sand mixed with straw as its definitive colour. He had little creases at the corners of his eyelids—creases he needed a woman to kiss away with soft, tender lips—and he had a tanned curve of neck at the back which could make that same woman want to stroke it with her fingers, then thread them upwards into the soft prickle of his hair as she sighed against him.

Only not me, Emma thought in sudden panic. Why on earth am I suddenly thinking this way?

‘We’re good to go here, Houston,’ said anaesthetist Harry Ang.

‘One day I am going to kill that man,’ Nell muttered.

It was one of Dr Ang’s harmless quirks that he liked to speak as if this was NASA Mission Control and he was an astronaut about to launch into space. Nell had a limited tolerance for harmless quirks.

Emma didn’t mind Dr Ang—he was a nice guy, and always pleasant to the nurses, which counted for a lot—but she had to suppress a laugh all the same when Pete said, ‘Apollo Thirteen, do you mind if we cut satellite communications for the rest of this mission?’

‘Just trying to raise team morale.’

‘Consider it already more than sufficiently raised, Dr Ang,’ Nell came in. Her tone could have lasered through glass.

Gian Di Luzio ignored the whole thing. He simply asked for a piece of equipment, and the surgery began. Emma and Nell were standing by, waiting for the baby, and Emma found that her focus stayed fixed on Pete. She’d never realised it would feel so intimate to know that he’d lived in her house, and she wondered if he felt in any way the same.

The intimacy had to be even greater, perhaps. He’d slept in her bed. He’d used her dishes. He’d sat on her couch. Her personal possessions had all been packed away, but rooms were personal, too. Air was personal. Grass was personal. He’d breathed her air and trodden her grass.

He had mowed it very neatly, too, just before he’d left. He’d dumped the fresh clippings from the mower in their usual spot beside the compost bin behind her shed, and she’d arrived home to find them still giving off their tangy, summery smell. It had seemed as if Pete must have left just minutes before.

Pete made the incision in Patsy’s abdomen and cut through the outer layers of fat and muscle to reach the uterus. He and Gian had decided on the more conservative midline incision, given the difficult placement of placenta, fibroids and baby.

Gian muttered a couple of suggestions, and Nell stepped close when it was time to lift the baby free. Dr Di Luzio was another very capable doctor, Emma knew, and he’d just become engaged to her fellow midwife and friend, Kit McConnell. The couple were still talking about dates for their wedding, and they’d just agreed to formally adopt his brother’s little girl, Bonnie.

‘Here we go,’ the obstetrician said.

He brought out a blue, slippery bundle of limbs and a tight, immobile little face, beyond the sea of green surgical fabric, and gave the baby girl at once to Nell. Above his mask, Pete looked tense, and the sound they were all waiting for—a baby’s cry—hadn’t happened yet. The lights were bright on Mrs McNichol’s exposed skin, with its rust-coloured splashes of antiseptic, and the seconds seemed to drag.

‘She’s small for dates. Tiny!’ Dr Ang exclaimed.

‘We knew she would be,’ Pete said, his tone clipped. Nell suctioned the baby’s nose and throat out carefully and chafed her chest, but nothing happened. ‘Hoping for better than this, though,’ Pete added.

‘Come on, sweetheart!’ Nell muttered. ‘Don’t scare us like this!’

Working closely beside Nell, Emma clamped and cut the cord. The baby was still limp. Her one-minute Apgar score wouldn’t be all that great. Emma calculated automatically. One for tone, one for colour, zero for respiration…

‘OK, she’s still not breathing. I’m going to bag her, I’m not going to wait,’ Nell said, grabbing the equipment quickly.

She laid the baby in the open tray of the resus trolley beneath the warming lights. Emma managed to slip a stretchy little cap on the baby’s head to keep vital body heat in. The umbilical stump was the most favoured site for IV insertion in a premmie, but sometimes one needed intravenous lines put in through the veins in its scalp.

She hoped she wouldn’t be taking the little hat off again soon for that purpose. A baby at thirty-three weeks shouldn’t need that level of treatment. That fibroid-crowded uterus hadn’t been good for her at all.

‘Got some bleeding here,’ Dr Di Luzio said. ‘Pete, the placenta’s looking very tricky, right across a mass of intramurals. Surprised she got this far with the pregnancy. Not a bit surprised about the size of the baby. Nell?’

‘Going as fast as I can here,’ she answered. She held the manual oxygen bag to the baby’s face, trying to pump air into the tiny lungs and listen with a stethoscope at the same time. Nothing was happening.

‘One more try, then I’m going to intubate,’ she announced. ‘Heart rate’s a little slow and thready, and there’s a bit of a murmur. It may clear up on its own. They often do. Still, we have to get moving on this.’

Already, nearly two minutes had passed since the clamping of the cord, and every second without oxygen was critical. Thank goodness Patsy was unaware of all this!

‘Emma?’ Nell prompted.

‘Yes.’ She had the intubation equipment ready, and the oxygen.

The tube was pitifully small, and it would be an extremely delicate procedure, with the risk of tubing into the stomach instead, creating yet another delay. Nell had her naturally pale face set like a mask as she made her final attempt to squeeze oxygen into the baby’s lungs manually.

‘Come on, darling,’ she repeated, tapping the tiny feet, chafing the chest, looking for the right stimulation.

Normally, her skin complemented her dark blonde hair, but that was all tucked beneath her royal blue disposable cap. She looked as efficient and as cool as a machine, but Emma knew she had a strong, passionate heart beating away underneath.

‘OK, we’ve got her,’ Nell announced at last. ‘No tube, thank goodness. She’s breathing on her own. Yes.’ She watched and listened. ‘Yes! Heart rate is better already. Colour’s improving. She’s picking up quickly now.’

The five-minute Apgar score was the crucial one as a predictor of long-term health and development. Emma added the figures again. One for tone, one for colour, two for respiration…Seven. Eight would have been nice, but if she’d added that extra point, she would have been cheating.

‘Good. Go for it. Got our own problems over here,’ Gian said, in answer to Nell.

‘Houston, we have a—’ Dr Ang began.

‘Shut the hell up, Harry,’ Pete sang at him.

‘Sure. Sure.’

‘Can we tie off this vessel?’ the obstetrician asked.

‘Got it,’ Pete murmured. ‘How’s the placenta looking?’

Emma didn’t have time to look over at the table to see what was happening. She heard Pete’s voice, muttering something else, and Dr Ang confirming that everything looked fine at his end, although the patient’s blood pressure was beginning to drop.

‘OK, placenta’s coming away,’ Gian said. ‘Most of it. Getting a big bleed now.’ His voice was calm, almost lazy, but no one was fooled. ‘Cautery, Mary Ellen. Good. Thanks. Let’s get this closed off.’

There was a hiss, and the acrid smell of burning.

‘Good girl, what a lovely pink colour now! What great breathing!’ Nell said, as if it was the baby’s own success, not hers, and perhaps she was right. She leaned closer, listened once more just to check. ‘You good, darling girl! Now we’ve got it all happening,’ she crooned at the tiny baby, still working quickly as she spoke.

She taped a pulse oximeter to the baby’s hand, checked the fluctuating numbers that appeared on the screen. Climbing. Pink had now begun to radiate outwards from torso to extremities. Emma blinked back tears of relief. Blue was just the wrong colour for a baby, frightening and wrong. Pink was like the sun coming out on a cold, cloudy day, lifting spirits at once.

‘Thank God!’ she whispered.

She saw Pete’s glance cut across in her direction from the table. His face looked frozen for a moment, stark. He was thirty-six, she knew, but he looked forty today. A very masculine, competent, good-looking but stressed-out forty. Her fingers suddenly itched to smooth the lines on his face, to trace the shape of his mouth until it softened beneath her touch.

Then he blinked those tired brown eyes with their creased lids, grinned at her and nodded, wordlessly sharing her prayer of relief. She grinned back, and felt a rush of warmth and happiness. Gian’s running commentary suggested he had the bleeding in hand. Most importantly, the baby girl was breathing.

Emma wasn’t, as she smiled at Pete.

She seemed to be floating a good three inches above the ground, and she wasn’t breathing at all.

But at the moment breathing didn’t seem remotely important.

CHAPTER TWO

‘DR CROFT, we’ve got Rebecca in transition and almost ready to push,’ said Bronwyn. She was an efficient, thin and rather cool brunette, married with a school-aged son and daughter.

‘Right.’

Pete took a deep breath, switched his focus quickly. Little Lucy McNichol was looking good now, better than he’d dared to hope. She was small, just over three pounds on the old scale, but after that initial, frightening hitch with her breathing, she seemed reasonably strong, and she’d even taken the breast.

Nell had said she thought the gestational age might be closer to thirty-five or thirty-six weeks, not the thirty-three he’d been working on. Patsy might have mistaken bleeding at the beginning of the pregnancy for a period, and he’d dated the baby on that basis. With the spread and position of the fibroids retarding growth, the ultrasound scan at seventeen weeks hadn’t contradicted those dates.

But now here was Rebecca Childer about to give birth, and Bronwyn thought her dates might be wrong in the other direction. With no accurate date of LMP—last menstrual period—and no ultrasound measurements, they were working purely on the measurement from pelvic bone to top of uterus.

‘Don’t be surprised if you get called back up here,’ he told Nell, as she stripped off gloves and mask and prepared to head back down to A and E. ‘We have another iffy pregnancy on hand.’

‘I’ll be back up here anyway as soon as I can, just to make sure Lucy’s doing as well as we think,’ she said. ‘I did hear a faint murmur over her heart, did I tell you? But, of course, that’s very common. I’ll let it go as long as her stats are good.’

‘It’s your call. She looked good to me, too.’

‘See you in a while.’ Nell went towards the lift.

‘Rebecca, how are you doing here?’ Pete asked his new patient, as he entered Delivery Room Two.

She didn’t answer, just gave him a hostile look which he shrugged off. If he hadn’t asked about her state, the look would have been just as grim. In the grip of a powerful contraction, she wasn’t enjoying herself at the moment.

As soon as the contraction was over, he gave her a manual exam. It wasn’t routine policy to do so in this department, but Rebecca wanted a progress report. He listened to the baby. Heartbeat was fine. Dilatation was almost complete. The head was nice and low, but small. He agreed with Bronwyn. This wasn’t a thirty-seven-weeker.

‘Have we got extra staff?’ he muttered to her.

‘Vanessa Gunn is coming in,’ Bronwyn answered. ‘Emma will go into Special Care, with back-up from Sue North in post-partum. We’ll juggle it.’

Rebecca moaned. ‘I’m not ready for this. Nobody said it would be this bad.’

‘You’re doing really well, Rebecca,’ Bronwyn told her.

‘Don’t give me that garbage…’

Pete listened to the heart again, and found that the rate was perceptibly slower. ‘Get Dr Cassidy up here again,’ he told Bronwyn. ‘We might not need her, but if we do, I don’t want to wait.’

‘What about Emma?’

‘Her, too, as long as the post-partum staff have got Lucy’s care covered.’

Rebecca groaned, half sat up and opened her legs. The head was already crowning, propelled forward by the action of the uterus. Contractions were coming without a pause in between. Rebecca strained again. They’d have a baby very soon…

‘OK,’ Nell said. ‘She’s stable. She’s good.’

Like Patsy, Rebecca had delivered a tiny girl, whom she’d named Alethea. It was an old-fashioned name, but it was pretty, Emma thought. She clung to this thought—that the baby’s name was pretty, that the baby was pretty—because the little creature had problems at the moment.

She’d needed intubation and she was on a respirator. It had taken Nell, Emma and Pete an hour to get her stabilised enough to move her to Special Care, and Nell, who’d actually thought that was ‘nice and fast’ under the circumstances, was still working over her with a severe frown on her face.

Pete had left to check on Patsy McNichol.

‘Oxygen saturation’s gone up,’ Nell said. ‘I like her heart rate. I like how quickly we got this done. I like most things.’

‘That’s good.’

‘For the moment. And I’m hoping we’ll get her off the respirator within the next couple of days.’

‘What’s worrying you, Nell?’ Emma said. She knew her friend well enough to realise there was something.

‘I don’t know.’ She shook her head, as if to clear swimming-pool water from her ears. ‘I think I’m hearing a murmur again.’

‘Lucy had one, too.’

‘I know. They’re so common in babies, especially early babies, and mostly they mean nothing. With Lucy, I wasn’t so concerned. Her dates were better, even though she was almost as small. A small baby delivered within a few weeks of term is almost always better off than a larger one delivered earlier.’

‘And this one wasn’t large, in any case.’

‘I know. Which worries me, too, because I don’t know why.’ Nell listened to the heartbeat again. ‘I don’t know whether to be concerned about this baby’s murmur either,’ she said. ‘Certainly want to get the rest of her stronger before we start worrying about her heart. Hey, Alethea? Do you support that plan, darling? You don’t want a whole lot more mucking around, do you?’

Her voice was soft and cooing as she addressed the motionless baby. Then she straightened and spoke to Emma again.

‘All indications are that the heart is working fine at the moment,’ she said. ‘If it wasn’t, her numbers wouldn’t look so good. If I keep hearing this, though, or if it changes, I’m going to do a couple of tests. Let me know if there are any indications that her heart isn’t doing its job.’

‘She’s premature…’ Emma said.

‘I’m guessing thirty-three or thirty-four weeks.’

‘So…Patent ductus arteriosus is a fairly common condition in premmies, isn’t it? Treatable, too.’

Emma knew that in a normal foetal heart, the ductus arteriosus was open. In a full-term baby, this vessel closed automatically at birth, as part of the heart’s almost miraculous shift from foetal circulation to the circulation pattern it sustains throughout its life. A premmie baby’s heart can’t always manage this shift on its own, however, and if the ductus remains open beyond early infancy, permanent heart damage could result. Fortunately, the condition could be monitored and treated if necessary.

‘If it’s that, and if the PDA doesn’t close on its own, there’s a drug we can use to encourage it,’ Nell agreed. ‘It doesn’t always work, and that’ll mean surgery.’

‘In Sydney.’

‘A few years ago, we’d have had no hope of handling a baby like this in Glenfallon at all, with or without the need for surgery. Even now, I wonder if we should be starting to look at arranging medivac transport.’

‘We’re a level two unit.’ Emma was a little defensive. ‘I’ve handled several thirty-four-weekers, and even a couple of younger ones whose mothers had their dates wrong, like this one did.’

‘Yes, I’m not kicking her out of here yet, am I, Alethea? There are no real danger signs, and it would be great if we could get her strong and well ourselves…but I still think Sydney’s on the cards.’

‘There’s no point in having the facilities to handle premmies here if we don’t use them to maximum potential,’ Emma said. ‘Thirty-four weeks is the cut-off, I know, but personally I’m trained to a higher level than that.’

‘True. And people get better at it if they practise. There are going to be a few of us practising on this baby.’

‘Don’t put it like that, Nell, as if she’s an anatomical model.’

‘Oh, I’m not. I’m not. You know I’m not. I’m just nervous. That thumb-pricking feeling that something’s not right, despite all the things that clearly are.’

‘The way you were worried about that little girl who was revived after she fell in her pool?’

‘She was Pete’s patient, too.’

‘This one was dropped into his lap,’ Emma pointed out, although why she felt this instinct to leap to Pete’s defence, she didn’t know. ‘He’d never seen her before.’

‘The man has trouble with the women in his life, doesn’t he?’ Nell commented lightly. ‘Whether they’re patients or family.’

Emma bit back a comment which she might regret. Was Nell implying Pete’s troubles were his fault? Again, she felt a need to protect him and to leap to his defence, which she didn’t understand. He was extremely competent and very intelligent. He worked hard, he cared and he had the right priorities. Just because he’d been living in her house, that didn’t mean he needed her nurturing. What was wrong with her today?

‘Let’s take this one across to the unit,’ Nell added.

It took them another hour to get the baby settled in Glenfallon’s tiny special care unit, which was simply a small, closed-off room with thick, almost soundproof windows opening onto the rest of the maternity unit. It was most often staffed by the midwives rostered for post-partum care.

Lucy was already there, in the care of Sue North now, but she’d probably go home with her mother in a few days’ time, if her condition continued to be this good and she began to feed properly. Alethea’s arrival would necessitate the juggling of staff so that Emma and a roster of two or three other experienced nurses could provide her with the acute care she’d need at first, round the clock.

In the meantime, Nell was staying.

‘I hope my department’s quiet,’ she said. ‘No doubt I’ll hear the yelling soon enough if it isn’t! We can let the dad come in and see Lucy now.’

Brian McNichol had been shepherded aside as soon as Patsy had been taken into the operating theatre. He’d probably been fed several gallons of tea by now. Emma had lost track of time. Where was Patsy? Still in Recovery? After her general anaesthesia and the extent of her bleeding, she’d probably be kept there for longer than usual. Had her husband been able to see her yet?