The Witching Hour

The Witching Hour is when time tends to stand still...when things are slightly eerie and foreboding.

If there was a witching hour in pregnancy – it would be at 23 weeks. Or for those drenched in OB lingo – the time of “pre-viability.” In the world of maternal-child health – pregnancy is broken down into segments. Everyone is familiar with trimesters of pregnancy. What everyone isn’t familiar with is how we segment the pregnancy if something goes wrong. 24 weeks is the mark of “fetal viability” – where the Neonatal ICU team would be present for delivery and be able to do full resuscitative measures if requested by the parents. Also - on labor and delivery - we will not see pregnant patients under 20 weeks. (An exception being if a patient that is terminating a pregnancy for medical reasons.) So -- if a woman has a miscarriage prior to 20 weeks it is categorized as a “spontaneous abortion” and is usually seen in the ER. If a baby passes in utero after 20 weeks – it’s categorized as an IUFD (intrauterine fetal demise).

Clinical definitions tend to keep everything emotionally at arms’ length with sanitary language. “I’ve got an IUFD in room 22.” is a lot easier to say than “I’ve got a mom with a stillborn baby that needs to deliver in room 22.”

In my career – I’ve taken care of several patients undergoing terminations and those with an IUFD. The most notable being when I was about 13 weeks pregnant with Jacob. A little Hispanic girl walked into labor and delivery stating that her water broke at 19 weeks. She was visiting her cousin that lived in Southern California from Mexico and spoke very little English. She had been turned away by 4 other hospitals in the area due to religious objections to her case. Since she was pre-viable and her amniotic membranes were ruptured– the chances of her keeping the pregnancy for 5 weeks to viability and not developing an infection or having severe fetal complications were extremely rare. The other hospitals would not allow termination and they would only keep her and treat her if she was imminently delivering. Since that was not the case - we would need to induce labor and terminate the pregnancy. After admission and start of induction - It only took her 6 hours to deliver the baby. The baby was perfect and flawless. It hit hard because it was a little boy and I had just found out that week that the little baby growing inside of me was a boy as well.

Part of our job as labor and delivery nurses is taking care of the fetal remains. This includes weighing and measuring for statistical data, taking footprints and pictures for memento boxes, and making the appropriate phone calls to coordinate all other aspects of the demise. The paperwork is one of the most frustrating parts of completing a demise case. Each hospital has a different protocol of how to handle fetal remains and once again it is classified under weeks of gestation. Babies under 20 weeks get handled differently than those that are over 20 weeks.

I stress the demarcation because the period between 20 and 24 weeks is this gray area of no-man’s land. You are far enough along in your pregnancy to be seen on labor and delivery and be obstetrically managed – but you aren’t far enough along for the baby to be treated if you imminently deliver. The heartbreaking thing about this gray area – is that sometimes babies are born with a heartbeat and minimal respiratory effort (if any at all). I remember sitting with one little 22-week baby and holding it in blankets with a stethoscope glued to my ears in order to call time of death. The parents didn’t want to have the baby in the room after delivery – so I held the baby until I could no longer hear a heartbeat (which was a full hour after delivery). A second nurse always has to confirm if there is no doctor around. Once time of death is called – then it’s on to the paperwork part. Talk about transitioning from one role to another.

It’s a difficult balance to maintain composure and express compassion all while trying to keep the grief of the family from sinking in too deep. However - sometimes it’s almost too much to bear. I wrote a poem describing the experience of seeing someone lose their baby while feeling extremely guilty carrying my own healthy pregnancy. This poem is also dedicated to all of my sister nurses who have felt the heavy grief after a demise case. I’ll share it below:

Making Footprints

She patiently awaits

As the doctor gives the call

Come on, just one more push

And the mother gives her all.

She stands in place

And knows her role to play

To collect the memories

Of this boy’s only day.

The mother came in crying

He hasn’t moved all day

Ten weeks ‘til he is due -

The twentieth of May.

No heartbeat could be found

And the mother lost her voice

She must push out this little soul

There was no other choice.

I can’t do this anymore

Came her tearful cry

You have to do it, you must

Just give it one more try.

Then he came sliding out

Steady and very slow

The room filled with a heavy sigh

As his mother let him go.

She dons her gloves

And takes him from the bed

He must be examined

From his tiny feet to his head.

The room is deafly quiet

As she looks for what went wrong

She carefully lifts each little limb

Which will never grow up strong.

His body is cold, skin intact

Features perfectly formed

But too much time has passed

And his body must be warmed.

She wraps him up and places a hat

Upon his tiny head

She hands him to his mom

Who is still sobbing in her bed.

I’ll give you time to be with him

Just let me know when

I will return to finish the rest

And the process will begin.

She gives them time to bond

For these moments are their last

She must now prepare his remains

Before too much time has passed.

She knows there’s not much time

That this little boy will keep

His skin will start to peel

And tissues will start to seep.

She gathers all she needs

Tools of her sullen trade

Pictures must be taken

And footprints must be made.

It’s not long when she returns

They’ve said their last goodbye

She’s left to do her task

While she listens to them cry.

Taking pictures of such a thing

Is not an easy job to do

Now that his color has changed

To a darkened purple hue.

The face is the first part

To cause added shock

Can’t you close his mouth?

His jaw has already locked.

She picks the angles with care

As tasteful as she can

Usually shots of the feet are best

Or his tiny little hands.

Now it’s time for footprints

Which are easier in this case

They aren’t kicking around

And they stay in their place.

The feet that will never run

Or score that winning goal

The feet that will never be tickled

Or splash in a muddy hole.

She catches her breath

as she makes a downward glance

As she feels two little feet inside

Do their hourly belly dance.

A pang of guilt washes over

As she rubs her favorite spot

She does her best to squeak out

I’m sorry for your loss.

She goes home that night

Events of the day still raw

She lays down in bed

And tries to forget what she saw.

Little feet dance inside

And she feels more relief

A prayer is said for the lost little soul

And she cries herself to sleep.

_______________________

23 weeks is the point in the pregnancy when it finally feels real. You’re passed the point of people trying to guess if you’re pregnant or just fat. You are wearing special clothes that are tailor-made for your pendulous belly. You’ve passed the nail-biting anatomy scan to make sure all the parts that are supposed to be there are present and working – nothing extra – nothing missing. You’ve probably picked out a name or have a few names in mind. You’ve started decorating the nursery and making a registry. You start feeling the baby squirm around inside. Flutters at first….then periodic bubbles. You’re so close to the coveted “viability” part of pregnancy. Which is why having a loss at this point in the pregnancy is overwhelmingly tragic...

This is the point in Jillian’s pregnancy when time stood still. When Baby Madeline was still inside of her– but stopped thriving. The nursery was taken apart, baby stuff was boxed away, and dreams of having a family were put to rest.

I am at the exact point of this pregnancy where Jillian’s pregnancy ended. This is the point in this pregnancy where apprehension is at its height –and understandably so. Even me – where at times I feel like I am unshakable – feel the pressure of this gestational week.

With that said – I am elated to share that my appointment with Dr. Farringer this week went well. Baby Annabella is measuring right on track – heartbeat is strong. And bonus points... I am still in the clear as far as the Pregnancy Purgatories (hypertension and gestational diabetes).

The Witching Hour is also believed to be when magic and the supernatural influence are the most powerful. I absolutely believe this pregnancy is a product of science and magic.

I am privileged to be the vessel of this Light illuminating from within.

Baby Stats:

Gestational Age: 23 weeks 4 days

Size: Mango

Development: Blood vessels in lungs, REM sleep cycles, lanugo (baby hair), sense of hearing (good for all of that bluegrass fiddle jamming)

Stork Sensations: Butterflies, bubbles, and burps (yes I’m getting more and more gassy). It’s hard to sleep at night due to heartburn. My gait is slowly shifting to the Mother Goose waddle. I find myself catching my breath after a flight of stairs or even when I have to speak for a long time at work giving instructions. Overall -- very mild complaints – if I can even call them that. All normal inconveniences for the greater good. I’m getting pregnancy massages on a bi-weekly basis (I recommend this to every single pregnant woman!) and I still take ballroom/swing dance lessons every week. This baby is going to come out moving and grooving – watch out Anthony and Jillian!