The babies too keen to come into this world
Each year, thousands of premature babies are coaxed from the edge of viability to the point where they're ready to go home. Over 13 weeks, Adam Dudding followed Theodore Bradbury and his parents, Rebecca and Cameron, as he made that perilous journey.
TWO DAYS BEFORE
Middlemore Hospital, South Auckland, Sunday September 28, just after dinner
Rebecca Bradbury is trying to talk her way into the maternity ward at Middlemore Hospital.
Sorry, they say, visiting hours are over.
No, she says. You don't understand. I need to see someone.
Yeah, but who?, they ask.
Well I don't know, says Bradbury. I don't have a name - I just need to see a doctor.
The ward's gatekeeper is totally baffled, then does a double-take.
Ooooh. You're pregnant!
Yes, says Rebecca. I am. Can you let me in please!
The confusion's understandable. Bradbury is wearing a loose jumper, and her bump isn't all that big - after all, the baby's not due till mid-December.
She's expecting nothing much of this unscheduled checkup. The pregnancy has been totally normal. The twinges today were probably just Braxton Hicks - small and erratic practice contractions that don't lead anywhere.
Anyway, she can't have a baby right now. Tomorrow she needs to be on a plane to Queensland, heading home after a 10-day whistlestop tour of New Zealand friends and family before she gets too big to fly.
And yet . . . during today's baby shower there was also a bit of leaking fluid, and that's definitely not normal. So a friend who had a baby recently gave her a number for a midwife, and the midwife said get to hospital now. She had dinner first, then her sister Sandy drove her up from Waiuku, just south of Auckland, and here she is - filling in forms, getting tested for infection, being attached to a baby monitor, providing a swab of the suspect fluid in case it is, indeed, amniotic fluid. Also: a jab of steroids in her leg, just in case there really is a baby coming, in which case the drug will help ready its lungs for an early birth.
Everything is "just in case": the steroids, the cannula installed in her arm so if she needs a drip they can do it quickly without making a mess of it; the admission to a two-bed ward where she spends a night top-and-tailing with her sister, interrupted only by little spasms every hour or so, and the occasional toe in the nose.
THE DAY BEFORE
Brisbane Airport, Monday, September 29, 6.30am
Cameron Bradbury's flight to Auckland is meant to be taking off right now, but it's been delayed two hours. He's beyond stressed out. He's been up all night, driving the 500km from Gladstone, the latest in a succession of remote Australian towns where he's worked as a boilermaker on big construction projects, salting away the cash for his and Rebecca's eventual return to New Zealand.
He packed super-fast after the call from Rebecca: toothbrush, undies, passport. Oh, and a marriage certificate, because Rebecca's medical data in New Zealand is still in her maiden name, and she doesn't want her child coming out a Rattrie. She'd tried to sound all nonchalant, but he knows her and beneath the characteristic giggliness he could hear the anxiety.
He tries to sleep but fails. He plugs in headphones and listens to some of the soothing forest and ocean recordings he and Rebecca downloaded for use during the birth they've meticulously planned for December. The recordings are surprisingly effective. By the time he gets off the plane in Auckland he's feeling just about ready: This is it. Game on.
Cameron is 31. Rebecca is 28. They're both from Waiuku, but only hooked up in their 20s when back home after various adventures. They're a fond, dryly witty pair who finish each other's sentences, say "we" rather than "I", and sneak looks of unmistakeable warmth at each other.
They married in early 2013 and started trying for a baby on the honeymoon. They've read endless books about pregnancy and birth, but nothing whatsoever about prem babies. They're about to get a crash course.
Middlemore Hospital, Tuesday, September 30, 3.30am
After a day of convincing herself it's not really happening, it is really happening. A nurse helps Rebecca dial Cameron's number, as her hands are shaking too much.
Contractions. Nausea. Broken waters. Down to delivery, where technicians are setting up a $30,000 "Giraffe" neonatal cot with its long neck and overhanging heater. Antibiotics through the just-in-case cannula. Magnesium sulphate for something. Shivers. Strangely tense legs. Beeping machines. Labour is definitely uncomfortable, but not outrageously painful. She's just getting the hang of the pushing when suddenly it's done. Once the head's through Theodore just slips out. It's 5.38am.
He's tiny, like a little doll. But there's hardly time to marvel at him before he's whisked away, because the birth isn't over yet, and it's going wrong. The placenta won't come away despite increasingly vigorous tugging, and then it tears - three-quarters comes away but the rest is still in the uterus.
Rebecca doesn't yet realise how serious this might get, but the staff do, and have already booked a theatre, as the uterus begins its own reckless attempts to expel the placenta by flooding itself with blood - 250ml at a time. By the time Rebecca gets to theatre it's flooded three times already, and she's pale, slipping in and out of consciousness. Local anaesthesia is too slow, so the mask goes on and she's counting backwards.
Cameron is freaked out. There's so much blood. But he's told that Rebecca will be sorted in an hour, and is sent upstairs to his baby. He swallows his anxiety and watches as a crowd prods and pokes Theo, setting up his wires and tubes and sensors, and constructing a tiny plastic greenhouse around him - a humidity tent because his skin is too immature to retain the body's moisture. Theo weighs 1365g - three pounds.
Three hours later, Rebecca is still in theatre and Cameron is beside himself, thinking the darkest of thoughts. At last, the phone. Rebecca is in recovery. She's fine, but required "internal massage" to shift the recalcitrant placenta, lost 3 litres of blood and needed two transfusions. At one point, a hysterectomy wasn't out of the question.
A week later Rebecca will discover a profusion of stitches and wonder what the hell the doctors were doing while she was under, because she'd got through Theo's birth with barely a graze.
Middlemore, Wednesday, October 15, 10.30am
Cameron lifts himself from the recliner where he's been holding Theo on his bare chest, and cradles him over to the giraffe. It's time for "cares".
As Cameron pulls his shirt back on, Rebecca kisses Theo on the tummy and admires his healing bellybutton. Her hand's width spans his belly from hip to throat.
An oxygen saturation monitor glows red on his foot. A feeding tube snakes into his spit-bubbled mouth. The prongs of the "continuous positive air pressure" (CPAP) apparatus connect his nostrils to two fat hoses supplying humidified, lightly pressurised air. The hoses are velcroed to a sort of cloth helmet, whose wide chinstrap holds Theo's mouth shut to stop the air escaping.
He briefly opens his eyes - shiny, black, unfocused. When the nurse tucks a thermometer into his armpit he waves his arms - unusually long, like his father's. The three adults clustered around the bed are giants and Theo a reverse Gulliver trying to break free of his tethers.
Rebecca holds Theo steady as the nurse unplugs the nostril prongs and delicately threads a thin plastic tube alarmingly deep into one nostril. There's a harsh gurgle, like the final suck of a milkshake, as the tube hauls out mucus built up because of the CPAP. Theo screws up his face.
Rebecca gently wipes his eyes, nostrils and mouth with a sterile swab. He's tiny, and a little wrinkly, but with the strange CPAP helmet briefly removed, he suddenly looks much more cute.
Cameron takes off the nappy.
"A little more solid than yesterday," he announces, and Rebecca and the nurse nod approvingly. Then all three juggle baby and bedding to weigh him on the giraffe's built-in scales.
"Oh," says Rebecca, downcast at the modest increase since the last weigh. "Ten grams."
"It's not backwards," says Cameron. "Ten grams is good."
He replaces the nappy. The nurse reconnects Theo to his everything. Theo wriggles and swivels his hands like a Thai dancer.
Each year around 5000 babies - 8 per cent of live births - are born premature, defined as under 37 weeks gestation. Several thousand of those will need critical life support, and the earlier and lighter they're born, the more help they need.
In 1959, a prem baby born under 1000g had next to no chance of survival, and those weighing 1000-1500g had a 50-50 chance. Now, those figures are around 80 per cent and 99 per cent.
The biggest improvements began in the 1970s, after New Zealanders Graham Liggins and Ross Howie found that giving corticosteroids to a mother just before a birth accelerated foetal lung development, reducing the lung "stickiness" that made it near-impossible for prems to breathe properly in their early days. Dr Guy Bloomfield, one of Middlemore's five neonatal specialists, says since then advances have been slower, with subtle improvements in diet, breathing assistance, drug treatments and monitoring methods.
There are still limits. Even now, says Bloomfield, babies born at 23 weeks (17 weeks early) are "pretty hopeless", those born at 24 weeks are "marginal"; but for those born at 25 weeks or more, "we're actually pretty good at that".
The ultimate prognosis for 29-weekers such as Theodore may be excellent, yet his is still a complex and perilous journey. For the Bradburys, the first week in particular is a blur of anxiety, a succession of things that seem to be going wrong because their child isn't ready for the world.
Even with the steroids, Theo's lungs are immature. He frequently forgets to breathe (apnoea), or his heart slows excessively (bradycardia). He can't eat or poo yet and his kidneys aren't processing sodium properly. He has jaundice. He can't regulate his own temperature and his skin can't hold moisture. He's probably suffered a brain bleed from the birth trauma, and the heart valve that in a full-term baby would have clapped shut at the first breath to push blood through the lungs, isn't yet closed, putting his heart under strain.
Yet as the staff keep telling Cameron and Rebecca, these are all known issues. There are no cast-iron assurances that all of them will turn out perfectly, yet day after day, Theo's issues are slowly ticked off.
A drug called "surfactin" goes into his lungs to counteract the stickiness and help the tiny air sacs to inflate better, and the CPAP assists each breath he takes.
Nutrition is delivered directly via the umbilical artery, and later to the stomach, via a gravity-fed feeding tube.
There are scans, X-rays, blood tests, mucus tests, stool tests and eye tests. Blue light sessions for the jaundice. A single, tiny dose of ibuprofen persuades the heart valve to close itself. A tiny daily dose of caffeine, equivalent to 10 espressos for an adult, reduces incidence of apnoea. The skin comes right on its own. The kidneys too. There was a brain bleed, but it was minor. The digestive system eventually kicks into gear. Weeks later, when asked to name the high point of Theo's journey so far, Rebecca is unequivocal: "The first bowel movement!"
In intensive care there are two babies per nurse. The daily cost per baby is $1500. Gram by gram, millimetre by millimetre, under close watch of nurses, machines, his parents and doctors, Theo meets his milestones and eats and poos and sleeps and grows.
And amid these minor medical miracles, there's a couple trying to be first-time parents to a baby who they're barely allowed to touch. On the first day, they briefly put their hands inside his little tent to touch his hands and feet and let him know they're there. That's all that's allowed.
By day five, though, his skin is waterproof and strong enough, his brain resilient enough, that they can pick him up for the first time. That is a very good day.
As soon as possible, Rebecca and Cameron start "kangaroo care": extended sessions of skin-to-skin contact. Since its development in the 1970s in a Colombian hospital where incubators were in short supply, it's been shown to be good for everything from stabilising temperature and reducing apnoea, to improving weight gain and neural development.
It's pretty nice for the parent, too. Week after week father and mother take turns - hours at a stretch - from early morning till they head back to their relatives' in the evening, on a recliner in an open hospital gown, chest to chest with their tiny boy with his ridiculously small nappy and his tangle of tubes and wires. The soundtrack is the constant bubbling of the CPAP, which sounds like a fishtank aerator, and they talk to him, make up stories and songs. Or, like Theo, they nod off.
The first time Cameron puts Theo on his chest it feels like he's holding a large bird - so light, and so fragile. On Cameron, Theo tucks his legs up like a little frog and puts his arms by his side, but when he's on Rebecca he raises his hands up by his face and stretches his legs out. Every time. He knows the difference.
Rebecca's Dad's house in Waiuku, Friday, December 30, afternoon
Cameron and Rebecca perch on bar stools, facing the camera for a wrap-up video interview. Cameron is holding Theo, who's mainly sleeping but occasionally grizzles. He looks like a newborn - plump, pink, small - and in a sense he is: subtract the 11 weeks of prematurity and he's just two weeks old.
He was in the Middlemore neonatal unit for eight weeks in total - the final 10 days in the lower-intensity "special" ward, where the babies are all "feeders and growers". They're breathing unassisted but are still closely monitored, and partly tube-fed to ensure rapid weight gain. Sometimes, says Cameron, as he watched Theo's tummy ballooning up with each two-hourly feed, it felt like the plan was to make prem foie gras.
After Middlemore, Rebecca spent two more weeks with Theo in an ordinary maternity ward in Pukekohe Hospital as they made the final transition to 100 per cent breastfeeding. In early December she and Theo came "home" to Waiuku (flying to Australia won't be possible until late January).
A few days later there was a brief, panicky, return to Middlemore when Theo developed vomiting and diarrhoea and stopped gaining weight. Rebecca was terrified he'd caught a bug, but later figured the problem was a chicken korma she had for dinner and passed on through her breastmilk. The final, final homecoming, after a couple of days' monitoring and some tube-feeding top-ups in Middlemore, was December 16: Theo's exact due date.
It's been a hell of a trip. That relentless first week with all its life-or-death crises; the constant worry even as Theo began ticking all his boxes; the logistical hassles of being stranded in the wrong country; the strains of living with relatives for three months.
One of the nurses told Rebecca that having a baby in intensive care pushes a lot of couples to breaking point. She and Cameron have got through it by taking walks around the hospital, or better still, along Waiuku's Karioitahi Beach. They jogged. Cameron cut wood at his dad's place. Normally self-dependent, they made a point of accepting the endless offers of help from friends and family, and they're enormously grateful to the Middlemore staff.
And they've talked and talked to each other. In Australia, Rebecca had jobs in admin and retail, Cameron would leave home before 5am and get back around 6pm.
These past months "aren't an ideal situation, but it's nice to have had so much time together".
Rebecca says there's "a bit of sadness" that they missed out on the last trimester of pregnancy.
"I didn't get the full-term belly. I didn't get the whole 'I think we're in labour' excitement, and getting your hospital bag ready. We were going to have music and aromatherapy oils and posters and affirmations and breathing techniques.
"You read so much about delaying cord clamping, and having the baby on the belly, and Cam cutting the cord. All the stuff we'd thought about and wanted to do didn't happen. We're so lucky that we have Theo and he's doing well, but at the same time he would have been better off if he'd just stayed inside."
She's felt guilty at times - "maybe I'd done something wrong" - but no one knows why Theo came early. Tests on the placenta were inconclusive. There was no family history. Everything looked good just days before.
She feels guilty when Theo bawls during his eye tests.
"They're awful, and it's like - if he hadn't been early this wouldn't happen and he wouldn't be so upset. They tell me he's never going to remember it. But I will." After having one prem, the odds of having another increase, so future pregnancies will be overrun with specialists and ultrasounds. Plans for a second child while in Australia have already been canned: they'll wait till they're back in New Zealand.
"They say babies don't change your life, but they do if they come early. There's not much working around this."
For Cameron, those three hours when Rebecca was in limbo in theatre are still painfully raw. As he tries to describe it on-camera he chokes up, and Rebecca takes over till he's ready. It's like there's a thin crust over the emotion, says Cameron. "You think you're fine, but at any time it can be damaged, and you start crying for no reason."
According to a book he's just read, as a new father his brain has undergone a structural change.
"I've become a bit softer - hence me being a bit more emotional than normal - and apparently it's to do with an increase in grey matter to become more like the female brain.
"So I can multitask better, I forget more, and I cry at everything. It's been quite an event."
A specialist told them prem babies can encounter an extremely wide range of difficulties, including sight, hearing and behavioural issues, "and your baby may have them, or he may not". But if all continues to go well, Cameron says Theo's size and development could be on track by two.
He's a calm and happy baby. He likes cuddles. He makes a lot of noise when he's hungry. By the time he's an adult, says Cameron, "you can expect him to be 100 per cent normal, and we have no doubt he will be".
"He may need glasses," says Rebecca.
"That's still normal," says Cameron.
- Sunday Star Times