- Sign in Community Medical Center's neonatal intensive care unit
Bang.
Bang.
A fist thumps on the door at 6 a.m., waking Chad Shoumaker, just back from days traveling on a painting job in Idaho.
Groggily, he hears a policeman say his wife is in labor.
In his boxer briefs and Old Navy T-shirt, he drives from their home on the Flathead Reservation to a spot where cell phones get a signal.
Their daughter, Sasha, is coming - way too early.
In Missoula, doctors at Community Medical Center tell his wife, Jacqueline Peterson, to push.
Seconds earlier, the doctors had told her to be ready to say goodbye to her daughter, arriving prematurely at 22 weeks and six days.
She tells her teenage daughter, Victoria, to hand her a phone and dials her husband.
“Where are you at?” he asks.
She hisses: “She may die. I can see the tip of her head and you aren't here. Just forget about it.”
Victoria grips her mother's hand.
At 7:37 a.m., Sasha comes out fast and blue.
But trying to cry.
The next day, a tiny arm reaches into the air, searching for the walls of her mother's womb.
If all had gone smoothly, Monday, Aug. 25 - Jacqueline's due date - would have been a big day. But Monday came 122 days early.
Sasha is the size of a dollar bill. A piece of bubble wrap covers her body to keep her warm in the sterile-smelling, darkened Neonatal Intensive Care Unit.
A humidifier moistens her skin, which is coated in gooey emollient and glistens in the light of her new world outside the uterus. Veins in her tissue-thin skin resemble those in an autumn leaf.
Born April 27 at 1 pound, 1.7 ounces, Sasha is the most premature baby yet at Community Medical Center's NICU. Nine in 10 infants at her gestational age die.
In her charts, the nurses note Sasha's “chest wiggle,” as a respirator helps the newborn breathe. A long-term intravenous line nourishes her.
Her footprints are only slightly larger than the print of Jacqueline's right index finger.
Babies don't coordinate their ability to suck and swallow until about 34 weeks. Sasha is born in her 22nd week.
Sasha has no body fat and, with legs the size of a pinky finger, lies in a special isolette that keeps her warm, helps decrease the amount of water loss and infection, and buffers the alarms and sounds of the noisy unit.
A team of nurses watches her at all times.
“We get extraordinarily attached to these babies and spend a lot of hours with them,” says Fran Manson, a nurse who cares for Sasha. “These kids don't want to breathe. And our response is, ‘Not on my shift. You will breathe.' ”
It's constant tweaking.
Too much pressure from the ventilator or from stimulation - including light, touch and sound - and the baby's brain could bleed.
Too much oxygen, and the baby runs the risk of eye damage ranging from impaired vision to blindness.
These are babies on the edge of viability, says Dr. Jan Hiller, 58, one of two neonatologists at the hospital.
Leaning over Sasha in the delivery room, Hiller had heard the baby trying to cry.
“It was a sign that we might have something we could work with, but it's no guarantee,” Hiller says. “The majority of neonatologists do not actually attempt to resuscitate under 23 weeks. The chances of survival are so slim. The majority of us feel it is futile, if not cruel, to put them through all the procedures.”
The doctoring is intense, especially for the first 10 days of the baby's life, and Sasha is given about a 15 percent chance of surviving her first week. The NICU team is vigilant, watching for typical complications including brain bleeds, stiff lungs and the vision problems. The premature babies have immature immune systems, making them more susceptible to infections and liable to get sicker than other babies. More problems can arise when nurses start feeding the babies, because of their immature gastrointestinal systems.
According to the National Institutes of Health, premature birth occurs in
8 percent to 10 percent of all pregnancies in the U.S. and is one of the top causes of infant death. Those who survive are at increased risk of cerebral palsy, blindness, lung diseases, learning disabilities and developmental disabilities.
Hiller says: “I tell the parents, if we make it through the first week with good lungs and no brain hemorrhage, we've got a good shot.”
Jacqueline, 35, knew Sasha was a fighter from the time she tumbled and kicked inside of her.
After Sasha's birth, her cell phone serves as an electronic umbilical cord to her daughter, with daily checks to the nurses 41 miles away. She doesn't drive and depends on Chad, who frequently travels for painting jobs, for weekly visits to see Sasha.
“It's so stressful because I can't see her often. I haven't even held my daughter yet,” Jacqueline says days after delivery. “I keep freaking out and thinking she can't make it.”
On visits, she worries about unwittingly infecting her with a cough or cold. But she's torn as she sees the lines and probes stuck into Sasha, monitoring her blood pressure, temperature and oxygen.
“I feel so selfish, wanting to have this baby. Where I'm from, if you're pregnant, you'll have a baby. What her quality of life will be isn't my choice,” she says.
During the next 110 days, Sasha has heart surgery, loses weight and then regains ounce by ounce. Her maroon charts become voluminous, growing to the size of four telephone books.
With tawny skin and dark hair the shade of her mother's thigh-length ponytail, Sasha clings on for another day.
During a visit when Sasha is 2 weeks old, Chad's father places his wedding band over the baby's hand, where it dangles like a bracelet from her arm.
Chad, 28, a beefy man, frets his booming voice will harm Sasha.
Jacqueline and a nurse tuck a purple blanket tight around Sasha, swaddling her to mimic the womb. The baby opens one eye when she hears her mother's serene intonations.
“She obviously would have died without help,” Jacqueline says. “I believe a baby should have every chance. Life is life.”
Jacqueline and Chad met 13 years ago when she shut the door in his face.
Chad, then 15, lived in the same apartment complex in Lewiston, Idaho. He wanted her to know she had left on the lights in her car, but she was suspicious of his motives.
She was 22, never married and had three children by three different fathers. Chad baby-sat her children - Clifton, now 18, Virginia, 16 and Joseph, 13 - and did magic tricks for them.
Like her parents, Jacqueline was struggling with alcoholism. She was apprehensive about everyone.
“I would drink a six pack every day, and Bacardi Rum or Boone's Farm or tequila when I could afford it,” she says.
Chad, she says, “gave me a reason to give it up. It took me a long time to trust him. I always think people are trying to get something out of you. But we're really honest with each other.”
He told Jacqueline to quit drinking or he would quit living with her. It worked.
Chad says the family - which by then included their toddler son Duane - left Idaho and moved to the rural reservation in December for a “fresh start.”
Jacqueline, who was on bed rest for six months when she was pregnant with Duane, slipped into depression when she discovered she was pregnant with Sasha and was told to resume bed rest, which she did for nearly four months. During that time, her older children brought her sodas, cooked meals, and took Duane to the park so she could remain quiet.
Despite those precautions, she felt labor pangs for about two days before she went to Community. Hiller, the neonatologist, gently warned her the baby might not survive.
But Sasha's survival launched new anxieties.
“After she was born, I got really depressed,” Jacqueline says. “I didn't know how she was doing.”
The NICU tries to replicate a womb, even down to the details of positioning the baby as it would be in the uterus. Sasha is trying to make a transition from fetal life to extrauterine life.
“These babies get sick very fast and well very fast,” says Fran Manson, the NICU nurse. “There is a balancing act every day the baby is here.”
For the first week of Sasha's life, Martha Bleicher - one of 48 full-time nurses in the NICU - cares for her. To minimize having to move her, Sasha's isolette has a rotating mattress, built-in X-ray cassette, and an in-bed scale.
“You try not to touch them because of the risk of brain hemorrhage,” Bleicher says. “It's hard when we lose one.”
The nurses comfort each other when a baby perishes, says NICU clinical manager Colleen Purcell, recalling a stretch when they lost six infants in a few weeks.
“There are a whole lot of tears. We attend the funerals and keep in touch with the parents.”
On May 15, Sasha weighs just 1 pound and 7 ounces - about 5 ounces more than at birth almost three weeks earlier - when she has a surgery fixing a condition called patent ductus arteriosus. The surgery closes the fetal blood vessel which has failed to shut after birth, depriving her of sufficient oxygen.
Sasha is prone to apnea of prematurity, which is when babies stop breathing for 15 to 20 seconds during sleep. They're treated with caffeine, or what Manson jokingly calls a “latte,” to stimulate their systems and keep them breathing.
By mid-May, the nurses tell Jacqueline and Chad that Sasha is holding her own.
On May 19, the nurses start giving Jacqueline's breast milk to Sasha. Her stomach isn't much bigger than the tip of an eraser.
With her premature digestive system, they start slowly with less than 1 cc of milk - about a fifth of a teaspoon.
For the first time that day, Jacqueline holds her daughter, nearly a month after she was born.
“She's feather light, but she had an apnea episode where her little brain forgets to breathe,” she says. “I put her back in bed because I was getting nervous. I don't want to take any chances.”
Steroids help reduce the inflammation in Sasha's lungs. On May 23, the nurses disconnect her from a ventilator and put her on a form of assisted breathing, called nasal continuous positive airway pressure.
Despite Jacqueline's phone calls, she misses the daily moments and, at three months, has never heard Sasha cry. At home, an empty cradleboard waits.
“It's a very stressful time, especially for families who don't visit as frequently because of other children or finances,” says Purcell.
By mid-July, Sasha weighs 4 pounds and 2 ounces. A nasal cannula supplies her with minuscule amounts of oxygen. She's eating on her own, and has grown enough to leave the isolette and lies in an open crib.
Sasha is one of about 280 infants in the hospital's NICU each year; about 95 percent of them survive, says Hiller, who cared for Sasha for about 75 to 100 hours.
With older women having children, increased drug use, teenage pregnancies and more admissions from outlying areas, more babies end up in the NICU, Purcell says.
Babies weighing less than 2.2 pounds make up about 1 percent of the U.S. children born each year, or roughly 40,000 babies, according to the National Institute of Child Health and Human Development in Rockville, Md. The cost is daunting; Sasha's hospital charges so far total $536,700, according to Community.
“About 2 to 5 percent of babies like her will survive without impairment,” said Dr. Rose Higgins, who published findings on the outcomes for survival and disability of 4,446 extremely low birthweight infants in the April 17 New England Journal of Medicine. Higgins, of the NICHD Neonatal Research Network, said Sasha is still in a “gray zone” where her final outcome won't be known until later checkups.
The family hears Sasha will need laser surgery this week - the week Sasha should have been born - to correct abnormal growth of the blood vessels to her eyes, called retinopathy of prematurity, which can lead to retinal detachment. Even after the surgery, there's a one in three risk of vision problems later.
Jacqueline, who has been keeping her emotions in check since her daughter's birth, bursts into tears at the news. Chad caresses Jacqueline's back as she cradles Sasha, putting her cheek to her daughter's tiny face.
“I worry about every one of these babies,” Purcell says. “Premature babies are loved unconditionally even if they develop long-term disabilities. That's God's gift to the babies and the families.”
As they leave the hospital at 5:37 p.m. on Aug. 13, Jacqueline places Sasha in the back seat of their 1988 Oldsmobile Cutlass with 120,493 miles.
She's tearful and incredulous that Sasha is next to her, alive and sucking hungrily on a bottle. She credits the NICU team for Sasha's chubby cheeks and weight of 6 pounds, 8 ounces.
“I wanted them to do everything in their power to save Sasha, and that is exactly what they did,” she says. “I'm so grateful for Dr. Hiller. She's so awesome and honest and straightforward.”
When the couple tries to thank Hiller as they leave the NICU, they have to call out her name twice. Hiller is already engrossed in the next baby's care.
Chad drives home carefully, always taking the slow lane as they travel past Pow Wow Road and La Moose Lane. Shadows blanket the dun-colored mountains.
Cars whoosh by as the windows blow hay-scented air on Sasha, who is more accustomed to the hospital monitor's beep-beep-beep and the quick steps of sneaker-clad nurses.
Sasha doesn't open an eye on the drive.
Not far from the National Bison Range, Chad crosses the Jocko River and turns onto Blanket Hawk Lane.
There's no “Welcome Home Sasha” sign or cluster of neighbors waiting to greet them. The family's brown-and-white bulldog, Deuce, snores in a patch of bare soil. Taupe sheets hang listlessly on a clothesline in the still evening, which smells like dust.
The baby's oxygen tank hits empty as they pull up the dirt driveway.
It is a reminder of Sasha's fragility.
“She's turning blue,” Chad frantically whispers inside the car, not wanting to alarm their other children gathering outside.
After months of stoicism, he's suddenly anxious.
But Jacqueline is not as fearful now that Sasha is with her.
“Just get Sasha inside the house and change the oxygen tank,” she says calmly.
The baby cries. She sounds like a mewling kitten. It's feeding time.
The door closes quietly behind them.
Reporter Pamela J. Podger can be reached at (406) 523-5241 or at pamela.podger @missoulian.com. Photographer Tom Bauer can be reached at (406) 523-5270 or by e-mail at tbauer@missoulian.com.
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