Saylor Thomson was only hours old when she was wheeled into surgery to remove a life-threatening tumour so huge it weighed twice as much as the rest of her body.
WARNING: This story contains medical images that may be distressing.
Her distressed mum Rachel saw her baby for just a few minutes, stroking her tiny hand, before Saylor was taken to the operating theatre, her doctors unsure whether the little girl would survive.
For the next six hours, Mrs Thomson waited with husband Kieran as doctors operated on their daughter, who was born with a 2.1kg sacrococcygeal teratoma — a rare tumour occurring in about one in 35,000 births.
Not accounting for the tumour, Saylor weighed just 1.025kg after being born at the Mater Mothers' Hospital in Brisbane at 9.08am on August 9.
She was delivered by emergency caesarean more than 11 weeks early after developing heart failure in the womb.
Mater maternal fetal medicine specialist Sailesh Kumar said Saylor could have died during the birth if the tumour, identified during a routine scan in pregnancy, had burst.
He made a large vertical cut almost the full length of Mrs Thomson's abdomen and womb for the delicate delivery.
"These tumours can rupture very easily at the time of the delivery so you've got to have plenty of space and you've got to very gently deliver the baby, otherwise you run the risk of tearing and rupturing the tumour," Professor Kumar explained.
"The baby can bleed and die virtually in front of you. You've got to be really, really careful."
While the initial plan was for Mrs Thomson to have a spinal anaesthetic and to be conscious for Saylor's birth, she changed her mind soon after the caesarean began, pleading instead for the doctors to "put me out".
"I didn't feel pain but I could feel them cutting further up and further up," she said.
"I think I lasted seven to 10 minutes and I said 'I can't'.
"It was too much. I was overwhelmed. I didn't want to see that she'd passed and the tumour had ruptured."
'One of the lucky ones'
By the time Mrs Thomson woke up in recovery and asked if Saylor was still alive, her daughter was being cared for at the Mater Mothers' neonatal intensive care unit (NICU).
The 37-year-old was diagnosed with pre-eclampsia after the delivery, preventing her from seeing her newborn for hours.
"My blood pressure was extremely high and they wouldn't let me out of recovery until they could get it down," Mrs Thomson said.
It wasn't until about six-and-a-half hours after giving birth that she was able to finally see Saylor for the first time.
"They put blankets over her so I couldn't see the teratoma attached. She had lots of tubes," she said.
"I could touch her hand and that was it. She was oh, so tiny. I saw her probably for two minutes and they wheeled her off to surgery."
Her husband said they were comforted by knowing Saylor was in the best care possible as she was taken away.
"We knew everything would be done that can be done to save her life," Mr Thomson said.
"We just had to give her a chance, basically, and push through with the surgery."
Saylor was taken from the Mater Mothers' to the nearby Queensland Children's Hospital for the operation to remove the tumour, diagnosed during an ultrasound scan at 20 weeks' gestation.
Sacrococcygeal teratomas grow from a baby's tailbone and are four times more likely to occur in females.
Most contain many blood vessels and they can grow internally, as well as externally. Saylor's teratoma was one of the biggest her doctors had seen.
"I've probably seen about 20 or 30 such cases over the last 20 years or so," said Professor Kumar, who has worked in the United Kingdom and Singapore as well as Australia.
"Not everyone does as well as Saylor. Some babies obviously don't survive. Saylor's one of the lucky ones.
"All credit to the Mater Maternal and Fetal Medicine team of sonographers and midwives who monitored Mrs Thomson through her pregnancy."
Doctors had to act
Paediatric surgeon Peter Borzi said the tumour had grown into Saylor's abdomen and mushroomed into a big mass outside her body.
"The longer you left this tumour, the more likely it was to start to ulcerate and bleed and get infected," Dr Borzi said.
"We couldn't leave it any longer. It could have ruptured very easily … and that would have been catastrophic."
Dr Borzi briefed theatre support staff before the surgery, bracing them for the possibility Saylor may die during the operation.
"This is a unique situation but generally, we would say (there was) between a 10 and 15 per cent chance that she may not survive," he said.
"You've got to talk to the nurses and all support staff in the operating theatre for them to be aware of that.
"If that's going to be a problem with them, and they're not prepared to confront that, then they are at liberty to declare whether they want to be present or not and we can replace them accordingly."
Dr Borzi had to begin the complicated surgery with Saylor on her back so he could free the mass from deep inside her pelvis.
The theatre team used a "modified bean bag" to support the premature baby and reduce the risk of the tumour bursting.
"We had to start with her on her back and that, in itself, was a monumental effort because she's got this big thing sticking out. It was raising her off her body," Dr Borzi said.
"The nurses and I worked out a way of creating a bean bag around it. She lay on that and some padding on her back. It's intense but it's what you do.
"I had to initially start from the inside of the abdomen, so making an incision just below her belly button … to find the main blood vessels that are feeding the tumour, and then divide those vessels and … free the tumour."
Saylor was then flipped onto her abdomen so that Dr Borzi could complete the removal of the teratoma and cut off the bottom of her tail bone to reduce the risk of it recurring.
"If you leave any behind, it can become malignant," he explained.
Saylor required five blood transfusions during the intricate six-hour operation, her surgeon crediting her survival not to his skills with a scalpel but to preparation and the extraordinary teams at the Mater and the Queensland Children's Hospital that cared for her before, during and after birth.
"I'm just one small part of that cog, really," Dr Borzi said.
"From an anaesthetic point of view, there was quite a challenge to keep her ventilation and oxygenation optimal throughout the procedure. The size of the tumour was such that whenever we moved it, they had difficulty with the ventilation.
"As a result, we had to have very clear communication between myself and the anaesthetists so that we knew exactly what was happening minute to minute.
"We needed three anaesthetists to observe her, check on the blood loss and to maintain all her vital signs throughout the procedure."
Even the 15-minute transfer along corridors from the Mater to the operating suites at the nearby Queensland Children's Hospital in South Brisbane was medically fraught.
"That in itself is a critical time because of the size of the mass and making sure there's no rupture or bleeding during that transit to the actual operating theatre," Dr Borzi said.
'An absolute miracle'
After the successful surgery, Mrs Thomson, who has another daughter, Aubrey, 18 months, had to wait until Saylor was 10 days old to hold her daughter for the first time.
It took three nurses to lift her out of her incubator onto her mum's chest.
"I was so excited," Mrs Thomson recalled. "There were tubes everywhere. When they put her on me, they then had to clip parts of the ventilator and tubing onto my dress so they were held in the right spot."
That first, longed-for cuddle lasted an hour and a half.
"Her heart rate definitely was a lot calmer," Mrs Thomson said of the skin-to-skin contact. "That was a really special moment."
Mr Thomson had his first nurse four days later and Aubrey had to wait until her baby sister was 47 days old to hold her.
Saylor was finally able to go home with her family to North Lakes, north of Brisbane, late last month after 77 days in hospital and will need to be monitored for signs of regrowth of the teratoma.
She will also have to attend regular outpatient appointments for doctors to check on her development and any potential complications related to the surgery.
"I just think back to how many times we were told to prepare ourselves to lose her," Mrs Thomson said.
"Things like the baby was at high risk of not surviving, there was a significant risk of mortality.
"It's hugely amazing that she made it after all the doctors had to do to prepare us that she wouldn't. They can't give false hope.
"I'll be forever grateful for everything they've done in saving my daughter's life and for the people who donated blood to keep her alive."
As she looks into Saylor's eyes, Mrs Thomson said: 'You're here, you made it. You're just an absolute miracle."
