Monday, June 20, 2005

Delayed Cord Clamping - benefits for preemies

Delayed cord clamping (30 seconds to 2 minutes after delivery) has been around for a while, but it hasn't been standard practice - at least not at my hospital - for preterm deliveries. That's changing thanks to some recent randomized trials on the subject. There have been several. They have different study criteria and slightly different outcomes. They all have one thing in common, though. There are benefits to delaying cord clamping for 45 seconds or longer, even when the baby is less than 30 weeks gestation.

45 seconds feels like a long time while you're waiting for the OB to hand over that preemie -- if you're used to the traditional quick clamp and immediate resuscitation. It was fascinating and a little scary to watch as the OB dried the baby, bulb suctioned his mouth, waited nearly a minute before clamping the cord and - unthinkable only a few weeks ago - offered the scissors to the father to cut the cord.

8 hours later, the admission nurse was still griping about the delay and the small study in Rhode Island found that "the DCC* group were more likely to have higher initial mean blood pressures and less likely to be discharged on oxygen. DCC group infants had higher initial glucose levels (*ICC=36 mg/dl, DCC=73.1 mg/dl; p=0.02)." and a meta-analysis of 7 studies found decreased need for transfusions and decreased incidence of intraventricular hemorrhage.

Risks? Apparently nothing significant was discovered over the course of several studies and hundreds of preterm births - both vaginal and C-section.

*DCC=Delayed Cord Clamping. ICC=Immediate Cord Clamping

Wednesday, June 15, 2005

A quiet night

NPC 24 weeks, FDIU. Ominous words appearing on the monitor screen listing the patients in the birthing center.

NPC - no prenatal care at 24 weeks gestation. That's not terribly uncommon in our part of town. Some of our moms show up for their first prenatal visit fully dilated at term.

FDIU - fetal death in utero.

The nurse from the birthing center called for our help. The baby had died some time prior to 24 weeks and she needed a more accurate weight than they could get on their scales. Could she use one of our scales?

Sure, come on over.

340 grams - about 11 ounces.

Do you think the baby has some kind of syndrome?

He looks pretty odd, but he was breech and the cervix had trapped the head for over an hour.

No, I don't think it's a syndrome, but I don't think we should take pictures for the mom to keep either.

We need some kind of memento. Footprints?

Tiny footprints - and perfect palmprints. Both smaller than my fingertip. Think she'll notice that I missed a toe on that left foot?

Probably. Now I wish we'd tried again. It was a quiet night.

Friday, June 10, 2005

One, two, three......four, five!

I work in a level 3+ NICU. We do nearly everything the largest NICU's do except some of the more complex surgeries and ECMO. We're not one of the biggest ones, our average census is 12. On any given day, we have anywhere from 3 to 23 babies actually in the NICU. Life is painfully boring at times, and a frantic whirlwind of activity at others. Fortunately, we have several staff members who are willing to come in at a moment's notice when it starts hitting the fan. Oh, and thank God for agency nurses who'll do that too!

On a recent night, we started the shift with 11 babies and 5 nurses. The board in the birthing center was full, and I was the lucky person in charge. It was looking like an average, reasonably steady night. Looks can be deceiving. The outgoing charge nurse mentioned that the only apparent "threat", the mom of the triplets had been having a few more contractions, but the perinatologist was hoping to get her quieted down again. He'd been able to do that for 6 weeks, so we weren't too worried. Everyone else in the birthing center was either full term or delivered already.

I made out the patient assignments and the phone started ringing as I tried to get 8pm cares done on my patients.

First, the nursing supervisor: Did we want an extra nurse for night shift? One of the agencies had called to offer us one. There was one nurse from the pediatrics unit available to relieve the evening shift nurse in the step-down room with the bigger babies, but nobody else if the triplets came. It was Memorial Day weekend, so only one of the nurses willing to come in on short notice was in town and not already working. I asked the agency nurse's name and immediately agreed to add her to the staffing pattern.

Moments after the nursing supervisor hung up, the birthing center called. We had an hour to get ready. Triplets. 28 weeks.

We've done this enough that we have it pretty much down to a science, but it's always an adrenaline rush. The admission warmers had been set up for days. The respiratory equipment was in place, and we knew who we needed to call. The back-up nurse quickly agreed to come in and even arranged for a secretary to come with her. She arrived just in time to check her admission bed and get her gown, cap, mask, booties, and gloves on and head over to the OR with the rest of the team: 2 more nurses, 3 respiratory therapists, 1 nurse practitioner, 1 neonatologist, and 2 pediatric residents. Once we were in place, the OB started and we very quickly had the babies stabilized and ready for transfer.

We have 3 transport isolettes, but we prefer to use our lightest one for trips around the corner from the OR to the NICU. As charge nurse, I had shuttle duty. That was my aerobic exercise for the night, or so I thought. The triplets were quickly settled into place, lines inserted, and respiratory support in place. They were started on CPAP, continuous positive airway pressure, to help keep the lungs expanded and ease breathing. The remaining staff adjusted assignments to cover the other babies. Things were looking good. Did I mention that looks can be deceiving?

The evening nurse offered to stay over a couple of hours if we needed her, but the triplets had been settled in so quickly that it didn't appear necessary -- until she tried to walk out the door. I caught the call from the birthing center just as she walked past me. Another patient had just arrived, 34+ weeks, in very active labor, 4-5 cm dilated and the first baby was breech. We had about 30 minutes to set up for that delivery. I interrupted the report to shout at her receding back "Please don't go!"

Did I mention that I love my co-workers? She stayed. Until 5.

At 34 weeks, babies can be practically ready for the well-baby nursery - or they can be quite sick and need full ventilator support. More commonly, they're in the middle. They just need CPAP. We had used the last of our older machines for the triplets and there was no time to rent, so we quickly got approval to bring out two new machines we'd just been oriented on - a couple of days ahead of schedule. Kudos to our respiratory therapy department for having them ready!

That delivery went smoothly, and thanks to the additional staff, we made it through the night. A week later, all 5 babies were doing well, but the census had expanded to 18. This could be a long summer, but I certainly won't be bored.

Friday, June 03, 2005

Virgin Birth

MaddogMedic had me laughing out loud about Peanut butter balls. That reminded me of a time I just couldn't laugh.

The NICU was small, but crowded, with 3-4 other nurses doing patient care nearby. The baby weighed about 8 pounds, and was only in the NICU for a more-or-less routine sepsis workup due to maternal history. I wasn't particularly busy with patient care, so I had time to listen to his mom, the only visitor in the NICU that late on Christmas Eve. She told me that most people didn't want to hear her story.

Once I'd heard it, I wasn't too surprised by that. You see, she'd never had sex. Never. She explained that her father didn't believe her, but her attorney did. Her OB believed her, but the neonatologist didn't - and so on. The conception didn't require technology, and her definition of sex excluded anything that didn't involve penetration. As she went through the details of who the father was, and just how the baby had been conceived, my co-workers disappeared one by one. I could see them laughing through the nurses station window behind her. Fortunately, they regained their composure before she got up to leave.

3 years answering a suicide hotline, I thought I'd heard everything. I guess not.