Sunday, November 15, 2009

Another quiet night in the NICU

Telephone rings. It's labor and delivery. New patient just arrived. She's 28 weeks and she's fully dilated. We remind them to turn up the thermostat in the operating room. How high? We're not sure -- just turn it up. We'll find the policy for you later. We should all know what temperature, but "imminent delivery" can make you forget all but the essential numbers. That baby's probably coming before the temperature gets into the appropriate range anyway. Tropical. Thats what we want.

We check the admission bed, call respiratory therapy to set up the ventilator and check the resuscitation equipment in the delivery area. Must be a quiet night for them. We get 3 RTs. Not complaining. Sometimes you need 3. Tonight it's a good thing to have them all.

Over we go to the delivery area. It's already 72 and the temperature is rising rapidly. I'm not on admissions, but I'm in charge and the admitting nurse can always use an extra pair of hands with a little one. We'll be doing this in the OR to accommodate the extra people and equipment. Check equipment, draw up emergency drugs, measure and cut the endotracheal tube and the feeding tube we will use to give a dose of surfactant to help the baby breathe. Waiting for the OB team to bring in the mom.

Scrub tech has finished setting up for a C-section - just in case.

OB arrives sans mom. The news gets better. Mom had an ultrasound this week. Baby isn't 28 weeks. It's 25 weeks. Call the neonatologist to come in for backup. The nurse practitioner can handle this, but it's policy. No sleep for the neonatologist if the baby is 27 weeks or under.

Mom is FINALLY (maybe 5 or 6 minutes later) in the room and on the OR table.

"Don't push. Let me check her again"

I have my back to the action, double-checking and triple checking. I hear a wet splash and turn around to see the OB and one of the labor and delivery nurses wiping amniotic fluid from their full face masks.

The OB checks the mom again. Prolapse: the umbilical cord has slipped past the baby's head and is in danger of being compressed to the point of cutting off oxygen to the baby. The external monitor is showing a heart rate that exactly matches the mother's heart rate. We hope that the baby is just too far down in the pelvis for the monitor to pick up. There is no time to check with a sono or internal monitor.

Someone asks about fetal heart rate. A voice responds, "Three minutes ago it was 150." Three minutes is an eternity. We'd like to know what the heart rate is now, but there is no more time.

There are only a very few minutes to get that baby to the relative safety of our resuscitation warmer. The room is about 75 degrees now and much hotter for the people surrounding the warmer. Makes me glad I'm just the extra pair of hands, much as my control-freak side wants to have my hands directly involved.

The OB changes gloves as the anesthesiologist "crashes" the mom -- general anesthesia is much faster than other options for emergency C-sections. As soon as the anesthesiologist indicates that the mom is ready, things really go into high gear. An incredibly long few minutes later, we hear a weak cry. At 25 weeks, it's unusual to hear a cry. With a prolapsed cord, it's even more unusual, but it means we can take our time doing what we need to stabilize the baby. It also means that there is much less to do. No drugs. No chest compressions. That weak cry is a truly beautiful sound.

The OB hands the baby to the nurse practitioner who places it in our pre-warmed bed. The baby is covered in plastic from the neck down to minimize heat loss. The baby is working very hard to breathe, so one of the respiratory therapists begins bag-mask ventilation as another hands the laryngoscope and endotracheal tube to the nurse practitioner. In goes the tube and is carefully secured once placement is verified. Too far in? adjust it a little. Breath sounds are equal now and the baby is pink. Time for the surfactant which will help keep those tiny lungs expanded and decrease the risk of damage as we breathe for the baby.

The third respiratory therapist has finished setting up the ventilator on the transport incubator. We transfer the baby into it and off we go to the NICU ripping off masks and OR caps as we exit the OR. We're all hot, but it's worth it. When we get the baby into the NICU admission bed, the temperature is well within the normal range. WIN! But it's really only the beginning. If everything goes well, this baby will be with us until at least Valentine's Day.


Rita Martinez said...

did the baby make it?
I remember a case like that when I rotated through the OB-GYN hospital during my internship. The baby was 24 weeks, and while she cried for a few hours she died the next day. Sadly in my third world country most hospitals aren't equipped well enough to handle cases like those.

Judy said...


24 week preemies often don't survive even with access to the most high tech care and not all US hospitals are equipped to care for them long-term so we have an extensive transport system to move the sickest babies from smaller hospitals to tertiary centers where they have a better chance of survival.

This little one turned out to be more mature than was expected and did quite well.