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.
Showing posts with label Delivery. Show all posts
Showing posts with label Delivery. Show all posts
Sunday, November 15, 2009
Sunday, September 21, 2008
Perfect
The phone rang from the birthing center. "Crash section. No heartbeat. Please send the team."
So I did. And I went with them. An extra pair of hands or three comes in handy when you're trying to do everything at once.
By the time the OB handed over the baby, everything was in place. ET tube cut, drugs drawn up, umbilical line ready to go.
She was beautiful. At least I think she may have been a girl. I didn't really look. I was too focused on what I was doing at the time.
No heartbeat.
Dry the baby. Get her off the wet towels.
Bag-mask ventilation.
No heartbeat.
Chest compressions.
No heartbeat.
ET tube in place. Breath sounds equal. Placement checked with CO2 detector.
Epinephrine down the endotracheal tube while the doc placed the UV line (a tube into the large vein in the umbilical cord).
No heartbeat.
One minute APGAR 0
Two minute APGAR 0 -- no heartbeat. No respiratory effort. No muscle tone. No reflex response. Deathly pale.
Epinephrine via the UV catheter -- "Careful. Don't tug on it."
No heartbeat.
Saline for volume expansion. More epinephrine.
No heartbeat.
Coordination of effort could not have been more perfect. We followed the Neonatal Resuscitation Protocol to the letter.
Including the part that suggests that you should consider discontinuing resuscitation efforts if there are still no signs of life after 10 minutes of "continuous and adequate" resuscitation efforts. I don't much like that part, but I agree with it.
She was a beautiful baby. At least I think she was a girl, but she never had a heartbeat. Not while we worked on her.
On days like that, I don't much like my job. I love the people who work with me, though. I value their expertise and their compassion. I particularly appreciate their ability to support one another and to remind each other that no matter how perfect our efforts, the final outcome is sometimes completely beyond our control.
So I did. And I went with them. An extra pair of hands or three comes in handy when you're trying to do everything at once.
By the time the OB handed over the baby, everything was in place. ET tube cut, drugs drawn up, umbilical line ready to go.
She was beautiful. At least I think she may have been a girl. I didn't really look. I was too focused on what I was doing at the time.
No heartbeat.
Dry the baby. Get her off the wet towels.
Bag-mask ventilation.
No heartbeat.
Chest compressions.
No heartbeat.
ET tube in place. Breath sounds equal. Placement checked with CO2 detector.
Epinephrine down the endotracheal tube while the doc placed the UV line (a tube into the large vein in the umbilical cord).
No heartbeat.
One minute APGAR 0
Two minute APGAR 0 -- no heartbeat. No respiratory effort. No muscle tone. No reflex response. Deathly pale.
Epinephrine via the UV catheter -- "Careful. Don't tug on it."
No heartbeat.
Saline for volume expansion. More epinephrine.
No heartbeat.
Coordination of effort could not have been more perfect. We followed the Neonatal Resuscitation Protocol to the letter.
Including the part that suggests that you should consider discontinuing resuscitation efforts if there are still no signs of life after 10 minutes of "continuous and adequate" resuscitation efforts. I don't much like that part, but I agree with it.
She was a beautiful baby. At least I think she was a girl, but she never had a heartbeat. Not while we worked on her.
On days like that, I don't much like my job. I love the people who work with me, though. I value their expertise and their compassion. I particularly appreciate their ability to support one another and to remind each other that no matter how perfect our efforts, the final outcome is sometimes completely beyond our control.
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
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
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