Birth Plans

Mention that you have a birth plan and most people who work in Labor and Delivery or Neonatology will cringe. It's mainly because we have all seen parents cling to their birth plan when we thought that it went against the baby's best interest. I guess in a way the birth plan alerts us that a parent will only be upset if things do not go as expected. See the birth plan presumes a healthy, uncomplicated delivery, that everything will go as planned. And well those of us who work in a Neonatal Unit live in a world where that rarely happens. Remember I am only called to the delivery of infants when something is going wrong.

Some medical people hate birth plans because they immediately presume that the family will be needy. I differ here. I must confess, I do not cringe when I hear that a parent has a birth plan. In fact, I think that when the delivery is uncomplicated, that they are great. The birth plan tells me that this family has put a lot of thought in to how they want this special moment in their life to unfold. To me, a birth plan is written with love. And I will always do my best to honor a birth plan. But once the baby is at risk, well... I throw the plan out the window. Because all of us who had older sisters with bad relationships know that love can be blind and does not always lead us down the right path. I would rather that a parent take a healthy baby home and be a little angry that I did not follow the plan.

So I was not at this delivery, but a close friend of mine was. The mother and father were very specific in their plan. They did not want any drugs used during labor. They did not want their infant to have chemicals in her when she was born. They want a vaginal delivery and for the baby to be placed to breast within one minute of birth. They did not want antibiotic creams in the eyes and they did not want a Vitamin K injection. They were young (twenties), educated, attractive and had private insurance. From the outside, it appeared that life was unfolding easily for them.

They parents also have an Obstetrician who wants them to have the experience they want. So when the labor stalls, the OB does not encourage the use of pitocin (a medication that stimulates labor). Instead he waits. He let the young woman push for over three hours. The infant is not being traced with a scalp monitor because the family does not want invasive monitoring. Instead a belt around the mother's stomach is used to monitor the heart rate. It is not uncommon for the belt to "lose" the baby's heart rate for several minutes at a time or pick up the mother's heart rate by mistake and give a false sense of fetal well being. The infant begins to have serious dips in the heart rate after one hour of pushing. The dips are starting to get longer and take more time to recover. Recovery is when the heart rate has returned to its pre-contraction rate, referred to as baseline and typically 120 to 160 beats per minute. One might think that a woman would never have a heart rate of 150, but during labor this often occurs.

The decelerations tell me that the infant is stressed. During the contractions the oxygen level dips and the heart rate follows. The fact that it takes longer for the heart rate to recover tells me that the time of hypoxia is becoming greater. My friend suggested a cesarean section and was quickly dismissed. This is not a Neonatologist's call (cop out). Okay, it is not my expertise (this is the truth). The Obstetrician has years of experience with laboring mothers that I d0 not. The Obstetrician has two patients and must consider both the health of the baby and the health of the mother. However one thing that I am certain of is that if this mother had walked in off the street, had medicaid and no relationshiop with the Obstetrician, she would have been sectioned two hours ago.

The baby was born vaginally after three hours of pushing. She was bruised, had a slow heart rate, was not moving or breathing and her color was grey. My friend placed a mask over the baby's face and immediately started giving oxygen. She began to pump the oxygen bag to force air into the lungs. The baby was still grey and not moving. At this time a minute had passed and the father came over to my friend and asked if his daughter could go to the mother's breast. My friend tells the father that his daughter was not breathing and that she needed to give the baby oxygen. And that she'll bring her to mom when she was doing better. The baby did not go to the mother's breast. She went to the intensive care unit. The father doesn't really understand, but the first flicker crosses his consciousness that something could go wrong. Could? Had.

The little girl ended up on a ventilator because she wouldn't breathe and she started to have seizures that were difficult to control. She was on high doses of Phenobarbital (anti-seizure medication), antibiotics and blood pressure medications. The following day I stood at the bedside with the father. She was a beautiful baby. Everything perfectly formed and developed. The father was heartbroken and sick. He looked at me. It's crazy he said. My wife didn't even take pain medications because we wanted everything in the baby's system to be natural and now you guys are giving her all these powerful medications. I share a sliver of his sadness. I say a sliver because I can never really know how he feels. I hope to never feel what he was feeling.

Many people blame the birth plan but I blame the medical system and the Obstetrician. As physicians we have abducated our position of authority. Birth plans are created for healthy, full term infants in the midst of an uncomplicated delivery. But plans must be flexible and must place the health of the infant first. As physicians and nurses who work in perinatology, we need to educate parents and risk losing friends in order to do what we know is best.

I think that every prospective parent should give thought to how they want their baby's birth to unfold. And that a birth plan is a good idea. But the first line should read: At the first sign of trouble tear this up and do whatever is necessary to preserve the health of my baby.

I can feel my heart beat

Babies that are born close to full term sometimes get in more trouble than babies born more preterm. This may seem odd and the reasons are many, but one problem in particular has to do with the muscles surrounding the blood vessels in their lungs. See the very premature babies (less than 30 weeks) do not have much in the way of a muscle layer to their blood vessels. Late preterm babies (34-37 weeks) and term babies have well developed muscular layers to these blood vessels. And when the baby develops acidosis or low blood oxygen, which occurs if they have any respiratory illness, these blood vessels clinch up and close off blood flow to the lungs making the baby even sicker. This is called pulmonary hypertension and can be fatal.
Megan was born at 36 weeks and immediately started having trouble breathing. We placed her on oxygen blown up into her nose at high pressures. This allows her to breath more easily and increases her oxygen to help those blood vessels relax and open up. Well, she did well for about 24 hours and then I get called to her bedside because her oxygen level suddenly dropped. I walk (quickly) to her bedside and when she breathes I can see her pulling hard. The nares of her nose flare out and her belly caves in as she is using her abdominal muscles to help pull air into her lungs. I listen to her chest and while I can hear good breath sounds on her left side, I hear none on her right. On 100% oxygen her oxygen saturations stay in the 70's. You and I would be at 100%. Most of us get air hungry at 92%. I can see that she is hurting. I give her ativan and morphine to calm her down and ease her pain. I place a light against her chest and the entire right side lights up in a faint red glow. She has a pneumothorax. A pneumothorax is when a pocket of air has formed between the chest wall and the lung. It will push the lung over and can eventually collapse it.
So the baby is not doing well and we do not have time to confirm this with a chest x-ray so I ask the nurse for betadine, a butterfly needle and a syringe.
I pick the spot on her chest where I know the needle should go. I sterilize the site and we insert the needle. 80 cc of air comes out and her oxygen sats rise to 100% and she begins to breathe comfortably.
I have done this so many times before that I remain calm throughout. I could be ordering dinner off a menu. My pulse, naturally low stays in the 50's and my hands remain steady. I never raise my voice or even hint at the urgency that we all know exists.
So jump to my home where I am helping my seven year old with math. The problems involve counting by threes and I know Marcus knows how to count by threes. We work on problems for twenty minutes and I ask him what six plus three is and he says eight. Well I tell him "You know what six plus three is, we have been doing this for twenty minutes Marcus. One two THREE, four, five, SIX, seven, eight, NINE." So what is six plus three. And he says "Four". And I can start to feel my heart racing and I find my voice becoming much sterner and louder than I want.
So tell me how come I can stand at the bedside of a critically ill newborn without the slightest change in my emotional state but twenty minutes into homework with my son and I am a mess. It doesn't make sense. I am supposed to have perspective.

New Dream Job

I told a friend that the ultimate dream job was third-string quarterback on a Superbowl winning team. I said you get a great salary, will never get called in to play and earn a Superbowl ring. He laughed. He said wouldn't you want to play in the game. And I said what for.
Well I think I changed my mind.
See I like attending deliveries. When I get called to a delivery it means that "something is wrong". The nurse or obstetrition is expecting the baby to have problems. So if your having a baby, I guess you don't want to see me enter the room. It is not that I want something to go wrong, it's just that if something is going to go wrong, then I want to be there. You see, I feel very comfortable at what I do. When I walk into that room I can see the nervous expressions from the family, respiratory therapist and nurses. Of course they relax a little now that I am there, but they are still worried.
When a baby is born, the baby has to adapt to life outside of the womb quickly. Lungs, which are filled with fluid after to dry out and fill with air. The heart which has been shunting blood away from the lungs has to redirect it into the lungs. The blood vessels in the lungs which have been clinched tightly closed now must dilate to allow the blood in. No longer getting oxygen or having their blood filtered by Mom, the baby has to make some dramatic changes, all in seconds to minutes. One of my jobs is to help the baby make those changes and I know how to do this.
So the other day at work I get called to attend an emergency c-section. When I show up, they are wheeling mom into the room and there is a lot of bright red blood all over the bed sheets.
The OB looks at me and says "Term, abruption and we can't pick up a fetal heart rate." I have about a minute to prepare because that is how fast a good OB can get a baby out of an awake mother. I ask the nurse to get o-negative blood, saline and epinepherine ready. I prepare an umbilical line ( a plastic IV tube that goes into the vein in the umbilical cord). The baby is handed to us. He is as white as a glass of milk, no movement, no breathing, no detectable heart rate. The resident tries to intubate. This is when you place a plastic tube through the mouth and into the windpipe in order to breath for the baby. She can't see the windpipe because of blood. I ask her to step aside. I ask the nurse to place the umbilical vein catheter in while I intubate. I then suction out the mouth look inside and see a small opening with the vocal cords lining each side. I place the tube into the mouth and though the opening. We start giving breath with a bag. What's the heart rate? Not detectable. Is the umbilical line in? No. Okay start chest compressions. The baby is mainly pale white and still does not move. While I was intubating I got a call from one of the other doctors that I work with. He starts telling me about another patient. I interrupt him to ask him to come down to the help with the resucitation. We are now giving oxygen, but if the heart is not pumping blood to the lungs, we are not being that helpful yet. My partner placed the Umbilical line in while I was managing the breathing. We continue chest compressions. First we give normal saline. We still don't have blood. We ask the OB to draw us blood from the placenta. Normally there should be a couple hundred cc's of blood in a placenta. Word comes back from the OB. The placenta is dry. There is no blood. We give a second dose of saline, followed by epinepherine. We have a heart rate. The baby is seven minutes old. At ten minutes the baby makes a gasp. The blood arrives and we give a bolus of blood. We then move the baby over to the intensive care unit.
Well we saved the baby for the moment but what we did not know at the time is what did we save? Years earlier I would have told you that this baby was too far gone to have any meaningful recovery. But experience has taught me that some babies are plastic. By plastic I mean that they bend rather than break. They recover well beyond what we would ever predict. The following morning, this little guy opens his eyes and is breathing on his own so we take him off of the ventilator. Less than one month later, he leaves our hospital and at the time of discharge he had a completely normal exam. He may still have problems, but he also might not.
I told my partners that I was going to retire, because I will never have a part in saving someone who was so dead again. This baby did not have a heart rate for 7 minutes and did not take a breath for 10.
I don't know how this boy would have done with another physician at his side. Maybe he would have done better, maybe he would have died. But I feel that I had a part in giving him a good chance at life.
So when I hear the call overhead "Code C in Labor and Delivery" do I want to be sitting on the bench.
No way. Coach, put me in. I want to play.

Be Happy

This little ditty is borrowed from http://www.radiohead.com/

Madison was born after a relatively normal pregnancy. But immediately we knew something was wrong. The baby did not move, cry or take any breaths. She had a good heart rate which told me that the placenta was supplying adequate oxygen and could thus not account for the most common reason why an otherwise healthy baby might be depressed at birth. She was immediately placed on a ventilator.

When she was about two days old I knew that she would die soon. She had not taken any breaths on her own since birth. She did not open her eyes and was in a constant state of flexion, with tightly pulled in arms and legs. There is a condition called hyperkeplexia where children will startle and flex up. It can even be fatal if they stay flexed too long and do not restart breathing before their brain suffers from acidosis and a lack of oxygen. I thought this girl might have a severe form of this condition. But kids with hyperkeplexia have normal intelligence and when not flexed are normal. These children have normal EEGs. We performed an EEG and found that Madison lived in two states: she was either seizing or had no brain activity. I tried Vitamin B and anti-seizure medicines. Nothing worked. Madison's brain did not work.

I sometimes wonder why a case like that of Terry Schiavo garnered so much attention since everyday many people are taken off of life support. I have withdrawn supportive care and continued comfort care for many patients. Despite the euphemisms we create, it is never easy. Still some cases are harder than others.

After many conversations with Madison's parents they decided that their daughter would not want to continue living in her current state. With her brothers and sister close by, we took the ventilator tube out of Madison's mouth and handed her to her mother. Madison immediately flexed and then turned pale. She never took a breath. Her mother held her close to her breast and cried that she was sorry. I knew that she was not sorry for what we had done, but was sorry that it had to be done. Madison's father put his arm around his wife's shoulder and his palm on Madison's back and quietly wept. Later I gave Madison's mother a hug and whispered in her ear. I told her she was a good mother to Madison and gave her everything that a mother could give to a daughter. Madison's brothers held her and cried. At just 9 and 12, I know that they should not have to experience such things so young. And yet so many children do. I know that no parent should have to make the decision to take their newborn off of life support and yet so many have. And I stand by, helping as I can. Taking solace in my purpose to help them realize as normal this completely abnormal event.

And I feel.... lost

New Beginnings

At first your eyes are closed, you are wet, cold and blinded by the bright lights and poor vision. Hands grab you, thrust you, warm and dry you. Welcome to the world.
I am 39. A neonatologist and father of five. I always wanted to be a rock star but have no talent other than being able to dance like a maniac with my eyes closed. Something I wish for all of you. As rock stardom was not in my future I entered medicine. Given the amount of vodka I was drinking, I more or less stumbled into it.
I was just called to the bedside of a baby that weighs 590 grams. Her skin is a rich pink and her belly protrudes and is shrouded in a purple hue. The small veins, which look more like river tributaries drawn on a map, are easily visible through her translucent skin. There is no hair to her body, although a small amount of thin, short bristles lay flat along her head. This girl was actually less than 400 grams at one time. A wee bit more than what Sean Penn will exhale when he dies but still far below the typical minimal survival weight. If she lives, and yes it is possible, she will be the smallest baby I had ever taken care of that survived. I think that in Japan a few babies born at 23 weeks have survived, but most of these babies don't survive the first day. This baby is much smaller than my youngest, an 18 month old that already weighs 30 pounds and wears size 8 shoes. There are big paws on this one.
We don't all come in to this world the same. We don't have the same opportunities. And yet must of us have a chance. I say most, because obviously some have no chance.
That's the way the Bee Bumbles.