When I got the call, I was in a book store trying to find some X-Men comic books for my kids, Marcus really likes Wolverine. It was the Doctor working the day for one of the hospitals that I would be covering in the next hour. He said that he had just arrived home when he was notified that a woman presented in labor. She was 25 weeks along and fully dilated. She had a bulging bag. He could go in but it would likely take him an hour to get there with traffic. He asked if I would mind covering the delivery. “Of course not,” I said. “You’re off in an hour anyway and stabilizing that kid’s gonna take longer than an hour anyway.” Anyone who works with babies knows that a 25 week infant can easily fit through a 10 cm hole. If the mother was fully dilated she could deliver at any moment without even knowing it. I was closest, so I went in.
The pregnancy was not complicated. Mom had regular visits with her Obstetrician and no problems had surfaced. She simply felt some pelvic pressure earlier in the day and went in to see her Obstetrician. He performed an ultrasound which showed a fully dilated cervix and hourglass membranes. This means that the sack around the baby was half in the uterus and half in the vagina. Each was filled with fluid and so it looked like an hourglass on ultrasound. While in the hospital, the woman’s uterus started to contract forcing all of the fluid into the part of the sack that was in the vagina. Now the infant had no fluid around her and she started to feel the pressure. Her heart rate started dropping and an emergency c-section was performed. I was glad that I went in.
The baby was delivered and placed under a warmer in front of me. She was as small as a soda can with thin skin and fused eyelids. She was not breathing and her heart rate was low. The color quickly drained from her body and she looked lifeless. The first person to try to intubate her couldn’t see the vocal cords. When you place a baby on a ventilator you have to pass a tube into her mouth and through the vocal cords. This space in a 25 week infant is 3 to 4 mm wide. When the first attempt failed I placed a mask over the baby’s nose and mouth and began giving breaths. This does not work as well as having a tube in the trachea in small babies. While bagging breaths in, I took up my position at the head of the bed and asked for a clean tube. I then looked into the mouth and placed the tube in. I knew it was in. We started forcing air into her lungs with the bag now attached to the end of the tube. Her heart rate was low and her color remained bad. She was about a minute old. We still had time. I asked the nurse to place a catheter in her umbilical cord while I pushed air into her lungs.
“I need two mls of surfactant” I said. Surfactant is a protein that premature lungs are missing. It helps them to open and close more easily. It increases the amount of surface area where air can come into contact with blood thus improving oxygen delivery to the baby. I put that into the tube and forced it down with more breaths.
The c-section rooms are small at this hospital and about two feet from me I can see the Mom’s face and the father sitting beside her. They are looking at me. I smile.
“What’s our heart rate?” I ask.
“About 50,” says a nurse.
“Okay, begin chest compressions.”
“Is that UVC in yet. “ UVC stands for Umbilical Vein Catheter. It is a plastic tube that is placed in the umbilical vein, the largest and easiest venous access point in a newborn.
“Almost”
“Okay. Give me a dose of epinephrine.” I place the clear liquid in the endotracheal tube and slowly bag it into the lungs. It’s supposed to make its way to the heart and speed it up. Only it works better if it goes directly into the blood. No response. I keep bagging.
“Are we giving a hundred percent oxygen?”
“Yes.”
“Is the UVC in?
“Yes.”
“Okay give 10 ml’s of normal saline.”
A syringe is passed from one nurse to another where it is attached to the end of the umbilical catheter and delivered. “Given,” one of the nurses says.
“And our heart rate?” I asked.
“Still 50,” the charting nurse said.
“Is there a sat monitor on?”
“Yeah, but it’s not picking up.”
“Okay give a dose of epinephrine through the UVC.”
The dose is given and at the same time I start bagging with higher pressures and the infant’s heart rate starts to rise. It hits 80 and then quickly jumps to 140. Was it the fluid, the epinephrine or the higher ventilator pressures? I’m not sure. But the heart rate is good. The baby starts to move her arms. I even think I can feel her suck on my index finger that is still holding the endotracheal tube securely in her mouth. “Okay” I say. “Let’s go.”
We tape the tube and line in place and start to move out of the room. The baby is about 7 minutes old.
I look at the parents. They look worried and confused like they are out of their bodies and viewing these actions from someplace far away.
“Your daughter’s alive but she is very premature and very sick,” I quickly say. “Right now we are breathing for her and we have a good heart rate. We will do everything that we can for her. Right now I need to go with her into the unit.” They don’t say anything as I walk away with the baby.
The hospital that we are at can’t take care of a baby this small so I need to transfer her to another hospital. I happen to be the doctor on there too.
We stabilized the baby, replaced the umbilical lines adding one in the artery in addition to the vein. We then sent her to the other hospital, where I drove in my car to accept her. Once there I made sure she was secure for the rest of the night before laying down myself. I reviewed her orders, her fluids and her labs. But most important, I checked on her many times. While performing one last examination she reached up and grabbed my finger. I know that the baby’s reach was a reflex and not an intentional gesture but in it I felt hope.
The pregnancy was not complicated. Mom had regular visits with her Obstetrician and no problems had surfaced. She simply felt some pelvic pressure earlier in the day and went in to see her Obstetrician. He performed an ultrasound which showed a fully dilated cervix and hourglass membranes. This means that the sack around the baby was half in the uterus and half in the vagina. Each was filled with fluid and so it looked like an hourglass on ultrasound. While in the hospital, the woman’s uterus started to contract forcing all of the fluid into the part of the sack that was in the vagina. Now the infant had no fluid around her and she started to feel the pressure. Her heart rate started dropping and an emergency c-section was performed. I was glad that I went in.
The baby was delivered and placed under a warmer in front of me. She was as small as a soda can with thin skin and fused eyelids. She was not breathing and her heart rate was low. The color quickly drained from her body and she looked lifeless. The first person to try to intubate her couldn’t see the vocal cords. When you place a baby on a ventilator you have to pass a tube into her mouth and through the vocal cords. This space in a 25 week infant is 3 to 4 mm wide. When the first attempt failed I placed a mask over the baby’s nose and mouth and began giving breaths. This does not work as well as having a tube in the trachea in small babies. While bagging breaths in, I took up my position at the head of the bed and asked for a clean tube. I then looked into the mouth and placed the tube in. I knew it was in. We started forcing air into her lungs with the bag now attached to the end of the tube. Her heart rate was low and her color remained bad. She was about a minute old. We still had time. I asked the nurse to place a catheter in her umbilical cord while I pushed air into her lungs.
“I need two mls of surfactant” I said. Surfactant is a protein that premature lungs are missing. It helps them to open and close more easily. It increases the amount of surface area where air can come into contact with blood thus improving oxygen delivery to the baby. I put that into the tube and forced it down with more breaths.
The c-section rooms are small at this hospital and about two feet from me I can see the Mom’s face and the father sitting beside her. They are looking at me. I smile.
“What’s our heart rate?” I ask.
“About 50,” says a nurse.
“Okay, begin chest compressions.”
“Is that UVC in yet. “ UVC stands for Umbilical Vein Catheter. It is a plastic tube that is placed in the umbilical vein, the largest and easiest venous access point in a newborn.
“Almost”
“Okay. Give me a dose of epinephrine.” I place the clear liquid in the endotracheal tube and slowly bag it into the lungs. It’s supposed to make its way to the heart and speed it up. Only it works better if it goes directly into the blood. No response. I keep bagging.
“Are we giving a hundred percent oxygen?”
“Yes.”
“Is the UVC in?
“Yes.”
“Okay give 10 ml’s of normal saline.”
A syringe is passed from one nurse to another where it is attached to the end of the umbilical catheter and delivered. “Given,” one of the nurses says.
“And our heart rate?” I asked.
“Still 50,” the charting nurse said.
“Is there a sat monitor on?”
“Yeah, but it’s not picking up.”
“Okay give a dose of epinephrine through the UVC.”
The dose is given and at the same time I start bagging with higher pressures and the infant’s heart rate starts to rise. It hits 80 and then quickly jumps to 140. Was it the fluid, the epinephrine or the higher ventilator pressures? I’m not sure. But the heart rate is good. The baby starts to move her arms. I even think I can feel her suck on my index finger that is still holding the endotracheal tube securely in her mouth. “Okay” I say. “Let’s go.”
We tape the tube and line in place and start to move out of the room. The baby is about 7 minutes old.
I look at the parents. They look worried and confused like they are out of their bodies and viewing these actions from someplace far away.
“Your daughter’s alive but she is very premature and very sick,” I quickly say. “Right now we are breathing for her and we have a good heart rate. We will do everything that we can for her. Right now I need to go with her into the unit.” They don’t say anything as I walk away with the baby.
The hospital that we are at can’t take care of a baby this small so I need to transfer her to another hospital. I happen to be the doctor on there too.
We stabilized the baby, replaced the umbilical lines adding one in the artery in addition to the vein. We then sent her to the other hospital, where I drove in my car to accept her. Once there I made sure she was secure for the rest of the night before laying down myself. I reviewed her orders, her fluids and her labs. But most important, I checked on her many times. While performing one last examination she reached up and grabbed my finger. I know that the baby’s reach was a reflex and not an intentional gesture but in it I felt hope.
