In The Nick of Time

In The Nick of Time.

 

In The Nick of Time

Yesterday I was consulting patients when at 2:00 pm, I received a referral from a hospital where I will be attending to the delivery of a term baby via cesarean section. The procedure was scheduled at 4 pm. Since I don’t have a long queue of patients, I was taking time my time to attend to my outpatients. At 2:45 pm however, with 3 remaining patients, my phone rang again and the caller is the same hospital. I thought the CS was being rescheduled but it was a new referral. A mom who is on her 9th pregnancy, but this would be the 6th live baby, was admitted due to very high blood pressure at 220/120. She was being scheduled for emergency cesarean section. I asked what time, the resident said NOW! I asked for the indication and  the resident replied there was a sudden drop of blood pressure from 220/120 to 160/90. It was alarming indeed! With the three remaining patients I haven’t attended to yet, shall I ask them to come back tomorrow or will I finish my consultation before I proceed to the hospital? I decided to consult them all, anyway, they were all for an oral vaccine. I was really telling sorry I had to rush them, but they do understand that I am no regular pediatrician, and they also won’t prefer to come back the next day, so all was well.

I drove as fast as I could to reach the hospital on time. Upon arrival at the parking area, I saw the obstetrician handing her key to the guard so the latter could do the parking for her. I also did the same and ran towards the NICU. I first checked the equipment if they were all prepared and in less than 5 minutes, I was notified that the operation has began. (The NICU is adjacent to the operating room). I then went to the operating room and just as I finished gloving, the baby came out. The baby was limp, no spontaneous breathing, and was bluish in color. The obstetrician immediately cut the cord so I could attend to him. On the resuscitation table, after the initial procedure of drying the baby, wiping off the amniotic fluid, the baby was not reacting. So after clearing the mouth of any secretions, removing the wet towel and covering the baby with a newer one, I immediately did bag-mask ventilation.

Bag-mask ventilation. (Image credit: http://odlarmed.com/wp-content/uploads/2009/02/laerdal_als_baby_rescuer_cpr.jpg)

After few seconds, baby started to grimace, breath regularly, and his color improved. Heart rate was at a normal rate and baby began to cry. I heard then the OB gave a sigh or relief. I give credit to the obstetrician for delivering the baby as fast as possible.

When the baby already seemed alright, I immediately latched her onto the mother. While baby was on mother’s chest, I went to inspect the placenta as the obstetrician noted abruption. I noticed that on the uterine side of the placenta, it was black all over. This means that the placenta completely separated from the uterus prematurely, the black indicates blood has already clotted. (This explains why the blood pressure of the mother suddenly dropped from 220/120 to 160/90 even if the medications for controlling her blood pressure was just started). What is the implication of this? In cases of abruptio placenta (or placental abruption), the blood supply to the baby decreases depending on the placental surface that separated. The more placental surface separates, the more decreased blood flow. If this remains unmanaged, it may go to the extent where baby will become completely devoid of blood flow, loss blood volume and suffer shock. If this will still remain uncorrected, it can lead to the baby’s demise. In the case of this particular baby, the placenta completely separated, meaning, no blood flow was already going to the baby. That’s why when the baby came out, he was bluish, limp, not breathing spontaneously, and heart beat was very slow, almost towards death. The ventilation process that I provided (as illustrated above) reversed this process that’s why baby came back crying.

(Image credit: http://www.moondragon.org/obgyn/pregnancy/placentaabruption.html)

In less than 5 minutes that the baby was on his mother’s chest, I noticed that he was again turning pale to bluish and breathing was getting slow. I immediately took baby to the NICU for further care. After stabilizing him, I took his blood gas and showed a mixed acidosis, and the pH was at 6.9! (A pH below 7 usually is not compatible to life as the cellular enzymes and proteins already begin to coagulate). Glad thing it was reversed immediately.

ABRUPTIO PLACENTA is one of the very serious complications of pregnancy. Depending on how immediate the action is, the baby will eventually turn out normal (if the baby was delivered immediately upon detection of subtle signs, such as a sudden drop of blood pressure on a hypertensive mother at the time of evaluation or presentation), or dead (when the action was delayed, probably due to delay in recognition of symptoms, or no health care provider was able to assess the condition, such as in remote, rural areas, or when the patient is poor enough to afford a physician/hospital). The most common frank manifestation is vaginal bleeding in relation to abdominal pain and/or labor. Subtle sign may be the sudden drop of a blood pressure in a mother who was hypertensive during the course of pregnancy. Management of course would be immediate delivery of the baby or else the baby will die. For mothers who are hypertensive, let it be known and remembered that this elevated blood pressure is able to direct blood flow to the baby. Since it is not also good for the mother to be having a very high blood pressure, as it may also cause sudden rupture of blood vessel in the brain causing stroke, they are usually admitted for it to be controlled to a satisfactory level. The control is done gradually hence the titration of the anti-hypertensive drugs. If the blood pressure immediately drops, this will cause minimal to nil blood flow to the baby, and the baby will suffer shock, and eventual death.

This is one complication of pregnancy that we are wary of as babies often are the ones who suffer the complication, from ending normal, premature, with cerebral palsy, or dead. My baby was indeed premature at 32 weeks. This is facet of the reproductive health of the mother. If the bill get’s passed and enacted, health care providers may be able to reach pregnant mothers in the remote areas, those who cannot afford private obstetrician care. Once the health care provider is able to assess a mother at risk, then they can be referred to a higher institution capable of taking care of such cases. Luckily, my patient’s family can afford private physician’s attendance. But what of those poor mothers?

 

A Mother’s Day Story – Part 1

I was a faculty of a neonatal resuscitation program provider’s course when one afternoon I received a call to attend to the delivery of a preterm baby. The mother was 34 years old, on her second pregnancy, her first being 15 years ago. She was apparently alright except for her hypertension which was at 220/110 (we call these mothers, a walking time bomb). She was admitted for control as her baby is still premature but to no avail hence the emergency cesarean section. I was hoping that the hypertensive period and the current crisis hadn’t been occurring for a long time as it may greatly affect the well being of her baby. Minutes gone, and baby finally was delivered. He was a strong 1.5-kgs 32 weeks old (6 1/2 months by layman’s counting). But he had difficulty breathing spontaneously so I had to rush him to the NICU for intensive care. I provided mechanical ventilator and administer surfactant to ease his breathing. He went fine. Meanwhile, I learned that while the mother was in the recovery room the mother had seizure creating a commotion and series of procedures to keep her up…

–o0o–  –o0o– –o0o–

Few days passed, baby was now able to breath on his own. The respirator was already discontinued. He was already being fully fed via tube, meaning no more intravenous line (commonly called “dextrose”). He was now on low flow oxygen as respiratory support, still inside an incubator.

On his 10th day of life, baby suddenly crashed — his color was turning purplish, he was not breathing, the monitor indicated his blood oxygen saturation is low, and his heart has fallen below the normal. Suddenly, the nurse went to his rescue. She immediately provided bag-mask ventilation. Slowly, baby’s heart rate increase, he was turning pink back again and he resumed his breathing. While doing so, his mother was beside him, watching, caressing his head. 

(photo credit: http://www.rch.org.au/paed_trauma/manual.cfm?doc_id=12610)

Baby got stabilized thereafter… After about two days, similar incident happened. Baby again had near arrest (his heart beat fell to less than 60/min, bluish in color and not breathing spontaneously). Again, bag-mask ventilation was provided until he was pulled out. He regained consciousness and was crying as if he didn’t almost die. At the time the nurse was attending to him, his mother was again there providing comfort. She wasn’t talking but her facial expression said she wanted to be with her son always, caress him, comfort him, hug him, hold him, bathe him, nurse him forever. IF ONLY she could…

 –o0o– –o0o– –o0o–

At the recovery room when the mother had seizures, her BP shoot up causing rupture of blood vessels inside her head. She suffered what we call a hemorrhagic stroke (a stroke caused by hemorrhage in her brain from a rupture of blood vessels). She had to be operated on… She fell into coma… She laid there at the ICU with all the machines keeping her live… She arrested – her heartbeat stopped 10 days after she gave birth. Despite heroic measures, she didn’t make it. At that very same time she was being revived, the nurse in the NICU was reviving the baby… while the mother was caressing him…

The second time that baby was arresting, the nurse who saw mother caressing the baby while he was being resuscitated came from a leave, and had no idea that the mother passed away2 days ago …

 –o0o– –o0o– –o0o–

After discharged from the hospital, I saw baby for a few times for some vaccinations. But as days went, I noticed that baby hardly interacted. His face was becoming more and more expression-less unless he cried. He would never smile no matter how hard I try to make him. Deprived of maternal care… He was being passed from grandmother to grandmother, aunt to aunt depending on who’s free and available. This costs him inconsistencies of affection and care– something that confused his premature brain, which required consistency of maternal presence and care…

Few months more, I didn’t see baby anymore… I wonder how he is now…

As for the mother… she missed the chance of being a mother to her son. He was a vibrant boy until his emotional regression. She could have nursed him, bathed him, sent him to sleep, fed him. She could have watched him roll over, crawl, learn to stand and walk. She could have heard him say “mama” as his first word. She could have brought him to the park. She could stopped him crying. She could have… Only if death hadn’t stole him away from his son and family.