Yesterday's little man expired at about 7.20 last night. His mother was no longer on the floor this morning. There was much shrugging and sad shaking of heads.
***I rushed to the labor ward as the head midwife for the day called "Who wants to do this delivery!". The mother was bent over, clearly trying not to push. She climbed up on the table, and before I got my gloves on, before I even turned around, a splashing sound heralded the arrival of her obviously very, very preterm baby. Curled in a puddle, still cloaked in his amniotic sac, he wriggled weakly there for a couple of seconds while I finished pulling on my gloves, tore away his sac then quickly cut and clamped his cord. I took his tiny body to the resuscitaire again all the while thinking about how similar he is in size to the small boy wriggling in my belly.
I got him there, limp and floppy, not breathing, quick stethoscope to his chest: HR around 60. I grabbed the ambu-bag, and the tiniest mask I could find in the box of assorted masks piled next to the table and bagged him gently. Chest rise. A few puffs later, some small noises. I listened to his chest again, still below 80. I did 20 seconds or so of chest compressions, along with the bagging.
Had a moment of looking down at myself doing this, thinking "holy crap, you're doing chest compressions by yourself on a preterm baby who's fixing to die."
It's funny how the protocols tell you to do one thing and your gut says try something else in the moment. I listened again to his chest, his HR was now well over 100, and I picked up a towel and rubbed on him, flicking his tiny shiny feet. He opened his eyes and mewed at me and began trying in ernest to breathe. With the O2 flowing through the ambubag (I have no idea if it was functioning 'properly' but we seemed to have something which approximated a positive pressure ventilation system happening. I alternated between suctioning his mouth and nose with the machines and encouraging him to continue to breathe. As I took care of babe, midwife colleague snapped on gloves, delivered the synto which comes automatically with the birth of any baby here, and lifted the clamp to deliver the placenta. The scrawny looking cord lengthened, and then flopped limply into the waiting kidney dish with no placenta attached to the other end of it. Crap. Bloody cord had torn right off the placenta.
A passing OB was snagged, loaded her with morphine and proceded with a manual removal of the nastiest looking placenta I've ever seen. She continued to bleed though and about an hour later (things happen slowly here) she pushed out several large chunks of placenta. Officially now in hemmorage territory she was eventually taken to U/S to confirm retained products and then to the OR where a curette was needed to remove said products.
This woman had had no prenatal care, had no idea what her due date was, or even her LMP. We strongly suspect though that 'castom meresin' had been used to induce her labor. Based on her baby's size we estimate him to be 8-12 weeks early, probably around 30 weeks. He weighed in at 1.1kilos (2.4lbs).
I spent the afternoon convincing everyone, from the midwives to the pediatrician to the consultant docs to give him a crack at it. Initially the MW looked 'iffy' as I began his resucitation. I'm quite sure that he would have been left gasping on the table had I not been the one to pick him up. Honestly, had he been born dead, I could have left him be, but he wasn't dead, he was trying to breathe and his heart was beating! I'm not sure if helping him WAS the right thing to do as I write this, but I could only do what I've been trained to, which is to resucitate flat babies when they need it. As it was his breathing gradually improved, his RDS symptoms lessened and his color began to look decent. He was alert and responsive to handling, was rooting weakly by the end of the day (not that he'll be put anywhere near a breast for quite a while) and his O2 sats and HR were peachy (97-99% and 120's-130's).
Call me the eternal visiting optimist, but I would really like this little man to beat the odds. It's clear that I'm about the only person who is naive enough to think he's really got a cat's hope in hell. I scavenged a tiny knit cap (purple) and mismatched tiny preemie socks from a cuboard. I carefully changed his bedding - rolling the edges of a soft quilt up around him. I wrapped his tiny bum in gauze (no nappy small enough) and tucked him in before I left. I hope the night staff watch him closely and make sure he's warm enough.
I'm due to be off for a couple of days of much needed R and R. I suspect I may have to swing by and see how he's doing before Monday though.
As I was leaving a mama walked in. She had had her baby precipitously at home, attended by a TBA, but her baby had died (the body had been left at home). She had come in for a 'check-up', her eyes red and swollen from the crying she's begun. All I could do was rub her leg gently and say "Mi sorry tumas."
Too many dead babies for this student midwife.
So it goes somewhere south of the equator.