Nine Months

23 Minutes

I was asked to attend this repeat c-section at 31 weeks, 5 days due to variable fetal heart rate decels.  The mother is a G6P2A3 (6 total pregnancies, 2 living children, 3 early pregnancy losses) with pregnancy complicated by known 9p tetraploidy of the fetus.  Prenatal ultrasound had shown a variety of abnormalities.  Spontaneous rupture of the membranes occurred a few days ago and the patient was admitted.  She received betamethasone and was managed expectantly, having gotten full counseling and a birth plan was in place.  I spoke with the parents tonight prior to the c-section to review their wishes and expectations for resuscitation of their baby.  We agreed that, should the baby show any respiratory effort after suctioning and stimulation, that I would resuscitate with respiratory support, including intubation, then observe for response to this intervention.

At delivery, there was still a large volume of clear amniotic fluid present.  The baby delivered vertex (head first) and had little muscle tone.  We bulb suctioned and gave stimulation, and she made one or two weak cries.  We placed the neopuff on her, but her heart rated dropped to the 60's, so we gave PPV (positive pressure ventilation) with bag and mask instead.  Her heart rate came up and color improved.  I attempted intubation three times.  She had a bilateral cleft lip, small jaw, and rounded tongue, all making visualization of the cords very difficult.  It appeared that the anatomy around her airway had not formed correctly.  Between attempts, we gave PPV with the bag and mask, keeping her heart rate 80-90 with fair color.  I spoke with the parents, who asked me to try one more time to intubate.  I made one more attempt and was able to intubate.  Breath sounds could be heard bilaterally, the heart rate came up to about 130, and her color became pinker, but an air leak could be heard.  This occurred at 14 minutes of life.  We secured the tube and placed the baby into the transporter.  At that time, her color became poor and her heart rate plummeted.  On auscultation (listening for sounds in the body, usually with a stethoscope), I could hear good and equal breath sounds; an assistant verified.  However, the heart rate was very low and her color was very poor.  At this point, I felt that the baby had failed to respond to usual resuscitative measures and that, given the known aneuploidy and malformations, further resuscitation, such as chest compressions and medications, were not warranted and would only serve to prolong the baby's suffering.  We ceased resuscitative efforts at 23 minutes of life.  I spoke with her mother and father, who wished to hold her.  We removed the tube and gave the baby to the parents.  She was having some agonal breaths and a very slow heart rate at that time.