? for those at delivery hospitals

  1. 0 I work at a Children's hospital so I don't know a lot about deliveries. I figured someone here would have an answer.

    When a baby is born with an Apgar of 0, who is a suspected fetal demise, how long do you code the baby? We have a heartbreaking situation on our unit right now and I don't know enough to understand the situation.

    Thanks in advance!
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  3. Visit  Imafloat profile page

    About Imafloat

    From 'NC'; Joined Sep '04; Posts: 1,311; Likes: 1,064.

    16 Comments so far...

  4. Visit  Elvish profile page
    0
    I'm trying to understand what you mean by 'suspected.' Was there an ultrasound done? Decreased fetal movement? I hope this doesn't sound like I'm jumping on you; I'm just not quite sure what you mean by 'suspected.'
  5. Visit  Imafloat profile page
    0
    By suspected I mean decreased fetal movement, not sure on the heart tone, but it was an emergency c section because of nonreassuring strips.
  6. Visit  SteveNNP profile page
    1
    In this case we would have performed a reasonable prudent amount of resuscitation, including intubation, meds and chest compressions just like any neonate that is born needing advanced resuscitation. The diagnosis of fetal demise would have been an afterthought. In this case, since it seems that there was no way of knowing, everything needed to be done.
    Imafloat likes this.
  7. Visit  preemieRNkate profile page
    2
    Quote from WeeBabyRN
    When a baby is born with an Apgar of 0, who is a suspected fetal demise, how long do you code the baby? We have a heartbreaking situation on our unit right now and I don't know enough to understand the situation.

    Thanks in advance!
    My answer, unfortunately, is it depends on the attending present. We have an attending in house 24/7, and for a delivery like that, they would be called to the DR. We have some attendings who would see resuscitation as futile at a reasonable point and we have some that want to save anything and everything. Of course, it would depend the baby's response to the code too. What were the 5 and 10 minute APGAR scores? Just about a year ago, we had a baby with APGARs of 0/0/2. They didn't get a HR until 8 minutes of life, and that was after multiple rounds of epi. This poor baby did not qualfy for head cooling, and she wound up going home with her parents and hospice care. She passed away in November. She was born via emergency c-section for a poor BPP and mom reportedly did not feel movement all day. That day, we had one of the "save the world" attendings on. It was just an awful, awful situation. (Of course, the parents were the nicest people.)
  8. Visit  cshell1964 profile page
    3
    According to NRP if you are coding in the delivery room, the code should be called after 10 minutes if there is no improvement or response to resusitation efforts.
    RainDreamer, dawngloves, and Imafloat like this.
  9. Visit  Elvish profile page
    1
    If it's a fetal demise confirmed by u/s (as in no movement, no HR, no breathing movements), then no, we don't resuscitate.

    If it's suspected but not certain, then NICU does just like they do with any other baby. The longest I've heard of them coding a baby was 18 minutes on a 24-weeker. They were about to call it and she tried to cry, so they had to keep on going. She died a couple days later, to no one's surprise.
    Imafloat likes this.
  10. Visit  RainDreamer profile page
    3
    I'm really glad you brought this up because we actually have a really sad case in our unit right now in which a baby was resuscitated way too long, IMO.

    Mom was over in L&D, then all of a sudden, no fetal heart tones. So we went over for the crash section. Obviously baby came out dead, white as a ghost. The neo caught the baby and as he headed over to the warmer he told us "I'm not pronouncing another baby today" (as he had just gotten done prounouncing 23 week twins). To make a long story a bit shorter, Apgar scores were 0-0-0-2-2-3. I did chest compressions for 15 minutes, during that whole time we gave him 90 mls of fluid before we even got a heart rate (at 15 minutes). He wasn't responding and the neo should have called it. So now this precious baby is in our unit, with no brain.

    If the NRP guidelines are 10 minutes, then they need to stick to that. I honestly think the outcome of this would have been completely different if there was another neo that would have gone on that delivery or that neo that went (he's a good guy, good neo) hadn't of called the 23 week twins earlier that day.

    I'm really sorry you guys have a heartbreaking situation in your unit now ..... I know it's tough. (((HUGS))) for you all.
    crysobrn, danissa, and Imafloat like this.
  11. Visit  justjenny profile page
    1
    Quote from RainDreamer
    ...... I did chest compressions for 15 minutes, during that whole time we gave him 90 mls of fluid before we even got a heart rate (at 15 minutes). He wasn't responding and the neo should have called it. So now this precious baby is in our unit, with no brain.

    If the NRP guidelines are 10 minutes, then they need to stick to that.....

    Just my two cents to the above post (not a flame at all!)
    Anyone doing chest compressions in L&D should know NRP guidelines. I also think that support staff (like yourself) should give a long, hard look into why NO ONE questioned that Neo as to why this was occuring.

    Again, not a flame against you, but I think there is a point that a *reasonable* person would have to refuse to continue to what the Neo asked. This is definately an ethical/moral issue that is sure to upset a lot of people but the couple of details that you provided: 90 (?!?!?!) mls of fluid, no HR for 15 minutes, and the statement by the Neo of not wanting to call "another one" (sorry, it is a part of the job - you are not God) raises alarm bells and red flags all around for me.

    Sorry if this upsets people, but I sincerely think that if the Neo is going against standard guidelines and policies - someone needs to stand up for that baby and that family and call them on it....Docs are not the "be all end all" even though they like to think so.

    Jenny
    Skeletor likes this.
  12. Visit  RainDreamer profile page
    3
    Quote from justjenny
    Just my two cents to the above post (not a flame at all!)
    Anyone doing chest compressions in L&D should know NRP guidelines. I also think that support staff (like yourself) should give a long, hard look into why NO ONE questioned that Neo as to why this was occuring.

    Again, not a flame against you, but I think there is a point that a *reasonable* person would have to refuse to continue to what the Neo asked. This is definately an ethical/moral issue that is sure to upset a lot of people but the couple of details that you provided: 90 (?!?!?!) mls of fluid, no HR for 15 minutes, and the statement by the Neo of not wanting to call "another one" (sorry, it is a part of the job - you are not God) raises alarm bells and red flags all around for me.

    Sorry if this upsets people, but I sincerely think that if the Neo is going against standard guidelines and policies - someone needs to stand up for that baby and that family and call them on it....Docs are not the "be all end all" even though they like to think so.

    Jenny
    You weren't in the situation and unless you've been in that exact same situation and know the whole story, then you can't really criticize.

    There's more to the story, but for privacy reasons I'm not going to go into major detail here.
    Last edit by RainDreamer on Jan 12, '08
    danissa, elizabells, and prmenrs like this.
  13. Visit  canoehead profile page
    8
    It's not cool to have a "discussion" about calling a code for a new baby when the parents are right there listening to every word. Discuss comfort care after the fact, discuss limits on resuscitation with an ethics committee, but don't make the parents listen to health care workers disagree when their child's life is at stake.

    Refusing to continue a code could easily cost you your job, and have you reported to the BON. If there are no signs of life at 15 minutes you can be pretty sure the child is dead and likely to remain so. Hard to put your career on the line when there's only a 1-2% chance the child will regain a heartbeat and have to suffer....

    Every once in a while a bad situation happens to good people. The nurses and possibly the neonatologist are agonizing over what happened, and what they should have done. I would have done the same things, and been upset at the outcome too. Raindreamer did a good job, but life just isn't fair. I hope the baby passes peacefully.
    DDRN4me, Kiwimid, danissa, and 5 others like this.
  14. Visit  RainDreamer profile page
    0
    Quote from canoehead
    It's not cool to have a "discussion" about calling a code for a new baby when the parents are right there listening to every word. Discuss comfort care after the fact, discuss limits on resuscitation with an ethics committee, but don't make the parents listen to health care workers disagree when their child's life is at stake.

    Refusing to continue a code could easily cost you your job, and have you reported to the BON. If there are no signs of life at 15 minutes you can be pretty sure the child is dead and likely to remain so. Hard to put your career on the line when there's only a 1-2% chance the child will regain a heartbeat and have to suffer....

    Every once in a while a bad situation happens to good people. The nurses and possibly the neonatologist are agonizing over what happened, and what they should have done. I would have done the same things, and been upset at the outcome too. Raindreamer did a good job, but life just isn't fair. I hope the baby passes peacefully.
    Thanks so much for this post, it means a lot. I needed to hear that.
  15. Visit  prmenrs profile page
    4
    In that situation, the Neonatalogist is the team leader, the RN/RT cannot, in mid-resus, announce "we're going longer than NRP allows" and quit playing.

    And, as Canoe pointed out, discussions about ethics and philosophy should never occur in the DR.

    Sometimes you just have to "deal" w/the situation in front of you; all the Monday morning Quarterbacking in the world won't change things.

    Praying for peaceful outcomes for the OP and Rain. For all the good things about NICU, this is one of the difficult things.
    Last edit by prmenrs on Jan 13, '08
    Elvish, danissa, BittyBabyGrower, and 1 other like this.


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