Did we do the right thing? 23 wker

Specialties NICU

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I work in a small rural hospital. 300 births a yr. We had a 23 1/7 wk mom walk in at 0250, complaining of mild cramping since having intercourse around 1700. States she is feeling better. Rates pain 4, compares to mild period cramp. It had been a night from hell on our floor..anyhow. Hooked her up to EFM, showing 20-40 sec crampettes. Most she wasn't feeling. Got orders from doc to check her at 0320..bulging bag and complete. Doc gave orders not to resusitate, being the kiddo is only 23 wks. Anyhow baby delivered at 0330 with a HR of 100, no respirtory effort..agonal type breaths. ER doc came down who trained at a childrens hosp and was wanting to resusitate.

Baby weighed 597 gm (1# 5oz). This was my first experience with pre-term delivery(this early). My senior nurse was adamant we doing nothing per pt doc orders.

What does your NICU consider non viable and what is your criteria.

We don't have surfactant and our closest NICU is 45 min away.

I'd appreciate your input.

My perspective is comming from the NICU so keep that in mind.

Here ussually if the baby has a pulse and parents are sure of the dates they will resusitate...if that is what the family wants. Our smallest surviver at 22 wks was about 500 gms.

But so much other stuff goes into this type of dicision, and I'm honestly not sure what one of the referal hospitals would do if they couldn't transport the mom.

I wouldn't second guess yourselves, you did the best you could...what more can you do. Even with all the bells & whistles babys that small have a very tough go of it, and not all the outcomes are the best in the end.

We treat 23 weekers. How aggressively depends on specifics, but I think you did the right thing. This poor child would probably have been a mess by the time it made it to the NICU 45 minutes away and you would only have prolonged its suffering. I can't imagine anyone in your hospital would even have been able to intubate this child without doing some damage if it's uncommon to have premies there. The only way I can see a good outcome is if the mom is close to NICU care when she delivers.

Specializes in NICU.

I think you did the right thing, too.

Before we had inhouse peds, we had something similar happen. We were told not to do anything, he had no resp effort, so we didn't try.

If the transport team is available, and can take the little one from delivery, it would have the best chance. If the baby is ready to deliver when she comes in, and mom has not had steroids, they usually want to know it's a live one before they come down from Childrens.

I work in a small rural hospital. 300 births a yr. We had a 23 1/7 wk mom walk in at 0250, complaining of mild cramping since having intercourse around 1700. States she is feeling better. Rates pain 4, compares to mild period cramp. It had been a night from hell on our floor..anyhow. Hooked her up to EFM, showing 20-40 sec crampettes. Most she wasn't feeling. Got orders from doc to check her at 0320..bulging bag and complete. Doc gave orders not to resusitate, being the kiddo is only 23 wks. Anyhow baby delivered at 0330 with a HR of 100, no respirtory effort..agonal type breaths. ER doc came down who trained at a childrens hosp and was wanting to resusitate.

Baby weighed 597 gm (1# 5oz). This was my first experience with pre-term delivery(this early). My senior nurse was adamant we doing nothing per pt doc orders.

What does your NICU consider non viable and what is your criteria.

We don't have surfactant and our closest NICU is 45 min away.

I'd appreciate your input.

You've done the right thing , there's no time even for u to transfer the mom to the nearby hospital with an NICU . In my hospital parents are often counselled before labour if they are going to deliver premature . They'll be explained about the consequences of such high risk babies born at 23wks gestation , if the parents insist on carrying on we'll resuscitate the baby and go all the way out however if our census is really high , we'll transfer the mom to another hospital with NICU if she's not in active labour .

Personally I'll not want to keep the baby if I know that I'm going to deliver at 22 -23wks especially after having experience nursing such babies and seeing their outcome . I can't take it especially if I'm going to bring back a child with severe handicap , oxygen dependent and also a huge amount of medical bills to settle . I've seen marriages and families break up because of this .

What do u think ?

You've done the right thing , there's no time even for u to transfer the mom to the nearby hospital with an NICU . In my hospital parents are often counselled before labour if they are going to deliver premature . They'll be explained about the consequences of such high risk babies born at 23wks gestation , if the parents insist on carrying on we'll resuscitate the baby and go all the way out however if our census is really high , we'll transfer the mom to another hospital with NICU if she's not in active labour .

Personally I'll not want to keep the baby if I know that I'm going to deliver at 22 -23wks especially after having experience nursing such babies and seeing their outcome . I can't take it especially if I'm going to bring back a child with severe handicap , oxygen dependent and also a huge amount of medical bills to settle . I've seen marriages and families break up because of this .

What do u think ?

I'm with you on this one. Sometimes just because it CAN be done...doesn't mean it SHOULD be done. It also doesn't mean you are LETTING the baby die. You are simply letting nature take its course.

I think yours is a tough call because of not having a NICU there and no time to transport the mother to a high risk facility. Without the proper team and equipment, that kiddo would have had an incredibly poor prognosis.In my level III facility that kid would have just had a poor prognosis.

What were the mother's wishes?

Specializes in NICU.

We resuscitate 23+1 wks, but nothing younger. We don't worry so much beforehand about weight being a criteria for resuscitation because if the baby is too small, we likely won't be able to intubate it and that will be what stops the resuscitation. Resuscitating a micro is always a parent's decision and we would do what they want regardless of what the doctor orders (assuming over 23 wks). And we always have in the back of our minds that if things go downhill, we can still withdraw care if the parents desire.

How many of us here have gone home and actually prayed for God to take a tiny 23 weeker to Heaven so it won't suffer anymore because in addition to everything else, the poor baby's skin is all torn up? Myself, I woudn't resuscitate a 23 weeker and I'm unsure about a 24 weeker. 25 weeker, yes.

I actually have a story of a 22+6 weeker left with Mom and Dad to die peacefully and he would not die. Never received any kind of resuscitation except warm blankets and kangaroo care. He was crying and satting 100% on RA 3 hours later so we had to admit him. Gave him a NC and put him to bed. And oh, yes, he LOOKED every bit his age. Never was surfed either... Abslutely not the norm of course!

Thank you so much for all your replies. I do feel much better. I am a mom of a 28 wker so I have a little experiece with a healthy preemie.

What bothered me the most was the doc was 30 min away. Spoke to the pt by phone and wasn't really given a choice of resusitation. Basically told you are only 23 wks and the baby is nonviable. I know this..what bothered me was the little noises he made when he first delivered was exactly the same noise I heard my son make.

The parents were very grateful for our care and were so relieved they did come in because she could have easily delivered at home.

Again thanks for your replies!

2 nights later we delivered a 27 1/2 wk mom for severe pre-eclampsia, unstable to transport. The NICU team was there for delivery and it went great! The kiddo was only 60 gms bigger than the 23 wker. Definatley IUGR.

His head was much larger, they intubated without any trouble. It was awesome to watch.

Specializes in NICU, Infection Control.

I agree w/KRVRN. I think you did the right thing under the circumstances. It's important to warn parents that those little noises are not uncommon so they can be prepared for it. Most babies make them, it doesn't mean the baby can [or should] be rescuitated.

Given that there was ! 1/2 hour between admitting and delivery, there wasn't much time for anything else.

You did a good job.

I agree w/KRVRN. I think you did the right thing under the circumstances. It's important to warn parents that those little noises are not uncommon so they can be prepared for it. Most babies make them, it doesn't mean the baby can [or should] be rescuitated.

Given that there was ! 1/2 hour between admitting and delivery, there wasn't much time for anything else.

You did a good job.

Thank you! I've only been an OB nurse 18 mo and that was my first and I know not my last. I look at it as a learning experience and I know I was blessed to been able to be there for the parents. You don't forget the ones that were there with you during a time like that. They were very grateful and apprecitive.

What does your NICU consider non viable and what is your criteria.

For us it depends on which attending is on. Some will try and save everyone others it just depends. We have a former 22 6/7 week little girl 485 grams at birth that is a plump 6 lb piglet who is now doing great. No bleeds, never perf'ed, no ROP, just weaned off her oxygen, and eating everything in sight.

My own 23 weeker had a similar course to the one I described above.

In your situation I think it was the right thing to do.

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