Did I make the right decision not to aggressively resuscitate this baby?

[AnnieOaklyRN, BSN, RN, EMT-P]

Hi all,

I had a terrible call the other night and it has been on my mind since then, I keep second guessing myself and getting upset about it, and wondering what if I had...

Anyway we were dispatched for a woman in labor, updated enroute to the baby has been delivered, updated enroute to shallow respirations, updated to CPR in progress. It was in the middle of a bad snow storm so it took us about 20 minutes or so to get there. Fast forward to arrival there is a 26 year old woman sitting on a toilet at home holding a very small baby while a police officer gives blow by oxygen (They do not have the appropriate BVM so that is the best they could do) and doing compressions. The baby had no muscle tone, no pulses, and a very occasional gasping breathe. The eyes were still fused and his mouth was so small I honestly don't know that I could have even intubated him if I wanted to because the smallest we carry is a 0 blade and I don't think it would have fit. I had my people start ventilations with our neonatal BVM, the baby's face was so small the mask covered most of it. We continued CPR and I called my medical control doctor because I felt the baby was to early to be viable given his size and skin etc. Speaking with her I advised her that the mother reports some movement in the baby on initial delivery and she advised me to work him for a while and gave me the OK to stop efforts if there was no response. The mother had no idea she was pregnant and when asked she reported her last period was about 2 months ago (clearly that wasn't her period of course because this baby was a lot further along than 8 weeks). I asked when her last period was before that and she said she didn't know, so figuring out gestational age was even more difficult.

Per the mother, she felt cramping discomfort like she had to go to the bathroom for a couple hours starting around 2330 and when she got into the bathroom she felt a gush of water, pushed once and out came the baby. The baby was born around 0300 hours and we didn't get there until around 0340 ( for some reason there seemed to be a lapse in time from birth to the 911 call, but her times may have been off). The baby was probably about 6-7 inches long from head to toe ( I am totally estimating could have been more or less), as I said his eyes were fused, and his mouth was about 1 inch long maybe even more like a half inch. We did CPR with ventilations for at least 10 minutes and had no response other than a very occasional gasp, but no brachial pulse or heart sounds so I made the difficult decision to stop efforts and not go to Epi or IV fluid. I am now totally second guessing myself.

The weight at the hospital was 526 grams which I have read is a baby that some hospitals would do a full resuscitation on. Was I wrong to call it and stop efforts and not try and intubate or try epi? The labor and delivery nurse called me later to ask some more questions for the records and she said that they more than likely would not have tried to resuscitate that baby. She also said they were unsure of the gestational age and were still trying to figure it out (this was two hours later). It is a community hospital with no NICU or SCN.

Any advise or comments would be helpful, even if you disagree with stopping efforts, I need to learn in case this happens again. This is the first time I have ever had a field deliver of a preterm neonate so I had nothing to compare the baby too as far as using that to figure out an actually gestational age and viability.

A Heart Broken Annie

[essT]

The edge of viability is hard enough in the hospital setting; bless you for confronting it in the field. Please be kind to yourself.

The combination of the birth history, delay of treatment, iffy gestational age (sounds like *maybe* 23-24 weeks based on weight and fused eyelids) no heart tones or response after 10 minutes of CPR... This would not have been a good outcome no matter what. Even if resuscitation measures were to achieve some sort of stability long enough to achieve transfer to a level III/IV facility (sounds highly unlikely), there would probably be discussions of withdrawal of support due to overwhelming neurologic devastation or sepsis. Or, down the road, NEC as a result of gut ischemia from being "down" so long.

It sounds to me like you handled a terrible situation in a way that gave dignity to both mom and baby. Thank you for the work that you do.

[AnnieOaklyRN, BSN, RN, EMT-P]

Thank you so much for your thoughtful response! I feel a bit better today as I have had more time to process it and I do think that I did the right thing for mom and baby, as difficult as it was. As you said it would have had a bad outcome no matter what given the situation. The mother had a difficult time accepting that we did not aggressively work him because he was fully developed on the outside so she couldn't see the fact that his lungs and other organs were not ready for life on the outside. I think maybe he would have had a better chance if he was born in a hospital and immediately resuscitated, but that was not to be, and even then it could have been months of suffering.

Thank you for helping me process this call and learn from it.

Annie

[babyNP., APRN]

Trying to intubate a edge of viability baby isn't always a guarantee even while in a hospital, I can't imagine doing it out in the field. Plus you probably would've needed a 00 blade.

I think you did the best you could under very trying circumstances. If the baby was at 23 weeks (which is generally considered edge of viability), it's about a 50/50 shot if the baby makes it alive, and of those that do, another 50% or so that have moderate to severe co-morbidities. So even under the best of circumstances like a hospital, it's tough.

Hope you feel better soon, take care of yourself

[adventure_rn, MSN, NP]

I am so sorry you had that experience. As others have said, even in a hospital setting with several RNs, RTs, APRNs, and MDs in attendance, this would have been a difficult delivery. You almost certainly would have needed a 2.0 tube, a 00 blade, and potentially the ability to place umbilical lines in order to effectively resuscitate. Even if you had attempted to intubate and give epi, given the circumstances you described the baby likely wouldn't have survived. You did the best you could.

Again, I am so sorry you've had to go through this experience. We don't often lose babies, but when we do it can be very hard to make sense of the experience. If you feel up to it, I'd recommend debriefing with your coworkers and/or boss, or seeing if your employer offers an Employee Assitance Program (a free short-term counseling service). ((Hugs)).

[ruby_jane, BSN, RN]

As you said it would have had a bad outcome no matter what given the situation. The mother had a difficult time accepting that we did not aggressively work him because he was fully developed on the outside so she couldn't see the fact that his lungs and other organs were not ready for life on the outside. I think maybe he would have had a better chance if he was born in a hospital and immediately resuscitated, but that was not to be, and even then it could have been months of suffering.

So many maybes, Annie. You called it based on a doctor's OK. Who knows what happened to the baby between the time mom delivered and the time the police arrived? Hang in there. We are not miracle workers.

[lifelearningrn, BSN, RN]

You did what you could. Mom is probably questioning herself and in turn, questioning everything, including your interventions.

[audreysmagic, RN]

It sounds like you did the best you could, under the circumstances. If the baby had arrived in a hospital with a top-level NICU, there might have been more to be done...but with the equipment and resources at your disposal, you gave that baby the best you could. Take care of yourself.

[NICU Guy, BSN, RN]

There is nothing more you could have done. Even if you had the skills to intubate with a 2.0 tube and a 00 blade and a fully equipped Neonatal transport ambulance (Baby Buggy) with a heated isolette, at 526g born in the toilet, it would have very little chance of survival. It was probably in the 22-23 week gestation. At that age, even born at a hospital with a NICU team (docs, nurses, RT) ready to intubate at delivery and directly admitted to a Level IV NICU, there is a very slim chance of survival. I have not seen a baby born less than 580-600g survive longer than a week that were born in the ideal setting (adult hospital attached to a Level IV NICU).

[AnnieOaklyRN, BSN, RN, EMT-P]

Thank you everyone for your responses, I really feel better, and they are helping me. Crappy situation for everyone involved, especially the poor baby and parents. Bless you all.

Annie

[gonzo1, ASN, RN]

Please stop second guessing yourself. If it had been a witnessed birth maybe. But the fact that there is no way of knowing what the down time was before you arrived makes it most likely that this was not going to have a good outcome. You did everything you could and I'm sure the family is grateful for your help.

[AreN4lyfe, ADN, RN]

It may sound heartless, but nature knows. You saved that baby's life in a different way - from a longer life of suffering and eventual death.