preterm- breathing on own at 18-19w

[Lanesmama]

I am a nursing student. Just started OB rotations which I was so excited about! My first day I was placed in L&D... while there, ED called saying they needed L&D nurse to assist with stillborn delivery. Nurse went down, assuming fetus wasn't alive. When she arrived, fetus was alive. 295 g. Mom had no prenatal care, didn't know was pg. Came in with abd pain, needed a vag exam so removed the tampon she had in because she thought she started her period... pulled out fetus. Dr. said fetus was 18-19 weeks. Here is my issue, and maybe (probably) I'm wrong. This fetus was initially bagged until RT said to stop because fetus wasn't viable, so they did. Brought mom and baby to recovery in OB. 3 hrs later, fetus is still alive. How is that possible? Can a 19 week old fetus live that long with NO interventions other than the initial bagging? Is it possible that the baby had IUGR and that the docs treated the couplet differently because mom was obviously mentally unstable, off the street, probably and addict? I'm frustrated because not only am I confused but also, that poor baby was left laying on the end of his mother's bed to die rather than be held/comforted while dying. Even the nurses on the floor seemed surprised the baby was still living...

[libran1984, ASN, RN]

Weirder things have happened...

I'm thinking hard how to phrase this....

I'm an ER nurse, my good friend is a NICU nurse and I hear more terrible stories from NICU than I can think of in ER.

When a child is born that young, it isn't viable. If it were given the best of all medical technology (including that even 10 years from now) it would still become developmentally stunted. There are some parents that will request the whole she-bang, intubation, HFOV, and such for the child because they have so much love in their hearts for this baby but eventually many a parents reach a point down the road where its hard, even for the most caring of parents to love a child who refuses to ever make eye contact, a child who will never speak, a child will be incredibly stunted both mentally and physically- and this is the kind of stunted growth that is beyond a typical MRDD case.

You paint a picture of a mother on the streets with an unexpected pregnancy. That baby, even if it were to live, would never be right. That mother could probably never be expected to take care of it, nor could a family that will never feel the slightest reciprocation from it.

I believe comfort measures should have been in place, but simultaneously if that child truly were 18 or 19 weeks, it may have been best to let it pass as peacefully as possible with whatever baby-dignity it could obtain.

HOWEVER.... other factors might include: maybe it was a very small baby and was greater than 18 weeks. Just a possibility?

A few months ago, I assisted in a 14 week old spontaneous abortion. We took the fetus, which looked like a human gummy bear, swaddled it, placed a crocheted bonnet on its head, and tastefully took pictures of it for mom. We even had a blue candied heart that we spread its tiny fingers on. It was very touching. Sadly, mom was probably still high on whatever drugs she was taking and eventually stormed out of the hospital, then the next day threatened to bring a gun to the hospital to regain possession of the fetal body. Security was on standby and police sent to her residence.

I am told we will keep those pictures on file for 18 years.

[babyktchr, BSN, RN]

The weight you described is about right for that gestation, give or take. I have had babies at that gestation take gasping breaths and sustain HR's for 2 hours or so. Don't know how it happens, but it does. The lungs at this point are just not mature and no matter what the intervention, its just not a viable age.

Even though the patient did not know she was pregnant, it is still a loss and mom should be afforded the opportunity to be with her baby. ED staff is generally not well versed in this type of care, nor is it a comfortable place for them. Working in bereavement for 15 years now, I just hate to hear that a baby was left in a bucket, or emesis basin or on the end of a bed. It really takes no more effort to wrap whatever remains there are in a blanket, and unless mom expressly refuses to see or hold her baby, give it to her to hold and say her hellos and goodbyes. I would expect more from an OB floor if she had been moved there to recover and even if she was mentally unbalanced, high or not, the baby should've been taken care of.

Its always difficult not to intervene, even when your head knows that there is nothing you can do. Its only human. There are many tims I have attended deliveries of live babies at a non viable age and in my heart I just want to do SOMETHING. Sometimes just being there just has to be enough.

Hope the rest of your rotation brings you happier moments.....

[klone, MSN, RN]

At that age, there is not enough lung tissue development for the infant to ever be able to breath on its own. It's also at great risk for interventricular hemorrhage. Even if the infant was older and IUGR, I've never heard of an infant that small ever surviving more than a few weeks, and that's on all the life support available. I'm sorry you had to see that and that it wasn't handled as well as they should have.

[Lanesmama]

Don't get me wrong, I completely understand that if a baby isn't viable (which is wouldn't be at 18-19 weeks, then there is nothing medically we can do to save him.) I am just thinking that if mom didn't have prenatal care and was on the streets high/drunk/smoking that the baby could have IUGR and maybe it was older than that. I also totally understand how some people could say his death, whenever it happened, could be a blessing because he was born to a crappy mom... but I just feel like if he were breathing on his own for that long that maybe he were older and that the care was biased because of mom's socioeconomical status. But, if the dating were right, I then I also completely understand that mom has the right to say goodbye/hold him etc. She didn't. He was wrapped on the end of the bed. Dying by himself. Listening to his mom screech through the phone how she had an 'f-ing kid that is just about dead.' Can't/shouldn't the nurse have taken baby out or held him? I would have done it but they wouldn't let me in because she was nuts. I guess I am going to have to toughen up if I want to be an L&D nurse. I thought I was doing a good job by reading about fetal demise and looking at pictures and videos trying to desensitize myself a little. The good news of that day was that a low risk preeclamptic woman went into eclampsia 3 min after the nurse assessed her seizing, fetal hr dropped to 30 and less for 3 min but they got baby out and she is a healthy baby girl and mom is recovering. She had no anesthetic for the initial cuts but at least baby is fine! I guess I need to focus on the good! Thanks nurses!

[klone, MSN, RN]

Usually with a demise, the infant is kept in the room with the parents for as long as they want, and then the nurse takes the baby away. At our hospital, the baby is kept in a bassinet in the dirty utility room for about a day, then sent down the morgue. In the case of an infant who is born alive but isn't going to live, the parents will continue to hold the baby until it dies, with the nurse periodically checking HR until the baby is dead. A live baby should never be just abandoned. If the parents don't wish to hold the baby, then it's kept under a warmer (and the warmer the baby is kept, the quicker they usually die, so the warmer is usually a blessing).

[FlyingScot, RN]

but I just feel like if he were breathing on his own for that long that maybe he were older and that the care was biased because of mom's socioeconomical status.&nbsp

Although I wasn't there I am pretty comfortable in saying that I highly doubt that the mother's socioeconomic status had anything to do with the care the infant did or did not receive. That kind of stuff usually isn't on anyone's radar. Nobody is going to let a viable child die just because the mother is a total waste. Honestly, at 295 grams even if the child was IUGR we don't have equipment small enough to take care of them. Even the smallest ETT would be too large and would tear the airway.

[klone, MSN, RN]

Although I wasn't there I am pretty comfortable in saying that I highly doubt that the mother's socioeconomic status had anything to do with the care the infant did or did not receive. That kind of stuff usually isn't on anyone's radar. Nobody is going to let a viable child die just because the mother is a total waste. .

Totally agree. The neonatology team generally doesn't know much about the mother's history anyway when they come in for a resuscitation, other than the approximate gestational age. When they're working on a baby, they're focused on the baby and its immediate needs, not what the mother's social history is.

[Lanesmama]

Ok, thanks so much! I feel better knowing that. This baby was not in a warmer. He was wrapped and on the end of mom's bed. Also when he was brought up, the nurse carrying him had him wrapped and had his head covered. I know it was so other people in the hospital couldn't see this fetus who wasn't fully developed but I think instead of covering his head, he should have been in an isolette covered and wheeled up from ER or something. I guess, it's the mother instinct in me... I would be so angry if my baby (even if he was dying) was treated that way. But... at least he wasn't just left to die by a medical team because mom wasn't worth the time of day... just wish someone would have held him through the process... Maybe I will get to be more callused to this stuff the more I see it.

[klone, MSN, RN]

Was there any reason why the mother was not holding him? Perhaps she placed him there at the end of the bed because she did not want to hold or see him.

[FlyingScot, RN]

I know it was so other people in the hospital couldn't see this fetus who wasn't fully developed but I think instead of covering his head, he should have been in an isolette covered and wheeled up from ER or something.

An isolette wheeled up from anywhere draws a great deal of attention from visitors, staff and patients. It was much better to have him wrapped in a blanket and carried. Hopefully the nurse didn't carry him like a football but instead cradled him.

[Sugar Magnolia]

Where in the heck are dead babies left in dirty utility rooms?! That sounds so bizarre, and so sad...