Slate blue and utterly motionless, I thought for sure our baby was dead.
By an extraordinary coincidence, I had been at that moment in the middle of a lesson on neonatal resuscitation with Jacaranda’s first batch of very talented nurses to receive pediatric specialty training. I was dedicating my project time, on a 4-month leave from my own pediatric residency at UC San Francisco’s Leadership for the Underserved Program, to training this cadre to lead Jacaranda’s new pediatric service. We had just discussed how any baby with a difficult delivery may die without quick intervention. Suddenly, another nurse burst in and said something in Swahili that sent my team scurrying.
Jacaranda has very safe policies on who delivers in house – normal, full term babies not expected to have trouble. Assuming this was another routine case, I strolled casually into our delivery room to see what was up. I saw the mother being positioned on a birthing bed while a nurse was trying in vain to detect the fetal heart beat. Catherine, one of the outstanding Peds nurses, called out a date in mid-April.
“Her last period was in April?” I asked.
“No. Her due date.”
I had to pull out my phone to convince myself of what I’d just heard. It was the first week of February, so due mid-April meant that fetus was only about 30 weeks of gestation – over 2 months premature. At that age, the skin is transparent, the heart is the size of a pistachio and the lungs are barely capable of breathing air. In Africa, only about half of such infants survive. This could be a very real challenge.
We started scrambling to prepare. I still wasn’t particularly worried. I figured we’d either transport mom to a higher level facility before baby came or find out the baby was older and pretty healthy. Anyway, only a few minutes before, I’d been teaching my team that, even among those babies who need resuscitation, the vast majority perk up right away with just a little puff of air into their lungs.
Back in the delivery room, the situation looked less reassuring. Kathy, one of our most experienced midwives, had given up on the heart beat and was positioned for imminent delivery. That left Catherine & Christine on the Peds team looking a little stunned. I had been drilling them in emergency resuscitations, but we had never seen a real case like this. I was stunned, too, but I rallied our crew:
“Faith, could you run downstairs and grab my bag.” I had brought some donated emergency neonatal supplies from San Francisco. We’d need the tiniest facemask available in case our baby needed help breathing. I dug out the flow-inflating ventilator bag I’d stashed away. It’s great for preemies, but no one else knew how to use it yet. That would have been the next day’s lesson…
“Let’s get a blanket on the warmer.”
“Is there oxygen in that tank?” “…yes…”
“Rachael, can you please get the suction setup, now.”
“Christine, you lead. You’ll take the head of the bed. I will check the heart rate for you.”
Faith dashed in with my supply bag just as our baby’s started to emerge bottom first. “Wow, this is really happening.” I swapped in the preemie facemask as fast as I could, dropping the other to the floor. I stepped back as our baby delivered.
He was minuscule – maybe 2 pounds – pale, silent and floppy as a rag doll. “Baby’s out. 10:37.” Kathy cut the cord, and Christine scooped him over to the warmer.
“Let’s get him dry. Christine, stimulate now. Rub his back. I’ll check the heart rate.”
I grabbed his tiny umbilical cord stump to feel the pulse. Even a pretty sick preemie usually comes out with a decent heart rate. I felt…nothing.
“I don’t feel a pulse, and baby’s not breathing at all. Let’s start breaths.”
Christine applied the tiny facemask and ambu bag just as we’d been practicing. She started giving the baby breaths as I reached for the stethoscope. Surely there was a heart beat I couldn’t feel but would be able to hear.
Nothing.
I moved the stethoscope around. It had to be there. But still no. All I heard were the breaths Christine was giving. Our baby was still totally flaccid and pale as death.
“I still don’t hear a heart beat.”
Not even a trace of a heart beat. The gravity was all too clear now. I felt my heart sink into my stomach as I imagined the unthinkable. The guidelines said I should keep trying CPR for 10 minutes before calling time of death. And telling the mother her baby was dead. I shuddered.
“Christine, switch spots with me. I’ll use the flow-inflating bag. Catherine, turn up the oxygen.”
I wrapped my long fingers around his tiny jaw, gave tiny breaths and held air pressure in between all to try to get his lungs to start working. Another nurse appeared with a syringe of adrenaline. “Not now. Just leave it there, thank you.”
“Christine, do you hear a heart beat?” – wait… “Yes, it’s about 30.” Even that paltry rate seemed too optimistic to be true, but Christine had earned my trust in our few weeks working together.
“OK, the breaths and chest rise look good, but the heart rate is very low. We’re going to have to start CPR with chest compressions.”
Christine wrapped both hands around the baby’s chest. She counted as she squeezed his little chest 3 times.
“I’m concerned that we haven’t gotten a response yet…” – breath – “…is there anything we’re missing?” – breath – “I don’t see any obvious anatomic anomalies.”
As I said it, I caught our obstetrician’s glance from across the room. Radha, too, was very experienced and had been working tirelessly to train the Jacaranda midwives. Her eyes looked forlorn, imploring me for good news. I just looked away, back at our tiny patient.
“OK, let’s assess again. Christine, do you hear a heart beat?” – breath, breath, breath…
She said we’d reached 80 – good enough to stop chest compressions, but I was still terrified. I kept up the breaths. Color and tone were still terrible. It had been a few minutes now and hardly any sign of life.
30 seconds later, we checked the heart rate again. Back down to 40. Time to restart chest compressions – an ominous sign. My heart sank still further as I wondered if I had been right even to try to save this baby. Was it all futile?
“1, 2, 3.” – breath…
I glanced over at that syringe of adrenaline. If this didn’t work, we’d need to use it. But we didn’t have the proper equipment to place an IV through the umbilical cord. Without that, giving adrenaline would be a messy act of desperation. I didn’t want to think about it.
“OK, let’s reassess. Do you hear a heart rate?” – breath…wait…breath…
“Yes, about 75.”
“Over 60 – stop compressions.” – breath…breath…
This should have been a good sign, but by then we’d already done chest compressions twice. Maybe we just had the heart rate wrong. It’d have been an easy mistake to make amid the stress and frenzy.
But then the miracle happened. He started to move.
It was barely perceptible at first especially as I still had his jaw pressed tight against the facemask. But there it was – just a slight flexion of his arms at first.
“Heart rate is 90. I can see it beating.” – breath…breath…
Catherine was right. So thin and frail was he that, in the middle of his chest, where before there was silence, we could see the unmistakable twitch of his pistachio heart.
“His color is improving.” His shroud of deathly blue had started to give way to baby pink.
– breath…pause…breath… I slowed down to see if just maybe he might start breathing on his own.
He did. Still the with guttural gasps of premature lungs but there they were – our baby’s first breaths. He even managed a feeble little cry. The whole room breathed a sigh of relief.
“Heart rate is over 100.” Christine sounded equally terrified and ecstatic.
“OK, we have spontaneous breaths and heart rate over 100. I’m just going to hold steady pressure (CPAP) to support his lungs.”
I looked back at Radha with a half smile and a nod. “I think he’s going to be OK. Catherine, switch with me; take some practice with the mask. We want to keep the airway pressure between 5 and 10.”
It’s not easy keeping an open airway on a 2 lb baby with essentially zero muscle control, but Catherine & Kathy took turns like they’d done it a thousand times. Radha told us the placenta looked awful. Our baby must have had very little blood flow during labor. No wonder his heart had stopped by the time he’d emerged.
Of course, now we had to get him to a hospital equipped to keep him alive. The only option was to support him on the ride to Kenyatta National Hospital in downtown Nairobi. Only 15 miles away but, wow, what a 15 miles it was going to be. Our “ambulance” was just a van, and we were lucky to have that. The roads have massive potholes, and the snarl of midday traffic meant we were in for an hour and a half of jostling life support.
I knew warmth would be our biggest problem once we left the heated delivery room bed. With their thin skin and non-existent body fat, premature babies lose body heat extremely fast. And when they do, their heart slows, and they stop breathing. The Nairobi sun was plenty for me but not for our 2 pound patient. I ran down to the office kitchen and grabbed a role of plastic wrap. Not exactly professional grade, but it would have to do.
I bundled our baby in a few layers of plastic and wrapped blankets around that. Just his little face was exposed so we could keep supporting his breathing. I clutched him close against my chest and wrapped my arms around him to try to shield him from the cold while Christine held the mask to his face. And so we stayed on pins & needles the whole 90 minutes to the hospital and all through its labyrinthine halls that we traversed slowly in lockstep, me walking backwards cradling the baby while Christine kept breathing for him.
The pediatric resident in the chaotic triage pointed us to the newborn unit and remarked with surprise, “He’s pink.”
I smiled at Christine. “Darn right he’s pink. You saved that baby’s life.”
Reposted June 2021 from the original of February 2014, Nairobi, Kenya
