Early one Wednesday in November, Isaac and I were rounding up our kids to leave for a trip to La Ceiba, when I heard a call over the radio. “HR3 ACH, doctora Anna, adelante” It was one of the Honduran nurses, and she sounded frantic. I answered right away. She told me that they needed my help in the labor and delivery room. I told her that we were coming down to the hospital anyway. The nurse didn’t answer me. I figured that a patient had arrived on the verge of delivery. As we rushed out of the house, we heard another call. “CQ Balfate! Ayuda en la sala de parto!” Now, we knew that it was an emergency. CQ Balfate meant code blue, which is what we say when a patient is needing CPR.
We raced down the hill in our car with our children in tow. I jumped out while Isaac went to park the car. Upon entering the labor and delivery room, I found our visiting obstetrician standing at the warmer bagging a newborn boy (administering breaths via a bag/mask apparatus). He was limp and pale. She told me he had just been born and that the amniotic fluid around him had been thick with meconium (baby feces). This is dangerous not only because it signals that the baby was stressed before delivery, but also because the baby can inhale the meconium and cause damage to his lungs. The nurse had not been able to tell the obstetrician if the baby had a pulse, so she wasn’t sure if we needed to start heart compressions. I quickly felt the umbilical cord for a pulse. It was fast, definitely greater than 200, which was a relief. We did not need to give heart compressions.
The baby still had no respiratory drive and looked very limp and pale. The fact that his heart rate was even faster than normal made me wonder if he was perhaps infected. I took over breathing for him while the obstetrician went to attend to his mother and deliver the placenta. “Were there any signs of chorioamnionitis? How long was her water broken?” I asked. The obstetrician replied, “no”. The mom had not had any fevers during labor and the water had only been broken for 3 hours. The only sign of any distress was the fact that meconium was in the water.
We decided to give the baby a bolus of IV fluid, thinking that he was likely pale due to low blood pressure. After the fluid, he finally started breathing for himself, but he was still not crying like a healthy baby and he was still as white as a sheet. He also had a fever. We decided to start him on IV antibiotics (Ampicillin and gentamicin) and maintenance IV fluids with the assumption that he was infected. We ordered labs to check for anemia and/or sepsis and wrote admission orders, asking another doctor to keep an eye on him while we were in La Ceiba.
When we returned, I went back to visit our baby. He was breathing on his own with good oxygen saturations. He had been febrile but his pulse and respiratory rate were both normal. He still looked pale, almost ghostly. His labs confirmed our suspicion. They showed definite signs of infection and ruled out anemia.
When a baby is born with sepsis (severe infection in the blood), the most likely cause is a bacteria called Group B Streptococcus. GBS actually lives in the birth canal of one out of four women and doesn’t cause an infection in them, and 99% of babies who are exposed to the bacteria during delivery do not have any adverse effects from it. But 1% do. One percent of babies who are exposed to GBS during delivery come down with GBS infection. That amounts to 2 in 1,000 delivered babies. A rare but very serious disease. It has a 13% mortality rate in the first world with excellent ICU capabilities. Because of this, every pregnant woman in the United States is tested for GBS during her pregnancy. If she is positive, she is put on antibiotics while she is in labor in order to eradicate the infection before the baby is born. This testing and treatment is expensive, but the benefit in lives saved and NICU resources saved has been deemed worthwhile.
In rural Honduras, we don’t have the resources to test women for GBS. So we hope and pray that they don’t have it. And up until now, we have been fortunate. On Wednesday, the 2 in 1,000 statistic finally caught up with us.
I was worried that the baby had not bounced back as quickly as I had expected him to. Often a baby will look pale for a while after a difficult birth, but within a few hours, it starts to gain some color and the tone improves. This baby’s color had not improved. We warned the family that the baby was in critical condition, but they remained optimistic. A cousin of theirs had delivered a baby at Loma de Luz two months premature, and that baby had lived. Because of this, they felt confident. We tried to portray our concerns nevertheless.
In the middle of the night on Wednesday, we got a call about our baby boy. The nurses were nervous about him. They couldn’t quite describe what was making them nervous. He had desaturated into the 80s for a while so they had started him on oxygen, which brought his saturation back up to normal. Isaac went to check on him. He still didn’t look like he was improving. We kept him on oxygen.
In the morning, I went to check on him again. He was definitely worse. My heart sank. Instead of being pale, his skin was now mottled, a sign that his circulation was not adequate to perfuse his skin. His body was shunting his blood to the vital organs. He didn’t move much, and slept most of the time. I was worried that he was going into septic shock. Checking the pH of his blood with an arterial blood gas (ABG) would tell me how acidotic he was and how likely we were to win this battle.
|This is what mottling looks like|
Checking an ABG can be tricky even on an adult. You have to feel for the femoral pulse in the fold between the patient’s abdomen and leg and then stick a needle into that spot while aspirating, at the same time avoiding the femoral vein, nerves, and lymph nodes that are right next to it. The blood should be bright red. That is how you know it is arterial. If it is dark, then you have hit the vein. Once, you get arterial blood, you have to aspirate 2 cc and then inject the blood into the test cartridge, all the while making sure that you haven’t introduced any bubbles into the sample. All of this must be done within 3 minutes because the test cartridges must be calibrated by the machine and are only good for 3 minutes once they are calibrated.
On a hypotensive baby, feeling a femoral pulse beating at 160 times a minute is like feeling an eyelash brushing up against your skin. I missed on my first attempt. My needle was too big. The cartridge was lost and we had to get another. I switched sides and felt again, praying under my breath. Finally, I felt a tiny flutter. I placed my needle . . . nothing. I redirected, and bright red blood started flowing ever so slowly in to the syringe. A babies vessels are so small that getting 2 cc actually takes quite a while. Keeping my hand steady so that I didn’t accidentally exit the artery while aspirating was quite difficult. But we got the sample. And we got our result. pH 7.24 (normal is 7.4). Our baby was acidotic and not responding to fluids. What was even more worrying to me was that he wasn’t breathing faster to compensate for the acidosis. He was tiring out. If he stopped breathing, hope would be lost. We don’t have a ventilator that can provide breath volumes low enough to be appropriate for a newborn.
I prepared to put an umbilical central line in the baby. Septic shock that is unresponsive to fluids must be treated with pressors and those can’t be given through a peripheral IV. I sent the family out while I cut into the umbilical cord, looking for the vein. We found it and placed a small 5 french catheter into it, inserting up to 12 centimeters so that it would pass through the veins in the baby’s liver until it reached the inferior vena cava next to the heart. A chest X-ray confirmed that we were in the right spot, and we sutured it in place and placed a bandage over the area to keep it sterile.
We don’t often administer pressors here at Loma de Luz, mostly because ICU level care is so intense that we don’t have the resources to manage it adequately. But for a 1 day old baby, we were ready to try. We started him on a Dopamine drip. He started to perk up, moving his arms and legs more and opening his eyes. His face had already started to swell up from the sepsis, but every so often he looked out at us through his puffy little eyelids. He stayed mottled all day long.
We don’t have a way to check blood pressures on babies at Loma de Luz. Either the small cuffs are broken or the machines can’t detect the pulse. We spent hours that morning trying to rig a system that would give us a blood pressure. Finally, we got one of the monitors to work with one of our baby cuffs. We had no way of knowing if the blood pressures it gave us were accurate, but at least we knew if they were going down or up.
|We have a lot of broken vitals machines and monitors stored in our hospital bodega.|
I stayed with our baby boy until the afternoon and then went home for a while. We had called in the nurse with the most ICU experience to sit with him as well. When I went back to visit again in the evening, he looked even more concerning. His fontanelle, the soft spot between the bones of his skull, was bulging, a sign that he likely had meningitis. He was breathing less than 40 times a minute, LESS than normal for a baby, when he should have been breathing fast to make up for the acidosis. His mottling was still there. He had not urinated for hours. We were already at the max dose for Dopamine. We made the hard decision to start another pressor, all the while having a sinking feeling that this baby was not responding to the antibiotics as we had hoped.
Isaac mixed up an epinephrine drip and we started it. Again, the baby started becoming more active after the drip was started, but his mottling worsened, especially in the legs. We checked another blood gas (ABG). His pH was 7.14. I gave a dose of bicarbonate. We warned the family that he was in grave condition. His mother was 18 years old and he was her first child. She had never held him since his birth given he was born so ill. She never looked at him except to offer a bottle. I don’t know if it was a self-protection mechanism, but she stayed in her bed, turned away, most of the time.
Our baby never did turn the corner. He worsened throughout his second night of life, needing ever higher doses of Epinephrine and Dopamine. By the morning, he was on the max dose of both. When I went to see him, the mottling on his legs had turned to a dark purple. He no longer opened his eyes or kicked his legs. He was only breathing 20 times a minute, and they were shallow, ineffective breaths. I checked another blood gas. pH 6.8. His mother and grandmother were there. I told them he was going to die. The father was on his way to the hospital but his motorcycle had broken down, so he was coming on foot. I hoped that the baby would live until his father arrived, so I started to breathe for him again. I breathed for him for 20 to 30 minutes.
Eventually, he started having coffee ground emesis, a sign that he was bleeding internally. Severe sepsis can cause people to bleed easily, so I wasn’t surprised, but I knew that it was time to take him off of his medications. I didn’t want him to die in the warmer from choking on vomit. I wanted him to be with his mother.
I asked the mother if she wanted to hold him as he died. She wasn’t sure at first, but the grandmother encouraged her. She had lost a child of her own when she was younger. So, we disconnected the baby from his lines and tubes and placed him in his mother’s arms. She finally let down her guard and started sobbing.
Our baby breathed for another 10 minutes or so before his face turned stern for a moment, and then he relaxed and the fight was over. He was barely 2 days old. His father arrived 5 minutes too late. Isaac, the obstetrician, the nurses, and I were all in the room with the family. Everyone was crying. Such a tragedy. Such a sweet little baby, born with the odds stacked against him even before his first breath. He fought, but he never really had a chance.
We called the chaplain in. We had already had several prayers over the baby throughout his care and asked for prayers from family and friends. We prayed for understanding. We prayed that they would be able to give thanks in their suffering, thanks for his life and thanks for the time that they had spent with him.
How much should be spent in order to prevent the death of a baby from an infection that occurs in 2 in 1,000 deliveries and causes death in 3 in 10,000 deliveries? In America, the cost is paid, preventative measures are taken, and women who receive prenatal care do not have babies with GBS sepsis. Our lab doesn’t have the capability to do GBS cultures at Loma de Luz. Should we give every laboring mother a dose of antibiotics just in case she has GBS? Then, we will be treating 998 women unnecessarily and possibly causing allergic reactions or other side effects. When I was watching a first time mother crying as her two day old baby died in her arms, it made me want to do everything necessary to prevent this from ever happening again.