While working in a rural hospital, sometimes hard decisions have to be made to determine what scarce resources get to be used on an overwhelming number of patients. We have one bubble cpap (continuous positive airway pressure) machine to use for patients that need extra help breathing. Frequently it is used on children in respiratory distress from a pneumonia or premature babies that are born but whose lungs aren’t developed enough yet. About 5 weeks ago we had a situation of exactly the latter- a mother came in 32 weeks gestation in premature labor with twins.
During the delivery baby A was born vaginally and immediately needed oxygen support with the bubble cpap as his oxygen saturations were in the 80’s (normal is above 95%). Baby B began to show fetal distress after his brother was born and after a few tense moments, the mother was brought into the OR to complete an emergency c-section. Each needed immediate use of the cpap directly after delivery to sustain their oxygen levels, but the hospital only has one machine. A second “bubble cpap” type machine was created out of an extra oxygen concentrator and some plastic tubing, Macgyver style, to give respiratory support for both babies. In an area where home birth is common, these twins would not have survived without the medical care at Loma de Luz. Baby B would have perished in labor, and baby A soon after without oxygen support.
The twins had been on oxygen support for 1 week, doing well and looking like they would be able to recover within the month and be sent home. However, another mother pregnant with twins at 34 weeks arrived and had an ultrasound showing one fetus with discordant intrauterine growth. Discordant intrauterine growth is when one baby is much smaller than the other and stops growing at a normal rate. This is dangerous for the smaller baby especially because there are usually more complications such as hypoglycemia, polycythemia, and necrotizing entercoloitis that occur unless you deliver quickly after the diagnosis.
We realized that if we delivered the 34 week old twins at that time we wouldn’t be ready with cpap oxygen support that they would likely need. There were no more supplies to create another bubble cpap machine and the hospital was faced with a conundrum of what to do. Do we wean the first set of twins off oxygen early and see how they do? But what if they relapse and need to be placed back? Delay delivery of the second set of twins as far out as possible? But every day delaying the 34 week old twins delivery could cause further harm to the discordant twin.
Eventually it was decided to try and slowly wean the first set of twins off oxygen and to admit the second mother to watch her babies very closely. As soon as the first set of twins could wean off of cpap we would induce the second set. After about 4 days the first set of twins were doing well off of the cpap and our medical team was comfortable with inducing the second set. The induction was performed, but as expected both babies needed help breathing with the bubble cpap for several days post birth.
Everyone on the medical staff was able to breathe a sigh of relief when both sets of twins were stabilized and so thankful that only one set at a time had need of the cpap machine. In this case we were able to make our scarce resources work for all patients involved with a bit of creativity and flexibility of our medical staff.
“But he said to me, “My grace is sufficient for you, for my power is made perfect in weakness.” Therefore I will boast all the more gladly about my weaknesses, so that Christ’s power may rest on me. 10 That is why, for Christ’s sake, I delight in weaknesses, in insults, in hardships, in persecutions, in difficulties. For when I am weak, then I am strong.” (2 Corinthians 12:9-10) This verse came time mind as we reflected on how God provided for both sets of twins despite our limited resources during the past few months.