Sorry for the lack of posts, but as I’m sure you can imagine, internet access is limited and the blog is blocked from the hospital. That, and we've been enjoying ourselves on some very necessary excursions and diving tours. So basically, I have quite a few posts to catch you up on…
On Wednesday morning, I arrived at the hospital (in the rain again) and went to the nursery to start seeing our pediatric patients. The doctor and most of the nurses were in the nursery around one bed, and I thought I noticed that they kept dabbing their eyes with tissue. As I entered the nursery, I quickly realized why they were all congregated around that one bed. On it was a newborn baby who had been intubated and strapped to a heart monitor; the nurses were manually bagging him. The doctor quietly brought me up to speed as she wrote her note on the recent events.
The mother was brought to the hospital on Tuesday afternoon by the midwife, who felt that the fetus was in distress after she had attempted to induce labor. The mother is a 26 year old G1P0 (that means that this was her first pregnancy) at a few days past 41 weeks (post-term). When she got to the hospital, they gave her fluids and strapped her to a fetal monitor which showed strong contractions but that the baby’s heart rate had flat-lined. They quickly put the mother on her side to ensure that the abdominal aorta wasn’t compressed by her uterus (to increase blood flow to the baby) and the baby’s heart rate returned but it still wasn't too promising. At this point, and the pediatrician didn’t know why, the OB on call decided to monitor the patient rather than perform an immediate C-section. A C-section was eventually performed later that evening, during which they discovered the baby had passed meconium in-utero, probably several hours earlier as the baby’s skin, mouth, and umbilical cord were tinged green. He immediately went into respiratory distress, was intubated, and put on a ventilator. A chest X-ray showed extensive chemical pneumonitis bilaterally, both his lungs were basically whited out. For those of you reading this blog that are not doctors or medical students, meconium is that sticky green stuff that comprises the baby's first poop. Normally, it is stored in the baby's intestines until after birth, but sometimes the baby passes it in response to fetal distress while still in the confines of the uterus or during labor. When this happens, the baby inhales the contaminated amniotic fluid and the meconium reeks havoc on the his lungs (among other things). It acts as a physical obstruction in the airway, causes surfactant dysfunction and thus impedes gas exchange between the lungs and blood, irritates/inflames the lungs causing a chemical pneumonitis, and causes pulmonary hypertension. It's very very bad.
The pediatricians tried suctioning the mouth and trachea to remove the meconium and used positive pressure ventilation to force air into his lungs, but there just wasn’t much improvement overnight. Repeat X-rays only showed minimal improvement of air movement in the bases of the baby's lungs despite all that work. It was such a bad case. Dr. Mungal said that the baby’s lungs were so stiff that at one point the ventilator machine wasn’t even working very well. When I arrived that morning, they had recently made the decision to stop all life support measures. It was an incredibly sad moment for the family and also for the physicians and staff who work at the hospital. Palau’s population is only approximately 20,000 people (most people seem to know each other) and its birth rate is pretty low (I've been quoted about 300 births per year). Because of this, the labor & delivery and nursery staff seem to become very emotionally attached to their mother/baby patients. It was touching to see how personally the staff took this enormous loss and how much they supported the family. While I know that the family is still mourning, I hope that they have found some measure of peace since that sad morning.
So this was doctor error? What do the other doctors and the nurses say about the OB's error? Or is it not talked about because of the small community?
ReplyDeleteThey don't say much about it other than that they don't know the reasoning behind not performing an earlier c-section. They assume that the OB had a reason and they just don't know it. There isn't much blame placed in any particular direction in this scenario, and there are way too many factors for me to start assigning it. The mom was post-term which increases the chance of meconium in utero, she chose to deliver at home rather than in the hospital (and i'm not saying that's a bad choice, it just didn't work out well in this case), I don't know how long passed before the midwife brought her in, they waited on a c-section, etc. No one really knows how long the baby was in meconium; their best guess was a couple of hours but that's not definite. It's hard in these situations to determine if it was doctor's error or not, but I'm sure that in places like this, other physicians are particularly reluctant to blame the doctor. Good, thorough medical care is hard to get here so undermining what they have is a bad idea. It would be interesting to find out what the rate of complications during delivery is here. Was this a fairly isolated event or is it commonplace? How does the rate of complications that occur with hospital delivery compare to that of home deliveries brought into the hospital (which are always because of complications)? I might have to look into that....
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