• When Babies die…..

    by Jess Morton. Last modified: 08/12/14

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     When Babies Die

     Every fibre of our paramedic, nurse or doctor self yearns to help, prevent, assist or relieve the pain, suffering, injury & illness of our patients. It goes against our very being when we cannot do those things, where the only thing we can attempt to do, is comfort while we straighten our shoulders & swallow extra hard to remain focused.

    Death is a part of our job. We attune ourselves to the reality of this and our personal resilience is what gets us up for work the next day and the day after.

    Professionalism & fortitude is what enables us to leave one patient who has died, or is about to & walk into another with the ability to give the positive & proficient care they need.

     

     But what about when babies die? When babies die & we are just too late….Or they are far too early?

     

    This sadly is the reality too. Some babies will never make it to the Emergency or maternity department alive & likewise, some babies will never go home.

    In Australia, for every 135 live births, 1 baby is stillborn, equaling approximately 2000 stillbirths a year.

    Miscarriage is deemed the birth of a baby less than 20 weeks gestation with no signs of life.

    Intrauterine fetal death (IUFD) is the birth of a baby over 20 weeks gestation also with no signs of life.

    To determine if it is the case of a stillbirth; alongside normal assessment algorithms the paramedic can check for cord pulsation, reflex movements, colour or gasps. If none of these are present, the baby is stillborn.

    Current guidelines suggest to not attempt resuscitation of the foetus (or I prefer baby), that is 23 weeks or less gestation, less than 400grams or is already macerated.

    The out of hospital arena is one of uncertainty. Paramedics will unlikely have access to hospital records and the Mum for whatever reason may not not know how pregnant she is. It leaves prehospital providers in a difficult situation when needing to decide if the baby is viable for resuscitation. Paramedics do not carry the equipment to weigh a baby and estimation of only a few hundred grams cannot be an accurate or ethical method as even 100grams may make all the difference to the potential survival of the bub.

    Foetal maceration can be described as the  “process of tissue degeneration which begins to occur as soon as an undelivered infant dies.”- Dr. Richard Pauli

    It occurs in stages when the earliest sign within a few hours of death is the appearance of peeling skin. Observing & documenting the stage of maceration can be useful for estimating the time of death and will contribute to giving the parents closure.

    A Literature review published by the American Journal of obstetrics & gynaecology suggested that the outcome of resuscitation of a baby with an APGAR of zero at 10minutes was very poor and that it predominantly lead to later mortality or moderate to severe disability and morbidity.

    It should be kept in mind that the 10minutes from delivery may account for the entire time it took to make an emergency call, be dispatched & reach the neonate in some circumstances.

    The legal standpoint of the paramedics’ rights & responsibilities in relation to the non-initiation of resuscitation of the severely premature infant (SPI) has been discussed recently on twitter. Below are some of the contributions made.

     

     

    What are your thoughts? What are your guidelines?

    It seems it is not written into many CPGs in Australia (that I have found so far) that a paramedic is within their rights and ethical responsibilities to withhold resuscitation of a EPI.

    Even in a fully equipped and specialised neonatal intensive care unit (NICU), the ethics of withdrawing or not initiating treatment remain controversial.

    An interesting case detailed by in the article below is the story of EMS attending a Mum who delivered her EPI at around 24-25weeks into the toilet. On arrival, EMS were directed by the womans’ partner to care for her first and leave the baby. Once they were allowed to assess the infant, they found it to be cool and cyanotic and had been submerged for approximately 20minutes. They deemed that the baby was not viable. There was no documentation of any examination and the baby was placed in a plastic bag for transport to the hospital. On arrival at the ED 30-40minutes after the babes delivery, medical staff found the baby to be bradycardiac and apnoeic. Resuscitation occurred and the baby was intubated.

    The baby sadly had a rough journey of sepsis, metabolic acidosis and an ICH. After seven days, the decision was made to make the baby comfortable and it quickly died after extubation.  
    You can read the article for yourself and form opinions on the treatment given and not given based on facts.

    http://informahealthcare.com/doi/abs/10.3109/10903127.2011.616258

    Resuscitating an over 23 week baby and the process and management of withholding treatment from a little 0-23 weeker is a vastly different one.

    It is difficult in that we are trained to help & resuscitate. We are not trained to stand back & watch a little bub take a few futile breaths before dying & not acting.

    We of course are never emotionally prepared for the process of handing a distraught and exhausted Mum a lifeless baby.

    What can we do when we can’t do anything? 

    When you do this, language & terminology is important. Be respectful, but clear on the information to avoid misunderstanding & further distress.

    “I am sorry, your baby has died” makes this clear.

    Trish Wilson (CM, RN & counsellor) presented at the Paramedics Australasia International conference neonatal resuscitation workshop. Trish advises the best way that paramedics can start helping the mother & partner cope with the situation is by “normalising” it.  Do not appear to be walking “eggshells” around the Mum or by handling the baby in any other way than you would normally.

    The immediate practical management of the stillborn should include

    – Retrieving the baby & drying off as normal (some babies may be born into the toilet etc)

    –  Clamp & cut the umbilical cord. (Keep the placenta and document the condition & appearance)

    –  Wrap up the baby just as you would with any other.

    –  Hold, treat and talk to the baby as you would any other live baby.

    –  ALL Mums and babies require transport to hospital

    –  Reassure the Mum & others present that there is nothing they could have done to prevent this. Explain that the baby has died some time ago or is too small to survive and there is nothing that can be done.

    – Support Mum and Dad to hold the baby.

    I wanted to make special note of an incredible volunteer and free service which has been set up in Australia. It is called heartfelt and is serviced by professional photographers who volunteer their time and turn up in maternity units all around the country and the clock to take beautiful photos of babies and their family to keep as mementos. Anyone can call them out to give parents this eternal keepsake and help with trauma.

    Please put their details in your phone..  https://www.heartfelt.org.au

     

    Minimising Trauma

    “Obstetric emergencies can’t always be prevented, however PTSD doesn’t have to be consequence”

    Trish says there are three parts to this.

    Safety- Help the parents to feel safe both physically and emotionally and provide reassurance.

    Mastery- Provide information. Be honest. Answer questions directly.

    Control- Where possible, give the parents choices and options.

    These are the things we CAN do when we feel useless. Be honest with the Mum, if you cannot answer a question, it is ok to say so and that someone at the hospital will be able to help.

    Encourage Mum or Dad to hold the baby on the way instead of placing the bub in a plastic bag or wrapped up and transported separately. This may indicate that something is wrong with the baby or cause further distress to the parents.

     

    What happens then?

    A few weeks ago  I was sent to the antenatal unit to work for the first time in many years. This is where our sick, high risk Mums stay for up to several months of their pregnancy. This is also where sadness happens.

    Dead babies and those who will die are also delivered here.

    In one of my earlier pieces I talked about the night I was tasked with taking a tiny little baby to the morgue. I was incredibly young and junior and it left me with the inability to get up and go to work for 2 weeks. It was co-incidently the first time I went back to that unit in that hospital; 8years on and I was sent there two days in a row.

    In this time, 3 babies were delivered with no chance of survival and were not for resuscitation.

    The process after is intricate, sad and yet somewhat humbling.

    The after death care involves a multitude of forms and documentation by both the midwife and medical team.

    –        A Social worker referral is to be made.

    –        The baby is weighed and measured. Sometimes the baby needs to be separated out from the sac

    –       Placental & foetal swabs are obtained and are sent to pathology.

    –       Clinical photos are taken for the pathologist/coroner to inspect as records.

    –       Anti D if applicable for Mum

    –       Any birth defects to be noted & documented in the relevant form.

    –       A support bag with loads of information, contacts for support and follow up clinical services for the parents is given.

    –      A memory box is created for the parents. In this are kinder photos of the baby that we take. Footprints and handprints, a lock of hair and perhaps a pair of booties or outfit that the baby was dressed in at the time.

    –      Discharge paperwork and ultrasound.

    <20wk checklist

     

    The baby is able to be kept cool and remain on the ward or in birthing suite for much longer periods than before to allow the parents adequate time to grieve and spend with their baby. This is largely thanks to the wonderful invention of ‘cuddle’ or ‘cool’ cots.

    When the parents feel able and ready to say Goodbye, the baby can then be taken to the morgue. As to whether full autopsy or coroners inquest is done will depend on individual state/country laws and the gestation of the baby.

    So how do we get by? 

    I asked the seemingly robust midwife in charge on the evening if it still ‘gets to her’. Even after 25+ years as an RN & midwife, she still gets  teary. We both talked to the bub as we would any other and said sorry for the prodding that needed to be done to try and find some answers.

    As with any other patient that has died in other departments, respect was shown. When the bub was ‘being attended to’ in our room, no one laughed or mucked around. There was a different place we could swear, tear up or vent.

    The challenge from a nursing perspective is when there were 11 other women (and babies) under my partners and my care. When we walked away from those closed doors, we needed to go into others and smile and be positive, encouraging and reassuring. We mustn’t give any hint of what it happening just next door.

    All sorts of different personalities worked those 2 shifts with me. From the very junior new-grad to the most hardened midwife and our young, male Ob/GYN resident on the ward, no one felt at ease. The resident teared up as he enquired how the parents were going. The nurses and midwives felt helpless when they walked out of the room of a labouring Mum who knew there was no prize at the end.

    How the hell do you keep going?

    The first baby on my 2nd shift was delivered within 10minutes of us hitting the floor after handover.  We all needed to find a way to muster through a seemingly endless and really busy shift. I remembered Liz Crowes ( @LizCrowe2 ) talk from #smaccGOLD about “swearing your way through a crisis”. So we did! There was swearing, there was even some singing in the treatment room, there were chips and even chocolate. (And wine when I got home)…

    Moving on

    It is ok to ask the ED or neonatal team for follow up at the next opportunity to seek feedback, or see what answers were discovered.

    It is ok to be human and let the family see and know that you are not a robot. I say this as someone who has been with countless families as or immediately after their loved one has died.

    It is ok to cry. I admit, I am not a crier. I internalise things or get agitated. I get a pit in my stomach. But you can cry, you can get angry, you should be human!

    Talk to those who were there with you. Talk to your workmates or your work counselling service.

    Write a blog.. I started this piece the day after those horrible two shifts. It has taken me far longer than any other piece to write. It didn’t end up going in the direction I thought. I lost direction whilst trying to write this, much like I did in those two days as I struggled to go from patient to patient and then back to those grieving parents, labouring Mum and dead babies.

    This has been my therapy.. I hope through it, if and when you find yourself in this position, the pearls of information that I have shared from others will help you better help the family, the baby and yourself..

    Jess xx

     

    References

    2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Neonatal Resuscitation Guidelines. (2006). PEDIATRICS, 117(5), pp.e1029-e1038.

    Crowe, L. (2014). Swearing your way out of a crisis. http://lifeinthefastlane.com/swearing-way-crisis/

    Harrington, D., Redman, C., Moulden, M. and Greenwood, C. (2007). The long-term outcome in surviving infants with Apgar zero at 10 minutes: a systematic review of the literature and hospital-based cohort. American Journal of Obstetrics and Gynecology, 196(5), pp.463.e1-463.e5.

    Michael, S. (2014). ‘They’re the only memories you’re ever going to have with them’. Daily Mail, Australia. [online] Available at: http://www.dailymail.co.uk/news/article-2744458/Meet-parents-using-refrigerated-cuddle-cots-buy-time-stillborn-babies.html [Accessed 4 Dec. 2014].

    Sanders, W., Fringer, R. and Swor, R. (2012). Management of an Extremely Premature Infant in the Out-of-Hospital Environment. Prehospital Emergency Care, 16(2), pp.303-307.

    Wilson, T. (2014). .

    Www2.marshfieldclinic.org, (1995). Maceration and the Timing of Intrauterine Death. [online] Available at: http://www2.marshfieldclinic.org/wissp/wisspers/jan95001.htm [Accessed 8 Dec. 2014].

     

     

     

     

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    Jess Morton

    Jess Morton

    Student Paramedic.
    I am an Australian undergraduate Student Paramedic. I study part-time as I am also Mum to 2 beautiful boys. I am passionate about Friendship, Family & #FOAMed. I am keen to get more experienced as well as student Paramedics into the FOAM world to enable better access to education to result in better patient care. My interests include photography, thick shakes and sleeping in past 6am.

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