Day three of maternity week is living up to the excitement of the previous two days. Again, there were many c-sections. I was able to assist on three. The day ended with the resuscitation of a newborn after delivery via c-section. It’s a difficult case to discuss, but I think it illustrates a very common question healthcare practitioners face in low resource settings. The case starts with a mother who had developed elevated blood pressures with other concerning signs, a condition called pre-eclampsia. If the baby is at term (or even late preterm), delivery is indicated. If the blood pressures are controlled with medications then you can allow the mother to attempt induction of labor and a vaginal delivery. This is what this mother was doing. All was going well until baby’s heart rate dipped down into 80-90 beats per minute range. It was sustained for a few minutes despite efforts to improve it so the decision was made to take her for a c-section. When the baby was delivered, initial resuscitation efforts did not cause baby to breathe. Other resuscitation measures commenced and baby remained very ill, with poor oxygen saturation and requiring assisted breathing. As the heart rate fell, the providers were faced with a very difficult decision- do we start CPR on this baby with the chance of sustaining life but the potential for very severe brain damage from low oxygen levels? This decision is not simply life or death as it is in more developed countries where most parents would want you to do everything medically possible for their child no matter the long term ramifications. Here, the question is more complex and includes quality of life of the child (which of course is subjective but still factors in), services available in the community, beliefs of the parents and their families, other children at home, and if the parents are able to provide for the child’s care needs. None of these can be discussed in the moment. Herein lies the difficult decision that has to be made. Ultimately, the baby responded to CPR and had a strong pulse and was breathing spontaneously at the end of the resuscitation. Time will tell what long-term effects, if any, develop for this child because of these first 10 minutes of life.
Lugandan word of the day: ekinaabiro (noun, bathroom) …probably should have learned this one earlier!
Medical learning point of the day: For pregnant women with sickle cell disease, offer elective induction of labor at 38 weeks in an attempt to prevent triggering a vaso-occlusive crisis and increasing the risk of an intrauterine fetal demise.
