Saturday night, 8/6/11
- Contractions started out of the blue
- Betamethasone booster was given almost immediately
- IV was placed and magnesium sulfate infusion was started
- Transferred down to floor 5, the Labor & Delivery unit for continuous monitoring
Sunday, 8/7/11
- MgSO4 dose was increased from 2 grams/hour to 2.5 grams/hour because of increased contractions
- Stayed in Mag fog until 10 pm when it was discontinued and a second shot of betamethasone was given
- Contractions slowed down to every 8-10 minutes throughout the night
Monday, 8/8/11
- Considered stable and moved from Labor&Delivery back up to the regular floor to a single room that I hadn't stayed in before
- Mentally prepared for things to settle back into a routine
- 11:15 am, contractions started increasing in pain and frequency
- 1:00 pm, moved back to Labor&Delivery except onto the brand new remodeled floor 4 which had just opened at 8am that morning.
- First expected delivery in that room meant that our nurse had to go on a scavenger hunt for supplies
- Mid-afternoon, RH, our friend and duola arrived
- 5:30 pm, JD came from work
- 8:45 pm, parents from both sides came to give us best wishes
- 9:08 pm, ATD arrived after 4 pushes in a 10 minute period
For weeks, my OB was discussing the plan that was implemented on Saturday night. There is evidence that shows that giving another round of steroid shots might provide additional benefit for lung development, especially since it had been more than 5 weeks since the first round. The goal was to buy at least 24 hours by slowing down contractions with MgSO4 so that the steroids would have time to reach ATD. In addition, recent evidence has shown that giving at least 12 hours of MgSO4 for babies born before 32 weeks may provide neuroprotective benefits. We were very comfortable with this plan and just hoped that we would have enough time to carry it through. Aside from more time (i.e. weeks) in the womb, we felt comfort in everything we were able to do before ATD's arrival. My OB felt that if my body suddenly started contracting, there was a reason for it and we should let it happen instead of trying to buy another day or two with prolonged MgSO4. As we've mentioned in these posts, the biggest concern with ruptured membranes is exposing the baby to infection so if that was the case, buying more time would have been worse for ATD.
Another plan that had been decided on weeks ahead of time was based on an anesthesia consult for my little breathing problem (subglottic stenosis). They were very worked up about that and what plan should be in place in a worst case scenario, such as intubation. We were impressed with their thorough review but it was another choice that was taken away from us. They all felt very strongly that I should be given an epidural to reduce labored breathing and prevent any additional damage to the airway. One of the anesthesiologists has the same condition and she insisted on this plan as did my ENT surgeon. The epidural was placed after JD got there and it definitely helped with the speedy delivery - I can't take much credit for anything that happened that day.
Now for the much more interesting part...an update on ATD. Not only did he come out head first, he came out face first. His whole face was purple when he arrived which was quite shocking and a bit scary because the first thing you think is that he isn't getting enough oxygen. My dad said that he looked like one of those California Raisin toys which is a pretty accurate description. We felt quite a bit of reassurance because the neonatologist was joking around while they assessed him and she even brought him over for me to give him a kiss before taking him up to the NICU. I missed out on this part but JD was there watching them place an endotracheal (ET) tube, an IV in his head, and probes all to monitor temperature, his heart rhythm and rate, and his oxygenation. The neonatologist had the residents and fellow place bets on his size and they were all guessing in the 1200 grams (2 lbs, 10 ounces) range. They were all shocked when he was 1510 grams (3 lbs, 5 ounces). I guess one thing that might lessen the sting of me having such weak and unreliable membranes is that our babies tend to be on the bigger range. Medical staff have even referred to him as being huge.
A medical team rounds on ATD every morning and it is quite the scene. About 10 of them file into his room. There is an attending physician, a fellow, 2-3 residents, a medical student, a dietitian, a pharmacist, a respiratory therapist, some other tag alongs, and three computer stations. I appreciate listening to the rounds not only for a medical review of his overall condition but to hear the tone in their voices. We've found comfort in the lack of urgency or desperation in their discussions. Since then, they've been monitoring the following issues:
1) Premature lungs: Premature white boys tend to do the worst with breathing so we were prepared for that (they refer to them as wimpy white boys). Since then he has been diagnosed with respiratory distress syndrome (RDS) which is largely due to his inability to make enough surfactant. They gave him two rounds of extraneous surfactant and he responded well to that. They do a chest Xray every day to watch to see if his lungs become more dense in appearance rather than dusky. For a while this week they thought it might be possible that the dusky appearance was due to pneumonia but after presenting him as a case during their grand rounds on Thursday, all the neonatologists agreed that it was a case of RDS. We were quite pleased to have so many experts evaluating what is best for our son. His breathing is our biggest concern but during the evening rounds just now, they said the ET tube might be coming out in the near future. In fact, they said that if he happened to yank it out on his own that they would do a trial with the nasal cannula and not re-intubate him unless totally necessary.
2) Infection: Because he was exposed to ruptured membranes for so long, they started him on IV antibiotics for 48 hours until cultures come back. Fortunately all cultures have been negative and they discontinued the antibiotics. Exposing him to a low AFI has been a huge source of guilt for me and if he would have been infected because of me, that would have pushed me over the edge.
3) Feeding: Babies don't have the coordination to nurse until about 35 or 36 weeks gestational age so nursing is out of the question right now. Also, their guts aren't mature enough to digest food so ATD has received his nutrition from a TPN that optimizes his electrolytes, carbohydrates, fats, and protein. I always hated calculating TPN orders in pharmacy school but the pharmacist in the unit has years and years of experience with this and the whole medical team defers to her to get just the right mix for ATD. They placed a PICC line (peripherally inserted central catheter) so that the fluids can be delivered right into his superior vena cava and directly into his circulation rather than using the IV in his head which is in a smaller vein and may not have the capacitance to handle such high volumes of fluids. On Wednesday, they started to give him small amounts of breast milk (2 mL every 3 hours) and starting this evening, they will increase this to 8 mL and start to count that as his total fluid volume. The hospital provides a higher grade breast pump and supplies to all families in the NICU so we have a set of things here at the hospital and at home. The primary goal is for him to receive the good nutrition and antibodies that breast milk provides and a secondary goal is that nursing might still be an option when he matures a bit more. We are really encouraged that he is tolerating these feeds so far. They weigh him every night at midnight and so far he hasn't quite lost 10% of his birth weight which is usually the case with every baby. Last night he weighed 1395 grams (3 lbs, 1 ounce).
4) Temperature regulation: ATD is in an isolette so his temperature can be monitored and maintained. He can't wear any clothes so you can imagine they keep it pretty warm in there (it is set at 36.2 C / 97 F right now).
5) Bilirubin: There aren't specified normal bilirubin ranges for premature babies so they base decisions on rate of change from the baseline. ATD's bilirubin rose pretty quickly in the first two days after birth so they have him under a bili light therapy. This means he has to wear little goggles while the lights are on. Since he can't eat much milk, he doesn't have bowel movements and this is normally how bilirubin is cleared from the body. Also, the bruises on his face contributes to the high values as well. The bili light has been working and his levels have come down some.
6) Hemorrhage: Premature babies are also at a risk of a hemorrhage in their brains. I am too afraid to ask details about this since the attending said that there isn't anything they can do to prevent or treat it. They will do a brain scan early next week to determine if they see anything alarming.
So if you are wondering what specific things to pray about or send positive thoughts on, those are 6 things that are on our minds constantly these days. Now, here are some fun facts about our little boy:
1) He looks more and more like his daddy every day. Today, the position in which he is laying is exactly like his dad sleeps. One arm up and under the pillow.
2) His apgar score was 6 initially and then 8 at 5 minutes. KD was 7 and then 8 so very comparable.
3) Any concerns I had about him developing contraction due to low fluid volume are gone. He is completely stretched out and his arms and legs are moving all the time (almost too much that they try to strap him down and contain him).
4) The nurses say that he has a bit of a temper. He gets upset with cares (assessments and diaper changes every 3-4 hours).
5) He has a surprising amount of hair. We aren't sure what color it is since he hasn't had a bath but it looks darker than KD's did.
6) His middle name of Torbjorn is after very special family in Norway.
7) On rounds this morning, the team stated that probably the most important therapy decision they make is to have a bit more patience. Sounds like that is a prescription for this whole family.
I want to apologize if I haven't directly responded to your emails. I promise that I will. These past few weeks have been very difficult emotionally and keeping up with email was the first thing that dropped off the priority list. We so appreciate all your continued support. His physicians feel it is best to limit visitors at this time. ATD is basically completing the third trimester in that incubator and extra stimulation and exposure needs to be kept to a minimum. We will be excited to introduce ATD to the world in a few months.
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