No One Likes A Purple Baby

You can’t always tell a “bad” baby by the fetal heart strip.

That is to say, some babies look fantastic during labor and all the way through pushing, but when kiddo is born and the big moment comes, they just can’t seem to get the hang of “life on the outside”.

The majority of babies transition well.  When L&D nurses talk about babies “transitioning”, we mean the process that takes place immediately after birth where baby goes from being in-utero and fully dependent on mom’s body to breathe, feed, and remove waste to suddenly having to do all of that for himself.

Like I said, most babies figure it out on their own within moments of being born.  They take a surprised breath, and with a bit of drying and physical stimulation, they start to cry, their skin turns pink, and wa la!  Life doesn’t really begin as much as it just continues.

Still, my hospital requires that at all births, there is a nurse present for mom and a second nurse present for baby.  This ensures that if there is an emergency with either, both have their own dedicated staff member present and fully in-tune with their history and their treatment. The last night I worked, I got a great reminder of just why we require two RNs to be present at all births.

The Scenario

The nurse who had the patient in room 2, Barb, was an experienced L&D nurse who had an orientee, Marcy, working with her.  When one of my other coworkers mentioned that Barb and Marcy’s patient was about to deliver, I took a look at the strip and started heading down the hall.  As I was “up”–patient-less and waiting for an assignment–I was ideally free to help in the meantime.

“Well, I dunno, Sophie.  She should be good.  She has Marcy in there with her, and she’s almost off orientation.”  Breanna called from the desk.

“Oh, it’s no problem.” I replied, keeping in mind the happy FHR strip I had just seen on the monitor.  “You never know, after all.”

“True.”  Breanna agreed plainly.

As I arrived in the room with the doctor and the surgical tech, I prepared the bassinet, laying out the blankets, placing a blanket on mom’s chest, and making sure that suction, oxygen and my emergency equipment was functioning and turned on.

Barb and Marcy were helping their patient push, which was taking longer than they had expected for the first-time mom, but baby was clearly at about a +2 station and making progress with each push.  About five minutes later, baby’s head emerged, followed by the rest of his body with one last push.

As the doctor cut the cord, I stepped up at the bedside, drying and stimulating the baby as he was placed on mom’s chest.  APGARs are a little low on this one, I noted as I realized the baby wasn’t crying, had central cyanosis, and he wasn’t moving much.  Moments later, I heard the distinct sound of grunting on the end of each breath and retractions appeared around baby’s sternum.

Seconds into meeting this new little boy, it became obvious that he would require a little extra attention.  I kicked my assessment skills into high gear as I reached for my stethoscope to take a closer look.

Drying, Stimulating and Crying

Drying a baby is important as babies have difficulty maintaining their own temperatures, so the longer baby stays wet, the more likely it is for him to get cold and potentially experience some of the consequences thereof: dropping blood sugar, lethargy, and low blood oxygen to name a few.  While some of the “goop” (AKA: vernix) that baby is born in has been shown to protect baby against infection and help regulate baby’s temperature, making sure baby is dry is of paramount importance immediately after birth.  It is important to note that while some of the vernix will come off with drying, enough will stay on the newborn to provide the benefits associated with delayed bathing (which is a topic for another post!).

A natural result of drying baby is the stimulation that occurs when the blanket makes contact with his skin, and this stimulation usually causes babies to cry.  Crying will naturally help to clear any fluids that baby might have gulped on his way out, therefore opening his lungs and getting him used to the idea of breathing on his own.

Skin Color

Cyanosis is a general term that refers to a bluish coloring of the skin due to a lack of blood flow or poor oxygenation.  A little cyanosis of the hands and feet actually isn’t uncommon in newborns and is called acrocyanosis.  Acrocyanosis occurs normally as baby transitions from being in-utero to having to breathe on his own after birth: slower or decreased blood circulation to the extremities is normal as baby’s body learns to support itself through breathing.

Central cyanosis means that a baby looks purple or blue in his or her trunk.  When the infant’s chest, abdomen or face appear purple, it can be a sign that baby isn’t getting enough oxygen all around.  Though central cyanosis isn’t in and of itself indicative of decreased oxygenation, it is an indication to place an SPO2 monitor on baby’s right hand and make sure that the discoloration you’re seeing isn’t from low O2 levels.

Muscle Tone and Startle

Decreased movement is another potential sign of trouble.  When babies cry, they naturally tense their legs and arms.  In general, crying is a whole-body experience for a newborn.  Also, in addition to the stimulation of having been born, the noise and light associated with birth often triggers baby’s startle reflexes, and if baby doesn’t have good muscle tone and good reflexes pretty quickly after birth, this can point to trouble.

Of note: this can be a sticking point for babies born by C-section.  Vaginal birth and the process of emerging from the birth canal–and all the squeezing that entails–can naturally stimulate a baby as he’s being born and also force fluid out of baby’s lungs.  C-section babies aren’t privy to this particular set of benefits, however, and as a result, sometimes babies born by C-section require a little extra attention to get them to perk up after birth.

Retractions and Grunting

Retractions are a fancy term for when the skin pulls in around baby’s ribs and sternum as he tries to breathe.  The direct result of a baby working extra hard to pull in air, retractions are a sign of respiratory distress in newborns.

The same goes for grunting, which initially sounds like baby is humming a song.  As baby exhales, he closes his glottis (which normally covers the airway when you’re swallowing food or fluids), which causes a distinctive “ah-ah-ah-ah-ah” sound.  In doing so, he causes a change in pressure in his chest that helps improve his oxygenation.  If a baby is resorting to grunting, chances are, he will need some assistance in the breathing department, whether that be suctioning, oxygen administration, chest percussion, or a combination of all three.  Grunting can be a last-ditch effort to open baby’s lungs before things go south, and I’ve seen grunting babies decline from grunting to assisted ventilations (bagging) to intubation (ventilator) depending on the source of their respiratory compromise.

*Of note: breathing is a big deal.  I know that sounds like a given, but in most babies who require resuscitation, breathing is the culprit of their distress.  Say you have a baby who’s born at term with central cyanosis and a no heart rate.  Even before you consider starting chest compressions–even if baby didn’t have a heartbeat at all–per Neonatal Resuscitation Guidelines (NRP), you must give adequate assisted ventilations (bagging) before starting chest compressions.  Most of the time, correcting problems with baby’s breathing will correct everything else.

APGAR Scores

At one minute, five minutes and ten minutes after birth, nurses assess something called an APGAR score.  This quick, objective assessment looks at five categories: skin color, heart rate, breathing effort, muscle tone, and reflex irritability.  At most, baby can get a “2” in each category.  At the least, he can get a “0”.  So on a scale from 0 to 10, an APGAR score tells a provider quickly how a baby is transitioning.

At one minute, my baby scored as follows:
Breathing: 1 -irregular, discoordinated breathing efforts
Heart rate: 2 -pulse is 150bpm, normal range
Muscle tone: 1 -baby has some muscle tone present, but less than normal
Reflex irritability: 2 -baby’s reflexes are normal
Skin color: 0 -baby has central cyanosis

Total APGAR: 6
(As a reference, most babies are born with APGAR scores of 8-9.  A score of less than 7 indicates a need for medical attention).

Back to the Scenario

With baby’s physical assessment looking borderline, I took the baby to the warmer with his mother’s enthusiastic permission.  I placed an SPO2 (blood oxygen) monitor on baby’s right hand and looked for a baseline.  Heart rate was in the 170’s–up from when I had listened to him on mom–and his blood oxygen was lower than normal.

With audible gurgling and coarse lung sounds, suction was in order.  I suctioned baby’s nose and mouth quickly, immediately pulling out some thick, clear secretions.  Suctioning can be an irritating process to a baby which can have the added benefit of making baby cry.  My baby did just that.  He cried immediately after I suctioned him, producing more fluid from his mouth and nose.  A few suctions later, baby’s heart rate came down, his O2 went up, his retractions stopped and grunting significantly decreased, and we were looking at a much happier boy.

In the end, this baby did well.  He was brought back to his mother and monitored for the rest of his time in L&D, but he transferred to postpartum without issues and was discharged normally with his mom a few days after he was born.

However, this scenario just goes to show: a happy strip doesn’t mean a happy baby, and it pays to stay on your toes at all times!

Triage Tales: Inducing Irritation

Oy ve, I had another one.

What a scene. You would’ve thought she was about to deliver right then and there.  But let me back up a bit.

There I was at the nurse’s station, enjoying an evening that could easily be described as…er, well, we don’t say that word in my profession (it starts with a “q” and if you do say it, you run the risk of being assaulted by an angry horde of RNs!).

Quiet night

But nevertheless, there we were, standing around and chatting amongst ourselves, sipping our first cups of coffee and having a splendid time.

Then, the call came in from the front desk.  I was up for triage, so the yellow sticky came directly to me.

“Ashley Smith, G1P0, ctx/pain, 18 y.o., 36.4, Dr. Adams.”

In English: my patient is Ashley Smith. She’s an 18-year-old patient of Dr. Adams expecting her first baby.  She’s here for painful contractions and she’s at 36 weeks, 4 days gestation.

I glanced up at my charge nurse, who had taken the call. “Is this one for real?”

She shrugged. “I dunno.  The receptionist sounded pretty serious when she sent me the info.  It sounds like it might be.”

“Okey dokey.  I’ll put her in 2.”  I said, heading down the hallway and out through the double doors to our reception desk.

Ashley Smith was clearly uncomfortable, breathing heavily in the chair at the receptionist’s desk.  An older woman, presumably her mother, stood behind her.

“Ashley?” I approached, taking the consent forms from the receptionist.

“Yeah.” The girl replied, standing up painfully.  Her mother took one of her arms and together, we slowly made our way back through the double doors and into the triage room.  Ashley, panting and holding her belly, was obviously holding back tears as we went.

“I’m Sophina.  I’m going to be your nurse today.  When did your contractions start?”

“They started about 4 hours ago.  I’ve been up walking, moving around, all kinds of stuff.  They aren’t stopping.”  Ashley replied.

“OK.  Where’s most of your pain?” I asked.

“Down there.” She motions toward her privates.  “And sometimes in my back.”

“Gotcha.  How far apart are your contractions and how long do they last?” I ask, starting to wonder what exactly I was dealing with.  Ashley’s “contraction”, which should’ve been letting up by now, seemed more like continuous pain, and the pressure she was describing could be indicative of advanced dilation, which was causing baby’s head to push down on her perineum.  However, most women by that point are beside themselves with the urge to push and in much more distress, both symptoms that Ashley was not exhibiting.

“They don’t really stop.” Ashley said.

“I’ve tried to time them, and they seem to let up every three to four minutes for a few seconds, and then she’s right back into them.”  Ashley’s mom piped up as we arrived in the room.

Now my mind was really going.  Was I looking at a case of uterine tetany (contractions that last much longer than they should)?  Was Ashley really having contractions?  Or was this patient, a young primigravida, after something else entirely?

In the room, I started the process of gathering the data I’d need to make a full assessment.  I put Ashley on the monitor, revealing  a very happily gestating fetus.  When I placed the toco (the monitor used to measure the length of contractions), I checked Ashley’s abdomen, noting that her uterine tone felt relaxed and normal.  The toco wasn’t picking anything up, but Ashley continued to complain of contractions.  So in the midst of getting Ashley’s vitals and asking her questions, I adjusted the toco several times, taking the opportunity to touch her abdomen to assess for contraction strength.  There was absolutely no uterine tone to be felt.

Finally, it was time for the acid test: dilation check.  Ashley was dilated to about a 1 and 40% effaced–certainly not advanced or indicative of active labor by any means.  It was when I was entering her dilation into the computer, which provides a historic view of her previous checks, that I realized this was Ashley’s fifth time through triage that week.

Now with a much clearer idea of what I was dealing with, I told Ashley I’d get ahold of the doc and be back in about 15 minutes.  Shaking my head, I did a bit of charting, made sure I had a 20-minute strip of baby’s heart rate and Ashley’s non-existent contractions, and prepared to call.

Just as I was about to call, however, Ashley’s mom stuck her head out of the triage room door. “Sophina, can you come check her again? She’s having a lot of pain!”

I hopped up and zipped into the room, where Ashley was writhing on the stretcher. Once again, the toco revealed no contraction activity, and Ashley’s uterus was relaxed.  I pulled on a sterile glove and gel and performed yet another cervical exam–absolutely no change.  Reassuring Ashley and her mother that nothing was happening, I readjusted my monitors, headed to the computer and called the doc.

Generously, the physician agreed to give some Tylenol #3 (Tylenol with codeine) for my uncomfortable soon-to-be mom, and as I headed back into the room with the drug and a glass of water, I prepared myself for what I knew was likely going to happen.

“All right, Ashley.  It looks like you’re not in labor.  Your cervix hasn’t changed since last week, the majority of your pain is down low and in your back, both of which are common in normal third-trimester pregnancies, and I’m not picking up any contractions of any kind, which is consistent with how you’ve described your pain.”

It was like flipping a switch.  Suddenly, Ashley didn’t appear to be in pain anymore.  The tears and the writhing and the look of discomfort were instantly gone.  She was glaring at me with the sullen disgust of a teenager whose bluff had been called.

“I’ve got some Tylenol #3 here, which is Tylenol with codeine, so we’ll see if that will help your pain any.  Otherwise, your baby looks nice and happy and I think we’ll be getting you on your way home soon.”  I said, scanning Ashley’s bracelet and her med.

Ashley verified her name and date of birth without looking at me.  While she took her med, it was obvious she was on the verge of breaking down.  I waited, knowing it was coming, finishing my medication documentation as her patience wore thin…

Say it 1Say it 2Say it 3

Say it 4

Finally:

“This is stupid!  I’m so sick of being pregnant!  I just want an induction.  Go out there and tell the doctor I want to be induced tonight! I just don’t wanna be pregnant anymore!!!”  Ashley exploded, looking me dead in the eye.

Say it 5

I turned to face her.  “Ashley, your baby is not yet at term.  We absolutely do not induce before 39 weeks except for medical reasons due to the higher risk of C-section and poorer outcomes for both moms and babies.  Your vitals and assessment are perfect.   Your baby looks great.  What you are experiencing are the normal pains and aches of pregnancy, and unfortunately, there is very little I can recommend for that aside from Tylenol, walking, perhaps a warm shower, and a good massage.”  I explained firmly.  Ashley once more looked away and down at the sheet, angrily staring at her belly.

“I’ll give you about thirty minutes to see if that Tylenol #3 takes your pain down a notch, but in the meantime, I’m going to get your discharge instructions together.  Do you have any questions or is there anything I can get for you right now?” I asked.

Ashley shook her head “no”, still avoiding eye contact.  Ah, the silent treatment.  It was all I could do not to flash back to my own teenage years.

“All right. Call me if you need me or if you have questions.”

I left the room with both Ashley and her mother staring me down and headed to the computer.  I quickly printed discharge instructions, found a pen and finished up my charting.  Thirty minutes later on the dot, I entered the room again and noted Ashley sitting in bed casually, playing on her phone.

“How’s your pain, Ashley?” I asked.

“No change.” She replied shortly.

“I can’t believe you’re really going to discharge her when she’s in this much pain!  This is ridiculous!” Ashley’s mother exclaimed dramatically.

I looked at Ashley, who was absorbed in a game of Solitaire and coolly ignoring me, and back at Ashley’s mother. “Ma’am, what your daughter is experiencing is clearly not labor.  We do not admit healthy moms and babies for pregnancy discomfort.  If you are truly concerned that something else is wrong, then I will call over to the main ER and let them know your daughter has been medically cleared by L&D, and she can be seen there.  Is that something you’d like?” I looked at Ashley.

Ashley shrugged, clearly out of ideas. “I’m good.”

I nodded.  “Great. Now, let’s go over your discharge instructions.”

Ten minutes later, my biggest fans were heading out the double doors back to the parking lot.

So if you’re expecting a baby and find yourself tired of being pregnant, take a walk, take a Tylenol, watch some TV, read a book, cook some dinner–but whatever you do, don’t try to trick your triage nurse!