Rural Medicine: Pre-Term Twins

Rural Medicine: Preterm Twins

Vanessa Cardy MD and Julie Vieth MD

Print editor: Whitney Johnson MD MS

Take Home Points

• In term gestation delivery, with breathing or crying and good tone, dry the baby, clear the airway if needed and give the baby to the mother for skin-to-skin contact.
• If the heart rate is below 100 or they are apneic or gasping, provide positive pressure ventilation.
• If the heart rate is still below 100, keep doing positive pressure ventilation. If the heart rate drops below 60 beats per minute despite ventilation, do chest compressions.
• Saran wrap can be used to maintain temperature in premature babies.
• It may be appropriate to delay intubation until the transferring neonatal team arrives.

• It was a fairly calm ED shift on a fall Sunday morning in upstate New York. Vieth was sitting next to one of the physician assistants when the phone rang. It was a man calling to tell them that his wife’s water broke at home. She was at 26 weeks gestation and pregnant with twins. He was going to drive her to the hospital and would arrive in 30 minutes. Vieth called the pediatrician and OB team. They have obstetrics and pediatrics always on call although they may or may not be in- They are supposed to arrive within 20 minutes. They agreed to come in. Vieth requested a warmer to be brought to the ED from the nursery just in case although she was hopeful that she could screen the patient and send her up to Labor and Delivery.
• Thirty minutes went by and the patient still had not EMS called. The woman had contacted EMS halfway to the hospital because she felt like she needed to push. She was now traveling with EMS. Approximately 10 minutes later, she arrived to the ED on a stretcher.  Fortunately, the obstetrician had arrived in the ED. The patient was immediately placed in a room with OB, the pediatrician and an OB nurse to check if she was crowning. She was. The patient looked uncomfortable and said she needed to push. 
• The OB wanted to transfer the patient upstairs because she did not want to deliver her in the ED. The ward clerk ran down to the elevators. There were already people in the elevator so she made them get out and held the door. Vieth, the obstetrician, EMS with the patient on a stretcher, an OB nurse and the pediatrician with the warmer all came hurtling down the hallway while telling the patient to not push. They made it up to OB and transferred the patient to the OB bed.
• About 2-3 minutes later, the first baby was delivered.
• Do you remember neonatal resuscitation?
  • If it is a term gestation and the baby is breathing or crying with good tone, then dry them, clear the airway (if needed) and give the baby to the mother for skin-to-skin contact.
  • If they are not term and not breathing or crying, or, do not have good tone, then you need to dry and stimulate. You need to warm them and clear the airway. If the heart rate is below 100 bpm or they are apneic or gasping, provide positive pressure ventilation. If the heart rate is still below 100 bpm, keep doing positive pressure ventilation. If the heart rate drops below 60 beats per minute despite ventilation, do chest compressions.
• The first baby was 26 weeks gestation. The baby had tone and was trying to breathe but had poor respiratory effort. The baby was handed to the pediatrician who began resuscitation. The OB requested the ultrasound tech determine the presentation of the second baby. Respiratory therapy had arrived and was assisting the pediatrician in providing bag-valve-mask ventilations to the first baby. A second pediatrician was on the way to assist with the second baby. Vieth checked in with them to see if she was still needed before heading back to the ED. She was heading out of the room when the patient said she needed to push and the obstetrician delivered the second baby.
• The second pediatrician had not arrived, so Vieth put on gloves and transferred the second baby to another warmer. She needed to remember neonatal resuscitation. She had help. There was a pediatrician there. This is not something we do routinely.
• The experienced OB nurse helped stimulate the baby and apply the monitoring. The baby had some tone but poor respiratory effort. They suctioned the baby and then began ventilating with a bag-valve-mask. The pediatrician came over to see if Vieth needed help. She brought over saran wrap and they wrapped the baby in plastic. She continued to bag the baby. The heart rate was strong and greater than 100 beats per minute so she did not have to start compressions. The second pediatrician arrived and Vieth turned over care of the patient and returned to the emergency department.
• Vieth had just returned from ACEP where she was helping to teach the emergency delivery lab.
• The patient was rumored to have twin-twin transfusion syndrome although that turned out not to be the case. She had been at tertiary care center the previous day for threatened preterm labor. She had been given two doses of betamethasone. She arrived home at 1 a.m. and her water broke at 9 a.m. She had been started on labetalol for hypertension of pregnancy. This was her first pregnancy. Her GBS status was unknown. Baby A was 940 g and Baby B was 770 g.
• The total time between when the mother arrived and both babies were born was 15 minutes.
• After reflection, Vieth realized that she was not familiar with the resuscitation of premature babies.
  • The use of Saran wrap for temperature regulation was a new concept for Vieth. The torso was wrapped with Saran wrap but not so tightly that it would cause problems.
  • Management of the airway presented some learning points.
    • When an older patient arrives to the ED needing an airway, we are quick to establish an airway either with endotracheal intubation or devices such as an LMA. These babies remained up in the nursery under the care of the pediatricians for nearly 5 hours awaiting the transport teams, but were not intubated due to concern that unsuccessful attempts at intubation could complicate management by the experts. The babies were easy to bag. In most situations, just ventilating with bag-valve-mask will be sufficient.
    • There are different ways to bag the baby and different equipment that can be used when anticipating prolonged periods of resuscitation while awaiting transport.
    • The tidal volumes utilized are small. The recommended tidal volume is 5 mL/kg and these babies weighed less than a kg. It is helpful if you have a good respiratory therapist who is comfortable doing this.
  • The target oxygen saturation is different at birth. These babies should not be at an oxygen saturation of 100%. Most of the evidence is in term babies but has been extrapolated to younger babies as well. At 1 minute, the oxygen saturation is 60-65%. The oxygen saturation should increase by about 5% every minute. At 2 minutes, the oxygen saturation should be 70-75%. By 10 minutes, the oxygen saturation will increase to 95% but as low as 85% could still be normal.
• What happened? Both infants did well. Baby A was in the NICU for 4 months with some feeding difficulties. Baby B was in the NICU for 3.5 months. Baby A is doing well, has a stable intraseptal defect and is meeting milestones. Both babies have chronic lung disease and retinopathy of prematurity. Baby B had bilateral Grade 3 intraventricular hemorrhage early on but there was no hydrocephalus noted on the most recent ultrasound. Baby B is behind Baby A developmentally but is reaching some milestones.
• How did the mom do? She received Pitocin and synthetic prostaglandins. She had uterine atony and was given rectal misoprostol. She had hypertension and received magnesium for a few days and was then transitioned to oral labetalol.
• Do not forget to ask for help if you are in this situation.