EARLY ENTRY INTO THE WORLD - DAY OF DELIVERY -DR. NARASIMHA, KANNUR MEDICAL COLLEGE
(This is an article written by Dr. Narasimha, Dept. Paediatrics, Kannur Medical College based on the preparations for a successfull delivery of a pre-term baby)
I recieved a call at midnight on 23rd of march from our obstetrician.
It was an emergency call as the pregnant primi was in labor, nothing unusual until now, except when I heard her expected date of delivery was 2 months away !!
I have handled similar babies before as a post graduate trainee, but I wish to share this experience, which happens to be my first in KMC, in updating day to day progress, which could be quite interesting and dramatic (hopefully not - fingers crossed}.
KMCH has a level 2 fully equipped NICU, with radiant warmers, isolette incubator, CPAP equipment, phototherapy equipment, neonatal ventilator and an additional transport ventilator.
Well, being prepared is the first step towards recieving an early entrant into this world. Womb certainly would have been the safest place for the baby in the world, but nature has its own ways.
So I had to rush in to create an artificial womb environment in the NICU.
First major concern was lung maturity.
While in utero, baby is a parasite on mother and derives oxygen, nutrients via placenta. Lungs are nonfunctional as a ventilatory organ. When the baby enters this world, it will be 'clipped off' its lifeline and has to learn to adapt to 'external' environment for all its needs. Lung can be compared to a sponge. A solid organ, full of air spaces, which is distensible and also collapsible.
In-utero, lung air spaces are filled with lung fluid (nothing but the inhaled amniotic fluid). Compare this to a sponge dipped in bucket of water - soggy and absolutely no air in it.
Once the baby is out, its just like taking the sponge out of the water container. So what happens to the fluid? One portion gets squeezed out into the airway as the baby traverses the birth canal, just as if wringgling the sponge. Rest of the liquid, gets absorbed into the lung lymphatics.
Once the fluid is out, lung spaces have a greater tendency to collapse rather than to stay 'open'. Well this is where maturity matters. A chemical call 'surfactant' or 'SURFace-ACTive-ageNT' is required to keep the lung spaces 'alveoli' open. It is produced in type 2 pneumonocytes from 20th week onwards in-utero. By 28th - 32nd week, the surfactact production is 'fairly' good enough in quantity to keep the alveoli patent.
Well, in this case, 32 weeks period of gestation, this might not pose a major obstacle, but you never know! If baby develops respiratory distress (a state where atmospheric oxygen is simply just-not-enough) we might have to provide artificial surfactant. This is where deep pockets matter and a vial of 4ml of this drug can make the father poorer by 12 grand.
A premature baby is not just growth compromised, but also lags in development required for existance. Baby would certainly have to defy Darwin's survival of fittest theory, cuz every single cell is immature. Lungs, as i explained above, is immature to handle the prime function of ventilation. Gut including liver is immature in epithelium and enzymes to pass on the nutrient, digest, assimilate and absorb. Feeding could be a herculean task for the baby, cuz suck reflex, one of basic human instincts is immature. Once it sucks in milk, it has to be swallowed. This concept of coordination lacks again.
Central nervous system development amazes me the most. Brain is a nature's master piece and is definitely the most complicated machine in the world. CNS is in the process of development too. Brain has completed primary and secondary gyrations and tertiary gyri are forming. Interconnections are forming, blood vessels are fragile, special senses are maturing, areas of brain are not yet ready to execute their assigned function. Peripheral nervous system too is forming synapses, innervating and not quite 'there'.
Skin development matters too! It acts mainly in conserving temperature, which if other wise lost can't be regained. If we feel cold, we can shiver, shudder and muscle contraction produces enough heat to feel warm again. This is called shivering thermogenesis. Premature babies lack the muscle mass and hence the shivering thermogenesis is not an option at all. In case they are exposed to cool air, they rapidly lose heat, owing to the large body surface area compared to the small mass of body. They lose heat faster than us. Faster than term infants. Nature has its answer again. Brown adipose tissue in the nape of neck, is capable of 'generating' some amount of heat, which is called as non-shivering thermogenesis. However this tissue is lacking in premature babies and hence they are totally handicapped of heat producing mechanisms. You might be wondering "whats all the big deal of producing heat/ conserving heat/ risk of hypothermia?"
Well, on exposure to cold, cutaneous vaso constriction occurs which causes tissue hypoxia (recollect types of hypoxia in general pathology). Yeah, this would be ischemic hypoxia. And what hypoxia does to the cell? It deprives cellular metabolism of oxygen and cell resorts to anerobic metabolism to produce ATP. Harmful by product of anaerobic metabolism is lactate which causes metabolic acidosis, and also the ATP production is hugely insufficient when compared to a well aerated tissue. So where did we start? Hypothermia - hypoxia - low ATP - metabolic acidosis - irreversible cellular damage and DEATH !
So, after recollecting some of these pre clinical knowledge, it has to be put into action.
Well, warm environment hence is the first step in being prepared. The resuscitation table has to be warm, the transport of baby from place of delivery to NICU has to be warm and baby has to be nursed in a warm 'artificial womb' i.e the incubator. This is what is called, the warm chain.
Being prepared towards assisting baby initiate the first breath and maintaining the ventilation, is the next issue. This forms centre issue around neonatal resuscitation.
So clock struck 3a.m and the baby was out. All our senses had to defy sleep and ears sharpened to hear the baby cry. Baby's first cry goes a long way in opening up the airway deep down to last of alveoli and clearing the respiratory passage. Yes, it did happen and baby had a smooth transition to external world. So far, so good. Baby is 21 hours old and we are counting minutes. Every uneventful hour, will be a big achievement for the baby, relief for us and for parents.
Come, visit NICU and see the marvel of human development unfold in front of our eyes.
Well, being prepared is the first step towards recieving an early entrant into this world. Womb certainly would have been the safest place for the baby in the world, but nature has its own ways.
So I had to rush in to create an artificial womb environment in the NICU.
First major concern was lung maturity.
While in utero, baby is a parasite on mother and derives oxygen, nutrients via placenta. Lungs are nonfunctional as a ventilatory organ. When the baby enters this world, it will be 'clipped off' its lifeline and has to learn to adapt to 'external' environment for all its needs. Lung can be compared to a sponge. A solid organ, full of air spaces, which is distensible and also collapsible.
In-utero, lung air spaces are filled with lung fluid (nothing but the inhaled amniotic fluid). Compare this to a sponge dipped in bucket of water - soggy and absolutely no air in it.
Once the baby is out, its just like taking the sponge out of the water container. So what happens to the fluid? One portion gets squeezed out into the airway as the baby traverses the birth canal, just as if wringgling the sponge. Rest of the liquid, gets absorbed into the lung lymphatics.
Once the fluid is out, lung spaces have a greater tendency to collapse rather than to stay 'open'. Well this is where maturity matters. A chemical call 'surfactant' or 'SURFace-ACTive-ageNT' is required to keep the lung spaces 'alveoli' open. It is produced in type 2 pneumonocytes from 20th week onwards in-utero. By 28th - 32nd week, the surfactact production is 'fairly' good enough in quantity to keep the alveoli patent.
Well, in this case, 32 weeks period of gestation, this might not pose a major obstacle, but you never know! If baby develops respiratory distress (a state where atmospheric oxygen is simply just-not-enough) we might have to provide artificial surfactant. This is where deep pockets matter and a vial of 4ml of this drug can make the father poorer by 12 grand.
A premature baby is not just growth compromised, but also lags in development required for existance. Baby would certainly have to defy Darwin's survival of fittest theory, cuz every single cell is immature. Lungs, as i explained above, is immature to handle the prime function of ventilation. Gut including liver is immature in epithelium and enzymes to pass on the nutrient, digest, assimilate and absorb. Feeding could be a herculean task for the baby, cuz suck reflex, one of basic human instincts is immature. Once it sucks in milk, it has to be swallowed. This concept of coordination lacks again.
Central nervous system development amazes me the most. Brain is a nature's master piece and is definitely the most complicated machine in the world. CNS is in the process of development too. Brain has completed primary and secondary gyrations and tertiary gyri are forming. Interconnections are forming, blood vessels are fragile, special senses are maturing, areas of brain are not yet ready to execute their assigned function. Peripheral nervous system too is forming synapses, innervating and not quite 'there'.
Skin development matters too! It acts mainly in conserving temperature, which if other wise lost can't be regained. If we feel cold, we can shiver, shudder and muscle contraction produces enough heat to feel warm again. This is called shivering thermogenesis. Premature babies lack the muscle mass and hence the shivering thermogenesis is not an option at all. In case they are exposed to cool air, they rapidly lose heat, owing to the large body surface area compared to the small mass of body. They lose heat faster than us. Faster than term infants. Nature has its answer again. Brown adipose tissue in the nape of neck, is capable of 'generating' some amount of heat, which is called as non-shivering thermogenesis. However this tissue is lacking in premature babies and hence they are totally handicapped of heat producing mechanisms. You might be wondering "whats all the big deal of producing heat/ conserving heat/ risk of hypothermia?"
Well, on exposure to cold, cutaneous vaso constriction occurs which causes tissue hypoxia (recollect types of hypoxia in general pathology). Yeah, this would be ischemic hypoxia. And what hypoxia does to the cell? It deprives cellular metabolism of oxygen and cell resorts to anerobic metabolism to produce ATP. Harmful by product of anaerobic metabolism is lactate which causes metabolic acidosis, and also the ATP production is hugely insufficient when compared to a well aerated tissue. So where did we start? Hypothermia - hypoxia - low ATP - metabolic acidosis - irreversible cellular damage and DEATH !
So, after recollecting some of these pre clinical knowledge, it has to be put into action.
Well, warm environment hence is the first step in being prepared. The resuscitation table has to be warm, the transport of baby from place of delivery to NICU has to be warm and baby has to be nursed in a warm 'artificial womb' i.e the incubator. This is what is called, the warm chain.
Being prepared towards assisting baby initiate the first breath and maintaining the ventilation, is the next issue. This forms centre issue around neonatal resuscitation.
So clock struck 3a.m and the baby was out. All our senses had to defy sleep and ears sharpened to hear the baby cry. Baby's first cry goes a long way in opening up the airway deep down to last of alveoli and clearing the respiratory passage. Yes, it did happen and baby had a smooth transition to external world. So far, so good. Baby is 21 hours old and we are counting minutes. Every uneventful hour, will be a big achievement for the baby, relief for us and for parents.
Come, visit NICU and see the marvel of human development unfold in front of our eyes.
DR. NARASIMHA - KANNUR MEDICAL COLLEGE
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