Nanette is very low on her hematocrit. Normal for women is about 38%, but hers is down to 23%. Transfusion is an option if she feels really light headed and feels like she needs it. If her crit continues to drop and hits 19-20%, she will get a transfusion regardless of how she feels about it. She is still losing blood so a transfusion is very possible.
Zeke is off the bili light! They will monitor his bilirubin for a day and see if it remains low (~3 right now). His feeding volume is up to 20mL/day. His head ultrasound came back and it is normal. Yea! (This is understated, but there is not a word sufficient to communicate how great this news is.)
Gabe was a peeing machine last night. He had 143mL during the night shift and over 100mL in the day shift. His size and puffiness have decreased remarkably. In addition, his arms and legs have been active fro the first time. Because of his urine output his electrolytes look better. His potassium is almost half of what it was 24 hours ago (which is a good thing). He is completely off dopamine and his blood pressure is quite high today (high 40s).
Gabe is also off the bili light. Today is the first time Nanette has seen him without the eye mask to protect his eyes from the light. His is really cute. Dad also got to change his diaper twice. Dad is still a pro.
They put Gabe on a Drager ventilator this afternoon. It is pretty cool. It measures his breathing and actively finished his breaths if Gabe doesn't do it on his own. The Drager also adds breaths between his spontaneous ones. The breath rate, tidal volume per breath, PEEP (positive-end expirator pressure), and PIP (peak inspiratory pressure) are adjustable.
We also got Gabe's head ultrasound official results back today. Dr. Chan, Dr. Bridget Burshear, and the nurse practitioner, Karen, came to Nanette's room to discuss the results. While in utero, probably 3-5 weeks ago, Gabriel had a grade 4 intraventricular hemorrhage (IVH). This means that there was bleeding in the brain. Some white brain tissue did not get the oxygen needed and no longer functions, creating cysts where the tissue should be. These cysts show up as holes in the brain. The term for this event is PVL (periventricular leukomalacia). Once it has occurred, there is no treatment for PVL. Most babies who have PVL develop cerebral palsy (CB) and other moderate to severe neurological impairments. Dr. Chan told us that they advise parents of babies given this severe of damage that they may discontinue care if they choose to. We have chosen to continue care. The diagnosis of PVL does not necessarily mean that any or all of those problems will occur, it simply means that there is a very high likelihood. There is still a chance (maybe 10-15%) that he will not have any major problems. We will not know whether he has CB or other problems until we watch his milestones in his early months and years of life. Some of these milestones include rolling over, crawling, smiling, walking, and speaking.
Tuesday, March 8, 2011
Day 4 (GA: 28 Weeks)
Nanette was diagnosed with an uterine infection last night after her temperature hit 38C and then 38.1 C ten minutes later. She was started on 3 different IV antibiotics and will not get discharged today as previously expected.
The good news is that her milk has come in and she is now producing enough to meet the needs of little Zeke. Gabriel will not start on milk until he is off his blood pressure medicines and has some more improvements. But Dr. Chan did have a few drops of milk swabbed into Gabriel's mouth to get him a few extra antibodies.
The good news is that her milk has come in and she is now producing enough to meet the needs of little Zeke. Gabriel will not start on milk until he is off his blood pressure medicines and has some more improvements. But Dr. Chan did have a few drops of milk swabbed into Gabriel's mouth to get him a few extra antibodies.
Monday, March 7, 2011
Day 3, part II
Today has been especially difficult for Nanette. In the last few years, she has given birth to 6 babies vaginally with no pain medication at all. So it is fair to say that she has a high tolerance to pain. However, today's post-op pain has been very intense (8/10) even though she is getting a substantial amount of pain medications, including narcotics. She is getting antibiotic treatment for a possible skin infection. But we are worried about the possibility of a uterine infection. She is on close watch. Update: Nanette just measured a high temperature, which is an indication of infection. . .
Zeke did well today, although his stomach is not emptying his breast-milk meals very well. They always check the stomach before a feeding. Often, the milk is withdrawn by a tube, observed to be laden with bile, and then not returned to the stomach. So this is on watch. Other than that, the rest of his vitals have maintained their positive levels today. Nanette helped the nurse change his diaper and got to "hold" him a little bit by clasping her hands around his head and legs.
Gabriel continues to do very well considering his history. Most of his key indicators have trended positively today. He uriniated 40mL and then 20mL this morning, indicating that his kidneys have finally kicked in and have started to work. This is fantastic news! His output slowed down the rest of the day, but is still coming. I sat in during the rounding today and thoroughly enjoyed it! I saw how the team discussed his care and made plans to improve his condition. Their decisions led to the complete weaning of one blood pressure medicine (norepi) and the dialing back of the other (dopamine) to 7 ug/kg/min (it was as high as 20 just yesterday). His blood pressure has responded positively and was in the low 30s (which is great for now). The other positive step was the decrease in his potassium levels which removed the necessity of his insulin drip. The pulmonary culture came back today and E. coli was confirmed to be in his lungs. The final results for the blood culture are not back yet. His blood gases looked good this morning so the intensity of his ventilator settings has decreased (mean pressure of 8-9cm) and his ingoing oxygen levels are at 27%. The preliminary result from the head ultrasound shows some brain bleeding (intraventricular hemorrhaging, or IVH). We will find out how severe it is when the final report is shared with us tomorrow.
Zeke did well today, although his stomach is not emptying his breast-milk meals very well. They always check the stomach before a feeding. Often, the milk is withdrawn by a tube, observed to be laden with bile, and then not returned to the stomach. So this is on watch. Other than that, the rest of his vitals have maintained their positive levels today. Nanette helped the nurse change his diaper and got to "hold" him a little bit by clasping her hands around his head and legs.
Gabriel continues to do very well considering his history. Most of his key indicators have trended positively today. He uriniated 40mL and then 20mL this morning, indicating that his kidneys have finally kicked in and have started to work. This is fantastic news! His output slowed down the rest of the day, but is still coming. I sat in during the rounding today and thoroughly enjoyed it! I saw how the team discussed his care and made plans to improve his condition. Their decisions led to the complete weaning of one blood pressure medicine (norepi) and the dialing back of the other (dopamine) to 7 ug/kg/min (it was as high as 20 just yesterday). His blood pressure has responded positively and was in the low 30s (which is great for now). The other positive step was the decrease in his potassium levels which removed the necessity of his insulin drip. The pulmonary culture came back today and E. coli was confirmed to be in his lungs. The final results for the blood culture are not back yet. His blood gases looked good this morning so the intensity of his ventilator settings has decreased (mean pressure of 8-9cm) and his ingoing oxygen levels are at 27%. The preliminary result from the head ultrasound shows some brain bleeding (intraventricular hemorrhaging, or IVH). We will find out how severe it is when the final report is shared with us tomorrow.
Day 3 (GA: 28 Weeks 3 Days)
Yesterday went pretty well for both babies. Thank you to all who prayed and fasted for our little guys.
Ezekiel was intubated and put back on the ventilator for about 6 hours in the morning, but quickly came off it and is on a SiPAP, which is similar to the CPAP but also help regulate breathing by adding some breaths between his own. He is still breathing 21% oxygen (room air). Breast milk is being fed to him, about 2.5mL every 3 hours. He has lost weight and is less than 950 grams (2lbs 2 oz). I say less than, because they measure with a diaper on and some stuff on his head. During his rounds, where the doctor, nurse practitioner, and pharmicist pow wow over his treatment and progress, I sat in and heard some more positive news: his nucleated red blood cell (NRBC) count is increasing. NRBCs are little RBCs that still have their nucleus; mature RBCs lose their nucleus. This means that Zeke's bone marrow has kicked in and is making new blood cells. Overall, Zeke is doing very well.
Gabriel continues to be very sick, but he has made small but positive improvements, which is the right direction. His care was mostly to wait and see how his body responds. By the end of the day his blood pressure was getting higher (good thing) and his main blood pressure medicine (Dopamine) was reduced. His blood oxygen levels remained high with a 40% concentration going in (it had been 80% most of the day). They are closely monitoring his sodium, potassium, and calcium levels. His potassium was trending high so they treated him with insulin. Insulin is the drug used by diabetics to reduce the glucose in their blood. Insulin turns out also to induce potassium going into cells. But since it draws sugar out, they have to increase his blood sugar prior to administering the insulin. He continues to have pulmonary hypertension and patent ductus arteriosus (PDA). Today he will get an ultrasound of his heart again to look at the PDA. He (and Zeke) will also get a head ultrasound, where they look for bleeding in the brain, called intraventricular hemorrhaging (IVH). This is the main cause of cerebral palsy (grade 4) and neurological development issues (grades 2 and 3). There have been some positive signs that Gabe has not had any bleeding: his hematocrit has stayed steady. When there is bleeding is the brain, the hematocrit takes a sharp decrease. So his constant hematocrit is a good indicator. We will know more tomorrow, after the head ultrasound is read by the doctors. And the best news for last: He had not urinated since he was born and this was a huge concern to his care providers. But by midnight he had made about 5mL. He has retained a lot of water and he has gained a bit of weight. His is now roughly 1650 grams (3 lbs 5 oz). He looks like the Stay Puff baby compared to the baby Gollum that Zeke is. It is quite the contrast.
Ezekiel was intubated and put back on the ventilator for about 6 hours in the morning, but quickly came off it and is on a SiPAP, which is similar to the CPAP but also help regulate breathing by adding some breaths between his own. He is still breathing 21% oxygen (room air). Breast milk is being fed to him, about 2.5mL every 3 hours. He has lost weight and is less than 950 grams (2lbs 2 oz). I say less than, because they measure with a diaper on and some stuff on his head. During his rounds, where the doctor, nurse practitioner, and pharmicist pow wow over his treatment and progress, I sat in and heard some more positive news: his nucleated red blood cell (NRBC) count is increasing. NRBCs are little RBCs that still have their nucleus; mature RBCs lose their nucleus. This means that Zeke's bone marrow has kicked in and is making new blood cells. Overall, Zeke is doing very well.
Gabriel continues to be very sick, but he has made small but positive improvements, which is the right direction. His care was mostly to wait and see how his body responds. By the end of the day his blood pressure was getting higher (good thing) and his main blood pressure medicine (Dopamine) was reduced. His blood oxygen levels remained high with a 40% concentration going in (it had been 80% most of the day). They are closely monitoring his sodium, potassium, and calcium levels. His potassium was trending high so they treated him with insulin. Insulin is the drug used by diabetics to reduce the glucose in their blood. Insulin turns out also to induce potassium going into cells. But since it draws sugar out, they have to increase his blood sugar prior to administering the insulin. He continues to have pulmonary hypertension and patent ductus arteriosus (PDA). Today he will get an ultrasound of his heart again to look at the PDA. He (and Zeke) will also get a head ultrasound, where they look for bleeding in the brain, called intraventricular hemorrhaging (IVH). This is the main cause of cerebral palsy (grade 4) and neurological development issues (grades 2 and 3). There have been some positive signs that Gabe has not had any bleeding: his hematocrit has stayed steady. When there is bleeding is the brain, the hematocrit takes a sharp decrease. So his constant hematocrit is a good indicator. We will know more tomorrow, after the head ultrasound is read by the doctors. And the best news for last: He had not urinated since he was born and this was a huge concern to his care providers. But by midnight he had made about 5mL. He has retained a lot of water and he has gained a bit of weight. His is now roughly 1650 grams (3 lbs 5 oz). He looks like the Stay Puff baby compared to the baby Gollum that Zeke is. It is quite the contrast.
Saturday, March 5, 2011
Day 1 (Gestational Age: 28 Weeks 1 Day)
It has been over 24 hours since the twins were born. Nanette, who is recovering much better now (she lost almost 2 liters of blood after the surgergy), saw her baby twins for the first time this morning. She is walking around a little and the color is starting to return to her face. She is sleeping when she can and crying when she can't.
First the good news:
Zeke weighed 2 lbs 5 oz and was given Apgar scores of 6.5 and 6. He was intubated and put on a ventilator right after birth and given pulmonary surfactant to reduce friction in the lungs and help them expand. His blood sugar was a bit low (40 mg/dL) after birth, which is very typical, and he was given a little sugar (dextrose, I believe) in his IV. His blood oxygen has been very good so he was extubated, taken off the ventilator, and put on CPAP (positive air pressure). The air given to Zeke has the same oxygen concentration as regular air (21%). He is pink in color and very calm and relaxed. He had his first meal today: 1 mL of colostrum that Nanette had previously pumped. Overall, Zeke is doing very well for his situation.
Now the bad:
Gabriel weighed 2 lbs 15 oz and was given Apgar scores of 2 and 7. He was also intubated, put on a ventilator, and given surfactant. He is still on the ventilator. He has been under the bili light to help with his jaundice. Tonight the doctors informed us that Gabe has sepsis, which is an infection of the whole body. He also has pulmonary hypertension, which means that the pressure in the lung vessels is high. The high pressure is caused by constricted pulmonary vessels. The bacteria which is causing the sepsis exacerbates the constriction. Furthermore, as the antibiotics and the baby's body start to fight the bacteria, toxicity will increase, further increasing the constriction in the vessels. The result of the poor circulation through his lungs is a low level of oxygen in the blood. Thus, the air forced in his ventilator is about 90-100% oxygen. These concentrations have kept his blood oxygen levels in the high 80s/low 90s, as they should.
They are administering all sorts of drugs to Gabe:
- one to keep the pressure up in the lungs to get the blood moving in the vessels
- one to increase vessel constriction in the rest of the body to decrease the blood pressure there
- one or two other blood pressure medications
- continued antibiotics
- sedation medication
- At least 6-7 more drugs (I don't know what they do, I just see them by his bedside)
The doctor told us that Gabe has roughly a 60% probability of survival in the next 24-36 hours. Please fast and pray for our little twins and our family.
Friday, March 4, 2011
28 Weeks Part II
Gabe and Zeke arrived today! Both are doing well for being 28 weeks old. More details to follow on their progress (pictures at the end).
Gabriel Workman Stevenson: 4:40pm weighing 2lb 15oz.
Ezekiel Wade Stevenson:4:41pm weighing 2lb 5oz.
Here's the play by play of how the labor and delivery unfolded:
2:30pm: Jared gets back to the hospital after spending the night and part of the workday back in Utah County. Unloads groceries (we have really moved in) and starts doing some work on his laptop.
3:30pm: Nanette tells Jared that she is having some serious contractions and they are ~10 minutes apart. We start to monitor them.
3:45pm: The contractions are 5 minutes apart now and we call in the nurse.
3:50pm: Nurse comes in nonchalantly with the fetal heart tone monitor. Nanette tells her that this is it and that she needs to go to Labor and Delivery.
3:55pm: Doctor comes in and agrees that Nanette should be in L&D.
4pm: Roll bed to L&D.
4:05pm: The L&D nurses casually ask her how she is doing and tell her the doctor will come by in a few minutes to do a speculum (unique tool, look it up) exam. Meanwhile they start to put on the baby heart monitors and the waist belt (stretchy stuff that wraps around the tummy to hold the monitors in place).
4:07pm: Nanette tells the nurses (several are in the room noq) that she is going through transition and needs to be in the operating room right now. They tell her that the doctor will be in soon to do an examine. Nanette tells the nurses that she has had several babies and knows what is going on. Jared tells the nurses that Nanette is in transition and that she needs to be in the OR. Intense contractions are right on top of each other.
4:10pm: The doctor comes in, sees Nanette's condition, drops the speculum, and does a quick manual examination. Nanette is 7cm dilated.
4:15pm: Nanette is wheeled to the OR. All the nurses and doctors follow her. As Jared leaves the room last in line, a nurse tells him to stay in the room.
4:16pm: Jared waits in the L&D room by himself, thinking that Nanette will have to be under general anesthesia---in which case he may not be present---and he will miss the births. Nanette is taken to the operating room and the doctor asks if the contractions are still on top of each other. She says no. The doctors decide to try a spinal. Two more contractions come right away.
4:20pm: Doctors poke Nanette to decide how well the spinal is working. Jared is given hospital scrubs, hair net (he was flattered), face mask, and shoe covers.
4:30pm: Nanette's poke test has indicated that the procedure may begin. A nurse comes to get Jared, saying they have already started.
4:35pm: Jared sees Nanette's determined and calm face behind the blue sheet. Laying on her back with her wrists strapped to the perpendicular arm extensions, Nanette looks like she is on a crucifix and it creates a visual reminder of her sacrificial devotion to our helpless baby twins.
4:40pm: Watching the Discovery Channel pales in comparison to watching a live c-section. It is intense. Bloody. Amazing. Chilling. Heart wrenching and heartwarming at the same time. After a serious struggle getting Baby A's head out, Gabriel is born.
4:41pm: Ezekiel comes out relatively easy.
4:42pm: After getting the placenta out, it is a matter of putting the puzzle back together. I was not aware that the uterus comes completely out of the body during this portion. It is remarkably smooth and round, just smaller than a volleyball. Apparently, this is a puzzle the doctors are good at putting back together. They wrap up the whole thing in 20-30 minutes. Some staples and Nanette is ready to go back to her L&D room.
5:10-9:30pm: Nanette recovers. It is crazy. Continuous bleeding. Uncontrollable shaking. Drugs of all kinds. Nausea. And the occasional update from the newborn ICU.
9:30pm: Moved back to our old room in the Women's Special Care unit. I walked by the bed pushing the morphine-like drug (drug pusher, I guess!). Feels like home here. Alisha is one of our favorite nurses and is our nurse tonight.
Gabriel Workman Stevenson: 4:40pm weighing 2lb 15oz.
Ezekiel Wade Stevenson:4:41pm weighing 2lb 5oz.
Here's the play by play of how the labor and delivery unfolded:
2:30pm: Jared gets back to the hospital after spending the night and part of the workday back in Utah County. Unloads groceries (we have really moved in) and starts doing some work on his laptop.
3:30pm: Nanette tells Jared that she is having some serious contractions and they are ~10 minutes apart. We start to monitor them.
3:45pm: The contractions are 5 minutes apart now and we call in the nurse.
3:50pm: Nurse comes in nonchalantly with the fetal heart tone monitor. Nanette tells her that this is it and that she needs to go to Labor and Delivery.
3:55pm: Doctor comes in and agrees that Nanette should be in L&D.
4pm: Roll bed to L&D.
4:05pm: The L&D nurses casually ask her how she is doing and tell her the doctor will come by in a few minutes to do a speculum (unique tool, look it up) exam. Meanwhile they start to put on the baby heart monitors and the waist belt (stretchy stuff that wraps around the tummy to hold the monitors in place).
4:07pm: Nanette tells the nurses (several are in the room noq) that she is going through transition and needs to be in the operating room right now. They tell her that the doctor will be in soon to do an examine. Nanette tells the nurses that she has had several babies and knows what is going on. Jared tells the nurses that Nanette is in transition and that she needs to be in the OR. Intense contractions are right on top of each other.
4:10pm: The doctor comes in, sees Nanette's condition, drops the speculum, and does a quick manual examination. Nanette is 7cm dilated.
4:15pm: Nanette is wheeled to the OR. All the nurses and doctors follow her. As Jared leaves the room last in line, a nurse tells him to stay in the room.
4:16pm: Jared waits in the L&D room by himself, thinking that Nanette will have to be under general anesthesia---in which case he may not be present---and he will miss the births. Nanette is taken to the operating room and the doctor asks if the contractions are still on top of each other. She says no. The doctors decide to try a spinal. Two more contractions come right away.
4:20pm: Doctors poke Nanette to decide how well the spinal is working. Jared is given hospital scrubs, hair net (he was flattered), face mask, and shoe covers.
4:30pm: Nanette's poke test has indicated that the procedure may begin. A nurse comes to get Jared, saying they have already started.
4:35pm: Jared sees Nanette's determined and calm face behind the blue sheet. Laying on her back with her wrists strapped to the perpendicular arm extensions, Nanette looks like she is on a crucifix and it creates a visual reminder of her sacrificial devotion to our helpless baby twins.
4:40pm: Watching the Discovery Channel pales in comparison to watching a live c-section. It is intense. Bloody. Amazing. Chilling. Heart wrenching and heartwarming at the same time. After a serious struggle getting Baby A's head out, Gabriel is born.
4:41pm: Ezekiel comes out relatively easy.
4:42pm: After getting the placenta out, it is a matter of putting the puzzle back together. I was not aware that the uterus comes completely out of the body during this portion. It is remarkably smooth and round, just smaller than a volleyball. Apparently, this is a puzzle the doctors are good at putting back together. They wrap up the whole thing in 20-30 minutes. Some staples and Nanette is ready to go back to her L&D room.
5:10-9:30pm: Nanette recovers. It is crazy. Continuous bleeding. Uncontrollable shaking. Drugs of all kinds. Nausea. And the occasional update from the newborn ICU.
9:30pm: Moved back to our old room in the Women's Special Care unit. I walked by the bed pushing the morphine-like drug (drug pusher, I guess!). Feels like home here. Alisha is one of our favorite nurses and is our nurse tonight.
 |
| Gabe, about 1 hour old. |
 |
| Zeke, about 1.5 hours old. |
28 Weeks
28 Weeks!
Reproduced below is a chart that shows data from a 2002 study. Keys points:
Reproduced below is a chart that shows data from a 2002 study. Keys points:
- Survival rates hit a big knee at 28 weeks! Great news!
- Severe neurological problems are down to 20%.
- Apparently, 20% of kids born at term still have problems at school. Bummer. I won't tell my full term kids that stat.
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