Tuesday, 18 January 2011


A nice normal lovely Friday morning covering the postnatal ward. Our rota is balanced by giving us a week of half days when we cover postnates, which theoretically means we get to disappear at midday. We never do, obviously - far too busy up there - but it's a nice thought.

Six babies to check and two reviews. Nothing compared to busy hospitals, and although having less to do naturally slows one down, I'll be out of here on time.

One of the midwives potters over. "Oh, could you look at Baby C first, he's grunting."

Grunting in an infant is a sign of respiratory distress. Basically, in normal breathing, you relatively empty your chest, and then the inherent negative pressure in the chest inflates it again. It's why you struggle to breathe out when you're winded, because the muscles that do this for you have been stunned.

Babies with respiratory pathology can struggle with this. Newborns, particularly preterms, who don't produce enough surfactant, can struggle to inflate their lungs - they're "stiffer". Infants with infections can work harder and start to tire. Grunting helps with this; by breathing against a closed outlet at the end of expiration, you are maintaining the pressure in your chest and helping to keep the lungs slightly inflated. Think about blowing up a balloon - the hardest blow always comes first.

So, this baby was apparently grunting. I get told this a lot by the midwives, and the baby's absolutely fine. I was quite relaxed looking through the antenatal notes, as clearly they weren't too concerned if they were happy to wait for the routine day team to have a look at him.

I went to see the baby. He WAS grunting. He was also breathing fast. Hmmmm. I wheeled him through to the nursery where my equipment lives, popped him onto the resuscitaire, and also noticed he was recessing - he was breathing with such high pressures that he was sucking his skin into his chest, highlighting his rib cage more, as seen here.

Clearly, this baby wasn't right, but he didn't look too bad on balance. I asked one of the midwives to stay with him, took a blood gas from his heel, and popped to the gas machine on the neonatal unit it. I'd taken the postnatal notes with me, and noticed the night midwives had diligently documented how Baby C had been grunting when transferred up from labour ward, continued to grunt throughout the night, started having difficulty with his temperature, and they'd finally suggested at 7 hours of age that the day staff should perhaps get the paediatric doctor to review him this morning. Brilliant.

His blood gas - a quick measure of the gases in the bloodstream, along with other key chemicals that affect acidity of the blood - showed a respiratory acidosis. His breathing was poor, causing him to retain carbon dioxide, which was dissolving in the blood and causing it to turn more acidic. Generally, this is a bad thing. I advised the neonatal unit to expect an admission, sprinted back up the stairs, and transferred the baby down on oxygen, as he was looking a bit unwell by this point.

Chest x-ray showed a pneumothorax. Baby C was intubated and ventilated, had a chest drain inserted to drain the air pressing on his lung, and was transferred to a bigger hospital for ongoing care. Would this outcome have been any different if someone had called for help earlier? Who knows. Would I have been slightly less miffed? Yes. Would I have had a lovely relaxed Friday morning and afternoon? Definitely!

If a baby is grunting, get some help. The same rules apply for parents and midwives. Could somebody please tell the midwives?

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