TX - pregnant wife unresponsive on life support, husband hopes to fulfill her wishes

[K_Z]

While I am holding out hope for the baby. I understand that it's most likely not gonna be a happy ending.


But why would they just leave her body after the c section? Why not clean her up. Even if she isn't leaving the Or alive. Why won't the give her the same treatment as everyone else. That's really awful what you described. I hope that's not how it all happens.

BBM. There is no reason to keep her body functioning, or her heart beating, once the fetus is cut from her body, and the umbilical cord cut.

The nurses will do their best to clean her up before tagging her body, and wrapping it and doing the paperwork before she is moved to the morgue. But she will be a bloody mess that will continue to seep and soak thru any wadding or packing that can be applied. There will be no effort to stop hemorrhage, give Pitocin to clamp down a flaccid uterus, etc. She is dead. She will be even "more dead" when the baby is cut out. Except that in her "second" death, she is now a coroner's/ ME case. So all tubes will be left in place, and I doubt that even the C-section incision will be sutured. They will pack her full of lap sponges to soak up the amniotic fluid and blood.

And, BTW, there won't be a nice "bikini" pfannenstiel incision. It will be a huge midline incision from the bottom of the ribs to the symphysis pubis. Flayed wide as possible. There is no earthly reason to do a pfannenstiel incision to preserve the uterus-- she isn't having any more kids. Rapid exposure will be necessary to get the fetus out as quickly as possible. It will be a bloody mess.

But we will never hear the story of MM's last moments in the OR. All that will be broadcast and covered is the story of the fetus. MM will be invisible as soon as the cord is cut. She is the decanting jar in this brave new world.

 

[jjenny]

BBM. There is no reason to keep her body functioning, or her heart beating, once the fetus is cut from her body, and the umbilical cord cut.

The nurses will do their best to clean her up before tagging her body, and wrapping it and doing the paperwork before she is moved to the morgue. But she will be a bloody mess that will continue to seep and soak thru any wadding or packing that can be applied. There will be no effort to stop hemorrhage, give Pitocin to clamp down a flaccid uterus, etc. She is dead. She will be even "more dead" when the baby is cut out. Except that in her "second" death, she is now a coroner's/ ME case. So all tubes will be left in place, and I doubt that even the C-section incision will be sutured. They will pack her full of lap sponges to soak up the amniotic fluid and blood.

And, BTW, there won't be a nice "bikini" pfannenstiel incision. It will be a huge midline incision from the bottom of the ribs to the symphysis pubis. Flayed wide as possible. There is no earthly reason to do a pfannenstiel incision to preserve the uterus-- she isn't having any more kids. Rapid exposure will be necessary to get the fetus out as quickly as possible. It will be a bloody mess.

But we will never hear the story of MM's last moments in the OR. All that will be broadcast and covered is the story of the fetus. MM will be invisible as soon as the cord is cut. She is the decanting jar in this brave new world.

Again, if she were an organ donor, her heart would be cut out while still beating. Is that not gruesome? I don't see how c-section is any more disturbing to the OR staff.
If they can not handle this, maybe they shouldn't be working in OR to begin with.

 

[Karmady]

Not every serverely disabled baby dies, though. If mother was alive, and had tests done, and was told fetus has severe disabilities, she could decide whether she wants the pregnancy to continue. But it doesn't sound like this will be allowed to happen since mother is brain dead.

and in some cases/places, even then she couldn't decide Unless things have changed dramatically since those issues were directly relevant to me not that long ago. jmo

 

[Karmady]

BBM. There is no reason to keep her body functioning, or her heart beating, once the fetus is cut from her body, and the umbilical cord cut.

The nurses will do their best to clean her up before tagging her body, and wrapping it and doing the paperwork before she is moved to the morgue. But she will be a bloody mess that will continue to seep and soak thru any wadding or packing that can be applied. There will be no effort to stop hemorrhage, give Pitocin to clamp down a flaccid uterus, etc. She is dead. She will be even "more dead" when the baby is cut out. Except that in her "second" death, she is now a coroner's/ ME case. So all tubes will be left in place, and I doubt that even the C-section incision will be sutured. They will pack her full of lap sponges to soak up the amniotic fluid and blood.

And, BTW, there won't be a nice "bikini" pfannenstiel incision. It will be a huge midline incision from the bottom of the ribs to the symphysis pubis. Flayed wide as possible. There is no earthly reason to do a pfannenstiel incision to preserve the uterus-- she isn't having any more kids. Rapid exposure will be necessary to get the fetus out as quickly as possible. It will be a bloody mess.

But we will never hear the story of MM's last moments in the OR. All that will be broadcast and covered is the story of the fetus. MM will be invisible as soon as the cord is cut. She is the decanting jar in this brave new world.

mm has already had her last moments, imo.

 

[jaxibear]

Again, if she were an organ donor, her heart would be cut out while still beating. Is that not gruesome? I don't see how c-section is any more disturbing to the OR staff.
If they can not handle this, maybe they shouldn't be working in OR to begin with.

I don't know for sure, but I imagine a staff that is trained for labor and delivery would be accustomed to totally different outcomes than a staff that is trained for organ removal or trauma surgery. They are normally doing everything in their power to save the mother's life. This will be a very different and probably distressing situation for them. JMHO.

 

[Linda7NJ]

While I can appreciate the gruesome description, how is it any less gruesome that what would happen if her organs are to be donated?
For organ donation to work, a donor has to be brain dead, with the heart beating (at least for some organs like that heart). Do they close up the donors after taking the heart out? Is that not a horrendous bloody experience for everybody in the OR?

You tell me?

"But in at least two studies before the 1981 Uniform Determination of Death Act, some "brain-dead" patients were found to be emitting brain waves. One, from the National Institute of Neurological Disorders and Stroke in the 1970s, found that out of 503 patients who met the usual criteria of brain death, 17 showed activity in an EEG.
Even some of the sharpest critics of the brain-death criteria argue that there is no possibility that donors will be in pain during the harvesting of their organs. One, Robert Truog, professor of medical ethics, anesthesia and pediatrics at Harvard Medical School, compared the topic of pain in an organ donor to an argument over "whether it is OK to kick a rock."
But BHCs—who don't receive anesthetics during an organ harvest operation—react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates. Doctors say these are simply reflexes."
http://m.us.wsj.com/articles/SB10001424052970204603004577269910906351598?mobile=y

According to court papers, McMahon grew concerned when he saw the patient being administered a muscle paralyzer during a full-organ harvest. The anesthesiologist told him the surgeon had ordered the drug because the female patient was "moving and jerking" during the initial surgical incision on her chest.

The patient's reaction was a "clear sign" she wasn't brain dead at that time, court papers contend. It further showed that a colleague had improperly obtained consent from the patient's family.

http://www.silive.com/news/index.ssf/2012/09/lawsuit_organ_donor_network_pr.html

Maybe it's just me, but I see some room for genuine concern


Sent from my iPhone using Tapatalk

 

[K_Z]

While I can appreciate the gruesome description, how is it any less gruesome that what would happen if her organs are to be donated?For organ donation to work, a donor has to be brain dead, with the heart beating (at least for some organs like that heart). Do they close up the donors after taking the heart out? Is that not a horrendous bloody experience for everybody in the OR?

Because she is brain dead and pregnant. A full 25-30% of cardiac output goes to the uterus at term. That's about 500cc a minute. Until the heart stops. Then there will be seepage for hours.

Most brain dead organ donors aren't pregnant, with a 16-20 inch cut in their gravid uterus. Once they cross clamp the aorta in typical organ procurement, things are relatively not so bloody.

A gravid uterus is a whole different thing.

And no, I sincerely doubt that the incision will be closed in the OR. Maybe a few superficial sutures to bring the edges together, to make it a little more palatable situation, but probably not. She is a coroner's case. They will leave her open. With all tubes in place. The residents will not be allowed to practice their closures on this case.

Joypath-- are you around on this thread?

 

[jjenny]

Because she is brain dead and pregnant. A full 25-30% of cardiac output goes to the uterus at term. That's about 500cc a minute. Until the heart stops. Then there will be seepage for hours.

Most brain dead organ donors aren't pregnant, with a 16-20 inch cut in their gravid uterus. Once they cross clamp the aorta in typical organ procurement, things are relatively not so bloody.

A gravid uterus is a whole different thing.

And no, I sincerely doubt that the incision will be closed in the OR. Maybe a few superficial sutures to bring the edges together, to make it a little more palatable situation, but probably not. She is a coroner's case. They will leave her open. With all tubes in place. The residents will not be allowed to practice their closures on this case.

Joypath-- are you around on this thread?

While presumably they can do it the way you describe, nobody says they have to cut her open and not close her up. Why is it do you think they are going to just let her body bleed for hours? Yes, they don't have to close her up since she is already dead, but nobody says they can't do it.

 

[jjenny]

I don't know for sure, but I imagine a staff that is trained for labor and delivery would be accustomed to totally different outcomes than a staff that is trained for organ removal or trauma surgery. They are normally doing everything in their power to save the mother's life. This will be a very different and probably distressing situation for them. JMHO.

Then they can do the c-section in exact same way they would do it on any other patient.

 

[Karmady]

Then they can do the c-section in exact same way they would do it on any other patient.

And they don't have to do it if they don't want to. eta, the c-section, I mean. They don't have to participate at all if it offends them morally or ethically, per the statute.

 

[K_Z]

Regarding organ procurement and anesthesia management, for many years it has been standard to administer muscle relaxants (paralytics) as well as titrate anesthetic agents ("gas") and narcotics, to attenuate spinal reflexes and endogenous catecholamine flood. The rationale is to normalize the donor hemodynamics to give the organ recipients the best chance at good function.

http://www.aana.com/newsandjournal/Documents/inhalational_0810_p293-299.pdf

http://www.clasa-anestesia.org/revistas/eeuu/HTML/Estados_UnidosThe_Anesthesiologist_And_The_Bra.htm

http://download.springer.com/static...552_90247daa5823c02ab7ab90bbf690a24a&ext=.pdf

 

[Linda7NJ]

Regarding organ procurement and anesthesia management, for many years it has been standard to administer muscle relaxants (paralytics) as well as titrate anesthetic agents ("gas") and narcotics, to attenuate spinal reflexes and endogenous catecholamine flood. The rationale is to normalize the donor hemodynamics to give the organ recipients the best chance at good function.



http://www.aana.com/newsandjournal/Documents/inhalational_0810_p293-299.pdf



http://www.clasa-anestesia.org/revistas/eeuu/HTML/Estados_UnidosThe_Anesthesiologist_And_The_Bra.htm



http://download.springer.com/static...552_90247daa5823c02ab7ab90bbf690a24a&ext=.pdf

Thank you for the links. I've book marked and will read later. Was going blind trying to read on my iPhone....gotta wait till I get home and my hands on my iPad


Sent from my iPhone using Tapatalk

 

[K_Z]

Again, if she were an organ donor, her heart would be cut out while still beating. Is that not gruesome? I don't see how c-section is any more disturbing to the OR staff.
If they can not handle this, maybe they shouldn't be working in OR to begin with.

Actual beating heart donation is in its infancy.

Typically, a stainless steel basin or pitcher of icy slush preservative solution is dumped directly on the beating heart. Exactly as is done in open heart surgery (with cardiopulmonary bypass, for the living patient). The combination of the slushy preservative, and the aortic cross clamp, produces a fibrillating heart, that rapidly goes into a still asystole. Then the heart is dissected out.

The irony in organ procurement is that blood pressure maintenance is critical to the success of abdominal organs, using pressors and other strategies. Those same strategies that help abdominal organs function better in the transplant recipient, directly have a negative impact on hearts.

As for the staff, typically an organ procurement team is from OUTSIDE the hospital where the brain death was pronounced, so there is no conflict of interest. No one is conscripted to be on a procurement team-- they know what they are getting into.

In MM's case, I doubt that a procurement team will be called in to do the hysterotomy. Regular staff will be used. And regular staff are accustomed to a vastly different goal for the mother-- a lifesaving goal, which is not the goal for MM's body. Even if they volunteer, I think this is a very traumatic situation for the staff.

The baby team will have no involvement with the care of MM, so it will be easier for them to compartmentalize the situation, and focus on the baby.

 

[K_Z]

Then they can do the c-section in exact same way they would do it on any other patient.

No. That is not what is going to happen, respectfully. This is not the same thing as doing a C-section on any other patient. Not by a long shot. MM's body will not have a beating heart when it leaves the OR. There is no PACU goal here.

There may be a few bland and sterile comments in MSM articles that MM was "allowed to die naturally", or "was removed from support once the baby was delivered." There will not be a single article describing what happened from the perspective of MM's body-- only the baby's. She will become invisible as soon as the cord is cut.

 

[jjenny]

No. That is not what is going to happen, respectfully. This is not the same thing as doing a C-section on any other patient. Not by a long shot. MM's body will not have a beating heart when it leaves the OR. There is no PACU goal here.

There may be a few bland and sterile comments in MSM articles that MM was "allowed to die naturally", or "was removed from support once the baby was delivered." There will not be a single article describing what happened from the perspective of MM's body-- only the baby's. She will become invisible as soon as the cord is cut.

Links? What is the basis for all these claims? While they don't have to close her up, it doesn't mean they won't. If she is an organ donor, her organs might still end up being donated (at least some of them). Why is that not traumatic but c-section is?

 

[K_Z]

Here is a medscape article about Perimortem cesarean delivery (in an extremely urgent scenario).

MM's will be planned, but usage of the broad midline incision is indicated. The purpose of a pfannensteil (bikini) incision in MOST c-section is both aesthetic, as well as preserving the uterus from a long midline incision (and lessening the incidence of future uterine ruptures, or placenta accrete-- which are life threatening). But a bikini incision is NOT the quickest or easiest way to get the baby out, and would not be indicated in a case like MM's.

http://emedicine.medscape.com/article/83059-overview

Laparotomy

Most young obstetricians perform Pfannenstiel incisions almost exclusively for cesarean deliveries; however, this is problematic in the setting of PMCD. The available equipment is likely to be minimal, the equipment is generally not neatly arranged, and a scrub technician probably will not be standing at the ready. Although many spectators may be present, none is likely to be of value as an assistant. Lighting may be poor and not deployable where needed within the incision.

Given these restrictions, a midline abdominal incision remains the appropriate choice for PMCD. The incision should extend from the level of the uterine fundus to the pubic symphysis. Rapid but careful dissection or incision should be made through all layers of the abdominal wall, including the peritoneum.

Hysterotomy

Gain exposure to the uterus. Use retractors to pull the abdominal wall laterally on both sides, and bluntly dissect down until the peritoneum is entered. A bladder retractor may be used to reflect the bladder inferiorly and gain better visualization of the uterus.

Closure

Closure should be based on maternal circumstances and the mother’s response to resuscitative efforts. If possible, closure should be performed in the operating room.

If the resuscitation team believes the mother has a chance of survival, a careful, layered closure should be performed. Attention to meticulous closure technique is vital because poor perfusion at the time of surgery may cause areas of bleeding to be inactive, which would then become active when circulation is restored. In addition, disseminated intravascular coagulation is a common sequela of massive hemodynamic challenge. Avoiding needless blood loss may help prevent or mitigate this condition.

If the mother’s condition is thought to be hopeless, then a rapid closure for purposes of aesthetics is indicated.

 

[al66pine]

While presumably they can do it the way you describe, nobody says they have to cut her open and not close her up. Why is it do you think they are going to just let her body bleed for hours? Yes, they don't have to close her up since she is already dead, but nobody says they can't do it.

BBM

Just guessing here waiting for the med or path'ist folks to ring in.

IF MM lives until the point where there is a C section, and IIUC, then
after C-section delivery, two things.
1. No private med ins, no fed or st ins/program will pay for further procedures, because MM is dead.
I imagine some OR team members would be willing to do some procedures to staunch bleeding/seeping, and close MM, etc.
But I dont think they may lawfully do so.

BUT more importantly
2. As soon as the baby is delivered, all/virtually all med procedures must stop.
MM was already dead before and her remains must be transferred to the MedExam'r.
As med folks here said, they need to leave tubes, ports, etc. in her, so ME can do proper exam.
MM is a 'coroner case.' Maybe med folks doing anything further would be deemed to be destroying evd?

MM's remains are not the equivalent of dept store merchandise,
which a store employee can generously gift wrap for free, as a favor for a customer.

I may be all wrong and await correction or clarification by the med/path folks or anyone else who knows. :seeya:

 

[DeeMarie]

No. That is not what is going to happen, respectfully. This is not the same thing as doing a C-section on any other patient. Not by a long shot. MM's body will not have a beating heart when it leaves the OR. There is no PACU goal here.

There may be a few bland and sterile comments in MSM articles that MM was "allowed to die naturally", or "was removed from support once the baby was delivered." There will not be a single article describing what happened from the perspective of MM's body-- only the baby's. She will become invisible as soon as the cord is cut.

I want to thank you so much for sharing you knowledge and giving us all a reality check on what is going to happen to MM.

 

[K_Z]

More links.

http://www.slate.com/articles/healt...tion_how_to_save_the_mother_and_the_baby.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3516125/

http://www.nytimes.com/2014/01/19/opinion/sunday/bruni-the-cruelest-pregnancy.html?_r=0

It’s not at all clear, for starters, that the fetus has a good chance of surviving inside the womb or of flourishing outside of it. In a study of a few dozen cases of continued pregnancies inside brain-dead women, only one of the five fetuses that were between 13 and 15 weeks at the time of the mother’s brain death was successfully delivered — by cesarean section — and kept alive, though the study tracked the boy only until 11 months after his birth.

BBM

 

[Karmady]

Here is a medscape article about Perimortem cesarean delivery (in an extremely urgent scenario).

MM's will be planned, but usage of the broad midline incision is indicated. The purpose of a pfannensteil (bikini) incision in MOST c-section is both aesthetic, as well as preserving the uterus from a long midline incision (and lessening the incidence of future uterine ruptures, or placenta accrete-- which are life threatening). But a bikini incision is NOT the quickest or easiest way to get the baby out, and would not be indicated in a case like MM's.

http://emedicine.medscape.com/article/83059-overview

So the situation described in the article wouldn't be anything like this scenario then, since there's no extreme urgency about it. It would be carried out in the OR with proper lighting and organized surgical implements, support staff, etc. I suppose they COULD do a vertical incision, which isn't unheard of in normal practice (my roommate from college has one and she isn't ancient), but they wouldn't have to. I had a tiny bikini line incision for an emergency c-section for placental abruption. My dd was out in literally minutes from being rushed to the ER to delivery. I marvel to this day how they got her out of that tiny incision under those circumstances.

jmo