Woman: 'Hello. Ambulance.'
(Man mumbles)
'Hello!
Man: Quick!
Why do you need the ambulance?'
'I'm dying!'
(Siren)
From the moment an emergency call is made... a clock starts ticking.
(Siren)
Doctors and paramedics are in a race against time.
Continue straight for 500m.
(Siren)
When you're looking after critically ill patients people talk about the Golden Hour, when the interventions you make and the treatment you start can make the difference between whether someone lives or dies.
Man: Guys, priority now is to go to theatre.
Right, come on.
There's no blood pressure though.
Come on, let's have a Kn*fe.
This series will countdown minute by minute... (Man groans) .. second by second, the life saving decisions made in the first hour of critical care.
It's vital we get there quickly and we try and reverse that dying process.
(Alarm)
Some babies are born in very poor condition and it could take seconds or minutes for them to die unless somebody intervened.
Emergency medicine is changing.
Every day those on the frontline are breaking new ground.
(Siren)
We are always trying to push the limits of what's possible.
Man: Let's go. On you.
From open-heart surgery in the street...
No pulse. Right, carry on. We're doing a thoracotomy.
We're going to open the chest and fill her up with blood.
.. to the intubation of newborn babies.
Many more babies are surviving conditions nowadays that five or ten years ago would have been impossible to imagine.
We can give some surfactant to try and minimise lung trauma.
(Baby cries)
These are the medics using cutting-edge science to save time...
We're really struggling here.
.. and to save lives.
You can't give up.
There's always a chance this patient might survive.
Never give up.
(Clock ticks)
Every year there are almost a million pregnancies in Britain.
And every day over 2,000 babies are born.
At least 200 of them will experience life-threatening complications.
(Siren)
Yet thanks to advances in neo-natal medicine, more babies than ever are winning their fight to survive birth.
This film follows the medical journey of three babies who need emergency care the moment they are born.
A routine birth that suddenly goes wrong.
(Alarm)
A baby delivered ten weeks premature.
And a newborn whose only hope of survival is surgery to repair a hole in her diaphragm.
All three are being treated at Leicester Royal Infirmary, home to one of Britain's largest maternity services and equipped to deal with the most serious neo-natal emergencies.
So that is the baby's... chest there.
Laura is 37 weeks pregnant.
Scans have revealed that her baby has a problem with her diaphragm.
OK, that's the baby's stomach within the chest cavity.
The defect in the diaphragm has caused the bowel to come up into the chest cavity The diaphragm is the muscle that separates the chest cavity from the abdomen.
Essentially, there's a hole in the diaphragm, which means that the bowel... can go up into the chest, filling the space in the chest.
If your bowel is up in the chest, then there's no room for your lungs to grow.
The bowel is squashing the baby's tiny lungs so much when she's born she may struggle to breathe.
This life-threatening condition is called a congenital diaphragmatic hernia.
Woman: The chances that they gave us originally were around 60%.
A bit later on in the pregnancy, they noticed the hernia was quite large and there was quite a lot in her chest, so I think it got to around 50/50.
It was our first pregnancy, so having the odds of 50/50 as to whether she was going to survive or not was... was quite a lot for us to take on board.
Laura's baby will eventually need surgery to close the hole in her diaphragm, but first she must survive birth.
Erm... so when the little one's born, my first job will be to put a breathing tube down into the airway to secure the airway and to protect the breathing as much as possible.
I mean, how soon would we know if the worst is possibly happening?
Erm, I think we'll have a pretty good idea within the first few hours.
OK.
In the antenatal clinic, Tahira has come in to see Consultant Obstetrician, Farah Siddiqui.
Just over seven months pregnant, she has a history of losing babies in the womb.
We know that you're an extremely high-risk patient, we know when things happen with you that it happens extremely suddenly.
I don't bleed, I don't get any of those signs, it happens in a couple of seconds, the baby's gone.
In the past her placenta has suddenly failed.
We don't know what exactly it is about the placenta which means it doesn't work or fails so... early on.
This is my eighth pregnancy.
I've got four children that are alive and then I've had three stillborn babies.
It seems that delivering early is the only way of actually enabling her to have a live baby.
I think it's brilliant that we got you to 30 weeks gestation.
I know from 24 weeks you've been having this pain.
We were quite worried about you at that point.
Some tissues, Tahira. Do you want some tissues?
Thank you.
(Tahira sobs)
Being born ten weeks premature carries risks of serious complications.
But with the baby in danger, Farah decides to deliver her as soon as possible.
With Tahira, the situation can change very, very quickly and very, very suddenly.
Hi, Jonathan, it's Farah.
Have you got any cots? Erm...
There was one time when we'd done a CTG monitor in the morning, and... by the time we actually transferred her to theatre and checked the baby's heartbeat in theatre, the baby had actually passed away during that time.
When you see other people's children, you think, "Oh, my kid would be at the same age."
I didn't want to have a stillborn baby again.
At the low-risk birth centre on site, midwife Harriet is worried about one of the mums she's looking after.
She came in with spontaneous labour about four o'clock this morning.
And then at... 9.45, I heard a D cell on this which I timed to about 70.
CTG's in progress.
And we're having D cells on the CTG with contractions.
Everything was fine and then the heart rate just dropped.
And my heart kind of drops as well when I hear a baby's heart rate drop.
Kirsty was admitted six hours ago expecting a routine delivery, but her baby is showing signs of distress.
A significant drop in heart rate means the baby can lose its vital blood and oxygen supply, risking brain damage or even death in the womb.
Kirsty, Laura and Tahira have reached a critical point in their pregnancies.
Now the survival of all three babies depends on the medical decisions and interventions made over the next hour of care.
Laura's baby has been diagnosed with a diaphragmatic hernia and is now being delivered by Caesarean section.
The baby's bowel has been pushed up into her chest, stopping her lungs from growing properly.
dr*gs we've got, Pancuronium.
Yes.
Whilst the C-section is happening, next door neo-natal consultant, Andy Currie, is preparing to intervene as soon as Laura's baby is born.
Yes, it's all ready.
The first few minutes are... risky for the baby, because we don't know what we're dealing with.
We have to assume this baby's lungs are very badly affected and at high risk of not working.
Whilst in the womb, Laura's baby doesn't need her lungs, as she's supplied with oxygen through the placenta.
As soon as the umbilical cord is cut, she will attempt to breathe for herself.
But her lungs may be so underdeveloped that she will struggle.
The lungs are very new, they're very small and they're very fragile, which obviously leads to significant problems from a respiratory point of view, and ultimately can lead to the death of a baby if they're very underdeveloped.
Nurse: Congratulations!
Laura has given birth to a baby girl.
But within minutes of the birth, Andy needs to stop her baby crying and even breathing for herself.
In a normal situation, when a baby's born you like to hear them having a good lusty cry to help expand their lungs.
In a baby with a diaphragmatic hernia, we don't want that to happen.
It's a little girl.
(Baby cries)
When babies are born, they generate very high pressures in order to inflate their lungs.
But in a baby who's got underdeveloped lungs, they may be very small, those forces could actually be too great and they might actually cause the lung to pop a hole and the lung to collapse.
The only way for Andy to protect the baby's lungs is to stop her breathing as soon as possible.
(Baby cries)
The injection we give is a muscle relaxant.
And this stops the muscles working, so the baby can't breathe for herself.
Once the drug paralyses the baby's muscles, she will no longer be able to draw oxygen into her body.
The team have just moments to insert a tube into her windpipe and connect her to a ventilator.
(Sucking noise)
More than 100?
Hmm.
OK.
Are we giving oxygen? Are we giving oxygen?
We're in air at the moment.
By controlling the ventilator, Andy can regulate the volume and pressure of air in her underdeveloped lungs.
So her tube is at 9.5.
Sats are 91. Heart rate's 156.
And with the breathing tube in place, Andy can also reduce the risk of air going into the baby's bowel.
That's fine.
We have a baby who has got stomach and bowel in the wrong place in her chest.
Often they will swallow a lot of air into their bowel as well, so they will start to inflate their stomach and the bowels inside the chest, and that will just put even more pressure on the lungs.
Is it a girl?
A girl. A little girl.
And eventually, if that was allowed to persist, she would effectively suffocate.
Does dad want to come and say hello?
Yes, he does.
I don't know.
Do you want to see if dad wants to come in?
Can he come now? Yep?
Yep.
Right, this is dad.
Ah, here you are.
Come and see your daughter.
Hi.
OK?
Yeah.
Let's find a hand for you.
There we go. Want to hold her hand?
Thank you.
Congratulations.
Now, you see she's not moving very much at the moment, cos we've given her something just to relax her.
Yeah.
Has she got a name? Evelyn Rose.
Evelyn.
Evelyn Rose, OK.
It was difficult knowing that my child may not actually come out of that room alive.
Well, congratulations.
Thank you very much.
That was... petrifying.
So... you'd been through this whole pregnancy and told what to expect, but actually you didn't even know if she'd be strong enough to even survive getting up to the neo-natal unit.
Do you want to come around this side?
Evelyn still needs an operation to fix the hole in her diaphragm.
And until her fragile lungs are assessed, no-one knows if they will be able to cope when she breathes for herself.
For most of these parents going through this, the most obvious fear that they'll have is, is their baby going to live or die?
And we can't give 'em that reassurance.
Upstairs on the delivery suite, Kirsty has just been transferred from the low-risk birth centre.
Just going to have a feel of your tummy, if that's all right?
Yeah.
She's being monitored closely by Senior Midwife, Kerry Hewitt, as her baby's heart rate has started to drop significantly.
The baby's heartbeat was going down quite low.
I think it was at around 49 beats per minute at one point.
A normal foetal heart rate should be well over 100.
Are you getting a contraction now?
Yeah.
Do you want to go onto your left side for me?
Just slow onto your left side slightly. See if I can...
I turned the lady onto her left side, because obviously the heart rate had dipped down.
If the woman's lying on her back, the weight of that uterus and that baby can press onto one of the major blood vessels, which is then stopping the oxygen through to the baby.
Birth Asphyxia, or a lack of blood and oxygen during labour, can cause permanent disability or even death.
You can't see what's happening inside that woman's body.
You don't know why that baby's heart's dipping down, you just don't know.
It's not normal to hear a baby's heartbeat dip like that.
(Monitor beeps)
This FH has gone right down again.
But turning Kirsty on her side doesn't solve the problem.
If you think anything deviates from the normal, there's no time to mess around, we just have to get that help in there and act on it as soon as we can.
Yeah, it's been down a while now, you need to get 'em in.
It's all right, we're going to get a few people in.
Kerry calls for consultant obstetrician, Farah Saddiqui.
Come in.
Erm... here I did think it was maternal pulse, but the FH did just go down to about 49 and it stayed down for about three-plus minutes, I'd say.
Hi. My name's Dr Siddiqui. I'm one of the consultants.
Is it OK if I just examine you?
Yes.
If the baby's not coping with the labour process and I'm concerned about the baby's wellbeing, then it's important that we deliver the baby urgently within the next 30 minutes.
Nine minutes ago, Tahira was brought to theatre.
Her baby is being delivered ten weeks premature, because the risk of her continuing the pregnancy is too great.
Tahira has already lost three babies in the womb, each time because the placenta has stopped working.
Despite extensive investigations, doctors cannot explain why.
There's a little bit of a bleeder there.
(Indistinct chatter)
A team of neonatologists are standing by, led by consultant Jonathan Cusack.
Any baby born prematurely is in danger.
We've got an ET tube out already, although the baby's 30 weeks gestation so may not need to be intubated.
Annie, do you want to be the person listening for heart rate and things?
Yes.
Being born prematurely is associated with a number of significant long-term complications.
They can be related to the lungs and importantly related to the brain, things like neuro disability are much more common in pre-term babies.
Tahira already has three children that were delivered prematurely, one of whom suffers from cerebral palsy.
Intervention in the first few minutes is absolutely critical.
What happens can make a difference between having a good outcome, so going home alive, or having a poor outcome, either dying or having a significant disability.
All right.
OK?
Hello, little person.
Ten weeks early, Tahira has a baby girl named Alyssia.
A baby girl.
The first risk to her life when's she's born is the risk of getting cold.
A baby born at 30 weeks gestation has very immature skin and it doesn't work very well as a barrier.
You can lose a lot of moisture through the skin and a lot of heat very quickly.
Hello, baby girl! Pop you in there.
One of the best ways to keep a baby warm is to put them into a plastic bag to minimise the loss of moisture and heat from the skin.
Erm... and green arm switches, please.
Without the bag, 30-week-old Alyssia will start to become cold and dehydrated.
Good.
Thank you very much.
(Baby cries)
(Baby cries)
(Indistinct chatter)
The plastic bag buys Jonathan time to assess premature Alyssia.
At just under 1.4kg, she's less than half the size of an average-term baby.
(Baby cries)
(Baby grunts)
But after her first cries, Alyssia's breathing suddenly changes.
She starts grunting, a sign that she's struggling for air.
(Baby whimpers)
I'd give some inflation breaths, her breathing' not quite as good as it was.
(Monitor beeps)
I started to give some pressure to the lungs, doing that with a mask.
And that's a way of partly inflating the lung, which makes it much easier to breathe.
(Monitor beeps)
It works on the same principle as a balloon.
When you blow up a balloon, you have to put quite a lot of effort in to start blowing up the balloon and then it's much easier to move it in and out.
And the lung is exactly the same.
(Indistinct chatter)
OK, the sats are in the 80s now, going up into the 80s.
We've got a good heart rate. So let's transfer her into the transport system whilst we've got good saturations.
Yep.
And then go up to the unit.
Alyssia needs to go to the intensive care unit.
She's grunting a bit now. You can hear the grunting.
But before Jonathan has time to move her, her breathing suddenly deteriorates again.
(Baby cries)
It's quite a significant decision.
Yeah, we are needing to rush at the moment, we're just... giving her a very few minutes to decide if she needs respiratory support for going to the unit.
She's grunting and we've got a bit of recession now.
We had a difficult decision.
I didn't want to move her at a time when she might be getting worse.
She might deteriorate suddenly in transit, so sometimes pre-term babies will just stop breathing.
You don't want that to happen in an uncontrolled environment.
OK. So, rather than risking things getting worse on the way, cos she's got worse over the first 5-10 minutes, so why don't we put a tube in now, intubate now.
(Baby cries)
OK.
Intubating premature baby Alyssia, will make it safer to transport her...
We've got good sats and a good heart rate.
.. but it's not without danger.
(Baby cries)
There are risks associated with intubating a pre-term baby, the tissues are more delicate and the distances are much smaller.
It's technically challenging.
That should be it.
OK, do you feel comfortable with that?
Yes.
So hold the tube.
To supply both lungs with air, the tube must sit just above the point where the windpipe divides into two.
I think she's breathing round the tube at the moment.
We might just check this tube position in case it's slipped out.
I'm getting some sounds on the right, nothing on the left.
Do we think it's slid too far down?
It sounds like it.
But just as Jonathan and his team have the tube in place, Alyssia's coughing dislodges it.
Back again. Let's have a listen.
The distance that you're talking is only half a centimetre or so, the distance between being in the right place and being in the wrong place.
Let's have a listen.
(Baby cries)
Let's lose the tube.
(Monitor beeps)
We've lost entry. Mask, please.
As Alyssia is now not getting the oxygen she needs, Jonathan must start the process again... costing valuable minutes.
Saturations and heart rate, please?
Heart rate 192, sats of 80 now.
(Indistinct chatter)
On the delivery suite, Kirsty's unborn baby's heart rate keeps dropping to dangerous levels.
That did sound like it was...
Once you had the contraction, it went down to a maternal pause.
But that last one, it definitely was FH.
OK.
My concern at this point was that the baby's heartbeat would go down, and rather than recovering between the contractions may actually stay down.
And that can cause brain damage and it can cause the baby to die.
It dips down to about 106 and then it just...
What now?
(Indistinct chatter)
When she had another contraction there was a further deceleration in the baby's heartbeat.
The baseline had been about 120 and it dropped to less than 60, which is quite concerning.
Just hoped that when I had a contraction, it would just stay the same, but it didn't, it just kept going and then coming back even lower than it was before.
At this point, I thought there might be a problem with the baby's cord, that the cord was being compressed by the contractions.
The cord can get between the baby and the uterus and, basically, be squeezed.
(Monitor beeps)
The blood going from mum to the baby during a contraction can be stopped.
In the womb, the cord connecting the baby to his mother is his only oxygen supply.
I'm concerned that the baby's oxygen levels are dropping.
(Monitor beeps)
But as soon as Farah leaves the room... the heart rate drops again.
Not knowing what was going to happen was... the scariest part.
But then they pressed that button and well...
(She laughs)
(Alarm)
Midwife Kerry presses the emergency buzzer to alert the entire team.
(Hubbub)
Oh, you need to go to theatre, OK.
(Alarm)
(Indistinct chatter)
The baby's heartbeat was still decelerating quite significantly.
And, therefore, I felt that a delivery by Caesarean section should be the next step.
Are you OK?
I ensured that the neo-natal team were bleeped, so that they were present for the delivery, because the chances were that the baby will need resuscitation.
Born ten weeks early, premature baby Alyssia is struggling to breathe for herself.
Jonathan is trying to connect her to a ventilator, but Alyssia is very small and the breathing tube has become dislodged.
I see it spasm a little bit there.
Every minute counts when you're born prematurely, because if you don't get the oxygen to the baby's brain, you'll get brain damage relatively quickly, over kind of... minutes if the oxygen levels are very low.
OK, that looks good.
That's lovely.
OK.
Sats at 76.
Thank you.
Let's just go upstairs.
So we're going to move across.
OK, are you ready?
Yes, ready.
OK, door down, please.
OK. Thank you.
Come on. There we go.
With the tube reinserted, Jonathan can control the amount of oxygen Alyssia receives.
Sats are a little bit low.
Can we turn the oxygen up a little bit to 30%?
But it's a delicate balance.
You want to give enough oxygen to get her saturations into an acceptable level.
Turn the oxygen down a bit.
But oxygen itself can be toxic.
OK, that's fine.
We weren't designed to be breathing high amounts of oxygen.
Particularly in pre-term babies, we know that excessive oxygen can be harmful for the lungs and may worsen your chance of getting chronic lung disease.
It's 31 now.
That's fine, good.
Jonathan has got Alyssia's oxygen levels as stable as he can, but as she's ten weeks premature, he knows her situation can change without warning.
On the Intensive Care Unit, it's been 30 minutes since baby Evelyn was born with severely underdeveloped lungs, due to a hernia in her diaphragm.
Hello, child.
Are you starting to wake up a bit?
We don't want you waking up.
She needs to be kept paralysed so she doesn't try to breathe for herself and damage her lungs even further.
She's starting to move a little bit.
(Monitor beeps)
Can I have... a three-way tap?
Thank you.
The drug I gave in the resuscitation room helped to paralyse the baby, but it will start to wear off after several minutes.
What I don't want is this baby to start waking up and certainly not fighting a ventilator and breathing against the ventilator, cos this baby's lungs are very delicate.
And if that were to happen, then I... we could actually end up with a baby with collapsed lungs.
OK?
Andy and his team need to provide a reliable way to give baby Evelyn the medicine she needs to stop her moving.
With newborn babies, we've got the umbilical cord which has recently been cut.
In the umbilical cord, you've got two arteries and one vein, so we can use those to get dr*gs into a baby relatively quickly, which is much more effective than having to give them through a canula in the back of a hand or in a foot.
It's a very delicate thing to do.
If you are... too forceful, you can very easily tear the lining of the artery or the lining of the vein and the catheter will end up going into the wrong place.
Got it?
Yeah.
OK.
(Monitor beeps)
OK?
Uh-huh.
All done.
OK.
With secure lines placed in her veins, Evelyn's muscles will be kept paralysed and she will rely on the ventilator to breathe for her.
But to survive long term, she needs a major operation to remove the bowel from her chest and repair the hole in her diaphragm.
What I need to know is just how strong those lungs are going to be before putting a baby through surgery.
If the lungs are not working, then no matter what sort of surgery you do, you're not going to be able to make those lungs better, because they will be too underdeveloped to sustain a life long-term.
Born ten weeks early, premature baby Alyssia has arrived on the Intensive Care Unit.
We've got a nearly 31-weeker, a tube went in, she's got active and the tube got dislodged, so she's had... a second tube.
(Monitor beeps)
But neonatologist, Tamanna Moore, is worried her oxygen levels have dropped since she left the resuscitation room.
She's hitting 20 and not achieving.
We not getting very much at all, why is that?
I don't know.
Something had happened to her between delivery and admission to the Intensive Care Unit.
Those oxygen levels were fine when she left the delivery room, but by the time she's got to intensive care, minutes later, her oxygen levels were low, at 60%.
She's nasal flaring, she's got some subcostal recession.
We needed to work out quite quickly where the problem lay.
(Monitor beeps)
Much better air entry on the right than the left.
I listened to her chest and could only hear the air entry going into one side of her chest and not into the other.
Where are we at the lips and where are we supposed to be?
We were... It was sitting at about nine.
I think we've slipped down cos we're louder on the right, so I'm going to pull this back a little bit, cos it looks like it's ten at the lips now.
Yeah, it probably has slipped Tamanna can tell that air is only getting into one of Alyssia's lungs, a clear sign that the ventilation tube has slipped again.
The risk of you just inflating one lung and not the other is that you're not delivering enough oxygen to the baby.
Half a centimetre either way could make that breathing tube go down into one lung instead of into both.
That's it.
The longer it takes to get her breathing stable, the more she is at risk of long-term brain damage.
Her sats are in the 80s now.
Sounds better than it did.
Equal both sides?
Yeah.
After adjusting the tube, Alyssia's oxygen levels have come back up.
But she will always struggle to breathe until her lungs mature.
At only 30 weeks old, they lack a vital substance naturally produced by the body called surfactant.
Surfactant works like a lubricant and it stops the air sacs in the lung collapsing and closing.
So if you are deficient in surfactant, you're lung is quite stiff and it's much harder to breathe, you take much more effort to breathe.
Let's give some surfactant now. Is the surfactant warm?
(Monitor beeps)
The surfactant that we gave her is one of the things that's revolutionized neo-natal care.
Babies that have got bad respiratory distress are twice as likely to survive if you treat them with surfactant versus if you don't.
Surfactant... it's one of those medications where you can see an improvement before your eyes.
Gradually her work of breathing decreased a little, but more quickly that pressure that the ventilator was delivering came down and down as it became easier and easier and easier for her lungs to inflate.
She's not needing any additional oxygen, she's breathing well above the number of breaths that the breathing machine is giving her.
So it's looking good.
Although Alyssia is now getting surfactant, she is still incredibly vulnerable.
It's easy, I think, to forget that she's ten weeks early, that her lungs are small, that her stomach and her intestines are small and underdeveloped, that her skin is thin and fragile and she's at high risk of infection, and that her brain is not as developed as it would be if she'd born... at a later stage.
(Monitor beeps)
(Indistinct chatter)
Kirsty has been rushed to theatre because her unborn baby's heart rate has been dropping dangerously low.
Obstetrician Farah is concerned that the baby's not getting the steady oxygen supply he needs through the umbilical cord.
Two little ones, please.
There have been cases of babies being brain damaged as a result of lack of oxygen during labour.
Neo-natal doctor, Razi Paracha, has been called to the delivery.
We need to be ready for the worst case scenario of if this baby needs intervention and is very poorly when it comes out.
Cord tight round the neck.
The cord was quite tight around the baby's head, and you could actually see that the baby's head was quite red, cos it was obvious that the blood had actually been trapped into the baby's upper circulation.
Just as Farah suspected, the umbilical cord was being compressed, reducing the oxygen supply to Kirsty's baby and causing his heart rate to drop.
When the baby's oxygen levels have fallen, it's the build-up of carbon dioxide and lactic acid in the baby's circulation that suppresses the baby's respiratory centres.
And it can mean that the baby may not be stimulated to take the first breath.
(Monitor beeps)
When the baby was first delivered, I noticed that he was quite floppy.
He looked quite blue and wasn't showing an awful lot of movement, he wasn't making an awful lot of respiratory effort.
I just... needed to get him in to the neonatology team.
He didn't cry straight away.
Any meconium?
No.
I just remember the midwife taking him into that room.
Just time seemed to stop, sort of thing.
I didn't hear him cry when she said he was out.
I couldn't hear him cry and that was the worst bit.
I know with this baby, I need to get the breaths in and get oxygen in as soon as possible.
The breathing was... There was some effort but it was irregular.
Over 100?
Yeah.
To get those lungs inflated, get some oxygen in, I deliver air with some pressure into the... into the mouth and nose.
You're just waiting to see that baby respond to what you're doing and make that effort to breathe.
(Baby cries)
(Monitor beeps)
That's it. There we go!
(Baby cries)
Excellent.
Do you mind if I have a quick listen?
Of course not.
Thank you.
Excellent.
Gorgeous.
Off you go.
For the last 60 minutes, doctors and midwives have fought to keep three babies alive.
The decisions made in this first hour have given them the best chance of survival.
For one family, the battle to survive birth has already been won.
That's the best thing, I think, seeing that family together for the first time.
Whether it be a normal birth or whether it be a section, all I wanted was to make sure that that baby was safe and that their little family was safe.
I've got him.
But for Evelyn and Alyssia on the neo-natal unit, the fight for life is not over.
Doctors have kept them alive through this critical first hour.
Now premature baby Alyssia needs ongoing intensive care to help her breathe.
And baby Evelyn is waiting for a vital operation to fix the hole in her diaphragm and remove the bowel from her chest, which has stopped her lungs from developing.
For the moment, her underdeveloped lungs are supported by a ventilator.
Andy can now assess how much damage the bowel in her chest has caused and whether she will ever be strong enough for the life-saving surgery she needs.
4.4.
The right-hand side here, the dark area here, this is the right lung, which looks a good size actually.
Whereas on the left side, you can see this very white area, and this is the left lung here.
Very small triangle, the dark patch there.
So the left lung is very underdeveloped. OK?
And what we're seeing here, all this white, a lot of this will be bowel that's up in the chest.
With such fragile lungs, Andy needs to manage Evelyn's ventilation carefully to avoid catastrophic injury.
We are going to have to rely on this right lung for her ventilation, cos the left lung is so small it's not going to do very much.
And if we start trying to ventilate the left side too much, there's a danger that we might actually cause an air leak, so that the lung will actually collapse and we'll get air leaking out into the chest, which will only add to her problems.
My job is to support this baby's breathing, support this baby's circulation, and to give this child's lungs a chance to expand and to see how well they work, cos that's going to dictate whether we would go through with major surgery.
If these lungs are too underdeveloped, then no amount of surgery is going to fix that.
(Monitor beeps)
Hello. Hello.
Hello.
It's Dr Currie.
So we've... put her on a ventilator.
Yeah.
We've given her some medicines to sort of relax her, a muscle relaxer, and she's not needing a lot of ventilation.
OK? It's still... very early days, all right?
Yeah.
And then we're just going to have to see what happens over the coming hours.
Yeah. I know we've got a long way to go, but it's a good start. Yeah.
Before we do any surgery, we have to be really sure that the lungs are going to be OK and they're going to work well.
Yeah, that's fine.
So these next few days are going to be very critical for her.
Yeah.
I was hesitant about wanting to reassure the parents too much, because I've... I've seen children where everything seems fine to start with and then after a few hours you then start to see the complications develop.
Tahira has come to the neo-natal unit to be with her daughter who was born prematurely at 30 weeks.
It's been nine hours since baby Alyssia was delivered, but she's not yet stable enough for Tahira to hold in her arms.
Alyssia was under 3lb at the time when she was born and she had to be ventilated and everything.
As a parent, we're on the sideline, we're just watching.
You do want to get involved, but there is nothing you can do at the time.
They're doing their bit to make sure that your baby goes home with you.
Alyssia is still on a ventilator, but neonatologist Tamanna must now decide whether she's strong enough to breathe on her own.
Taking this baby off the ventilator is a decision that's not to be taken lightly, but it's also important to do it as soon as possible, because it still involves having a piece of plastic in that baby that's an infection risk.
And giving her too much support on the breathing machine can cause lung damage.
Her gases are good.
Sugar's fine as well She's got low pressures, her rate's 35, she's got a good rate. She's in air, saturating at 99.
I think we should take her off, don't you?
Yep.
Do you want to put the mask on and get a seal?
Yeah, we've got a decent seal there. Do you want me to take the tube out?
Yep. I'll untie on this side.
Thank you.
I'll put the pipe here.
Come through here.
(Monitor beeps)
OK. Yep. Ready to go?
Yep. Uh-huh.
Very good!
That's it.
Is she breathing?
(Monitor beeps)
Yeah! Good girl!
There you go.
With the help of a little pressurised air, Alyssia is managing to breathe for herself.
But whether her prematurity has affected her in other ways remains unclear.
Good girl! There we go!
Getting through the first hours is really important and she responded well, but we still don't know the long-term consequence of being born prematurely and there are some of the complications that only happen later, things like haemorrhage, particularly in the first 72 hours of life.
This is the hardest thing I think a parent could go through.
Your FPTT is fine.
Your INR is all right.
Those look OK.
The blood gases look fine.
The settings are very, very minimal.
Baby Evelyn has been closely monitored for the last two days.
Neonatologist, Dr Akuma, must now decide if she's strong enough to survive a major operation to remove the bowel from her chest and repair her diaphragm.
These babies... are usually very sick.
They are one of the sickest babies we come across.
Did we pull that ET tube up?
The first decision I have to make on a child like Evelyn is... should we go ahead and give her surgery?
Is her lungs telling me the story that, "Yes, if you help me, I will do this job long term?"
I looked at the amount of help I'm giving Evelyn, which was very minimal.
My conclusion was that Evelyn...
Evelyn's lungs have the capacity after the surgery to support her to live.
So I've examined her. She's... she's very peaceful there as you can see.
I think that she's in a very good condition to have surgery.
It is most likely that we will get her to theatre today.
And then she will then start the next phase of the journey.
Evelyn's lungs are looking strong enough for her to undergo surgery, but the procedure itself carries risks.
Anything can still go wrong.
In the process of surgery, you could damage those organs that you are trying to bring back to their normal location.
And... Evelyn could bleed to death.
Just two days old, baby Evelyn is taken down to theatre.
Surgeon Bharat More will now attempt to close the hole in her diaphragm and delicately move the organs inside her chest down into her abdomen.
So you can see that that's all small intestine which is in, so all the abdominal content including spleen is all in the chest.
The part I had to be most careful with was the spleen, because the spleen has got a very delicate blood supply, so you have to be very careful that you don't cause any bleeding.
Spleen is out, yeah.
With the abdominal contents moved, Bharat can now focus on repairing Evelyn's diaphragm.
So there is the two ends we want to join together.
OK. Get three or four ready.
(Indistinct chatter)
I'm going to start tying that.
By pulling the sides of the existing muscle together, Bharat manages to close the hole.
So you can see the diaphragm going up and down.
And then I'm slowly going to put this...
This is the stomach that I'm going to put... I'll just push here.
Until neonatal surgery for diaphragmatic repair was introduced in the 1980s, it was rare for babies with this condition to survive.
It's not used to all that in the abdomen, that's the idea.
Well, it was in the chest.
Yeah. So it's new for it to go in the abdomen.
She's stable, isn't it? So...
Yeah.
Once Evelyn recovers from her surgery, doctors can reduce the medication that is keeping her muscles paralysed.
The hope is that her lungs will be strong enough for her to survive when she starts breathing for herself.
(Monitor beeps)
Nurse: Happy tears this time.
(Nurse laughs)
Baby Alyssia was delivered ten weeks early because of her mother's failing placenta.
But she has survived her first three days of life outside the womb.
Jonathan is about to scan her brain to see if her prematurity has caused any long-term impact.
There's two things you look for in a head scan.
In pre-term babies, sometimes you get a haemorrhage into the fluid-filled spaces in the brain called ventricles.
The other thing is you can look at the brain tissue itself to see if it looks bright, which you sometimes get if you've had damage to the brain from low levels of oxygen.
Premature babies have a brain that hasn't fully developed yet and the blood vessels in the brain are very delicate and they're prone to bleed.
Three of Tahira's other children were also born prematurely, and one now has cerebral palsy.
All of the interventions we've done, putting her on a ventilator, putting a tube in, all change the blood pressure.
And swings in blood pressure can affect the blood supply to the brain and that seems to be one of the things that leads to haemorrhage.
So on that view there, you can see the skull round the bottom, this is brain tissue and these black spaces here are the ventricles.
We can look... You basically scroll through and look at the brain from a range of different views.
(Monitor beeps)
That's good. That's excellent news.
Of course, we don't know for sure how any baby's development is going to progress and that's something we'll need to keep an eye out for.
But at the moment, I'm very optimistic that things have gone to plan.
She's got a normal head scan and her chances are very good.
It's been two days since baby Evelyn had surgery on her diaphragm.
Her paralysis medication has been stopped and she's starting to move.
Air entry is better on the right compared to the left, as we'd expect.
Neo-natal doctor, Daniel Bronnert, must now test Evelyn's lungs to see if she can breathe on her own.
So we'll come down to nine with an aim to extubate... this morning, hopefully.
When we come to take Evelyn off the ventilator, it's not guaranteed that she'll be able to breathe without it.
The only way of really finding that out is trying her.
For Evelyn, that's a pretty major step, she's working with one and a bit lungs essentially, so we need to see whether she can manage with that.
Everything had led up to this big dramatic moment of, "Is she going to be able to breathe for herself?"
And there was that thought in the back of my head that if she couldn't, everything that we'd already been through and that she'd already been through was almost for nothing.
Saturations are fine. Heart rate's fine.
Good girl.
And she's looking very comfortable at the moment.
There was a bit of muck in the tube, but...
That moment that she could take her own breath meant that everything we'd been through before that meant something.
It meant that we probably would actually be able to bring her home.
So it was really important.
Aw. Oh, dear!
(Baby gurgles)
Oh!
Baby Alyssia's done really well.
She doesn't seem to have long-term lung problems, it's very reassuring that she's got a normal head scan.
If she'd not had intervention, particularly in the first few minutes, she was showing some quite significant distress in her breathing, she may well not have survived.
Every premature baby is individual, you don't know what's going to happen.
But if she wasn't delivered early, I don't think I would have a baby, to tell you the truth.
When I held Alyssia the first time, it's like you've got peace.
All the bad things, they kind of vanish and you're just looking at this baby.
And you just kind of... fall in love.
Whatever problems that she has in the future, I think I can fight them on my own... with my daughter.
Hey.
The doctors and nurses were brilliant.
And if them doctors weren't there, then... our baby might not have been here.
The best moment was when we got to take him home, really.
That was the best moment ever.
Didn't get a wink's sleep all night, cos we just couldn't take our eyes off him, could we?
No.
He's there as if... as if nothing's happened, really.
(Baby sneezes mum laughs)
He's smiling now as well, which is lovely.
If we hadn't intervened in the way we had in those early minutes of life, Evelyn wouldn't be with us today.
She would have d*ed because of the size of the hernia she had, her lungs would not have been able to cope.
Mwah!
Evelyn's done fantastically well.
She will always have lungs that are underdeveloped compared to other people, and certainly her left lung will probably always be on the small side, but they will grow and there is no reason to think that she shouldn't have a good life ahead of her.
Aw.
I remember Dr Currie saying to us that she'll probably never run a marathon, and after everything she's done when she runs that marathon, I'll probably send the video to Dr Currie to show him what she's done.
Next time...
Stay on this main road.
A young mother's heart suddenly stops and doctors race to find out why.
Can we just quickly roll her just to make sure we are not dealing with a stabbing?
A 26-year-old man suffers a serious brain injury.
A 26-year-old male driver with front impact RTC.
And a cyclist is left fighting for her life after a collision with a lorry.
So it's pelvis and which leg?
So that femur's gone.
Yeah.
02x02 - Surviving Birth
"An Hour to Save Your Life" is a medical science series exploring the life or death decisions facing doctors in the first critical hour of emergency care.