Births of multiple complexity
By Jan Jarvis
The message that popped up on dozens of pagers at 8:52 a.m. that Thursday was direct and to the point: Code 5 QUINTUPLETS.
With those few words, months of meetings, drills, and planning worthy of a NASA space launch went into effect as UT Southwestern Medical Center prepared for the arrival of its first set of quintuplets – Will, David, Marcie, Seth, and Grace Jones.
Gavin and Carrie Jones had been working as missionaries in New Guinea when they learned she was carrying quintuplets during a trip to the United States. The family then moved to the Dallas area to live with her parents.
Their decision to entrust the birth of their babies to the medical experts at UT Southwestern was based on the Medical Center’s reputation as a leading academic center. They felt that UTSW, with its array of specialists from multiple medical disciplines and its experience in clinical care, was uniquely equipped to handle such a complicated and potentially risky delivery.
And they were confident it would provide the sophisticated postnatal care needed to address the lung, digestive, and other potential medical challenges the five tiny additions to their family might face.
Although the actual Code 5 alert went out shortly before 9 a.m. on Aug. 9, some members of the Code 5 Team had been busy for most of the preceding night. Nurses at St. Paul University Hospital had been closely monitoring Mrs. Jones – who was hospitalized at 26 weeks on July 27 and put on strict bed rest – after the 34-year-old mother started having contractions.
Despite a few health issues, Mrs. Jones’ physician, Dr. Patricia Santiago-Munoz, Associate Professor of Obstetrics and Gynecology, had been optimistic that the babies would not be born before 28 weeks. But at around 5 a.m., Mrs. Jones’ membrane ruptured. After that, things moved quickly as more than 50 UTSW nurses, respiratory therapists, lab technicians, pharmacists, physicians, and others prepared for the special delivery.
About 7 a.m., Aziza Young, Manager of the Neonatal Intensive Care Unit (NICU) at St. Paul University Hospital, went over the final details of the comprehensive plan she had been working on since she learned of Mrs. Jones’ pregnancy on June 24. On a wall calendar in her office, she had tracked every day since then. Now on Aug. 9, just 27 weeks and five days into the pregnancy, that day was here.
As she looked around the NICU one last time, knowing the Code 5 alert was imminent, Mrs. Young felt so peaceful that it startled her.
“OK,” she said to herself. “This is the perfect day. Bring it on.”
It Takes a Village
To get to this day, it took members of a team drawn from all areas of UTSW who kept their pagers on 24/7, sacrificed vacation days, skipped family outings, and planned their lives around an unknown delivery date.
For months, UTSW physicians from various disciplines had met regularly to go over every detail of the pregnancy and to prepare for the delivery.
Rigorous planning before the quintuplets were born made all the difference, said Dr. Rashmin Savani, Professor of Pediatrics and Division Director for Neonatal Perinatal Medicine.
“The drills, communications, and planning added up to a positive outcome,” he said. “That’s why the resuscitation at the time of delivery went so well. It’s a testament to the technology and expertise of the team at UTSW.”
Orchestrating the birth of five babies, all born at the same time but with different medical challenges, requires triple-checking everything and planning for anything, said Dr. Gary Burgess, Medical Director for the St. Paul University Hospital NICU.
“With five babies it’s tough,” he said. “You worry constantly about all the things that can happen.”
Quintuplets born at 27 or 28 weeks face enormous challenges. “Just being born too early puts them at risk,” Dr. Savani said.
To make sure the quintuplets had the best chance of a healthy delivery, it would take a village – the UTSW village, as many on the team are fond of saying.
“This was not a one- or two-person show,” said Dr. Santiago-Munoz, who cared for Mrs. Jones throughout her pregnancy and delivered the babies. “Everyone involved was a key player.”
Those players developed their own blueprint to follow as they prepared for the delivery. They obtained advice from physicians who had delivered quintuplets and practiced drills until they ran flawlessly.
Having physicians from multiple disciplines readily available to address any possible scenario played a major role in the success of the births.
To achieve a flawless delivery, everyone had to be ready at a moment’s notice, whether their job was to run specimens to the lab, prepare medications, or monitor mom Carrie Jones’ anesthesia.
Multiple births take a lot of manpower, whether they involve twins or quintuplets, said Dr. Charles Rosenfeld, Professor of Pediatrics, Anesthesiology and Pain Management, and Obstetrics and Gynecology.
Among the first decisions to be made were how to get the word out to team members and then get them to the hospital quickly.
Will Jefferson, Senior Information Resources Manager, decided pagers were the best way to alert the 128 staff members.
Tara Andrews, Operations Manager of Auxiliary Services, and Rashard Johnson, Assistant Vice President of Support Services at University Hospitals, devised yellow dashboard signs to allow team members on delivery day to park in any spot on campus.
The team then confronted the challenge of how to electronically pre-admit the babies so that once they were born, they could get their medications quickly. Sam Seeger, Lead Business Analyst/Architect; Xochilt Keller, Senior Business Analyst; Nedra Hennelly, Business Analyst Supervisor; and Lizette Lopez, Manager Patient Access Services, devised a way to admit the infants before their birth. That’s when things got complicated.
The system would allow only three babies with the same mother to be pre-admitted at the same time. The solution: admitting the babies as if they were adults, something that never had been tried before. By pre-admitting the babies as adults, the team would only have to plug in the date, time, and gender when they were born, Mrs. Young said.
Next came the biggest challenge – caring for five fragile babies.
The UTSW team knew the babies could face numerous chal-lenges from being born so prematurely. What they could not predict was which babies would need special equipment. So the hospital obtained five of everything – including oscillating ventilators that would keep the babies’ fragile lungs open and conventional ventilators if the more complex oscillators weren’t needed.
“We couldn’t guess that we might need two of one thing or three of another,” Mrs. Young said. “We had to have five of everything.”
In planning the births, the team knew it enjoyed the complete support of hospital and Medical Center administrators to obtain whatever was needed for the health and safety of the Jones babies.
To manage traffic flow on the floor of the NICU, color tape was used to create a “room” without walls around each bassinet. Everything associated with the infants, including charts and monitors, was color-coded for quick identification.
Drills gave team members the chance to practice their roles. One nurse would direct traffic as each baby was moved to the NICU.
“We looked at everything,” Dr. Burgess said, “even where people might trip.”
A nurse and a respiratory therapist would be assigned to take care of each baby exclusively throughout the process. Three physicians and two nurse practitioners also would be there.
“The goal was to be able to get from the birth to the NICU in an hour,” Mrs. Young said. “If we could do it in an hour, that would be good.”
The Big Day
When the Code 5 page went out across North Texas, Reynaldo Ray, R.N., was in the elevator at St. Paul University Hospital, headed to breakfast. Farida Minner, R.N., had worked the night shift. Convinced Mrs. Jones would not deliver that day, she left for a conference nearby. When her pager beeped, she immediately returned to the hospital.
Kathy Warren, R.N., was at home in Caddo Mills, some 60 miles away, when her pager went off.
“Normally, it takes me an hour to get to work,” she said. “I got here in 45 minutes.”
For Dr. Santiago-Munoz, delivery day arrived earlier than she had expected since the average gestation for quintuplets is 28 to 29 weeks. Earlier that week, she had canceled a trip to Disney World with her family, sending them to Florida without her. Although Mrs. Jones was stable and not expected to deliver that week, Dr. Santiago-Munoz took no chances.
“I would have stayed behind no matter how stable she was,” she said.
After being paged at about 5:30 a.m., Dr. Santiago-Munoz arrived at the hospital within 30 minutes. Although she hoped to delay the delivery, by 8:50 a.m. there was no postponing it. Mrs. Jones was prepped for a cesarean section as Labor and Delivery bustled with excitement.
Despite the tense situation, Dr. Santiago-Munoz remained steady when at 10:01 a.m. she delivered Baby A, followed by Babies B, C, D, and E. Within five minutes, she had delivered five babies.
Mrs. Young held the hand of father Gavin Jones and kept him calm throughout
“The daddy was very calm, and the mother, when she was wheeled in, was just as calm as could be,” Mr. Ray said. “Everything went so well, like well-oiled machinery.”
After the delivery, the babies were moved to an adjacent operating room before they were transferred, one by one, in their special beds to the NICU. Each personal team went with its baby. Instead of taking an hour to transfer the newborns, it took just 30 minutes.
The months of planning had paid off.
“You would have expected it to be chaotic, but it wasn’t,” said Jennifer Jarrett, R.N. “It was so smooth and organized.”
The pharmacy staff had medications prepared and responded as needed. Radiology technicians were already in the NICU when the babies arrived. Blood for the newborns was on standby. It took just 13 minutes from the time of birth to have all babies’ medical information and orders placed in the records system.
“Steroids, given to the mother prior to birth to increase the amount of surfactant and to help the lungs stay open, certainly improved outcomes,” Dr. Savani said.
All of the babies needed support breathing, and each has faced its own medical challenges. Indeed, one of the quintuplets has experienced serious breathing problems and remains under intense observation and care at Children’s Medical Center Dallas.
While babies born at 27 weeks usually face some health issues, often they are able to overcome them with time, Dr. Rosenfeld said.
During those critical first days of life, Dr. Burgess literally lived at the hospital.
“There was just too much going on, and I felt like it was important for me to stay,” he said.
“It was amazing how willing people were to help in every way,” Mrs. Young said. “Some came in on their days off, while others did not want to leave.”
Mrs. Minner said, “It was a once-in-a-lifetime experience. The kind of story you tell your grandchildren.”
After the babies were stable, and a meal was ordered for the family and staff, Mrs. Young realized that she might get a full night’s sleep for the first time since June 24.
“It was a good day,” she said. “I don’t think we should have done anything differently.”
When she was finally able to check her phone messages that day, Dr. Santiago-Munoz noticed a text from Dr. Robyn Horsager-Boehrer, Chief of Obstetrics and Gynecology at St. Paul University Hospital. Dr. Horsager-Boehrer had used her frequent-flyer miles to reserve an 8 p.m. flight to Florida for Dr. Santiago-Munoz, who before leaving for the airport, checked on Mrs. Jones and assured her she was being left in the best of care.
Much, much later that night, while the quintuplets lay in their beds, the doctor who delivered them finally was able to join her own two children in Orlando.
“I was able to surprise my daughters when they saw me in the bed next to them on Friday morning,” Dr. Santiago-Munoz said.
Following the quintuplets
Gavin and Carrie Jones have been remarkably open about the birth of their quintuplets. Since the moment they discovered they were having quintuplets, the Joneses have maintained a blog in which they have shared with the public extensive details about the pregnancy, delivery, and care their babies have received at UT Southwestern. They have discussed, almost on a daily basis, their personal trials and tribulations about the various medical conditions, procedures, and short- and long-term challenges inherent with quintuplets born at 27 weeks. And they support the idea of telling the story about the preparations undertaken to ensure the safe delivery of their babies.
To date their blog – http://www.gavincarrie.blogspot.com/ – has had almost 580,000 page views.
Dr. Horsager-Boehrer holds the Luis Leib, M.D., Professorship in Obstetrics and Gynecology.
Dr. Rosenfeld holds the George L. MacGregor Professorship in Pediatrics.
Dr. Savani holds the William Buchanan Chair in Pediatrics.