A day at the Bonn Frauenklinik!

Neonatal intensive care units (NICU or NIPS in Germany) started right after post world war 2. However, it wasn’t until the 1970’s that they became firmly established in all hospitals in developed countries. They have continued to evolve greatly since the 1970’s and now play a critical role in hospitals. I received the opportunity to get a first-hand look at a modern women’s hospital and NICU at the Uniklinik Frauenklinik in Bonn, Germany. The Uniklinik was first established as a private institution in 2001 and is currently responsible for the care of more than 1,700 newborns annually, of which about 80-90 very small preterm infants with a birth weight below 1,500 grams. The hospital deals with congenital malformations of which 100 are operated in the first days of life per year approximately 150 newborns. The clinic is both a hospital and research center and is known most noticeably for their research into Twin Transfusion Syndrome, pediatric infectious disease, and perinatal neuroprotection.

During my time at the Uniklinik two babies were born, each of them by caesarian section. I got the chance to see both from different view points. During the first C-section I was in the operating room and witnessed the entire surgery.  The first incision was a lateral cut made into the abdomen just above the bladder of the mother. A second incision was then made into the uterus. After that the amniotic fluid was suctioned out, first with a syringe and then by a suction tube. It was a definitely a surprise to me how much volume was in it. The baby was then delivered and the umbilical cord cut. After this, every layer was either stitched (innermost layers) or stapled (outer layers) back together. This surgery was slightly more gruesome than other ones I’ve seen because, due to the speed at which they need to get the baby out, the surgeon was less precise and careful during the whole procedure. By this I mean she literally used her hands and body weight to pull back the top fat and skin layer and to dig around and detach layers inside. Also, I couldn’t understand exactly what was going on because everyone in the operating room spoke German, but I believe there was a complication during the C section. Normally the mother is kept awake but is given a local anesthesia. Part of the way through the surgery when they had already stitched her part of the way up, the anesthesia must have made her nauseous and she ended up vomiting a couple time. This must have made some of the internal stitches rip out because unlike a normal C-section that is supposed to take 30 minutes or so to stich up, it took over an hour and a half.

For the second procedure I stayed in the room where the newborn gets its first examination immediately after birth. This viewpoint was a lot more enjoyable. Unlike the first child delivered who had a low respiratory rate and was therefore later admitted into the NICU, the second child was happy and healthy. In the check-up they helped him get out his first cry, trimmed the umbilical cord and looked at his respiratory and heart rate and color and counted all of his fingers and toes. Ten finger and toes later and they were wiping him off and wrapping him up an overwhelming amount of blankets. He was ready to go and off for his first visit with his mom. This was the first time that I had seen a birth or even a baby that was that new. People always sound cliché when they talk about “the miracle of life”, but it really was an unbelievably incredible and unexplainable experience to see the process and newborn that up close and personal.

After the C-sections I was taken back to NICU to shadow the resident pediatrician for the U2 check-ups (2 day-1 week after birth) of the babies born in the hospital. That day there were three babies there for examinations by Dr. Welzing. He explained how to read records, what to check for during the exam and how and why, tips for the check-ups, and he even let me and the other two students have a go at it. By the grace of God, the parents gave consent for three college girls to attempt to examine their newborns. It was a quick but extensive exam. He first did the things that he needed the child to be calm for; auscultation of the heart, lungs, and head (for a shunt that could lead to hydrocephalus). This was done after making sure to “protect himself” as he put it, especially with little boys. That point was greatly stressed to us. Next, the femoral pulse was taken for which Dr. Welzing had some tips also. The fatness of babies can make it hard to feel their pulse but they tend to occasionally pause their breathing and this is the time when it’s easiest time to get the pulse rate if you’re have issues measuring it. This is when we were handed the stethoscope and allowed to try it ourselves. Reflexes were then checked including the Babinski reflex (Big toes flex out and other out when stroked on the bottom of the foot), Moro (drop hand outwards with a sudden shift in position, also known as startle reflex), Galant (legs and hip swing to the side of touch application when stroked on the back), sucking, rooting, walking, and the Palmer grasp (Finger gripping). These reflexes check for normal development, especially normal neural development. Eyes and ears were checked for cataracts and hearing. Muscle tension in the arms and legs of the babies were tested along with their hips by pressing down on the feet when they were perpendicular to the hips and then splaying them out. This checks for whether they or easily dislocated (pop out when pushed down on) or if they already are (can’t be splayed out). Of course by this time the babies had had enough so he finished by administering the standard vitamins; Potassium to decrease the risk of bleeding and vitamin D with Fluoride to help bone formation He also stressed all the “ back to bed” points for SIDS which was interesting, especially after just having a whole presentation on it this semester.After the check-ups I received a tour of one of the units in the NICU. The children in the unit varied in the degree of their complications from just small size from prematurity and Down’s syndrome to a handful of children that had more extreme conditions. One of the doctors walked me and the two other German students through the room to examine and talk about the children’s conditions and the physical implications they had on the children.

            The first child examined had a diaphragmatic hernia. This is a defect that creates a hole in the diaphragm. This causes the abdominal organs to be shifted up into the chest cavity.  When it is congenital, as in this little boy’s case, it causes pulmonary hypoplasia (incomplete development of the lungs) and pulmonary hypertension (high blood pressure). Therefore, he suffered from a pneumothorax (one collapsed lung) and was on CPAP (continuous positive airway pressure) as well as ECMO (Extracorporeal Membrane Oxygenation). His condition has also led to other developmental issues. His x-rays showed that he was not only barrel chested but the diameter of his ribs were very thin compared to other normal neonatal x-rays making them more fragile and he continues to be an extremely small size despite his age (roughly 2 months if I remember correctly).

            Another one of the PreNates suffered from a rare (1 in 40,000) genetic defect called Prune Belly that results in lack of the presence of abdominal muscles. It is believed that this is due to an enlargement of the bladder and intestines. The enlargement prevents a development in the abdominals resulting in skin folds on the stomach (“pruney-ness”) for which the defect is named. This syndrome often goes hand in hand with undescended testes and kidney problems both of which the baby at the Bonn NICU suffered from. The complication meant that the child was receiving ECMO and jet ventilation along with many other treatments. Due to the extended ventilation he furthermore suffered from a bilateral pneumothorax (two collapsed lung). This is normal in prenatal children who lack adequate amounts of surfactant and for prenatal children that are forced to be on ventilation. The condition normally corrects itself as the child develops and is weaned of ventilation, but they had previously tried to take him off of it but within a few hours he was placed back on it. The list of complications is long, but when talking to the doctor’s they still thought the little guy had could have a chance.

The reason I was sent to the Uniklinik Frauenklinik was because of my interest in pediatrics. Although this was neonatal and not pediatrics it is the closest I was able to get. My trip to the center was fun and educational and greatly exceeded my expectations. I was finally able to integrate some of the things I have been learning in Physiology with real life situations which was awesome. On top of that I learned a great deal of things that you would never learn in a classroom or a textbook, but that only comes from experiences and talking to trained and practiced people. Dr. Welzing gave me many good examples of this. For instance he made sure to show and tell us to never leave the child during a check-up. He said that it happens more than you would think that doctors leave the baby for a second and he/she rolls of the examination table. It seems like a common sense and a simple thing to not leave the patient, but it’s something that I’m not sure if they always teach in the classroom. Then when you’re going through procedures you’ve learned in a textbook you don’t always take into account that now you’re working on a real person that moves around and has emotions. Another example from Dr. Welzing was to always keep a heater to warm your hands up with so the baby feels more comfortable and keeps a better temperament for the examination.

Besides just from an educational standpoint, I think this visit was a very important step in solidifying my career path decision. I was able to witness almost every process that occurs up to the point when I would be handling the child from the birth to the NICU of the sick/premature babies to the first in hospital check-up. While I enjoyed it, I am sure that the pediatrics is more suitable for me. Without a doubt NICU can be very rewarding. You get the chance to save babies lives and make parents and families extremely happy, but I do not think people can understand the extreme amount of physical and emotional stress that the doctors and nurses go through every week in that ward. Not only is it hard to watch such small, helpless babies hooked up to so many tubes and machines but it’s a hard truth to bear that despite their lack of life experienced yet, some of the babies hold no chance of survival or shot of living a full life no matter what you do. While I was there the ward got a call from the parents of the child with prune belly. He was one of a set of triplets and with the extensive problems that he was undergoing the parents had decided to request that the doctors stop treatment. This was both heartbreaking and upsetting to me especially since the doctor’s thought there could still be a chance. I felt this way and I had only seen the child for a few minutes. I cannot even imagine how the staff felt after personally taking care of the child for so long. There was definitely a different atmosphere throughout the ward after this occurrence. Sadly, this was not the first time this had happened that week. When another student went on Monday she was also told that a parent had just called to ask that treatment be stopped. I do not think I would be able handle, or maybe it’s just a matter of not wanting to handle, such high stress instances as often as those doctors do. While I understand that pediatrics may have its ups and downs and hard times, circumstances with such a large magnitude of strain and tension and pressure are few and far between compared to NICU. On the other side, spending time in the examination rooms felt right and almost natural for me. I loved interacting with families the babies and their parents and being able to talk and joke with the parents who were all on an emotional high with the arrival of their newborns. It was a completely different environment from NICU and interactions with the people and parents were almost polar opposites. The pediatric side of the ward was interesting and fun and I can confidently say that this experience has made me able to picture myself happy and thriving in that same position just a few years down the road from now.