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“Is there a doctor on board?” These are words every young doctor fears. During their intern year, Dr. Amine Sahmoud, an OBGYN resident, delivered a stillborn, pre-term fetus to another passenger in labor on a transatlantic flight. Dr. Kaitlin Payne interviewed them regarding their emotional and terrifying experience.

What was the situation leading up to the delivery?

About halfway through a transatlantic flight traveling from the Middle East to the United States, an overhead announcement called for a doctor, initially in Arabic and then in English. At first, I hesitated to respond. However, shortly after, I noticed a woman in distress, clutching her abdomen as she moved towards the back of the plane. I became concerned, and I approached a flight attendant to get more information. The passenger was pregnant, and another passenger, a med-peds intern, was already attending to the patient. I introduced myself as an OBGYN resident, and he visibly relaxed. We were the only two physicians on the plane.

Who was the patient?

The patient was a young woman in her late teens and this was her first pregnancy. She was uncertain about her gestational age, suspecting she was around 6-7 months. She had a family member present who assisted with her medical history. Her water had already broken, and she was experiencing frequent, painful contractions. The other physician on board had taken her vitals, noting an initial systolic blood pressure in the 200s, followed by a reading in the 110s. Fortunately, I spoke some Arabic, her first language, and calmly explained that we needed to perform a pelvic exam to assess the stage of her labor.

Walk me through what happened next.

Taking charge, I followed the steps ingrained during my recent labor and delivery rotation. We asked the patient to lay across the seats in the middle row at the back of the plane, ensuring privacy with draped blankets. A flight attendant shined a cell phone flashlight behind me. By the time I performed the pelvic exam, she was fully dilated and the head was visible. I guided her through the delivery, but tragically, the fetus was stillborn. It was clear that resuscitation attempts would be futile. Gently, I conveyed the heartbreaking news, emphasizing that she bore no responsibility for the outcome. I remained at her side on the floor beside her seat until landing, monitoring vital signs and offering comfort as I could.

The patient was early in her pregnancy; at this point, were you worried about the possibility of stillbirth?

Although only six months into residency, I had previously delivered live babies at similar gestational stages. I had not yet encountered a fetal demise. My entire focus was on the pregnant passenger in active labor. She pushed just a few times, and she delivered a small, unresponsive fetus, devoid of a heartbeat or spontaneous respirations. My attention shifted to the umbilical cord, which appeared hypercoiled, with a dark red hue at its connection to the umbilicus, providing no blood flow to the fetus. I delivered the placenta, using my fingers for downward traction while supporting the uterus behind the pubic symphysis, then provided fundal uterine massage with only minimal blood loss.

Was there any attempt at resuscitating the newborn?

The fetus appeared it had likely been dead for some time, indicated by signs like abdominal desquamation and the hypercoiled umbilical cord, possibly contributing to preterm labor. Even if resuscitated, its prematurity would likely have required neonatal intensive care for survival. It was a very sad situation. When I reflected on the experience, I considered what I'd do if the baby had been born prematurely and was crying. In this scenario, I would have initiated skin-to-skin contact with the mother and requested an oxygen mask for the baby.

What resources did you have available to you on the flight?

Many essential resources were not made available to me until after delivery. Prior to the birth, I had a thermometer, a blood pressure cuff, and non-sterile gloves. The airplane's blood pressure cuff appeared unreliable due to erratic readings, and the thermometer showed very low and clearly inaccurate temperatures. Post-delivery, I learned of a first aid box containing gauze, a needle driver, scissors, and pick-ups, but no sutures. An exact list of emergency medical supplies required on board by the Federal Aviation Administration can be found here. Additional supplies vary between airlines. A clamp, like a Kelly, would have been helpful to deliver the placenta, but instead I used my fingers to hold traction. Fortunately, the placenta was delivered without issue. Suture would have been helpful, but fortunately she did not have significant tearing or excessive bleeding.

How was the decision made to land the plane?

The flight attendants repeatedly asked me about the need for an emergency landing. Initially, I did not have enough information to be able to make a recommendation. After I felt the fetal head, my priority shifted completely to the delivery. Post-delivery, I did ultimately advise landing the plane. My rationale was based on my lack of knowledge of the passenger's underlying medical conditions, current stability, or reason behind the unfortunate fetal demise.  The imminent Atlantic crossing made turning back challenging, and the absence of medical equipment raised concerns about hypertension, fever, preeclampsia, eclampsia, intraamniotic infection, or ongoing bleeding, potentially necessitating a transfusion.  I recommended emergency landing, and the pilot concurred. Upon landing, I briefed the EMTs who transported the passenger and the deceased fetus to the nearest hospital.

Was there any documentation or legal actions that needed to be done?

There were no legal actions taken, but I did have to fill out several documents, many of which were redundant. I filled out a birth form, a death form, and a general medical form asking details about the incident. I included as many details as possible, including estimated blood loss, apgar scores, and vital signs. Luckily the Good Samaritan laws also protect physicians from all in flight emergencies.

What advice or insight do you have for other healthcare providers if they ever find themselves in a similar situation?

As an obstetrics resident, I was lucky that I knew what needed to be done in this unique situation, but I can think of many other in-flight medical emergencies that I would not know how to handle. With birth, there are so many things that can go wrong: from shoulder dystocias to postpartum hemorrhage, but they are generally rare. I remind myself often that birth occurs unaccompanied for a lot of people around the world. I would advise providers to review the basics: the cardinal movements of labor, to support the perineum, and not to forget a fundal massage.

Thank you for sharing your experience. How did the experience make you feel at the time, and how did it affect you moving forward in your career?

It was very emotional, but I know it was life altering for her. With obstetrics, you are a part of the highest of the highs and the most devastating lows. With the lows I have always focused on the patient and their needs at the moment. I have become resilient and more empathetically capable in those dire situations where I have to balance caring for the patient during a surgery or delivery with also creating a calm environment for all those involved.

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