Extra Topic 3.8 -- Neonatal Resuscitation

Question 1

How would you manage the care of this neonate?

(You are called to be available during the vaginal delivery of a term neonate. The mother has refused an epidural for labor and thick meconium was noted following artificial rupture of maternal membranes. Moreover, she is a diabetic patient with preeclampsia.)

Answer 1

Prior to delivery

I would ensure that the appropriate support personnel and equipment were available for neonatal resuscitation

(i.e. a self-inflating bag attached to 100% oxygen, a neonatal oxygen mask, wall suction, a radiant warmer or other heat source, warmed linens, appropriately sized laryngoscopy blade and ETTs, resuscitation medications, and blow by oxygen capabilities).

My intervention following delivery would depend on the condition of the neonate.

If the neonate was vigorous, with strong respiratory effort, good muscle tone, and a heart rate > 100 beats/minute, I would dry and stimulate the baby, provide warmth, position and clear the airway as necessary, and continue to evaluate respirations, color, and heart rate.

If, however, the baby was not vigorous, I would – repeatedly suction the trachea until only a small amount of meconium was recovered (usually with an endotracheal tube attached to a meconium aspirator which is attached to a regulated suction source), or until it was necessary to proceed with additional resuscitative measures.

Further resuscitative efforts would be based on a continual assessment of respirations, heart rate, and color.

Clinical Note:

• Current recommendations NO longer support routine intrapartum oropharyngeal suctioning (i.e. bulb suction when following delivery of the head and prior to delivery of the shoulders) of neonates born to mothers with meconium staining of the amniotic fluid.
• This is due to the fact that large multicenter studies have not demonstrated any benefit to this practice, combined with the potential for inducing bradycardia in the neonate with vigorous oropharyngeal stimulation.
• Also, the decision to perform endotracheal suctioning is no longer based on the density of meconium staining (“thick” or “thin”).
• Rather, the recommendation is to base your decision on whether the baby is vigorous or not (tracheal suctioning should be performed if the baby does not demonstrate strong respiratory effort, good muscle tone, and a heart rate > 100 beats/minute).

Question 2

Immediately following delivery, the baby is making no respiratory effort, grimaces with stimulation, demonstrates flaccid muscle tone, is acrocyanotic, and has a heart rate of 80 bpm.

What is this infant’s APGAR score?

(You are called to be available during the vaginal delivery of a term neonate. The mother has refused an epidural for labor and thick meconium was noted following artificial rupture of maternal membranes. Moreover, she is a diabetic patient with preeclampsia.)

Answer 2

Since the baby grimaces with stimulation (+1), is flaccid (+0), demonstrates no respiratory effort (+0), is acrocyanotic (+1), and has a herart rate < 100 bpm (+1),

he would be assigned an APGAR score of three.

The APGAR score, which was developed to aid in the rapid assessment of the newborn, is calculated by summing the assigned score (ranging from 0-2 points) for 5 different categories, consisting of the following:

• Appearance (skin color),
• Pulse (heart rate),
• Grimace (reflex irritability),
• Activity (muscle tone),
• Respirations (breathing rate and effort).

The score is assessed at both 1 and 5 minutes following delivery, with a score of 8-10 indicating a normal clinical status; a score of 4-7 indicating moderate impairment; and a score of 0-3 indicating a need for immediate resuscitation.

• Clinical Note:*
• (see Apgar score figure attached)*

Question 3

How would you treat this infant?

(You are called to be available during the vaginal delivery of a term neonate. The mother has refused an epidural for labor and thick meconium was noted following artificial rupture of maternal membranes. Moreover, she is a diabetic patient with preeclampsia.)

Answer 3

After suctioning the trachea until only a small amount of meconium was recovered, I would dry and stimulate the baby, provide warmth, position and clear the airway as necessary, and continue to evaluate his respirations and heart rate.

If after following these initial steps the baby’s heart rate was still below 100, he remained apneic, or he was gasping, I would provide positive mask ventilation with air, or an air/oxygen mixture, and consider applying a pulse oximeter.

If after 30 seconds of positive mask ventilation the HR was less than 60, then I would intubate, increase the oxygen concentration to 100%, begin chest compressions (3 compressions to 1 breath for a total of 120 events/minute), and establish venous (umbilical vein catheterization) or intraosseous access (risks include tibial fracture and osteomyelitis).

If after another 30 seconds there were still no improvement, I would administer 0.01-0.03 mg/kg of epinephrine via the umbilical vein or established intraosseous access, and consider volume expansion.

Hypoglycemia, magnesium toxicity, and narcosis should also be considered in this particular case given the mother’s diabetes, probably treatment with magnesium sulfate (due to her preeclampsia), and pain control with intravenous narcotics.

If magnesium toxicity were confirmed, I would administer calcium (100 mg/kg of calcium gluconate or 30 mg/kg of CaCl2), recognizing that calcium therapy has been associated with cerebral calcification and decreased survival in stressed newborns (therefore, it should only be administered to reverse the effects of magnesium toxicity).

In the case of hypoglycemia (glucose < 35 mg/dL), glucose should be administered (8 mg/kg/minute of 10% solution).

While placental transfer of maternally administered narcotics could potentially be exacerbating this neonate’s condition, I would not administer naloxone unless all other resuscitative efforts had failed;

as this drug is no longer recommended during the initial resuscitation in the delivery room (can worsen the neurologic damage caused by asphyxia).

If I felt that the administration of naloxone was necessary, I would first ensure the restoration of the neonate’s heart rate and color with supported ventilation and then give 0.1 mg/kg by either the intravenous or intramuscular route (endotracheal administration is no longer recommended).

Given the relatively short duration of action of naloxone when compared to many narcotics, I would plan to monitor the neonate for an extended period of time to avoid recurrent respiratory depression.

• Clinical Notes:*
• Naloxone administration should be avoided when the neonate’s mother is suspected of long-term opioid abuse, because it has been associated with seizures and intraventricular hemorrhage under these circumstances.

Question 4

When would you consider placing a pulse oximeter and where would you place it?

(You are called to be available during the vaginal delivery of a term neonate. The mother has refused an epidural for labor and thick meconium was noted following artificial rupture of maternal membranes. Moreover, she is a diabetic patient with preeclampsia.)

Answer 4

I would consider utilizing oximetry –

• when I anticipated the need for resuscitation,
• when positive pressure ventilation was required for more than a few breaths,
• when supplemental oxygen was necessary, or
• when cyanosis was persistent.

I would place the oximeter on the right upper extremity (finger, wrist, or medial palmar surface) in order to monitor pre-ductal blood flow, which provides a better assessment of central nervous system oxygenation.

Unfortunately, it often takes 1-2 minutes to place and obtain reliable readings from the pulse oximeter.