Case Files Pediatrics, (LANGE Case Files) 4th Ed.

CASE 14

You are called to the delivery room because a now 2-minute-old male was born floppy and blue; his Apgar scores were 4 and 5. He has not responded well to stimulation and blow-by oxygen. The obstetrician who is resuscitating the infant informs you that the child was born by a spontaneous vaginal delivery to a 24-year-old primagravida parity 1 woman. Her pregnancy was uncomplicated. Fetal heart tones were stable throughout the labor. Spinal epidural anesthesia was administered but was only partially effective; the obstetrician supplemented her labor analgesia with intravenous meperidine (Demerol) and promethazine (Phenergan). The amniotic fluid was not meconium stained, and the mother had no evidence of intraamniotic infection.

Image What is the next step?

ANSWER TO CASE 14: Neonatal Resuscitation

Summary: A newborn is born floppy, blue, and has responded poorly to initial resuscitation efforts of warming, drying, and stimulation.

• Next step: Evaluate heart rate (HR) and respirations. If no respirations are found or if HR is less than100 bpm (beats/min), initiate positive-pressure ventilation (PPV) by bag and mask. Because this mother received meperidine during the labor process, naloxone (Narcan) administration is an important step in resuscitation.

ANALYSIS

Objectives

1. Understand the steps of newborn delivery room resuscitation.

2. Become familiar with use of the Apgar score.

3. Become familiar with conditions causing newborn transition problems.

Considerations

This depressed infant was born to a healthy mother without prenatal or delivery complications other than the partially effective epidural anesthesia, which was supplemented with meperidine and promethazine. PPV was initiated and naloxone administered. The provider must appreciate the timing of maternal meperidine administration and its continued effects on the neonate.

APPROACH TO:

Neonatal Resuscitation

DEFINITIONS

NARCOSIS:The condition of deep stupor or unconsciousness produced by a chemical substance such as a drug or anesthesia.

PERINATAL HYPOXIA: Inadequate oxygenation of a neonate that, if severe, can lead to brainstem depression and secondary apnea unresponsive to stimulation.

POSITIVE-PRESSURE VENTILATION (PPV): Mechanically breathing using a bag and mask.

CLINICAL APPROACH

Delivery room resuscitation follows the ABC rules of resuscitation for patients of all ages: establish and maintain the Airway, control the Breathing, and maintain the Circulation with medications and chest compressions (if necessary).

In this case, the meperidine given during labor probably is responsible for the infant’s apnea and poor respiratory effort. Neonates with narcosis usually have a good HR response but poor respiratory effort in response to bag-and-mask ventilation. The therapy for narcotic-related depression is intravenous (IV), intramuscular (IM), subcutaneous (SQ), or endotracheal administration of naloxone (Narcan); repeated doses may be required should respiratory depression recur.

The Apgar score (Table 14-1) is widely used to evaluate a neonate’s transition from the intra- to extrauterine environment. Scores of 0, 1, or 2 are given at 1 and 5 minutes of life for the listed signs. The 1-minute score helps to determine an infant’s well-being in the period just prior to delivery, and scores less than 3 historically have been used to indicate the need for immediate resuscitation. In current practice, HR, color, and respiratory rate (RR) rather than the 1-minute Apgar score are used to determine this need. The 5-minute score is one indicator of how successful the resuscitation efforts were. Some continue to measure Apgar scores beyond the 5-minute period to determine the continued response to resuscitation efforts. The Apgar score alone cannot determine neonatal morbidity or mortality.

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Table 14-1 • APGAR EVALUATION OF A NEWBORN

COMPREHENSION QUESTIONS

14.1 A female infant is born through emergency cesarean section to a 34-year-old mother whose pregnancy was complicated by hypertension and abnormal fetal heart monitoring. At delivery she is covered in thick, green meconium and is limp, apneic, and bradycardic. Which of the following is the best first step in her resuscitation?

A. Administer IV bicarbonate.

B. Administer IV naloxone.

C. Initiate bag-and-mask ventilation.

D. Initiate chest compressions immediately.

E. Intubate with an endotracheal tube and suction meconium from the trachea.

14.2 A term male is delivered vaginally to a 22-year-old mother. Immediately after birth he is noted to have a scaphoid abdomen, cyanosis, and respiratory distress. Heart sounds are heard on the right side of the chest, and the breath sounds seem to be diminished on the left side. Which of the following is the most appropriate next step in his resuscitation?

A. Administer IV bicarbonate.

B. Administer IV naloxone.

C. Initiate bag-and-mask intubation.

D. Initiate chest compressions immediately.

E. Intubate with an endotracheal tube.

14.3 A 37-week-gestation male is born after an uncomplicated pregnancy to a 33-year-old mother. At birth he was lethargic and had an HR of 40. Oxygen was administered via bag and mask, and he was intubated; his HR remained at 40 bpm. Which of the following is the most appropriate next step?

A. Administer IV bicarbonate.

B. Administer IV atropine.

C. Administer IV epinephrine.

D. Administer IV calcium chloride.

E. Begin chest compressions.

14.4 A term female infant is born vaginally after an uncomplicated pregnancy. She appears normal but has respiratory distress when she stops crying. When crying she is pink; when not she makes vigorous respiratory efforts but becomes dusky. Which of the following is the likely explanation for her symptoms?

A. Choanal atresia

B. Diaphragmatic hernia

C. Meconium aspiration

D. Neonatal narcosis

E. Pneumothorax

ANSWERS

14.1 E. An attempt is made to remove the meconium from the oropharynx and the airway prior to initiation of respirations. Ideally, the obstetrician will begin suctioning the meconium upon delivery of the head, and the pediatrician will further remove meconium with an aspirator or through endotracheal intubation with suction. Ventilation is initiated after meconium is removed. The goal is to remove airway meconium and to prevent its aspiration into the small airways where ventilation-perfusion mismatch may occur with deleterious effects.

14.2 E. The case describes diaphragmatic hernia. As a result of herniated bowel in the chest, these children often have pulmonary hypoplasia. Bag-and-mask ventilation will cause accumulation of bowel gas (which is located in the chest) and further respiratory compromise. Therefore, endotracheal intubation is the best course of action.

14.3 E. If the HR is still less than 60 bpm despite PPV with 100% oxygen, then chest compressions are given for 30 seconds. If the HR is still less than 60 bpm, then drug therapy (usually epinephrine) is indicated.

14.4 A. Infants are obligate nose breathers until about 4 months of age. When crying they can breathe through their mouth, but they must have a patent nose when quiet. Choanal atresia is identified by passing a feeding tube through each nostril or by identification of clouding on cold metal held under the infant’s nose. Should choanal atresia be diagnosed, endotracheal intubation bypasses the airway obstruction until surgical repair can be completed.


CLINICAL PEARLS

Image An infant with slow heart rate, poor color, and inadequate respiratory effort requires immediate resuscitation.

Image The therapy for narcosis (newborn respiratory depression because of maternal pain control) is intravenous, intramuscular, subcutaneous, or endotracheal administration of naloxone (Narcan).

Image A child with diaphragmatic hernia often presents with immediate respiratory distress, scaphoid abdomen, cyanosis, and heart sounds displaced to the right side of the chest.

Image Choanal atresia results in respiratory distress when a child stops crying; immediate treatment is intubation until surgical correction can be completed.


REFERENCES

Carlo WA. Delivery room emergencies. In: Kleigman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: WB Saunders; 2011:575-579.

Carlo WA. Routine delivery room and initial care. In: Kleigman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: WB Saunders; 2011:536-538.

Ekrenkranz RA. Newborn resuscitation. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD, eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:207-213.

Thilo EH, Rosenberg AA. Diaphragmatic hernia. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR. Current Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011:46-47.

Thilo EH, Rosenberg AA. Perinatal resuscitations. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR. Current Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011:25-30.

Wyckoff MH. Delivery room resuscitation. In: Rudolph CD, Rudolph AM, Lister G, First LR, Gershon AA, eds. Rudolph’s Pediatrics. 22nd ed. New York, NY: McGraw-Hill; 2011:164-170.

Yoon PJ, Kelley PE, Friedman NR. Choanal atresia. In: Hay WW, Levin MJ, Sondheimer JM, Deterding RR. Current Diagnosis & Treatment: Pediatrics. 20th ed. New York, NY: McGraw-Hill; 2011:473.

Zenel JA. Nose. In: Rudolph CD, Rudolph AM, Lister G, First LR, Gershon AA, eds. Rudolph’s Pediatrics. 22nd ed. New York, NY: McGraw-Hill; 2011:177.