Perinatal Education Programme - Care of infants at birth

Case problems

CASE 1

An infant is delivered by spontaneous vertex delivery at term. Immediately after birth the infant cries well and appears normal. The cord is clamped and cut and the infant is dried. The infant has a lot of vernix. As the infant appears healthy and the mother has no vaginal discharge, chloromycetin ointment is not put in the infant’s eyes. The infant is placed in a cot beside the mother.

1. When should the infant be given to the mother?
   As soon as the infant is dried, the cord cut, the 1 minute Apgar score determined and a brief examination indicates that the infant is a normal, healthy term infant. The mothers should give skin-to-skin care of her infant after birth. The infant should not be left in a cot. The father should also be present to share this exciting moment.
2. When should the mother be encouraged to put the infant to her breast?
   As soon as she wants to. This is usually after she has had a chance to have a good look at her infant. There are advantages to putting the infant to the breast straight after delivery.
3. Should the vernix be washed off immediately after delivery?
   Infants should not be bathed straight after delivery, as they often get cold, while vernix should not be removed as it helps protect the infant's skin from infection. It would be better to bath the infant later, in the mother's presence, when most of the vernix will have cleared.
4. Do you agree that this well infant does not need chloromycetin eye ointment?
   No. All infants should be given chloromycetin eye ointment, especially if gonorrhoea is common in the community. Gonococcal infection may be asymptomatic in the mother.
5. Should the infant stay with the mother after delivery?
   Yes, if possible the mother and her infant should not be separated after delivery.

CASE 2

After a normal pregnancy, an infant is born by spontaneous vertex delivery. There are no signs of fetal distress during labour. The mother received pethidine 2 hours before delivery. Immediately after delivery the infant is dried and placed under an overhead radiant warmer. At 1 minute after birth the infant has a heart rate of 80 beats per minute, gives irregular gasps, has blue hands and feet but a pink tongue, has some muscle tone but does not respond to stimulation. At 5 minutes the infant has a heart rate of 120 beats per minute and is breathing well. The tongue is pink but the hands and feet are still blue. The infant moves actively and cries well.

1. What is the infant's Apgar score at 1 minute?
   The Apgar score at 1 minute is 4: heart rate=1, respiration=1, colour=1, tone=1, response=0.
2. Does this infant have asphyxia? Give your reasons.
   Yes, the infant has asphyxia because the infant failed to establish adequate, sustained respiration by 1 minute. The diagnosis of asphyxia is supported by the low Apgar score at 1 minute.
3. What is the probable cause of the asphyxia?
   Sedation due to the maternal pethidine given 2 hours before delivery. These sedated infants usually respond rapidly to resuscitation. If not, Narcan can be given to reverse the sedative effect of the pethidine.
4. What should be the first 2 steps in resuscitating this infant?
   If respiration cannot be stimulated by drying the infant then the following 2 steps must be taken:
   1. Clear the airway by gently suctioning the throat.
   2. Breathing must be started with mask and bag ventilation.
5. What is this infant's Apgar score at 5 minutes?
   The Apgar score at 5 minutes is 9: heart rate=2, breathing=2, colour=1, tone=2, response=2. This indicates that the infant has responded well to resuscitation.
6. Why is this infant very unlikely to have suffered brain damage due to hypoxia?
   Because there is no history of fetal distress to indicate that this infant had been hypoxic before delivery.
7. What should be the management of this infant after resuscitation?
   The infant should be kept warm and be transferred to the nursery for observation. As soon as the infant is active and sucking well it should given to the mother to breast feed.

CASE 3

A woman with an abruptio placentae delivers at 32 weeks in a clinic. Before delivery the fetal heart rate was only 80 beats per minute. The infant has a 1 minute Apgar score of 1 and is ventilated with bag and mask. Cardiac massage is also given. With further efforts at resuscitation, the Apgar score at 5 minutes is 5 and at 10 minutes is 9.

1. What is the probable cause of asphyxia in this infant?
   Fetal distress caused by hypoxia. Abruptio placentae (placental separation before delivery) is a common cause of fetal distress.
2. What is the significance of the Apgar scores at 5 and 10 minutes?
   The good responds indicates that the resuscitation is successful. If the Apgar score is still low at 5 minutes it is important to repeat the score every 5 minutes. The normal score at 10 minutes indicates the infant's response to the resuscitation.
3. Is this child at high risk of brain damage due to hypoxia?
   The good response to resuscitation suggests that this infant will not have brain damage due to fetal hypoxia.
4. When should all attempts at resuscitation be abandoned?
   If the Apgar score remains low at 20 minutes, attempts at resuscitation may be stopped.

CASE 4

After fetal distress has been diagnosed, an infant is delivered vaginally after a long second stage of labour. At delivery the infant is covered with thick meconium. The infant starts to gasp before 1 minute. Only then are the mouth and throat suctioned for the first time. The Apgar score at 1 minute is 3. By 5 minutes the Apgar score is 6.

1. What are the probable causes of the low 1 minute Apgar score?
   Fetal distress, as indicated by the passage of meconium before delivery. The prolonged second stage may have caused fetal hypoxia. Inhaled meconium may have blocked the airway and prevented the infant from breathing.
2. What mistake was made with the management of this infant?
   The infant's mouth and throat should have been well suctioned BEFORE the shoulders were delivered. This should prevent severe meconium aspiration as the airway is cleared of meconium before the infant starts to breathe.
3. What size catheter would you have used to suction this infant's mouth and throat?
   A large catheter (F 10) must be used as a small catheter will block with meconium.
4. Should this infant be given a bath and stomach washout in labour ward after it starts to breathe spontaneously?
   No. These should not be done until the infant has been stable for a number of hours in the nursery.
5. What 2 complications is this infant at high risk of?
   This infant may develop meconium aspiration syndrome as it probably inhaled meconium into its lungs after birth. It may also suffer brain damage due to hypoxia causing fetal distress during labour. The poor response to resuscitation suggests that some brain damage may be present. It would be important to repeat the Apgar score every 5 minutes until 20 minutes after delivery.

Text prepared by Dave Woods

Print this page

Edited by Aldo Campana,