Neonatal resuscitation

Postgraduate Training Course in Reproductive Health/Chronic Disease 2004

Dave Woods
Neonatal Medicine
School of Child and Adolescent Health
University of Cape Town

16-1 WHAT IS NEONATAL ASPHYXIA?

Newborn infants normally start to breathe without assistance and often cry after delivery. By 1 minute most infants are breathing well. If an infant fails to establish adequate, sustained respiration after birth, the infant is said to have NEONATAL ASPHYXIA.

NEONATAL ASPHYXIA IS DEFINED AS THE FAILURE OF AN INFANT TO CRY OR BREATHE WELL AFTER DELIVERY

Neonatal asphyxia is an important cause of neonatal death if not managed correctly.

16-2 WHAT IS HYPOXIA?

Hypoxia is defined as TOO LITTLE OXYGEN IN THE CELLS OF THE BODY. Hypoxia may occur in the fetus or the newborn infant. If the placenta fails to provide the fetus with enough oxygen, hypoxia will result and cause fetal distress. Similarly, with failure to breathe well after delivery (i.e. neonatal asphyxia) the infant will develop hypoxia. As a result of hypoxia the heart rate falls, central cyanosis develops and the infant becomes hypotonic (floppy) and unresponsive.

Note that neonatal asphyxia and hypoxia are not the same although they often occur together. Fetal hypoxia may result in neonatal asphyxia while neonatal asphyxia will result in hypoxia if the infant is not rapidly resuscitated.

HYPOXIA IS DEFINED AS TOO LITTLE OXYGEN IN THE CELLS OF THE BODY

16-3 WHAT IS THE APGAR SCORE?

The Apgar score is a method of assessing an infant's clinical condition after delivery. The Apgar score is based on 5 vital signs:

Heart rate.
Respiratory effort.
Presence or absence of central and peripheral cyanosis.
Muscle tone.
Response to stimulation.

Each vital sign is given a score of 0 or 1 or 2. A score of 2 is normal, a score of 1 is mildly abnormal and a score of 0 is severely abnormal. The individual vital sign scores are then totalled to give the Apgar score out of 10. The best possible Apgar score is 10 and the worst 0. An infant with a score of 0 shows no sign of life.

Normally the Apgar score is of 7 to 10. Infants with a score between 4 and 6 have moderate depression of their vital signs while infants with a score of 0 to 3 have severely depressed vital signs and are at great risk of dying unless actively resuscitated.

Due to the presence of peripheral cyanosis in most infants at delivery, it is unusual for a normal infant to score 10 at 1 minute. By 5 minutes most infants will have a score of 10. If the Apgar score is guessed and not correctly assessed, too high a score is usually given.

*** The Apgar score is named after the late Dr. Virginia Apgar, an anaesthetist, who described the scoring method in 1953.

The method of assessing the Apgar score is described in skills workshop 16.

16-4 WHEN SHOULD YOU DETERMINE THE APGAR SCORE?

The Apgar score should be performed on all infants at 1 minute after birth to record the infant's clinical condition and to assess whether the infant requires resuscitation. If the 1 minute Apgar score is below 7, then the Apgar score should be repeated at 5 minutes to document the success or failure of the resuscitation efforts. If the 5 minute Apgar score is still low, it should be repeated every 5 minutes until a normal Apgar score of 7 or more is achieved. In many hospitals, the Apgar score is often routinely repeated at 5 minutes even if the 1 minute score was normal. This is not necessary and the infant should rather be handed to the mother.

16-5 WHAT CAUSES A LOW APGAR SCORE?

There are many causes of a low Apgar score. These include:

Fetal distress due to hypoxia before delivery.
Maternal anaesthesia or recent analgesia.
Preterm infant.
Difficult or traumatic delivery.
Excessive suctioning of the pharynx after delivery.
Severe respiratory distress.

Note that fetal distress due to hypoxia during labour is only one of the many causes of neonatal asphyxia. However, neonatal asphyxia will result in hypoxia after delivery if the infant is not rapidly resuscitated.

It is important to always try and find the cause of a low Apgar score.

16-6 WHAT IS INFANT RESUSCITATION?

Resuscitation is a series of actions taken to establish normal breathing, heart rate, colour, tone and activity in an infant with depressed vital signs (i.e. a low Apgar score).

16-7 WHICH INFANTS NEED RESUSCITATION?

All infants who do not breathe well after delivery (i.e. infants with neonatal asphyxia) or have a 1 minute Apgar score below 7 need immediate resuscitation. The lower the Apgar score the more resuscitation is usually needed. Any infant who stops breathing or has depressed vital signs at any time after delivery or in the nursery also requires resuscitation.

ALL INFANTS WITH A 1 MINUTE APGAR SCORE BELOW 7 REQUIRE RESUSCITATION

16-8 CAN YOU ANTICIPATE WHO WILL NEED RESUSCITATION AT BIRTH?

Yes. The following clinical situations often lead to the delivery of an infant with neonatal asphyxiated and a low Apgar score at 1 minute:

Signs of fetal distress during labour.
Delivery before 37 weeks of gestation.
Abnormal presentation of the fetus.
Difficult or traumatic delivery.
General anaesthesia or recent analgesia (pethidine or morphine within the last 4 hours).

Remember that any infant can be born with neonatal asphyxia without prior warning. It is essential, therefore, to be prepared to resuscitate any newborn infant. Anyone who delivers an infant must be able to perform resuscitation.

ANY INFANT CAN HAVE NEONATAL ASPHYXIA WITHOUT WARNING SIGNS DURING LABOUR

16-9 WHAT EQUIPMENT DO YOU NEED FOR INFANT RESUSCITATION?

It is essential that you have all the basic equipment needed for simple infant resuscitation. The equipment must be in working order and immediately available. The equipment must be checked daily.

A warm, well lit corner of the delivery room should be available for resuscitation. A heat source, such as an overhead radiant warmer, is needed to keep the infant warm. A good light, such as an angle poise lamp, is required so that the infant can be closely observed during resuscitation.

The following essential equipment must be available in the delivery room:

SUCTION APPARATUS: An electric or wall vacuum suction apparatus is ideal but the vacuum pressure should not exceed 200 cm water (i.e. 20 kPa or 200 mbar). Soft 10 end hole suction catheters are needed.
OXYGEN: Whenever possible a cylinder or wall source of 100% oxygen should be available. However, infants can be resusciteted without oxygen.
RESUSCITATOR: A neonatal ventilation bag (e.g. Laerdal, Ambu Penlon or Cardiff) or simple Samson resuscitator must be available to provide ventilation.
ENDOTRACHEAL TUBES: 2,0 mm, 2,5 mm and 3,0 mm tubes, straight or shouldered, must be available. Introducers are also needed. Cuffed endotracheal tubes must not be used in newborn infants.
LARYNGOSCOPE: A laryngoscope with a small, straight blade (Miller 0 and 1 blades). Spare batteries and bulbs must be kept with the laryngoscope. This is the only expensive piece of equipment that is essential for all hospitals and clinics where deliveries are done.
NALOXONE: Ampoules of naloxone (Narcan). Syringes and needles will be needed to administer the drug.
WALL CLOCK or watch: To time the Apgar scoring.

*** Ampoules of 4% sodium bicarbonate and ampoules of 1:1000 adrenaline.

16-10 HOW SHOULD YOU STIMULATE RESPIRATION IMMEDIATELY AFTER BIRTH?

After birth all infants must be quickly dried in a warm towel and then placed in a second warm, dry towel before starting resuscitation. This prevents rapid heat loss due to evaporation. Handling and rubbing the newborn infant with a dry towel is usually all that is needed to stimulate the onset of breathing. Gently flicking under the infant's feet may be helpful in stimulating breathing. Stimulation alone will start breathing in most infants. There is no need to smack newborn infants.

Infants who breathe well at delivery should NOT be routinely suctioned as suctioning sometimes causes apnoea. Infants born by caesarean section also need not be routinely suctioned.

IT IS NOT NECESSARY TO ROUTINELY SUCTION THE MOUTH AND NOSE OF INFANTS AFTER DELIVERY

16-11 HOW DO YOU RESUSCITATE AN INFANT?

If the infant fails to respond to stimulation, then the infant must be actively resuscitated. The most experienced person, irrespective of rank, should resuscitate the infant. However, all staff who conduct deliveries must be able to resuscitate infants. It is very helpful to have an assistant.

There are 4 main steps in the basic resuscitation of a newborn infant. They can be easily remembered by thinking of the first 4 letters of the alphabet, i.e. "ABCD" - AIRWAY - BREATHING - CIRCULATION - DRUGS.

STEP 1. OPEN AND CLEAR THE AIRWAY.

OPEN THE AIRWAY by placing the infant’s head in the neutral position with the neck slight extended. Do not flex or over extend the neck.
GENTLY CLEAR THE THROAT. The infant may be unable to breathe because the airway is blocked by mucus or blood. Therefore, if the infant fails to breathe after stimulation, gently suction the back of the mouth and throat with a soft F 10 catheter. Excessive suctioning, especially if too deep in the region of the vocal cords, may result in apnoea and bradycardia by stimulating the vagal nerve. This can be prevented by holding the catheter 5 cm from the tip when suctioning the infant's throat. Do not suction the nose before suctioning the mouth or throat as this often causes the infant to gasp.

If stimulation, positioning and suctioning fail to start breathing, the infant needs mask ventilation. Do not waste time by giving oxygen without also applying mask ventilation.

VENTILATION IS THE MOST IMPORTANT STEP IN NEWBORN RESUSCITATION

STEP 2. START THE INFANT BREATHING BY PROVIDING ADEQUATE VENTILATION.

MASK VENTILATION: If the infant still fails to breathe adequately, some form of artificial ventilation (breathing) is required. Most infants can be adequately ventilated with a bag and mask. The mask must be held tightly over the infant's nose and mouth. Make sure the head is in the correct position and the airway is clear. Even if breathing is not started, most infants can be kept alive with face mask ventilation until help arrives. Intubation and ventilation are needed if adequate chest movement cannot be achieved with mask ventilation.
INTUBATION AND VENTILATION: The most effective method of ventilation is via an endotracheal tube. All staff who frequently deliver infants should learn this simple technique. Infants who fail to respond to mask ventilation must be intubated. Ventilate the infant at a rate of about 40 breaths a minute. Make sure that the infant's chest moves with each breath and that good, bilateral air entry is heard. Adequate ventilation is by far the most important step in resuscitating an infant with severe neonatal asphyxia. Respiratory stimulants such as Vandid must not be used as they are dangerous and do not help.

MOST INFANTS CAN BE ADEQUATELY VENTILATED WITH A BAG AND MASK

The method of mask ventilation and tracheal intubation is described in skills workshop 16.

STEP 3. OBTAIN A GOOD CIRCULATION WITH CHEST COMPRESSIONS.

Apply chest compressions (external cardiac massage) at about 80 times a minute if the heart rate remains below 60 beats per minute after effective ventilation has been started. Place the fingers of one or two hands under the infant's back and press on the lower half of the sternum with your thumb or thumbs. Usually two chest compressions is followed by a breath.

The method of giving cardiac massage is described in skills workshop 16.

STEP 4. DRUGS TO REVERSE PETHIDINE AND MORPHINE.

If the mother has received either pethidine or morphine during the 4 hour period before delivery, the infant's poor breathing may be due to narcotic depression. If so, the depressing effect of the analgesia on respiration can be rapidly reversed with Narcan (a 1 ml ampoule contains 0,4 mg naloxone). Narcan 0,1 mg/kg (i.e. 0,25 ml/kg) can be given by intramuscular injection into the anterolateral aspect of the thigh. Do not use Neonatal Narcan as this preparation requires too big a volume. Narcan will not help resuscitate an infant if the mother has not received a narcotic analgesic during labour, or has only received a general anaesthetic, barbiturates or other sedatives.

*** Narcan acts more rapidly if injected directly into the umbilical vein or if given down the endotracheal tube. Flumazenil (Anexate) will reverse the depressant effect of benzodiazepines such as diazepam (Valium).

*** With experience and further training, additional drugs can be given if the above steps fail to resuscitate the infant:

The injection of 2 ml/kg of 4% sodium bicarbonate into the umbilical vein to correct acidosis and stimulate the cardiorespiratory system. Sodium bicarbonate should only be given once adequate ventilation has been achieved. An 8% solution must never be used as it is extremely hypertonic. Never give sodium bicarbonate down the endotracheal tube.
Adrenalin 1:10 000 given intravenously or placed down the endotracheal tube stimulates the myocardium if cardiac massage fails to improve the heart rate. One ml of adrenalin 1:1000 must first be diluted with 9 ml normal saline to give a 1:10 000 solution. One ml of the diluted solution can then be given to term infants and 0,5 ml to preterm infants (recommended dose is 0,2 ml/kg of diluted adrenalin).
If the infant remains shocked with poor peripheral perfusion despite all other attempts at resuscitation, a plasma volume expander such as stabilized human serum, Haemacceel or Plasmolyte B or Normal Saline can be given. The required volume is usually 10 ml/kg over 10 minutes.

A summary of the method of resuscitating a newborn infant is shown in flow diagram 16-1.

The 4 steps in resuscitation are followed step by step until the 3 most important vital signs of the Apgar score have returned to normal:

A PULSE RATE ABOVE 100 BEATS PER MINUTE. Easily assessed by palpating the base of the umbilical cord or listening to the chest with a stethoscope.
A GOOD CRY OR GOOD BREATHING EFFORTS. This assures adequate breathing.
A PINK TONGUE. This indicates a good oxygen supply to the brain. Do not rely on the colour of the lips or buccal mucosa.

16-12 DOES THE MECONIUM STAINED INFANT NEED SPECIAL CARE?

Yes. All infants that have meconium stained amniotic fluid (liquor) at birth need special care to prevent severe meconium aspiration. Whenever possible all these at risk infants should be identified before delivery, especially infants with thick meconium in the amniotic fluid.

16-13 WHY DOES THE MECONIUM STAINED INFANT NEED SPECIAL CARE?

As a result of hypoxia before delivery, the fetus may make gasping movements and also pass meconium. Meconium can, therefore, be sucked into the upper airways together with amniotic fluid. Fortunately most of the meconium is unable to reach the fluid filled alveoli of the fetus. Only after delivery, when the infant inhales air, does meconium enter the small airways and alveoli.

Meconium contains enzymes from the fetal pancreas that can cause severe lung damage and even death if inhaled into the alveoli after delivery. Meconium also obstructs the airways.

*** Meconium often burns the infant's skin and digests away the infant's eye lashes! Therefore, imagine the damage meconium can cause to the delicate lining of the bronchi and alveoli.

16-14 HOW CAN YOU PREVENT MECONIUM ASPIRATION AT VAGINAL DELIVERY?

Many cases of meconium aspiration syndrome can be prevented with the correct care of the infant during delivery. A suction apparatus and a F 10 end hole catheter must be ready at the bedside. If possible, the person conducting the delivery should have an assistant to suction the infant's mouth when the head delivers.

After delivery of the head, the shoulders should be held back and the mother asked to pant to prevent delivery of the trunk. The infant's face is then turned toward the assistant so that the mouth and pharynx can be well suctioned. Only when no more meconium can be cleared, should the infant be completely delivered. If the infant cries well after delivery, no further resuscitation or suctioning is needed. However, some infants develop apnoea and bradycardia as a result of the suctioning and, therefore, need ventilation after delivery.

If an infant needs ventilation, the pharynx should again be suctioned, preferably under direct vision using a laryngoscope, before ventilation is started. If the infant is intubated, direct suction can be applied to the endotracheal tube. Withdraw the endotracheal tube while applying suction Repeat until no more meconium is obtained. This aggressive method of suctioning is very successful in preventing severe meconium aspiration but should not be used when resuscitating infants that are not meconium stained.

MECONIUM STAINED INFANTS MUST BE SUCTIONED BEFORE DELIVERY OF THE SHOULDERS

16-15 HOW CAN YOU PREVENT MECONIUM ASPIRATION AT CAESAREAN SECTION?

When a meconium stained infant is delivered by caesarean section, the mouth and pharynx must be suctioned with a F10 end hole catheter, BEFORE the shoulders are delivered from the uterus. After complete delivery, move the infant immediately to the resuscitation table. If the infant does not breathe spontaneously, further suctioning under direct vision is needed before stimulating respiration or applying ventilation. Infants who breathe well after delivery do not need to be suctioned again.

16-16 WHEN IS FURTHER RESUSCITATION HOPELESS?

Every effort should be made to resuscitate all infants that show any sign of life at delivery. The severity of neonatal asphyxia at 1 and 5 minutes is not a good indicator of the likelihood of hypoxic brain damage or the possibility of an unsuccessful resuscitation. If the Apgar score remains low after 5 minutes, efforts at resuscitation must be continued. However, if the infant has not started to breathe, or only gives occasional gasps by 20 minutes, the chance of death or brain damage is extremely high. The exception is when the infant is sedated by maternal drugs. It is preferable if an experienced person decides when to abandon further attempts at resuscitation.

*** Some people claim that resuscitating infants with severe neonatal asphyxia is contra-indicated as they survive with brain damage. Research has indicated that this claim is not correct as the majority of severely neonatal asphyxiated infants that are aggressively resuscitated and survive recover completely.

16-17 WHAT POST RESUSCITATION CARE IS NEEDED?

All infants that require resuscitation must be carefully observed for at least 4 hours. Their temperature, pulse and respiratory rate, colour and activity should be recorded and their blood glucose levels checked. Keep these infants warm and provide fluid and energy either intravenously or orally. Usually these infants are observed in a closed incubator. Do not bath the infant until the infant has fully recovered.

If the infant has signs of respiratory difficulty or is centrally cyanosed in room air after resuscitation, it is essential to provide oxygen while the infant is being moved to the nursery. Some infants may even require ventilation during transport.

Careful notes must be made describing the infant's condition at birth, the resuscitation needed and the probable cause of the neonatal asphyxia.

16-18 WHAT CARE SHOULD YOU GIVE TO MECONIUM STAINED INFANTS IN THE NURSERY?

All heavily meconium stained infants should be observed in the nursery for a few hours after delivery as they may show signs of hypoxic damage or meconium aspiration syndrome. Most meconium stained infants have swallowed meconium before delivery. Meconium is a very irritant substance and causes meconium gastritis. This results in repeated vomits of meconium stained mucus. Infants with lightly meconium stained amniotic fluid who appear well after delivery can be kept with their mothers.

Meconium gastritis may be prevented by washing out the stomach tube with 2% sodium bicarbonate (mix 4% sodium bicarbonate with an equal volume of sterile water). Five ml of 2% sodium bicarbonate is repeated injected into the stomach via a nasogastric tube and then aspirated until the gastric aspirate is clear All heavily meconium stained infants should have a stomach washout on arrival in the nursery. This should be followed by a feed of colostrum. Routine stomach washouts in preterm infants or infants born by caesarean section are not needed.

*** Colostrum contains phagocytic cells that ingest any meconium that remains in the stomach. This reduces the chance of further vomiting.

A STOMACH WASHOUT IS ONLY NEEDED IF THE INFANT IS COVERED WITH THICK MECONIUM

16-19 WHAT IS THE DANGER OF FETAL DISTRESS DUE TO PRENATAL HYPOXIA?

If the cells of the fetus do not receive adequate oxygen during pregnancy or labour, many organs may be damaged. This may result in either:

Transient damage which will recover completely after delivery.
Permanent damage that will not recover fully after birth.
Death of the fetus or newborn infant.

16-20 WHAT ORGANS ARE COMMONLY DAMAGED BY HYPOXIA?

The BRAIN needs a lot of oxygen and, therefore, is very sensitive to hypoxia either before or after delivery.
The KIDNEYS may be damaged, resulting in haematuria, proteinuria and decreased urine output for the first few days after delivery. Occasionally renal failure may result.
The HEART may be damaged causing heart failure. This presents with hepatomegaly, respiratory distress and poor peripheral perfusion.
The GUT may be damaged causing necrotising enterocolitis.
The LUNGS may be damaged resulting in respiratory distress with pulmonary artery spasm (persistent pulmonary hypertension).

*** At the onset of hypoxia, blood is shunted away from the kidneys, gut and lungs to the brain and heart. This mechanism to protect the brain and heart may cause ischaemic damage to the kidneys, gut and lungs. The increased blood flow to the brain may cause intraventricular haemorrhage in preterm infants. With severe, prolonged hypoxia, cardiac output falls and as a result the brain and myocardium may also suffer ischaemic damage.

HAEMATURIA IN THE NEWBORN INFANT IS A USEFUL CLINICAL MARKER OF PRENATAL HYPOXIA

16-21 WHAT DAMAGE IS DONE TO THE BRAIN BY HYPOXIA?

Different types of brain damage can occur depending on the gestational age of the fetus and the severity of the hypoxia:

INTRAVENTRICULAR HAEMORRHAGE. Hypoxia may damage small blood vessels around the ventricles of the brain in preterm infants. These vessels may bleed into the ventricles which can damage the surrounding brain. An intraventricular haemorrhage usually presents within the first 2 days after delivery. A mild haemorrhage is usually asymptomatic but a severe haemorrhage causes apnoea, shock and death. The clinical diagnosis of intraventricular haemorrhage can be confirmed with ultrasonography of the brain.
Hypoxia may cause decreased blood flow (ISCHAEMIA) which results in INFARCTION (death) of part of the brain. In preterm infants this usually causes spastic diplegia (spastic weakness of both legs). In term infants hypoxia usually causes convulsions, mental retardation and cerebral palsy.
In term infants, hypoxia and ischaemia of the brain presents in the first 72 hours as NEONATAL ENCEPHALOPATHY (hypoxic ischaemic encephalopathy) with poor feeding, increased or decreased tone, and convulsions.
Hypoxia may also cause blindness, deafness or learning and behaviour problems at school.

*** REFERENCES

The method of resuscitation described is that advocated by the American Academy of Pediatrics and the American Heart Association:

JAMA 255: 2969, 1986
JAMA 268: 2276, 1992

CASE PROBLEMS

CASE 1

After a normal pregnancy, an infant is born by elective caesarian section under general anaesthesia. The indication for the caesarean section is two previous caesarean sections for cephalopelvic disproportion. 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 neonatal asphyxia? Give your reasons.

Yes, the infant has neonatal asphyxia because the infant failed to establish adequate, sustained respiration. The diagnosis of neonatal asphyxia is supported by the low Apgar score at 1 minute.

3. What is the probable cause of the neonatal asphyxia?

The general anaesthetic. Both the intravenous drugs and the anaesthetic gases cross the placenta and may sedate the fetus. These sedated infants usually respond rapidly to resuscitation.

4. What should be the first 2 steps in resuscitating this infant?

If respiration cannot be stimulated by drying the infant and flicking the infant's feet then the following 2 steps must be taken:

Position the head correcly and clear the airway by gently suction of the throat.

Ventilation must be started if the infants does not start breathing well. Most infants can be adequately ventilated with a bag and mask. If good chest movement cannot be obtained, the infant must be intubated.

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 for a few hours. Both the general anaesthetic and the low 1 minute Apgar score will increase the risk of hypothermia and apnoea.

CASE 2

After fetal distress has been diagnosed, an infant is delivered by a difficult vacuum extraction. At delivery the infant is covered with thick meconium. The infant starts to gasp before 1 minute. Only then are the mouth and pharynx 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 ?

Hypoxia resulting in fetal distress, as indicated by the passage of meconium before delivery. The difficult delivery by vacuum extraction may also result in a low Apgar score, while inhaled meconium may have blocked the airway.

2. What mistake was made with the management of this infant?

The infant's mouth and pharynx should have been well suctioned BEFORE the shoulders were delivered. This will usually 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 pharynx?

A large catheter (F 10) must be used as a small catheter will block with meconium. The catheter should have a hole at the end and not just at the side.

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 meconium was probaby inhaled into the lungs after birth. The infant may also suffer brain damage or damage to other organs due to hypoxia causing fetal distress during labour.

CASE 3

A woman with an abruptio placentae delivers at 32 weeks. Before delivery the fetal heart rate was only 80 beats per minute. The infant appeared dead at birth but was intubated and ventilated. Cardiac massage was also given. The 1 minute Apgar score was 2. Despite further efforts at resuscitation, the Apgar score at 5, 10, 15 and 20 minutes remained 2.

1. What is the probable cause of neonatal asphyxia in this infant?

Fetal distress caused by hypoxia. Abruptio placentae (placental separation before delivery) is a common cause of hypoxia and fetal distress.

2. Why is it possible to successfully resuscitate some infants that appear dead at birth?

If a fetal heart is heard just before delivery but the infant appears dead at birth, the duration of cardiac arrest has only been a few minutes. With ventilation and cardiac massage, it is possible to resuscitate some of these infants. Most of the survivors do not suffer brain damage.

3. What is the significance of the low Apgar scores at 5, 10, 15 and 20 minutes?

The failure to respond well to resuscitation suggests that the infant will die due to severe hypoxic damage to the brain and heart. If the Apgar score remains low at 20 minutes, attempts at resuscitation may be stopped.

4. Which 5 organs are likely to be damaged by severe hypoxia?

The brain, heart, kidneys, gut and lungs.