Complicated Delivery
If complications are anticipated (multiple pregnancy, meconium stained amniotic fluid, evidence of fetal distress, prematurity), the pediatrician is usually called to be present in the delivery room.
The first four of the following steps apply to the delivery room care of all babies. Steps five through ten may be needed if the infant is depressed or asphyxiated.
- Prevent hypothermia. Place the infant under a radiant warmer; quickly blot dry and discard the wet towel. Newborns: quickly after birth, particularly in the cold delivery room. Hypothermia increases oxygen consumption and metabolic acidosis.
- Open the airway. Place the babies supine (lying on the back) with the head in the midline and the neck slightly extended.
- Clear the airway. Suction the airway gently using a bulb syringe or a suction catheter; vigorous suction may cause reflex bradycardia.
- Stimulate the baby by thumping the bottoms of the feet or rubbing the back.
- If the respiratory effort is vigorous but the infant is cyanotic, blow oxygen over the infant's face. If respirations are weak or absent, begin bag-and-mask ventilation with oxygen at a rate of 40 breaths/minute. Insert an orogastric tube to prevent gastric distention. Observe chest excursion and auscultate the lungs to ensure adequate air entry. Continue ventilating until the baby is making vigorous and regular respiratory efforts. If the mother has received narcotics within four hours of delivery, respiratory depression in the neonate is treated with naloxone (Narcan) 0.1 mg/kg given IV, IM, or through the endotracheal tube.
- Perform endotracheal intubation if the heart rate continues to fall and the color does not improve despite bag-and-mask ventilation.
- Cardiac massage should be initiated if the heart rate remains below 80 beats/minute once ventilation is begun. Compress the lower one third of the sternum one-half to three-fourths of an inch at a rate of 120 beats/minute.
- Administer drug therapy. Any infant who after one to two minutes of effective ventilation is still apneic, cyanotic, bradycardic, and unresponsive should receive 1:10,000 epinephrine at a dose of 0.1 to 0.3 ml/kg intravenously or through the endotracheal tube.
- Treat hypovolemia. Signs of hypovolemia include persistent poor perfusion, weak pulse with a good heart rate, and decreased blood pressure. Hypovolemia is initially treated with normal saline, starting with 10 ml/kg given IV.
- Correct and prevent hypoglycemia. Chronic hypoxia depletes glucose stores, and acute hypoxia accelerates glucose consumption. An infusion of 10% dextrose should be started immediately.
Management in the post-resuscitation period should include close monitoring of vital signs, blood glucose level, and arterial blood gases. Some infants will require mechanical ventilation. Feedings often need to be delayed and fluids provided intravenously. Infants with seizures will require anticonvulsant therapy.
