A8b. Resuscitation of a Term Infant with Meconium Staining. Session Summary. Session Objectives. References

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1 A8b Resuscitation of a Term Infant with Meconium Staining Karen Wright, PhD, NNP-BC Assistant Professor and Coordinator, Neonatal Nurse Practitioner Program Dept. of Women, Children, and Family Nursing, College of Nursing Armour Academic Center, Rush University, Chicago, IL The speaker has signed a disclosure form and indicated she has no significant financial interest or relationship with the companies or the manufacturer(s) of any commercial product and/or service that will be discussed as part of this presentation. Session Summary This case study describes the delivery room management and full resuscitation of a term infant with a nonreassuring fetal heart rate and meconium staining. We will explore what else may be contributing to resuscitation outcomes in this case patient. Session Objectives Upon completion of this presentation, the participant will: understand a case study of a term infant with on-reassuring fetal heart rate and meconium staining; be able to discuss factors that contribute to resuscitation outcomes. References AACOG Committee Opinion, Number 348, November 2006 (Reaffirmed 2012). ACOG Committee on Obstetric Practice (Nov. 2006). ACOG Committee Opinion No. 348: Umbilical cord blood gas and acid-base analysis. Obstetrics & Gynecology, 108: American College of Obstetricians and Gynecologists (ACOG) and American Academy of Pediatrics (AAP) (Jan 2003). Neonatal encephalopathy and cerebral palsy: Defining the pathogenesis and pathophysiology. Washington, DC: American College of Obstetricians and Gynecologists. Armstrong, L. & Stenson, B. (2007). Use of umbilical cord blood gas analysis in the assessment of the newborn. Archives of Disease in Childhood, Fetal & Neonatal Edition, 92(6): F430 F434. Badawi, N., Kurinczuk, J., Keogh, J., Alessandri, L., O'Sullivan, F., Burton, P., et al. (1998). Antepartum risk factors for newborn encephalopathy: The Western Australian case-control study. British Medical Journal, 317: Handley-Derry, M., Low, J., Burke, S., Waurick, M., Killen, H. & Derrick, E. (1997). Intrapartum fetal asphyxia and the occurrence of minor deficits in 4- to 8-year-old children. Developmental Medicine & Child Neurology, 39: Low, J. (2004). Determining the contribution of asphyxia to brain damage in the neonate. The Journal of Obstetrics & Gynaecology Research, 30: Low, J., Lindsay, B. & Derrick, E. (1997). Threshold of metabolic acidosis associated with newborn complications. American Journal of Obstetrics & Gynecology, 177: A8b: RESUSCITATION OF TERM INFANT WITH MECONIUM STAINING Page 1 of 6

2 Riley, R. & Johnson, J. (1993). Collecting and analyzing cord blood gases. Clinical Obstetrics & Gynecology, 36(1): Thorp, J. & Rushing, R. (1999). Umbilical cord blood gas analysis. Obstetrics and Gynecology Clinics of North America, 26(4): Session Outline See presentation handout on the following pages. A8b: RESUSCITATION OF TERM INFANT WITH MECONIUM STAINING Page 2 of 6

3 Resuscitation of a Term Infant with Meconium Staining History 41 year old Gravida 1 Prenatal screening negative Pregnancy unremarkable Labor History Presented at 0730 in early labor 41 weeks gestation Unremarkable labor until 1130pm Late decelerations noted with contractions Membranes intact Delivery History C/S Decision at 0130 Originally communicated as a Stat section for a poor pattern Transferred to the OR at 0130 Incision at 0215 Meconium staining noted with ROM Difficult delivery because baby was floppy Cord gas drawn at birth Resuscitation Grossly hypotonic Intubated no meconium below the cords Stimulated briefly PPV with 100% O2 Intubated 3.5 ETT 1 minute Apgar 1 for heart rate of Bagged at a rate of 60 with 100% oxygen by ETT Poor chest excursion, breath sounds audible Neonatologist notified and enroute Resuscitation At 2 minutes of life there is no improvement, breath sounds verified Still hypotonic, no response, spontaneous movement or breathing Heart Rate and falling Epinephrine 1:10,000 given via ETT 3mls Chest compressions started Bag and ventilation checked, Breath sounds checked again, ETT markings checked no change, tube is at 9cms UVC placed Epinephrine repeated via UVC A8b: RESUSCITATION OF TERM INFANT WITH MECONIUM STAINING Page 3 of 6

4 Resuscitation Heart Rate rechecked, Reintubated quickly without event, 3.5 ETT ETT secured at 9cms, BS = with bagging Epinephrine repeated via UVC 1ml (BW est = 3kg) X 3 Volume expansion given X 2 Infant expired at 3am After infant expired Mother and Father were still in the OR Tubes and lines inadvertently removed by staff Neonatologist arrived Incidence The prevalence of fetal asphyxia, ranging from mild to severe at delivery, in the term infant is reported at 25 per 1,000 live births; of these, 15% are either moderate or severe (3.75 per 1,000)..in the absence of any other preconception or antepartum abnormalities, of approximately 1.6 per 10,000 Handley-Derry M, Low JA, Burke SO, Waurick M, Killen H, Derrick EJ. Intrapartum fetal asphyxia and the occurrence of minor deficits in 4- to 8-year-old children. Dev Med Child Neurol 1997;39: Low JA. Determining the contribution of asphyxia to brain damage in the neonate. J Obstet Gynaecol Res 2004;30: Badawi N, Kurinczuk JJ, Keogh JM, Alessandri LM, O'Sullivan F, Burton PR, et al. Antepartum risk factors for newborn encephalopathy: the Western Australian case-control study. BMJ 1998;317: Umbilical cord gas analysis Umbilical cord blood analysis is assumed to give a picture of the acid base balance of the infant at the moment of birth when the umbilical circulation was arrested by clamping of the cord. Armstrong & Stenson, Use of umbilical cord blood gas analysis in the assessment of the newborn. Arch Dis Child Fetal Neonatal Ed November; 92(6): F430 F434. it is the gold standard assessment of uteroplacental function and fetal oxygenation/acid-base status at birth Thorp & Rushing, Obstet Gynecol Clin North Am., 1999 Dec;26(4): A8b: RESUSCITATION OF TERM INFANT WITH MECONIUM STAINING Page 4 of 6

5 AACOG Statement Fetal asphyxia is a condition of impaired blood gas exchange leading to progressive hypoxemia and hypercapnia with a significant metabolic acidosis. The diagnosis of intrapartum fetal asphyxia requires a blood gas and acid-base assessment. The important question for the clinician is what is the threshold of metabolic acidosis beyond which fetal morbidity or mortality may occur? Low and Associates Scoring System Defined umbilical arterial base deficits at birth as: Mild 4 8 mmol/l Moderate 8 12 mmol/l Severe > 12 mmol/l AACOG Committee Opinion, Number 348, November 2006 (Reaffirmed 2012) Cord Gas Results Umbilical cord gas had been sent at delivery by obstetrical team at delivery ph 7.15 BE -7 Fetal Acid Base Disorders Review Acidosis an increase in hydrogen ions in fetal tissue Acidemia an increase in hydrogen ions in fetal blood. Respiratory acidemia refers to a low ph in the presence of a significantly elevated PCO2 and a normal serum bicarbonate concentration. Metabolic acidemia refers to a low ph with a normal PCO2 and low bicarbonate concentration. A mixed acidemia exists when bicarbonate concentration is low and PCO2 is elevated. Hypoxemia a decrease in oxygen content in fetal blood Hypoxia a decrease in oxygenation of fetal tissue. Asphyxia hypoxia with metabolic acidosis. Newborns with hypoxia severe enough to result in hypoxic ischemic encephalopathy (HIE) will usually exhibit an ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 348, November 2006: Umbilical cord blood gas and acid-base analysis. Obstet Gynecol 2006; 108:1319. American College of Obstetricians and Gynecologists (ACOG) and American Academy of Pediatrics (AAP): Neonatal encephalopathy and cerebral palsy: Defining the pathogenesis and pathophysiology. American College of Obstetricians and Gynecologists, Washington, DC, January 2003 p. 74 Root Cause Analysis What is the relationship of the cord blood results to the cause of death? Where is the significant acidosis? What were the ramifications for the NNP? Root cause analysis results? What is the best course to determine the cause of this outcome? What was the cause of death? What were the lessons learned? A8b: RESUSCITATION OF TERM INFANT WITH MECONIUM STAINING Page 5 of 6

6 Questions for Discussion References AACOG Committee Opinion, Number 348, November 2006 (Reaffirmed 2012). ACOG Committee on Obstetric Practice. (2006). ACOG Committee Opinion No. 348, November 2006: Umbilical cord blood gas and acid-base analysis. Obstetrics & Gynecology, 108: American College of Obstetricians and Gynecologists (ACOG) and American Academy of Pediatrics (AAP): Neonatal encephalopathy and cerebral palsy: Defining the pathogenesis and pathophysiology. American College of Obstetricians and Gynecologists, Washington, DC, January 2003 p. 74. Armstrong, L. & Stenson, B. (2007). Use of umbilical cord blood gas analysis in the assessment of the newborn. Archives of Disease in Child. Fetal & Neonatal Edition, 92(6): F430 F434. Badawi, N., Kurinczuk, J., Keogh, J., Alessandri, L., O'Sullivan, F., Burton, P., et al. (1998). Antepartum risk factors for newborn encephalopathy: the Western Australian case-control study. British Medical Journal, 317: Handley-Derry, M., Low, J., Burke, S., Waurick, M., Killen, H., & Derrick, E. (1997). Intrapartum fetal asphyxia and the occurrence of minor deficits in 4- to 8-year-old children. Developmental Medicine & Child Neurology, 39: Low, J., Lindsay, B., & Derrick, E. (1997). Threshold of metabolic acidosis associated with newborn complications. American Journal of Obstetrics & Gynecology,177: Low, J. (2004). Determining the contribution of asphyxia to brain damage in the neonate. The Journal of Obstetrics & Gynaecology Research, 30: Riley, R. & Johnson, J. (1993). Collecting and analyzing cord blood gases. Clinical Obstetrics & Gynecology, 36(1): Thorp, J. & Rushing, R. (1999). Umbilical cord blood gas analysis. Obstetrics and Gynecology Clinics of North America, 26(4): A8b: RESUSCITATION OF TERM INFANT WITH MECONIUM STAINING Page 6 of 6

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