Baby Reynolds

Baby Reynolds is a girl born at 34 weeks gestation after a spontaneous rupture of membranes, with meconium present. The mother waited 24 hours before attending the hospital, at which point she was found to have a fever. Contractions had started three hours beforehand. The fetal heart rate was atypical, but not abnormal.

As the cervix was found to be fully dilated, the team elected to continue with labour, instead of Caesarean section.

 

 

The baby was born one hour later. She initially had poor tone, no respirations, and was cyanotic across her body.

Important equipment includes:

 

radiant warmer (turned on) and warm towels

gloves, clock, stethescope, pulse oximeter, tape

equipment for:

• suction (mechanical suction, catheters, meconium aspirator)
• positive pressure ventilation equipment, with oxygen supply and blender
• intubation equipment: laryngoscope with 0 and 1 blade, 2.5, 3.0, 3.5 ETT, stylet
• alternative airways

medications (discussed in another case)

 

 

Place the baby on a radiant warmer and towels without stimulating her.

Visualize the oropharynx using a laryngoscope, and if necessary clear the oropharynx with a large bore suction catheter.

Intubate the trachea with an ETT, attach a meconium aspirator, and suction through the ETT.

Dry and stimulate with a warm towel. If neccesary, stimulate further by flicking the feet or rubbing the back.

Reposition her head.

 

Assess for:

 

• respiratory function
• heart rate: palpate the umbilicus at the base, or listen with a stethoscope. Count 6 seconds and multiply by 10.
• colour: look for central cyanosis

 

Baby Reynolds remains cyanotic and apneic and her HR is 90.

Because her HR is below 100, begin postive pressure ventilation. This can be done using:

• self-inflating bag
• flow-inflating bag
• T-piece resuscitator

You have a self-inflating bag available, and you begin providing breaths using room air as the intial gas.

 

Assess for:

• adequate chest movement
• bilateral breath sounds
• improving colour and muscle tone
• a rise in heart rate

 

Unfortunately, the heart rate continues to drop, even as you provide effective ventilation. The heart rate is soon assessed at 54.

As the heart rate is now below 60, you should begin chest compressions, at a rate of 3 compressions:1 breath.

It is ideal if two team members participate to provide effective CPR.

 

Consider orogastric tube placement, intubation, and placement of an umbilical line may be started to provide fluids and epinephrine.

 

You listen to the lungs, and hear decreased breath sounds.

 

If there is inadequate air entry, follow Mr. Sopa to help establish good ventilation:
M- mask adjustment
R- reposition airway
S- suction mouth and nose
O- open mouth
P- pressure increase
A- airway alternative (consider Laryngeal mask airway)

 

Unfortunately, during the resuscitation, the baby did not respond, and the heart rate continued to decrease. After 10 minutes, the team realized that further resuscitation was not to be successful and stopped CPR.

 

The mother, understandably, is very distressed, and asks you to go tell the baby's father, who is in the waiting room.

 

One method of giving bad news is through the acronym SPIKES:

• Setting
  get the setting right
• Perception
  find out what the patient already knows
• Invitation
  find out what they want to know
• Knowledge
  give the information
• Empathise and Explore
  respond to the patient's reactions
• Strategy and Summary
  closing

Role play this with the tutor.

A post-mortem analysis is done, and E. coli was found in the infant's blood. Death was listed as neonatal sepsis, likely from an ascending route.