You are called to the delivery room because a now 2-minute-old male infant
was born floppy and blue; his Apgar scores were 4 and 5. He has not responded
well to stimulation and blow-by oxygen. The obstetrician who is resuscitating
the infant informs you that the child was born by a spontaneous vaginal delivery to a 24-year-old primigravida. Her pregnancy was uncomplicated. Fetal
heart tones were stable throughout the labor. Spinal epidural anesthesia was
administered but was only partially effective; the obstetrician supplemented
her labor analgesia with intravenous meperidine (Demerol) and promethazine
(Phenergan). The amniotic fluid was not meconium stained, and the mother
had no evidence of intraamniotic infection.
C What is the next best step in managing this infant?
Summary: A newborn is born floppy, blue, and has responded poorly to initial
resuscitation efforts of warming, drying, and stimulation.
Next management step: Evaluate heart rate (HR) and respirations. If no respirations are found or if HR is less than 100 beats/min, initiate positive-pressure
ventilation (PPV) by bag and mask. Because this mother received meperidine
during the labor process, naloxone (Narcan) administration may transiently
reverse the effect of the narcotic. Because the half-life of narcotics is usually
longer than naloxone, providing adequate ventilation is the key to resuscitation
until the newborn regains spontaneous respirations. The newborn should be
transitioned in a high-risk setting and observed closely for recurrent respiratory depression as the effect of naloxone subsides.
- Understand the steps of newborn delivery room resuscitation.
- Become familiar with use of the Apgar score.
- Become familiar with conditions causing newborn transition problems.
This depressed infant was born to a healthy mother without prenatal or delivery complications other than the partially effective epidural anesthesia, which was
supplemented with meperidine and promethazine. PPV was initiated and naloxone administered. The provider must appreciate the timing of maternal meperidine
administration and its continued effects on the neonate.
NARCOSIS: The condition of deep stupor or unconsciousness produced by a
chemical substance such as a drug or anesthesia.
PERINATAL HYPOXIA: Inadequate oxygenation of a neonate that, if severe, can
lead to brainstem depression and secondary apnea unresponsive to stimulation.
POSITIVE-PRESSURE VENTILATION (PPV): Mechanically breathing using a
bag and mask.
Delivery room resuscitation follows the ABC rules of resuscitation for patients of
all ages: establish and maintain the Airway, control the Breathing, and maintain the
Circulation with medications and chest compressions (if necessary).
In this case, the meperidine given during labor probably is responsible for the
infant’s apnea and poor respiratory effort. Neonates with narcosis usually have a
good HR response but poor respiratory effort in response to bag-and-mask ventilation. The first and most important corrective action is to provide effective PPV.
The therapy for narcotic-related depression can then be instituted in the form of
intravenous (IV), intramuscular (IM), subcutaneous (SQ), or endotracheal administration of naloxone (Narcan); repeated doses may be required should respiratory
The Apgar score (Table 1–1) is widely used to evaluate a neonate’s transition from the intra- to extrauterine environment. Scores of 0, 1, or 2 are given at
1 and 5 minutes of life for the listed signs. The 1-minute score helps to determine
an infant’s well-being in the period just prior to delivery, and scores less than 3
historically have been used to indicate the need for immediate resuscitation. In current practice, HR, color, and respiratory rate (RR) rather than the 1-minute Apgar
score are used to determine this need. The 5-minute score is one indicator of how
successful the resuscitation efforts were. Some continue to measure Apgar scores
beyond the 5-minute period to determine the continued response to resuscitation
efforts. The Apgar score alone cannot determine neonatal morbidity or mortality.