Baby Rebecca has just been born by normal vaginal birth in hospital. She has an Apgar score of 5 being lacking in tone (1) with a heart rate of 90 bpm (1) some respiratory effort but no crying (1) limited response to stimuli (1) and peripheral cyanosis (1).
Questions
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a) Once the cord is clamped and cut what are your priorities for care in the next 5 minutes?
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Correct answer:
Remember the need to keep Rebecca pink, warm and sweet. She needs drying and wrapping in warm, dry towels - this alone may stimulate her sufficiently to improve her clinical condition and bring her Apgar score up to 9 or 10. If not you should summon help by means of the emergency bell, take her to the resuscitaire where the clock should be started. Rebecca should be placed in a neutral position to maintain her airway and given oxygen via a facemask; the heater should be on to help keep her warm and her heart rate and respiratory rate checked again. If her heart rate is above 100 bpm, then the focus should be on keeping her warm and returning her to her mother for skin-to-skin if possible. If the heart rate remains below 90 bpm, then oxygen should be continued and rescue breaths given via the bag, valve mask equipment until help arrives.
It important that the mother and her partner are kept informed of events as much as possible as they will be understandably anxious. A thorough written record of all actions should be made using timings from the activated clock.
James is 2 days old and is breastfed by his mother Lucy who has breastfed her previous two children. Lucy reports that James is not waking for feeds and seems lethargic. On examination he appears to have pale yellow discolouration of the skin indicating jaundice.
Questions
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a) What should the management of James be whilst on the postnatal ward?
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Correct answer:
James will need blood taking for a serum bilirubin (SBR) level; maternal consent will of course be required for this. Whilst awaiting the result Lucy will need help and encouragement with feeding as it is important to maintain James' intake as dehydration will exacerbate his symptoms. Lucy will need reassuring that it is likely that the jaundice is physiological and that breastfeeding remains the best option for him. She may have experienced jaundice with her other two children, but this should not be assumed. The maternal notes should be checked to see whether any aspects of history from her other two babies indicate any other concerns. Accurate record keeping is essential and any treatment of the jaundice should follow the relevant clinical guidelines.
Teresa has just had a waterbirth at home at 39 weeks gestation; she used water only for pain relief, has no past medical history and does not take any medication. Samuel was born an hour ago now and his Apgar scores after birth were 9 at one minute and 10 at five minutes. Teresa is now out of the birthing pool, sat on the sofa having skin-to-skin contact with Samuel. Despite initially being pink, alert with good tone, Samuel is now making a groaning noise. Teresa does not appear concerned and wishes to be left by the midwives to enjoy some quality time with her husband and new son.
Questions
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a) What are the possible concerns about this baby?
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Correct answer:
- Respiratory distress.
- Hypothermia.
- Hypoglycaemia.
- Infection.
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b) What would the actions of the midwives be?
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Correct answer:
- Explain the concerns to Teresa and husband and reassess the baby's condition measuring and recording Samuel's temperature, heart rate and respirations.
- Ensure Samuel is warm and dry with a hat on and place skin-to-skin with Teresa covered by warm towels or blankets.
- Encourage Samuel to breastfeed.
- Observe and reassess temperature, heart rate and respirations, tone and responsiveness of the baby.
- Ensure the resuscitation equipment is ready.
- If no improvement, reiterate your concerns to Teresa and husband, explaining that Samuels's condition is giving some cause for concern.
- Explain that Samuel will need a medical review urgently by a paediatrician in the hospital; contact the maternity hospital and arrange urgent admission and paramedic assistance.
- Dress Samuel appropriately ensuring a hat and warm blankets are also applied.
- Accompany Teresa and Samuel to the hospital offering full explanations at all times and maintaining documentation.
