Medical Scenario #4

Important Reminder: 

These are hypothetical situations and are not meant to be taken literally. Always follow your hospital's policies, procedures, and guidelines. Your hospital will have specific guidelines that you must follow in each department. These scenarios are purely educational. Always consult with your hospital providers before doing any medical procedure on patients. 

Scenario: 

A 28-year-old G2P1 mother with a history of gestational diabetes is admitted to the hospital at 35 weeks gestation due to preterm labor. She experiences a rapid progression, and a 3.2 kg male infant is delivered via emergency cesarean section due to fetal distress. The neonate is born in the OR. 

SITUATION 

Baby is delivered still being held by the delivering physician. The baby is noted to have minimal respirations and limp tone. Physicians are asking you to let them know when 30 seconds are up for delayed cord clamping. 

& DISCUSS: What interventions are necessary at this time?  

ANSWER:

RT/ RN should ask the physician to hand them baby immediately since there is limp tone and minimal respirations. 

SITUATION: 

Baby is received at the radiant warmer with these vitals: 

• Heart Rate (HR): 60 bpm 

• Respiratory Rate (RR): 10 breaths per minute 

• SpO2: 56% on room air at 1 minute of life 

• Some tone but weak 

• No grimace 

• Central and peripheral cyanosis is noted 

• Weak cry when stimulated 

& DISCUSS: What is the APGAR Score for the baby at 1 minute of life? 

ANSWER: 

Appearance:  0  (cyanosis all over) 

Pulse:  1  (HR was less than 100bpm) 

Grimace: 1 ( weak cry when stimulated)) 

Activity: 1 ( some tone) 

Respirations: 1 (slow irregular breathing) 

Total APGAR Score at 1 minute = 4 

& DISCUSS: What interventions are necessary at this time? 

ANSWER: 

Since the HR is less than 100 the therapist initiates positive pressure ventilation using a T-piece resuscitator or flow inflating bag with 21% oxygen. 

Adjusts the oxygen concentration based on continuous pulse oximetry monitoring to target the appropriate range according to NRP guidelines. 

SITUATION: 

 You notice the babies HR has increased to 105 bpm after 1 minute of PPV. SPO2 is in the appropriate range. You discontinue PPV but then notice the baby is grunting and has mild retractions. 

& DISCUSS: What is the intervention needed at this time? 

ANSWER:  

CPAP should be initiated. If PPV and CPAP are done for longer than a few minutes, and OG tube should be placed and left to vent to decrease gastric distention. Typically, we start CPAP at 5cm H20 and adjust according to patient assessment.  

SITUATION: 

At 5 minutes of life the baby is on CPAP of 5 cm H20 and now having minimal retractions and grunting. The patient is generally pink with some peripheral cyanosis, crying loudly, good tone. HR is 142. 

& DISCUSS: What is the APGAR Score for the baby at 5 minute of life? What intervention should be done now?  

ANSWER: 

The baby should be brought back to the NICU for further evaluation. CPAP should be continued until the patient’s grunting and retractions are no more. 

Appearance:  2  ( peripheral cyanosis ) 

Pulse:  2  ( HR was less than 100bpm ) 

Grimace: 2 ( cries on stimulation ) 

Activity: 2 ( great tone) 

Respirations: 1 ( strong cry ) 

Total APGAR Score at 5 minutes =  9 

Always discuss APGAR scores with the other associates who are involved in the resuscitation. APGAR scores can sometimes be subjective, so it is imperative that you all agree on the final scores. 

Important Reminder: 

These are hypothetical situations and are not meant to be taken literally. Always follow your hospital's policies, procedures, and guidelines. Your hospital will have specific guidelines that you must follow in each department. These scenarios are purely educational. Always consult with your hospital providers before doing any medical procedure on patients.