Baby Cunningham was born three hours ago via a cesarean section for a failed induction following a normal pregnancy. The mother had come to the hospital with her membranes intact and having some moderate intermittent Braxton Hicks uterine contractions for the past 24 hours. A vaginal exam revealed a long thick cervix which was somewhat anterior and closed. The baby’s gestational age was established at 37 weeks by late ultrasound because of an uncertain LMP. Since she was near term and her exam revealed that she was not in active labor, the decision was made to try to induce labor. She was started with Cervidil for cervical ripening, then IV Pitocin was started. Contractions were established at 90 seconds, coming every 2 minutes. After more than eight hours of labor, her cervix had effaced 60% and dilated to 1 cm. The baby developed some repeated prolonged deep late decelerations with poor recovery and minimal STV. Because of fetal distress, it was decided to turn off the Pitocin and perform an emergency cesarean section for fetal distress and FTP. At delivery the infant was very pale with an extremely slow heart rate, no respiratory effort, and absent tone. Resuscitation included PPV by bag and mask with short-term CPR. The baby’s APGARS were 3 at one minute, 6 at five minutes and 8 by ten minutes without any need for epinephrine or sodium bicarbonate. At birth the nurse noticed the following physical characteristics: large amount of lanugo and vernix, breasts flat without buds, faint plantar creases, equally prominent clitoris and minora, slow recoil of the ears. The neuromotor exam was not performed due to the persistent depression of the infant’s tone and reflexes status post-resuscitation.
Baby Cunninham was shown to her parents and transferred to the SCN for observation and continued support including oxygen and O2 saturation monitoring. Under the radiant warmer, at 30 minutes of life, the baby was pale and breathing at 88 bpm with some nasal flaring and audible grunting present. Rales were heard bilaterally with a stethoscope. Baby Cunningham was continued on blow-by oxygen, warmth and suctioning prn.
At 45 minutes the respirations were 88-100 bpm, with audible grunting, sternal retractions, and nasal flaring. The baby was pale, cyanotic, and dusky even on 100% oxygen by oxyhood with a pulseox saturation of 87%. Her heart rate was 190, and the temperature continued low at 96 in spite of active warming. Random blood glucose was 25 at one hour. The physician ordered an IV to be started with D10, and blood cultures to be done.
1. What is the most likely cause of this infant’s distress?
2. Describe the dangers of elective induction.
3. How accurate are late ultrasounds for establishing gestational age?
4. What is the normal respiratory rate of a neonate at this age? How does baby Cunningham’s compare? Why do you think this is occurring?
5. Assess baby Cunningham’s temperature. Is this normal at this age? Why do you think this is occurring?
6. What is the normal range for neonatal blood glucose levels? How does baby Cunningham’s compare? Why do you think this is happening, and what problems could arise if it is not corrected?
7. Explain the compensatory principles behind tachypnea, nasal flaring, grunting, and retractions in RDS.
8. How does the environmental temperature affect baby Cunnigham’s chances of survival?
9. Why were cultures done?
10. How might this situation have been avoided?
11. What affects related to parenting can be expected as a result of the birth complications and infant condition?
12. How can the nurse minimize these consequences?
