Meconium-Stained Liquor and a Baby with Heart Rate 60 at One Minute
A 38-year-old woman, G4P3, gives birth at 38 weeks in a health centre after a precipitate labour. The liquor was thick meconium-stained. The baby is term, has poor tone, is not crying and is centrally cyanosed. At one minute the heart rate is 60 beats/min by auscultation. A second midwife is present, and a radiant warmer, self-inflating bag with 240 mL bag, masks, suction and oxygen are available. There is no paediatrician on site and no advanced airway trolley. The district hospital is 20 minutes away by ambulance. The mother is stable but anxious and asks why the baby is not crying.
1. State your actions in the first 60 seconds and justify each step.
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Call for help and tell the second midwife to prepare the warmer and resuscitation equipment. Place the baby under the radiant warmer, dry thoroughly with a warm towel, remove the wet towel, and stimulate by rubbing the back and soles. Position the head in a neutral sniffing position and clear the mouth and nose only if secretions are obstructing breathing; do not perform routine deep suctioning for meconium.
Assess breathing and heart rate. The baby is apnoeic with a heart rate of 60 beats/min, so effective positive pressure ventilation is the priority. Apply a correctly sized mask and give ventilation with the self-inflating bag at 40 to 60 breaths per minute, watching for chest rise. Use oxygen according to the local protocol and a blender if available. Reassess the heart rate after 30 seconds of effective ventilation.
The mother should be told briefly that the baby needs help to breathe and that the team is trained to provide it. Keep the baby warm throughout; cold stress worsens bradycardia and acidosis.
2. The heart rate remains 60 beats/min after 30 seconds of effective ventilation. What are your next steps?
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Because the heart rate is below 60 beats/min despite effective ventilation, start chest compressions while continuing ventilation. Use the two-thumb technique over the lower third of the sternum, compress to about one-third of the anteroposterior diameter, and coordinate 3 compressions to 1 breath, aiming for 90 compressions and 30 breaths per minute. Increase oxygen to 100% if available.
Reassess the heart rate every 60 seconds, preferably with a cardiac monitor or oximeter if available. If the heart rate remains below 60 beats/min after 60 seconds of compressions with effective ventilation, give adrenaline 0.01 to 0.03 mg/kg intravenously or intraosseously (1:10,000 solution) and consider volume expansion if there is evidence of blood loss. Do not give adrenaline before ventilation has been established.
If the heart rate rises above 60 beats/min, stop compressions and continue ventilation until regular breathing starts. Arrange urgent transfer to the district hospital with the baby warm and supported, and continue resuscitation en route if necessary.
3. How will you organise the team, communicate with the mother and document the resuscitation?
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Assign clear roles: one person ventilates, one performs compressions and checks the heart rate, and one prepares drugs and calls the ambulance. If only two midwives are present, the second midwife calls for help and the ambulance first, then assists with compressions while the first maintains the airway and ventilation. Keep the baby warm and avoid interruptions in ventilation.
Speak to the mother in short, honest sentences: the baby is not breathing well and needs help, the team is giving oxygen and compressions, and transfer to hospital is being arranged. Do not blame her or the precipitate labour. If possible, show her the baby before transfer or explain where the baby is going.
Document the time of birth, presence of meconium, Apgar scores at 1 and 5 minutes, heart rate at each check, ventilation and compressions given, oxygen concentration, drugs and doses, response, temperature and transfer time. Give a structured handover to the receiving team. Debrief the team afterwards to identify what worked and what needs improving.