Fetus and Newborn Case

A neonatal resuscitation team is called to an impending delivery of a 41-week gestational age male infant.

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The team is notified of thick meconium-stained fluid and persistent variable heart rate decelerations with slow recovery to baseline for the past 30 minutes. The mother had spontaneous rupture of membranes approximately 20 hours ago. Vacuum-assisted vaginal delivery is being attempted as the team enters the room. The infant is delivered after two pulls on the vacuum device. There was one pop-off of the vacuum device between attempts. The infant is handed to the waiting neonatal intensive care unit (NICU) team for assessment and treatment. He is not crying, has no spontaneous respirations, appears limp and cyanotic, and has a heart rate of 75 bpm.

What is the first step in the management of this infant?

A. Immediately begin tactile stimulation, including drying and gently rubbing the back to encourage respirations.

B. Apply free-flowing oxygen to the infant’s face as he is cyanotic.

C. Suction the mouth followed by the nose with a bulb syringe.

D. Intubate the trachea and suction for meconium.

E. Start positive-pressure ventilation (PPV) as the infant has no spontaneous respirations.

The correct answer is “D.” This newborn remains nonvigorous at the time of delivery with meconium present. Therefore, he should be intubated immediately (prior to any stimulation) and the trachea should be suctioned. A vigorous newborn is defined as an infant who has strong respiratory efforts, good muscle tone, and a heart rate greater than 100 bpm. If the newborn is vigorous despite the presence of meconium, suction the mouth and nose only. If the newborn in this case remains nonvigorous after intubation and suctioning of the trachea, then additional resuscitation should be undertaken promptly.


Question & Explanation: Peterson AR, Wood KE. Pediatrics Examination and Board Review. New York, NY: McGraw-Hill Education; 2017.

Photo: Kline MW. Rudolph's Pediatrics, 23e; 2018

Leah Carton

Associate Editor - Pediatrics, Dermatology, Geriatrics , McGraw Hill