Negligent Resuscitation of a Newborn

An infant’s entrance into the world is a challenging time. Going from intrauterine to extrauterine life results in many physiological changes; the lungs take over gas exchange and become filled with air rather than fluid, and blood flow to the lungs is substantially increased (Department of Health, 2014). If appropriate care is not provided to the newborn during delivery or while in the neonatal intensive care unit (NICU), many different complications, sometimes life threatening, can occur.

Some infants are born in distress and need assistance adjusting to the world outside the womb. One of the most common reasons this happens is because of preterm labor, or premature birth. Preterm labor refers to a labor that begins before 37 weeks of pregnancy, which is dangerous for the infant (National Institute of Child Health and Human Development [NICHD], 2014). Preterm infants usually experience more health risks because they weigh less and their organs, such as their brain, lungs, or liver, have not had enough time to develop; until their organs can function on their own, they must remain in the NICU (NICHD, 2014). Because of their unfinished organ development, premature infants may experience difficulty breathing from weak muscles or immature brain development, rapid heat loss from thin skin, fragile blood vessels, and small blood volumes (Kattwinkel, 2011).

Preterm birth is the most common cause of infant death and long-term nervous system disability (NICHD, 2014). Post-term pregnancy, defined as a pregnancy longer than 41 or 42 weeks, can also be dangerous as the baby may no longer receive sufficient nourishment (Todd, 2015).

Fetal distress is another problem health providers must look for during pregnancy. This occurs when sufficient amounts of oxygen are not being given to the fetus (American Pregnancy Association [APA], n.d.). It can occur during both pregnancy and labor, which can result in hypoxia, meaning not enough oxygen is reaching the tissues. Fetal distress can be detected by an abnormal fetal heart rate. The health provider may try intrauterine resuscitation techniques such as making sure the mother is well hydrated and has enough oxygen or aminoinfusion (i.e., fluid is inserted into the amniotic cavity). If still in distress, an emergency cesarean section and resuscitation may be required.

There are a number of other problems that can occur during labor and delivery in addition to the ones mentioned above (Todd, 2015). An abnormal presentation, meaning when the fetus is not positioned head down, can cause birth canal injuries, fetal injuries, or the cutting off of the blood supply to the baby. Problems may occur with the umbilical cord such as prolapse (i.e., the cord slips into the birth canal) or compression (i.e., stretching or constricting the cord). Another serious problem includes an amniotic fluid embolism, where amniotic fluid enters the mother’s blood stream; however, this is rare.

Complications during labor or delivery like those described above will often cause newborns to require resuscitation immediately after birth. Approximately 10 percent of all newborns will require some assistance, but less than one percent will require extensive measures (Department of Health, 2014). The goal of resuscitation is to prevent neonatal death and brain disorders caused by asphyxia (i.e., lack of oxygen). As such, the assessment should begin without delay, and if it is determined resuscitation is necessary, it should begin immediately (Kattwinkel, 2011).

The first step is to determine if the newborn is in need of resuscitation (all procedures are taken from Kattwinkel, 2011). There are three main questions that the doctor must answer to determine this: was the baby born at term, is the baby breathing or crying, and does the baby have good tone (e.g., color)? If the answers to all questions are yes, the baby may stay with the mother and undergo routine care (i.e., warming, cleaning airway, drying) but should still be continuously evaluated. If any of the answers are no, then the baby may need further care than what is normally provided. The doctor should then check the infant’s heart rate; a heart rate over 100 bpm, as long as the baby is breathing easily and is not cyanotic (i.e., skin appears blue), is a sign that the baby is fine. However, if the heart rate is under 100, the doctor should immediately begin resuscitation.

The next step of resuscitation is positive-pressure ventilation (PPV), which assists the infant’s breathing. There are three types of devices that can be used for this: a self-inflating bag (i.e., most common, squeeze it to pull gas in), a flow-inflating bag (i.e., compressed gas flows when mask is secured on infant’s face), and a T-piece resuscitator (i.e., a flow-controlled and pressure-limited device that uses compressed gas). If the baby is only in need of a short amount of assistance, blow by oxygen may be used, which is when an oxygen mask is held slightly away from the infant’s face. While this is performed, the infant’s SpO2 level (i.e., oxygen saturation in blood) should be monitored. PPV is almost always enough to bring an infant’s heart rate above 100 bpm as long as it is being performed correctly.

The effectiveness of resuscitation should be evaluated throughout the process. Two clear signs that resuscitation is working are increases in heart rate and SpO2 levels. Another option is to look at the infant’s Apgar score. This consists of five signs that are observed and rated from zero to two: color, heart rate, reflex irritability, muscle tone, and respiration. It should be measured at one minute and five minutes after birth. If the score is under seven at five minutes, additional measurements should be taken every five minutes for 20 minutes. The need for resuscitation cannot be determined from these scores because resuscitation should begin immediately; however, the scores can show if resuscitation is working.

If the infant’s heart rate drops to 60 bpm, chest compressions should be performed and intubation should be considered. Intubation is an option throughout the resuscitation process, as it can help open the infant’s airway. A correctly sized tube, based on weight and gestational age, is placed into the infant’s trachea to keep their airway open. This can help prevent hypoxia if PPV is not working. The doctors should check to ensure the tube is placed in the right spot before continuing with chest compressions or PPV.

Additional complications may arise during the intubation process. It is possible to insert the tube too far into the trachea. If the tube is inserted too far, it will go into the right main bronchus and critical oxygen exchange will be limited to the right lung. Moreover, intubation into the right main bronchus may cause pneumothorax. This occurs when air leaks form in the lung, which causes the air to collect in a space next to the lung. If a sufficient pocket of air develops, it can compromise lung function by blocking the lung from expanding and impeding blood flow.

Signs that it is in the right lung include no improvement in SpO­2 levels or heart rate and quieter or no breaths on the left side of the chest. To check if the tube is in the right place in the trachea, a doctor may look down the throat using a laryngoscope to see if the tube is in between the vocal cords. Additionally, caregivers should assure the correct “lip-to-tip” distance.   The lip to tip distance is a guideline for the depth of endotracheal tube insertion based on the baby’s weight. If still unsure of placement, an x-ray can be used to ensure the tube is not in the right lung.

It is also possible to insert the tube into the esophagus instead of the trachea. This blocks the baby’s airway and makes it harder to breath. There are multiple signs that the tube was placed in the esophagus rather than the trachea including being unresponsive to the intubation, failure to detect CO2, or no breath sounds. In the event of esophageal intubation, the tube should immediately be removed and correctly replaced. It is possible to detect if the tube is in the esophagus by using a CO2 detector. If the tube is in the trachea, the CO2 detector should show that CO is being exhaled, but if the tube is in the esophagus, there will be an absence of CO2.

Other problems arising from endotracheal intubation include perforation of the trachea or esophagus, obstructions of the tube, or bruises or cuts from rough handling of the tube or other instruments.

If all previous steps of resuscitation are still unsuccessful, which is highly uncommon, a doctor may resort to using epinephrine to raise the infant’s heart rate to 100 bpm.

Because of the complexity of resuscitation and because it is needed in so many births, at least one doctor who is trained and highly knowledgeable in resuscitation should be present in the delivery room. If the pregnancy is already considered high risk because of previous complications, at least two resuscitation competent doctors should be present. If a baby is born and in need of resuscitation, but it cannot be provided, the baby may suffer brain damage, organ damage, or death. This may also occur if resuscitation is not provided in a timely manner (i.e., within 60 seconds of birth). Because of these possibilities, it is extremely important that resuscitation is performed quickly and correctly to ensure that the baby’s entrance into the world is successful.

Even though there are clear guidelines for performing a resuscitation, cases involving negligence during delivery and neonatal resuscitation still occur. One example of a past case involves a baby who was not breathing when born. The team who was supposed to care for him was inexperienced and made a number of mistakes including giving blow by oxygen instead of PPV, which will not work on a baby who is not breathing. They also waited too long to intubate, and then used the wrong size tube and inserted it too far. The baby ended up suffering brain injury because the team did not perform the resuscitation correctly. Other cases have had similar problems: during delivery, a doctor experienced in resuscitation was not present even though it was considered a high risk pregnancy from previous complications. This baby did not receive intubation for hours after birth and similarly suffered brain injury because of it. In another case, an inexperienced team placed the intubation tube in a baby’s esophagus and failed to confirm a correct placement. This child suffered severe brain injury and died because of the team’s incompetence. The main commonality between these cases is the absence of a skilled resuscitation doctor. Being prepared and knowledgeable in resuscitation is essential during every delivery, and it could have made the difference in these children’s lives.

All articles in this blog are the collaborative effort of attorneys Jerry Meyers, Brendan Lupetin, and Gregory Unatin.

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