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CHAPTER 3 Perinatal Transport and Levels Of Care
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59
This model serves as a tool to help clarify and
improve the transport process, leading to safe and
consistent care.
83
Variability among neonatal transport teams exists
related to length of orientation, readiness for
independent transport, orientation content, procedures performed, and skills maintenance.
23,38,58,64,82
Competency assessment, based on the medical
education model, has also been recommended, thus
allowing teams to evaluate individual personnel,
focus on educational needs, and ensure acquisition
of necessary knowledge and skills.
58,80
A minimum of 2 years of level III neonatal
critical care staff experience is a basic requirement for the nursing and respiratory therapy
components of most neonatal transport services.
Nurses and respiratory therapists who specialize
in neonatal transport should have a basic understanding of neonatal pathophysiology, resuscitation and stabilization techniques, ventilatory
management, and radiographic interpretation.
In the event of a critically ill patient, a nurse practitioner or physician may serve as team leader with
respect to high-level procedures and patient management.
41,42
Programs using air transport should ensure
that all providers, including physicians who may
be involved occasionally, have education on air
safety, survival methods, and flight physiology
(including air transport effects of barometric pressure, g-force, humidity change, potential temperature loss, noise, and vibration).
54,77
Mode of Transport
The optimal transport of a neonatal or pediat-
ric patient is facilitated by the appropriate use of
resources, including staff, equipment, and vehicles.
Vehicles used in transport include surface (ground)
and air (rotor-wing or fixed-wing) ambulances. A
fully integrated transport system would include all
three modalities.58 When initiating a neonatal transport program, the first step should be to identify
the geographic catchment area, total number and
location of perinatal resources, distance in miles/
kilometers, and duration of transport time (ground
versus air) between the different levels of care. An
important factor is the particular characteristics of
the topography of the catchment area, which will
help determine the ratio of ground-to-air transport
resources required. In areas with good roads and low
traffic volume, ground transport may be the only
transport system required.
20,33,54,81
Selecting the proper mode of transport
(ground ambulance, helicopter, or fixed-wing
aircraft) depends on many variables. However,
the safety of the patient and crew must be the foremost consideration when determining the mode
of transport. Careful consideration of risks should
be made before any patient transport is initiated.
Variables that affect mode of transport and benefits of ground versus helicopter include clinical
status of the patient, medical care required by
the patient before and during transport, urgency
of the transport, and other logistical considerations. By shortening response time and transport
time in a clinically unstable patient, the selection of
one mode of transport over another may be lifesaving. Logistical concerns affect the appropriate selection of mode of transport and can include distance,
weather, traffic, and accessibility of area.
58
Potential advantages and disadvantages of the
available modes of transport should be considered.
Ground ambulances are the most common means
for interfacility transport of neonatal and pediatric
patients. Ground ambulances offer many advantages
over air transport. Ground ambulances are routinely
available, can operate in weather conditions that
restrict safe air operations, may be more user-friendly and functional with regard to the transport environment, and provide door-to-door service without
need for helipad, landing zone, or runway. There
are limitations to ground transport. There is a high
potential for a rough ride, as well as the possibility
of motion sickness for the patient, team members,
or family. Ground ambulances have significant time,
distance, and access constraints.
58
Helicopters have strengths and weaknesses as
well. Speed of travel is one of the unique characteristics of air transport. There is no need for a runway,
and helicopters are able to avoid common traffic
delays and ground obstacles and fly into areas that
are otherwise inaccessible to other modes of transport. The disadvantages associated with helicopter
transport include limitation in cabin size, landing
zone requirements, and weather considerations.
Fixed-wing aircraft travel at a greater speed and
cover a greater service area compared with ground
ambulances and helicopters. Other advantages
include a larger patient cabin than that of a helicopter and the ability to fly above or around inclement weather. The greatest limitation of fixed-wing
58
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aircraft is the need for an airport landing that may
be a distance from the referral and receiving facilities. Ground transport is needed between referral
and receiving facilities and the airport.
58
Selection of the appropriate mode of transport is not a simple decision, and no single
vehicle is ideal for all patients or transport
teams. The risks, benefits, advantages, and disadvantages of each mode should be considered,
as well as the mission of the team and needs
of the patient.58 In general, when transport time
exceeds 2 hours, air transport is more appropriate.54
However, local ground transport capabilities to and
from a referring hospital and airport must be known
when fixed-wing air transport is used.
Equipment and Medications
Transport teams should be self-sufficient with
dedicated, organized supplies for quick, efficient
access.58 The equipment and medications necessary
for neonatal transport are similar to those used in
the NICU. Equipment must be light, compact,
durable, and motion and g-force tolerant. All electronic equipment should have its own independent
power supply (AC/DCcapability),adequate visual
and audio alarms, and lack of electromagnetic interference.
vital importance to prevent potential interruption
in therapy. Maintenance of equipment should be
scheduled on a routine basis and be performed by
competent, well-trained biomedical technicians.
Equipment should be secured in all transport vehicles by approved methods.
and checked on a routine basis by transport team
members. It should not be standard practice to rely
on or plan to borrow equipment or medications
from referral facilities.
for the delivery of safe care. Special considerations
are needed for certain medications such as surfactant and prostaglandins that require refrigeration.
Security of controlled substances must be maintained as mandated by institutional, state, and federal
regulations.
tions needed for ground and fixed-wing transports
of neonates and pediatric patients are available.58
Table 3.2 provides a list of common transport
equipment and medications.
20,54
Compatibility of all equipment is of
58
Storage packs should be organized, maintained,
58
Medication storage is of the utmost importance
58
Sample supply lists for equipment and medica-
Novel Interventions
Because the objective of the perinatal transport
team is to bring the intensive care environment to
the newborn infant, it is also important that ini-
tial resuscitation and stabilization of the infant
be performed by skilled practitioners; this will
enhance the role of the transport team to successfully continue to offer appropriate high-quality
intensive care during the transport of the baby.
Level II centers should be equipped with surfactant,
nasal continuous positive airway pressure (NCPAP)
systems, and oxygen-air blenders to give prompt and
effective respiratory support while maintaining blood
saturation levels within acceptable limits awaiting the
arrival of the transport team. Adequate management
of the premature infant with surfactant deficiency
will include supporting adequate recruitment of the
lung and minimizing barotrauma. It is essential that
practitioners have the skills needed for noninvasive surfactant administration and appropriate
intubation so they can administer early NCPAP to
improve morbidity and mortality and decrease the
need for mechanical ventilation.* These requisite
skills are necessary in situations in which duration
of transport may be prolonged for hours because
of unforeseen delays. The use of early NCPAP
in the delivery room for infants with respiratory
distress is recommended for the management of
premature infants with respiratory distress syndrome and term infants with mild to moderate
respiratory failure.5 Because surfactant is an expen-
sive medication, level II centers can maintain one or
two ampules in their pharmacy to be restocked as
needed. The use of NCPAP during transport has been
evaluated and has been shown to be a safe and efficacious intervention for respiratory support.
The use of a resuscitation device such as the T-piece
infant resuscitator (Neopuff Infant Resuscitator,
Fisher & Paykel Healthcare, Auckland, NZ) may
help decrease the variability of pressures administered
to the neonate during resuscitation, stabilization, or
administration of surfactant. This device also has the
potential to minimize lung damage while supporting
lung recruitment with the use of positive end-expiratory pressure.
10,63
This system can also temporarily
replace the need for mechanical ventilation if NCPAP
is unsuccessful in maintaining respiratory stability.
*
References 5, 16, 18, 21, 26, 58, 69, 88.
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TABLE
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3.2
CHAPTER 3 Perinatal Transport and Levels Of Care
EQUIPMENT AND MEDICATIONS FOR NEONATAL TRANSPORT*
61
PHYSIOLOGIC
MONITORING
AND SAFETY
BPcuffs,#2–#4(2
each)*
Electrodes(2ofeach
availablesize)
Pulse oximeter
probes(2)
Dispensable
thermometers(2)
Skintemperature
probes(8)
Rectalprobe(1)
Warming pad porta-
ble:chemical(2)
4×4gauzepads(2)
Nonstickgauze
pads(2)
Bowelbag(1)
Sterilerolledgauze
(2)
Earprotectors(2)
Hats(2)
Flashlight(2)
Tapemeasures(2)
AIRWAY AND
SUCTION
EQUIPMENT
Laryngoscope(2)
Laryngoscope
blades(2ofeach
size)
Laryngoscopelight
bulbs(3)
AAbatteries(4)
Endotracheal tubes
(3ofeachsize)
Stylets(4)
CO2detector(2
self-contained,
sterile)
Closedsuction
catheter(2ofeach
size)
Meconiumaspirationdevice(2)
Bulbsuction(2)
Suctioncatheters
(2ofeachsize)
Salinebullets(4)
Replogle(2of
eachsize)
Orogastrictubes(2
ofeachsize)
RESPIRATORY
EQUIPMENT
Anesthesiabags
(2perT-PICUinfant
resuscitator)
Self-inatingbag(2)
Oxygenmask(2)
Facemasks(2ofeach
size)
Infant nasal cannula
(2)
CPAPprongs(2of
eachsize)
Neonatalowsensor
(2)
CPAPcircuit(1)
Ventilatorcircuit(1)
Point-of-care blood gas
equipment(1–2)
PROCEDURE
EQUIPMENT
Steriletowels(1)
UACtray(1)
Single-lumen
umbilical catheters
(2ofeachsize)
Double-lumen
umbilical catheters
(2ofeachsize)
Umbilicaltape(2)
Povidone-iodine(3)
Scalpels#11and
#15(1each)
4.0silksuture(4)
Dressingfor
umbilicalline(2)
Needleaspiration/
chesttubekit(2)
Transducer(2)
Chesttubes,10
Fr/12Fr(2of
eachsize)
Heimlichvalve(2)
Sterilegloves(5of
eachsize)
IV FLUID AND
ACCESS
D5W50mL(2)
NS250mL(1)
D10W500mL(1)
D50W50mL(1)
Heparinsodium
1000 mcg/mL
vial(3)
Syringes,3mL/
1mL(6each)
IVcatheter,#22and
#24gauge(5each)
Accesskit,including
dressing,tourniquet
(2)
Butteryneedle(3of
eachsize)
Armboard(2)
Heelwarmers(2)
Lancets(2ofinfant
andpreemiesize)
Syringes(5ofeach
size)
MEDICATIONS REFRIG-
ERATED
MEDICATION
Epinephrine
1:10,000(2)
Naloxone1mg/1
mL(2)
4.2%sodium
bicarbonate(2)
Dopamine(2)
Dobutamine(2)
Acyclovir(1)
Ampicillin(2)
Gentamicin(2)
VitaminKfor
injection(1)
Eyeointment(2)
LidocaineHCl(1)
Adenosine(1)
Vecuronium(1)
Sterilesalinefor
injection(2)
Abbojectneedle(2)
Fentanyl(2)
Midazolam(2)
Phenobarbital(2)
Exogenous
surfactant(1)
PGE(2)
*()designatesnumbersofpiecesofequipmenttobecarriedintransportkit.
BP, Blood pressure; CPAP,continuouspositiveairwaypressure;NS, normal saline; PGE, prostaglandin E; UAC,umbilicalarterycatheter;T-PICU, T-piece infant care unit.
Early mobilization of the transport team for
an impending premature delivery or delivery of
a sick neonate allows for earlier implementation
of tertiary care in the community. There has
been a change in philosophy regarding departure of
the transport team. The patient need not be born
to mobilize a team. Close monitoring of aborted
or prolonged transports is necessary to avoid inappropriate use of resources in a region. Time spent
awaiting the delivery must also be monitored.
Neonatal transport brings ICU care to the
patient including many of the same modes of
ventilation as in the NICU. Conventional venti-
lation as well as high-frequency ventilation can be
usedto transport infants.During thepast10 to15
years, the use of noninvasive respiratory support
on transport has increased for all gestational
ages. Multiple reasons may have contributed to
this including: increased use of antenatal steroids,
surfactant replacement therapy, improved resuscitation protocols, and improved knowledge and
availability of noninvasive modes.61 Nasal cannula,
nasal CPAP, and high-frequency nasal ventilation
are all examples of noninvasive modes being used
(see Chapter 23).
Another important intervention for perinatal
transport is the administration of prostaglandin
E1 (PGE1) for patients in whom a suspicion of
62 UNIT TWO Support of the Neonate
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cyanotic congenital heart diseases is supported
with a positive hyperoxia test and measurement
of upper and lower extremity blood pressures.
Adequate knowledge of dosing and preparation is
fundamental to the successful use of this medication,
which can prevent patients with ductal dependent
lesions from becoming clinically unstable and developing severe hypoxemia and metabolic acidosis
before the arrival of the transport team. The need
for intubation and ventilator support to prevent
apnea varies depending on the anticipated length of
transfer and the dose of PGE1 necessary to maintain
the infant asymptomatic.
13,29
A recent retrospective
chart review found that apnea began within 1 hour
of initiation of the PGE1 infusion in neonates diagnosed prenatally with ductal-dependent heart disease. Beginning the transport after the first hour of
infusion may make prophylactic intubation unnecessary.76 Knowledge by the referring physician of
the performance and interpretation of the hyperoxia
test will facilitate the decision to start PGE1 and
should be part of the maintenance-of-skills program. Level II nurseries should maintain a vial of
PGE1 in stock.
Inhaled nitric oxide (iNO) is used during
transport to support term and near-term infants
with hypoxemic respiratory failure that does not
respond to conventional mechanical ventilation.
14,55
The use of iNO can be lifesaving and may decrease
associated morbidities. Use of pre- and post-ductal
saturations facilitates the identification of neonates
whocanbenefitfromthistherapy.Duringtransport,
certain adaptations for both ground and air transport must be made to use iNO safely and effectively.
Therapeutic hypothermia is only offered at
high-level NICUs and is neuroprotective for
infants with moderate to severe hypoxic ischemic
encephalopathy (HIE). Passive cooling can be
initiated by turning off external heating devices
and can be continued on transport.6 However a
10-year retrospective study of passive cooling found
that the therapeutic temperature zone was met in
only 52.6% of the neonates during transport.46 A
recent retrospective study evaluated both passive
and active cooling on transport and concluded that
active cooling increased the odds that the infant
would arrive at the receiving center within the
therapeutic temperature range.79 These and other
researchers suggest that if cooling is considered on
transport, active servo-controlled therapeutic hypothermia be used.
2,53,79
Other considerations while
actively or passively cooling a patient during transport include: mode and length of transportation,
external temperatures, and the inclusion of ice packs
on the transport equipment list.
Neonates managed during transport with other
more complex interventions, such as high-frequency jet ventilation (HFJV) and extracorporeal membrane oxygenation (ECMO), have been reported.
Mobile ECMO units in Sweden,12 France,71 and
Italy24 found that although ECMO during transport is safe, many complications are possible, thus a
highly skilled ECMO team is required. The use of
HFJV during transport is feasible and has resulted in
safe transport of infants needing ECMO56 and those
with congenital diaphragmatic hernia.91 Use for
routine transport cannot be recommended, because
of the complexity of training, equipment, and logistics required for HFJV and ECMO. Every country
and regional perinatal center must determine its
priorities for transport based on epidemiologic
studies conducted in its catchment area to support
the demand with appropriate resources for adequate
perinatal transport.
FAMILY-CENTERED CARE FOR
TRANSPORT
Separation of the infant and mother is often a
consequence of neonatal transport. This physical
separation affects both bonding and attachment,
increasing the stress surrounding the delivery of
an ill infant.* Creative ways to minimize the negative
effects of this separation must be incorporated into
the transport process. Whenever possible, transport
should allow for the presence of a family member.
Principles of family-centered care used in the
inpatient setting should apply to the transport
environment. Despite the evidence of benefits,
there is no universal acceptance or implementation of family-centered care in transport. Transport
members cite multiple reasons for excluding parents, including anticipated difficulty caring for
the patient if the parent needs attention, potential
difficulty dealing with distraught parents, difficulty controlling the child with the parent present,
and general team member anxiety in providing
care with parent(s) watching.58 Before departure
from the referring facility, the transport team
*
References 3, 32, 40, 43, 44, 45, 60,62.
58
CHAPTER 3 Perinatal Transport and Levels Of Care
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63
should meet with the parents of the infant,
communicating the plan for transport, providing information with regard to the receiving
hospital (including phone numbers, directions,
and unit-specific guidelines), and answering any
questions the parents may have. The transport
team should identify a phone number that may be
used to communicate with the parents once the
infant is transported. In addition, the transport
team should enable the parents to see and touch
the infant before departure and should provide
the parents with a photograph of their infant.
54
Enabling parents to be present during provision of critical care is the cornerstone of family-centered care. The presence of the family
during resuscitation continues to gain support.
The presence of the family allows them to continue to act as allies in the care of their child
and enables them to see firsthand that team
members did their best and treated their child
with respect, dignity, and empathy.
58
With the presence of the family during transport, safety should remain the priority. All vehicle
occupants should wear appropriate restraints. Family
members should be educated if it is unsafe for them
to ride in the transport vehicle or in a particular
location in the transport vehicle. The transport
team has the responsibility to define a standard
of family-centered care during the transport of
sick neonates and pediatric patients.
58
If family is unable to accompany the child during
transport, upon arrival at the receiving medical
center, a transport team member should call the
parents to update them on the condition and the
safe arrival of their child in the receiving facility. At this time, the transport team should give the
parents the names of those who will be responsible
for the care of the infant. Once the infant is admitted into the receiving unit, the receiving physician
should communicate directly with the parents and
referring physician. Engaging the parents in the
caregiving process as soon as possible empowers
parents and assists the health care team in devising a
care plan that will be mutually acceptable and in the
best interest of the infant.
Facilitation of bonding between parents and
infant may be improved with the use of webcam technology in the NICU.75 Webcam tech-
nology provides virtual visitation with the infant
for the family regardless of the geographic distance
between them at the time.
FUTURE OF NEONATAL
TRANSPORT
Research, innovation, and enhancement of regionalization networks represent the future for perinatal transport. The mandate for highly motivated
leadership able to apply epidemiologic, research,
and quality-improvement methodology to the
area of perinatal transport is essential for progress.
The development and evaluation of new interventions, as well as the evaluation of what we consider “standard therapies,” are imperative to more
favorable outcomes. An example of the need for
further evaluation is the excessive physical strain
of the transport process on VLBW infants who
are at high risk for intraventricular hemorrhage
and specifically looking at ways to decrease sound
and vibration during ground and air transport.
The inclusion of continuous quality improvement
at the top leadership level of the organizational
structure of the perinatal transport system and the
systematic collection of relevant data within an
identified perinatal region represents the backbone
for research in standing and new technologies.
The use of evidenced-based practices is crucial
to the improvement of survival without severe
morbidity, especially for very preterm infants. A
recent prospective multinational population-based
observational study found that the combined and
simultaneous use of four practices for infants born
before 28 weeks of gestation lowered in-hospital mortality and morbidity, corresponding to
an estimated 18% decrease in all deaths without
an increase in severe morbidity.90 These evidence-based practices include: (1) delivery in a
maternity unit with appropriate level of neonatal
care, (2) administration of antenatal corticosteroids,
(3) prevention of hypothermia, and (4) surfactant
administration within 2 hours of birth and/or early
nasal continuous positive pressure.
Special attention must be focused on the
referral community to improve resuscitation and
stabilization efforts. In addition, benchmarking
with regard to morbidity and mortality outcomes
for transported patients will provide clarity for
evaluation of the transport experience. The ultimate focus of this effort is to improve maternal and
neonatal outcomes. Ultimate success will depend
on the level of multidisciplinary participation
of government, community, and private industry
stakeholders.
8,70
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CARE AT BIRTH
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4
SUSAN NIERMEYER AND SUSAN B. CLARKE
A GOLDEN OPPORTUNITY
The initial evaluation and management of the
newly born infant focus on promoting normal
adaptation to extrauterine life and integration
of the mother–baby dyad as well as detecting
significant medical problems so that they can be
evaluated and treated appropriately. In adjusting
to extrauterine life, the newly born infant experiences a complex series of physical and physiologic changes. These changes result from a variety
of processes, including perinatal surges in hormones,
labor, delivery, ventilation and oxygenation of the
lungs, umbilical cord occlusion, decreased environmental temperature, and activation of the sympathoadrenal system.
Such complex changes are essential for survival.
Every infant must successfully complete this
transition in order to survive in the extrauterine environment. For a small percentage of
infants, transition is never achieved; for a slightly
larger number, transition is delayed or complicated;
however, for most infants, transition is so smooth
it appears uneventful.2 It has been estimated that
in approximately 10% of live births, the active
intervention of a skilled individual or team is
necessary to ensure a successful transition.34
Consequently, the optimum care of the neonatal
patient during this period needs to be prospective
and anticipatory.
The purpose of immediate care after birth is
to support the normal physiologic changes in a
newborn’s respiratory and circulatory transition
from fetal to neonatal life. Normal physiologic
changes at birth include expansion of the lungs
with air, initiation of gas exchange across the alveolar membrane, and closure of circulatory shunts
that were necessary during intrauterine life. When
delivery is complicated by perinatal conditions
leading to perinatal depression, the aim of resuscitation is to reverse hypoxia, hypercarbia, and
acidosis. The survival and outcome of distressed
newborns depend on timely and effective intervention in the first few minutes after birth.
All resuscitation efforts begin with the basic
techniques of drying, providing warmth, and
stimulating, with clearing of the airway only
as needed.
assessment of oxygenation, supplemental oxygen
administration (if needed), bag-and-mask ventilation, endotracheal intubation, chest compressions,
and the use of epinephrine and volume expansion.
Emergencies at birth may require resuscitation, as
well as more advanced procedures during stabilization in the delivery area and transition to the neonatal care unit. Finally, truly successful resuscitation
depends on care of the family, collaborative
perinatal decision making, and teamwork and
communication among health care professionals.
3,81
Advanced resuscitation includes
PHYSIOLOGY
At birth, a rapid physiologic transition must occur
from the intrauterine to extrauterine environ-
43,67
ment.
begin within the first minute after delivery.
Environmental factors, such as a relatively cool
ambient temperature and tactile stimulation, assist
in initiating respiration. The changes in Pao2 and
Paco2 during birth affect chemoreceptors and aid
in the reflexive initiation of respiration. The initial
breath may generate from 20 to 70 cm H2O
Effective, regular respirations should
2,24
BLUE type highlights content that is particularly applicable to clinical settings.
67
UNIT TWO Support of the Neonate68
Carotid
v
https://t.me/medicina_free
of negative intrathoracic pressure to replace
lung liquid with air inside the alveoli.69 A
arteries
rapid decrease in pulmonary vascular resistance
and an increase in pulmonary blood flow occur
after expansion of the lungs with air and filling of
the pulmonary circuit with blood. This results in
increased pulmonary perfusion and oxygenation.68
Superior
vena cava
Resorption of fetal lung liquid across the respiratory
epithelium accelerates during labor, resulting in net
clearance of liquid from the potential airspaces.12
Colloid osmotic pressure and the relatively lower
Foramen
ovale
Ductus
arteriosus
postnatal hydrostatic pressure of blood within the
pulmonary circuit assist in absorbing alveolar fluid
after delivery. During this process, fetal right-to-left
shunts through the ductus arteriosus and foramen
ovale gradually close23 (Fig. 4.1; Table 4.1).
ASPHYXIA AND APNEA
Asphyxia is defined as inadequate tissue perfu-
Inferior
ena cava
Descending
aorta
Ductus
venosus
Umbilical
vein
sion that fails to meet the metabolic demands
of the tissues for oxygen uptake and waste
removal. Asphyxia is characterized by progressive hypoxemia (↓Po2), hypercarbia (↑Pco2), and
acidosis (↓pH). Hypoxic tissues convert from aer-
obic metabolism to anaerobic glycolysis, producing
lactate and metabolic acidosis that is initially buffered
by bicarbonate.17 When the buffering capacity is
exhausted, acidosis occurs. Acidosis and hypoxemia
initially result in reflexive, compensatory cardiovascular changes. After early tachycardia, cardiac output
decreases, and generalized peripheral vasoconstriction
occurs to maintain a blood pressure adequate for perfusion of the heart and brain. Prolonged asphyxia
FIGURE 4.1 Circulatory pattern before birth. (From Goldsmith JP.
Delivery room resuscitation of the newborn. In: Martin RJ, Fanaroff AA, Walsh
MC, eds. Fanaroff and Martin’s Neonatal-Perinatal Medicine. 9th ed. St. Louis:
Elsevier Mosby; 2011.)
Umbilical
arteries
results in eventual bradycardia and hypotension
as severe acidosis and cardiac failure develop.
Asphyxia may occur in utero or postnatally.
In either circumstance, a well-defined series of
respiratory events follows (Fig. 4.2).17 During pri-
mary apnea, respiratory movements cease after
a brief period of rapid breathing. At the same
time, the heart rate falls, and neuromuscular tone
diminishes. Intrapartum-related events may result in
the passage of meconium before birth. If the hypoxic-ischemic event continues, the heart rate falls
further, blood pressure falls, hypotonia worsens, and
a series of spontaneous deep gasps occurs. Gasping
continues but becomes weaker and more irregular and then finally ceases. After the last gasp, a
period of secondary apnea begins.
17,81
Another
simple, functional definition of asphyxia used by
the World Health Organization is the failure to
establish effective breathing at birth.
71
Delivery may occur at any point during an
intrapartum-related hypoxic event and the progression to biochemical asphyxia. If an infant is born
during primary apnea, stimulation will usually
induce respirations. If delivery occurs during
secondary apnea, the infant will not respond
to stimulation. Spontaneous respirations will
not resume until resuscitation is initiated with
assisted ventilation.
17,81
In the clinical setting of
birth, primary and secondary apnea are essentially indistinguishable. The infant who is not
breathing may have a heart rate of less than 100
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