Subject:  Management of Neonatal Respiratory Distress at Delivery

POLICY:         Infants that present with signs and or symptoms of respiratory distress while being cared for in the center will be appropriately assessed for continuing care, assessment and or transfer to an advanced neonatal care unit.

DESCRIPTION: The most common cause of respiratory distress is transient tachypnea of the newborn (TTN). This is triggered by excessive lung fluid, and usually resolves spontaneously. Respiratory distress also occurs in preterm infants, as well as “early term” infants (36-38 weeks gestation) that may be encountered at The Birth Center.  In these infants, respiratory distress can occur as a result of surfactant deficiency and underdeveloped lung anatomy.

                     Respiratory distress occurs in about 7% of infants. Most cases are caused by TTN, respiratory distress syndrome, meconium aspiration syndrome, or various other causes.

                     Other etiologies of respiratory distress in the newborn include: pneumonia, infection, sepsis, pneumothorax, persistent pulmonary hypertension, and congenital malformations. Newborns exhibiting signs of respiratory distress that cannot be resolved within their normal stay following delivery at The Birth Center, or present immediately with symptoms, will be evaluated by qualified neonatal staff at the nearest medical center immediately. Initial evaluation may include: lab work including complete blood count, chest radiography, and pulse oximetry. Treatment is disease specific.

CLININCAL PRESENTATION OF RESPIRATORY DISTRESS:

·         apnea

·         cyanosis

·         grunting/ expiratory grunting

·         inspiratory stridor

·         nasal flaring

·         tachypnea (more than 60 breaths per minute)

·         retractions in the intercostals, subcostal, or supracostal spaces

GUIDELINES: 1. Transient Tachypnea of the Newborn

·         Constitutes up to 40% of respiratory distress cases

·         Benign condition, occurs when residual pulmonary fluid remains in the fetal lung tissue after delivery

·         Fluid remains despite the normal mechanisms of dilation of the lymphatic vessels to remove fluid from the lung tissue, resulting in TTN.

·         Risk factors for TTN include: maternal asthma, male sex, macrosomnia, maternal diabetes, and cesarean delivery.

·         Clinical presentation includes tachypnea within the first two hours following delivery; symptoms can last from a few hours to up to two days. The infant presents with tachypnea only, absent are other signs of respiratory distress.

·         TTN is a retrospective diagnosis, and may not be able to be diagnosed at The Birth Center. Any infant presenting with tachypnea that does not resolve will be transferred for evaluation.

2. Respiratory Distress Syndrome

·         Also known as Hyaline Membrane Disease, is the most common cause of respiratory distress in premature infants.

·         Correlates with structural and functional lung maturity, most common in infants born at 28-34 weeks gestation.

3. Meconium Aspiration Syndrome (MAS)

·          Meconium-stained amniotic fluid occurs in approximately 15% of deliveries, causing MAS in 10-15% of those cases.

·         Typically occurs in term and post-term infants

·         Meconium is made up of desquamated cells, secretions, lanugo, water, bile pigments, pancreatic enzymes, and amniotic fluid. Meconium is sterile , however it is irritative, obstructive, and a medium for bacterial growth.

·         Meconium passage may cause hypoxia and fetal distress in utero.

·         MAS causes significant respiratory distress immediately after delivery. Hypoxia occurs because aspiration takes place in utero.

·         In the presence of meconium-stained amniotic fluid, we will follow current NRP guidelines for resuscitative measures as needed.  

4. Infection

·         Bacterial infection is a common cause of neonatal respiratory distress. Most common pathogens include: Group B Streptococci, Staphlococcus, Pneumoniae.  Many babies with infection are diagnosed with pneumonia.

·         Unlike other causes of respiratory distress, bacterial infections take time to develop, with noted respiratory consequences occurring hours to days after birth.

·         Risk factors for pneumonia include: prolonged rupture of membranes, prematurity, and maternal fever.

·         To prevent infection of GBS bactieria, all women are screened antenatally, and those who test positive will be offered treatment intrapartum with IV antibiotics at least four hours prior to delivery.

·         Universal screening for GBS and antepartum treatment is thought to reduce the rates of early-onset disease, including pneumonia and sepsis, by 80 percent.

PROCEDURE:  1. Evaluation : Detailed History

·         gestational age (respiratory distress syndrome affecting preterm infants; MAS affecting term or post-term neonates)

·         antepartum infection status (ie: GBS status/ prophylaxis)

·         information regarding rupture of membranes: duration, color of amniotic fluid, consistency

·         maternal vital signs: temperature, pulse

·         fetal heart rate patterns

·         all critical in detecting MAS and chorioamnionitis

2. Onset and Duration of Respiratory Symptoms:

·         TTN= begins early and improves with time, hours to days following birth

·         Sepsis/Pneumonia= may have no early signs, but may develop hours to days later

·         Respiratory Distress Syndrome= preterm infants, begins early without signs of spontaneous improvement

    3. Physical Examination:

·         Apnea

·         Tachypnea

·         Cyanosis

·         Grunting

·         Inspiratory stridor

·         Chest retractions

·         Abnormal pulse oximetry

·         Crackles, stridor heard upon chest auscultation

When Infant Presents With Respiratory Distress: 

1.   APGAR scores will guide resuscitation as delineated in the AAP guidelines. In addition:

a.   First APGAR score of less than 6 requires immediate call to emergency transport. 

b.   Second APGAR score of less than 7 requires transport to NICU for more extensive supportive measures.

2.   Staff will provide the following supportive measures:

o   Resuscitation following current NRP guidelines (suction, stimulation, PPV, o2 supplementation)

o   Pulse oximetry (placed on right wrist) in infants target range =>95% saturation

o   Consider percussion

o   Blood glucose monitoring for infants with respiratory distress

o   Assessment of neonatal vital s

·         If respiratory distress resolves spontaneously: suggests TTN, provide routine newborn care

·         If it does not resolve spontaneously: NICU transfer, MD care

·         Apply the “RULE OF TWO HOURS”: If condition does not resolve within two hours, NICU transfer from The Birth Center is indicated, or with any of the following:

-      Infant cannot maintain o2 sats (below 95%)

-      >40% oxygen needed to maintain sats

-      Condition deteriorates

-      Respiratory distress persistent, changes in color, tone noticed with continuous assessment