Index of Suspicion in the Nursery

Abstract

A Hispanic baby girl born at 42 weeks gestational age develops poor perfusion and respiratory distress at 28 hours after birth. She was born to a 17-year-old G1 P0 mother via cesarean section for failure to progress. The mother’s pregnancy was uncomplicated. Prenatal laboratory results were unremarkable; a vaginal culture for group B Streptococcus was negative. The mother had prolonged rupture of amniotic membranes for 19.5 hours. She developed a temperature of 100.3°F (38.0°C) during labor. No antibiotics were administered preoperatively. The amniotic fluid was stained with thick, “pea soup” meconium. The infant was vigorous at birth, with Apgar scores of 8 at 1 minute and 9 at 5 minutes, and a weight of 2.91 kg. Vital signs were initially stable. She fed and displayed normal newborn behavior during the first postnatal day. The next day, the baby appears dusky and experiences respiratory distress and periods of apnea. She also displays seizurelike activity. On physical examination, her temperature is 98.6°F (37°C), pulse is 165 beats/min, respiratory rate is 42 breaths/min, blood pressure is 56/32 mm Hg, and oxygen saturation is 38% on room air. The anterior fontanelle is open, soft, and flat. The heart has a regular rate and rhythm with no murmur. Lung examination reveals subcostal and suprasternal retractions with bilateral diffuse crackles. Extremities are cool, with a 3-second capillary refill. Laboratory analysis reveals a total peripheral white blood cell count of 8.7×103/mcL …