Index of Suspicion in the Nursery

Abstract

A term male infant presents 11 hours after birth with dusky color. He was born to a 38-year-old G5P3 mother via cesarean delivery because of recurrent fetal decelerations and the presence of meconium-stained fluid. Maternal history is significant for a history of posttraumatic stress disorder and bipolar disorder, requiring hospitalization during this pregnancy for suicidal ideation, as well as gestational diabetes and migraines. Maternal serologies are unremarkable. Maternal medications include clonazepam, fluoxetine, lithium, olanzapine, glyburide, and propranolol. She is given one dose of morphine more than 24 hours before the infant’s birth and epidural anesthesia with fentanyl and bupivacaine before delivery. At delivery, the infant has a weak cry initially. Once he is brought to the warmer, he has no spontaneous respirations. No meconium is suctioned below the vocal cords. Positive pressure ventilation (PPV) is initiated. Initial heart rate is less than 100 beats per minute, but then improves to greater than 100 beats per minute. He continues to require PPV because of apnea. After 3 minutes of PPV, his work of breathing is normal. It is felt that his initial respiratory depression at birth is related to the fetal distress he experienced as evidenced by the passage of meconium before delivery and fetal decelerations. Given his good response to neonatal resuscitation, the infant remains in the room with his mother. Initial physical examination by the pediatrician is unremarkable. Vital signs and results of glucose screening are unremarkable. He is noted to be feeding normally. At 11 hours after birth, his parents request that he come to nursery so they can sleep. While sleeping in the nursery, he is suddenly noted to be cyanotic and apneic. On examination, the infant is limp, cyanotic, and apneic with a heart rate greater than …