You can’t always tell a “bad” baby by the fetal heart strip.
That is to say, some babies look fantastic during labor and all the way through pushing, but when kiddo is born and the big moment comes, they just can’t seem to get the hang of “life on the outside”.
The majority of babies transition well. When L&D nurses talk about babies “transitioning”, we mean the process that takes place immediately after birth where baby goes from being in-utero and fully dependent on mom’s body to breathe, feed, and remove waste to suddenly having to do all of that for himself.
Like I said, most babies figure it out on their own within moments of being born. They take a surprised breath, and with a bit of drying and physical stimulation, they start to cry, their skin turns pink, and wa la! Life doesn’t really begin as much as it just continues.
Still, my hospital requires that at all births, there is a nurse present for mom and a second nurse present for baby. This ensures that if there is an emergency with either, both have their own dedicated staff member present and fully in-tune with their history and their treatment. The last night I worked, I got a great reminder of just why we require two RNs to be present at all births.
The nurse who had the patient in room 2, Barb, was an experienced L&D nurse who had an orientee, Marcy, working with her. When one of my other coworkers mentioned that Barb and Marcy’s patient was about to deliver, I took a look at the strip and started heading down the hall. As I was “up”–patient-less and waiting for an assignment–I was ideally free to help in the meantime.
“Well, I dunno, Sophie. She should be good. She has Marcy in there with her, and she’s almost off orientation.” Breanna called from the desk.
“Oh, it’s no problem.” I replied, keeping in mind the happy FHR strip I had just seen on the monitor. “You never know, after all.”
“True.” Breanna agreed plainly.
As I arrived in the room with the doctor and the surgical tech, I prepared the bassinet, laying out the blankets, placing a blanket on mom’s chest, and making sure that suction, oxygen and my emergency equipment was functioning and turned on.
Barb and Marcy were helping their patient push, which was taking longer than they had expected for the first-time mom, but baby was clearly at about a +2 station and making progress with each push. About five minutes later, baby’s head emerged, followed by the rest of his body with one last push.
As the doctor cut the cord, I stepped up at the bedside, drying and stimulating the baby as he was placed on mom’s chest. APGARs are a little low on this one, I noted as I realized the baby wasn’t crying, had central cyanosis, and he wasn’t moving much. Moments later, I heard the distinct sound of grunting on the end of each breath and retractions appeared around baby’s sternum.
Seconds into meeting this new little boy, it became obvious that he would require a little extra attention. I kicked my assessment skills into high gear as I reached for my stethoscope to take a closer look.
Drying, Stimulating and Crying
Drying a baby is important as babies have difficulty maintaining their own temperatures, so the longer baby stays wet, the more likely it is for him to get cold and potentially experience some of the consequences thereof: dropping blood sugar, lethargy, and low blood oxygen to name a few. While some of the “goop” (AKA: vernix) that baby is born in has been shown to protect baby against infection and help regulate baby’s temperature, making sure baby is dry is of paramount importance immediately after birth. It is important to note that while some of the vernix will come off with drying, enough will stay on the newborn to provide the benefits associated with delayed bathing (which is a topic for another post!).
A natural result of drying baby is the stimulation that occurs when the blanket makes contact with his skin, and this stimulation usually causes babies to cry. Crying will naturally help to clear any fluids that baby might have gulped on his way out, therefore opening his lungs and getting him used to the idea of breathing on his own.
Cyanosis is a general term that refers to a bluish coloring of the skin due to a lack of blood flow or poor oxygenation. A little cyanosis of the hands and feet actually isn’t uncommon in newborns and is called acrocyanosis. Acrocyanosis occurs normally as baby transitions from being in-utero to having to breathe on his own after birth: slower or decreased blood circulation to the extremities is normal as baby’s body learns to support itself through breathing.
Central cyanosis means that a baby looks purple or blue in his or her trunk. When the infant’s chest, abdomen or face appear purple, it can be a sign that baby isn’t getting enough oxygen all around. Though central cyanosis isn’t in and of itself indicative of decreased oxygenation, it is an indication to place an SPO2 monitor on baby’s right hand and make sure that the discoloration you’re seeing isn’t from low O2 levels.
Muscle Tone and Startle
Decreased movement is another potential sign of trouble. When babies cry, they naturally tense their legs and arms. In general, crying is a whole-body experience for a newborn. Also, in addition to the stimulation of having been born, the noise and light associated with birth often triggers baby’s startle reflexes, and if baby doesn’t have good muscle tone and good reflexes pretty quickly after birth, this can point to trouble.
Of note: this can be a sticking point for babies born by C-section. Vaginal birth and the process of emerging from the birth canal–and all the squeezing that entails–can naturally stimulate a baby as he’s being born and also force fluid out of baby’s lungs. C-section babies aren’t privy to this particular set of benefits, however, and as a result, sometimes babies born by C-section require a little extra attention to get them to perk up after birth.
Retractions and Grunting
Retractions are a fancy term for when the skin pulls in around baby’s ribs and sternum as he tries to breathe. The direct result of a baby working extra hard to pull in air, retractions are a sign of respiratory distress in newborns.
The same goes for grunting, which initially sounds like baby is humming a song. As baby exhales, he closes his glottis (which normally covers the airway when you’re swallowing food or fluids), which causes a distinctive “ah-ah-ah-ah-ah” sound. In doing so, he causes a change in pressure in his chest that helps improve his oxygenation. If a baby is resorting to grunting, chances are, he will need some assistance in the breathing department, whether that be suctioning, oxygen administration, chest percussion, or a combination of all three. Grunting can be a last-ditch effort to open baby’s lungs before things go south, and I’ve seen grunting babies decline from grunting to assisted ventilations (bagging) to intubation (ventilator) depending on the source of their respiratory compromise.
*Of note: breathing is a big deal. I know that sounds like a given, but in most babies who require resuscitation, breathing is the culprit of their distress. Say you have a baby who’s born at term with central cyanosis and a no heart rate. Even before you consider starting chest compressions–even if baby didn’t have a heartbeat at all–per Neonatal Resuscitation Guidelines (NRP), you must give adequate assisted ventilations (bagging) before starting chest compressions. Most of the time, correcting problems with baby’s breathing will correct everything else.
At one minute, five minutes and ten minutes after birth, nurses assess something called an APGAR score. This quick, objective assessment looks at five categories: skin color, heart rate, breathing effort, muscle tone, and reflex irritability. At most, baby can get a “2” in each category. At the least, he can get a “0”. So on a scale from 0 to 10, an APGAR score tells a provider quickly how a baby is transitioning.
At one minute, my baby scored as follows:
Breathing: 1 -irregular, discoordinated breathing efforts
Heart rate: 2 -pulse is 150bpm, normal range
Muscle tone: 1 -baby has some muscle tone present, but less than normal
Reflex irritability: 2 -baby’s reflexes are normal
Skin color: 0 -baby has central cyanosis
Total APGAR: 6
(As a reference, most babies are born with APGAR scores of 8-9. A score of less than 7 indicates a need for medical attention).
Back to the Scenario
With baby’s physical assessment looking borderline, I took the baby to the warmer with his mother’s enthusiastic permission. I placed an SPO2 (blood oxygen) monitor on baby’s right hand and looked for a baseline. Heart rate was in the 170’s–up from when I had listened to him on mom–and his blood oxygen was lower than normal.
With audible gurgling and coarse lung sounds, suction was in order. I suctioned baby’s nose and mouth quickly, immediately pulling out some thick, clear secretions. Suctioning can be an irritating process to a baby which can have the added benefit of making baby cry. My baby did just that. He cried immediately after I suctioned him, producing more fluid from his mouth and nose. A few suctions later, baby’s heart rate came down, his O2 went up, his retractions stopped and grunting significantly decreased, and we were looking at a much happier boy.
In the end, this baby did well. He was brought back to his mother and monitored for the rest of his time in L&D, but he transferred to postpartum without issues and was discharged normally with his mom a few days after he was born.
However, this scenario just goes to show: a happy strip doesn’t mean a happy baby, and it pays to stay on your toes at all times!