A 32 year old woman, gravida 4, para 3, at 39 weeks gestation comes the labor and delivery ward with painful contractions. Her prenatal course was unremarkable. Examination shows that her cervix is 5 cm dilated, 100% effaced and the fetal hea rate is in the 130s and reactive. She is given meperidine for pain control. She progresses rapidly and less than 2 hours later she delivers a 3.345Kg male fetus. The one-minute APGAR score is 1 and the infant is making little respiratory effo. Which of the following is the most appropriate next step in management?
Meperidine can be used as a systemic analgesia during labor. It is an opioid and readily crosses the placenta; therefore, the fetus is exposed to the medication. As an opioid, it causes respiratory depression. Neonates are at greatest risk for respiratory depression when delivery occurs approximately 2 to 3 hours after meperidine is administered to the mother. This neonate was born approximately 2 hours after maternal administration of meperidine, which makes neonatal respiratory depression likely. Naloxone is a pure opioid antagonist that displaces the opioid from its receptor sites and can help to reverse the opioid- induced respiratory depression. It has a sho duration of action so repeat doses may be necessary. Blood transfusion would not be indicated. Blood transfusions are used when there is evidence that the neonate is anemic. This neonate appears to have respiratory depression and not anemia. Therefore, naloxone, and not blood transfusion, would be indicated. Glucose should be given when there is evidence that the neonate is severely hypoglycemic. This neonate, given that its mother received an opioid 2 hours ago, is most likely to have respiratory depression from the opioid and not hypoglycemia. Sodium bicarbonate should be given to a neonate for documented metabolic acidosis. It is often used during a prolonged resuscitation. The first step for this neonate, however, would be to try to reverse the respiratory depression with naloxone. Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 19. Obstetrical Anesthesia. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e.
Blood transfusion
Glucose
Naloxone
Sodium bicarbonate