The sudden unexpected postnatal collapse (SUPC) of a presumably healthy newborn in the delivery room is uncommon. We report a case of an apparent life-threatening event (ALTE) of a healthy newborn who was in a prone position on her mother’s abdomen during early skin-to-skin contact.

Case report

A female infant was born by spontaneous normal vaginal delivery at 40+6 weeks of gestation to a primigravida mother. Mother was a 26 year old whose blood group was O positive, with normal serology and a negative GBS status. There were no other risk factors for infection. The mother’s antenatal scans were normal. The baby’s birthweight was 4030g. Apgar scores were 9 at one minute, 9 at five minutes, 10 at ten minutes. No resuscitation was needed initially and the baby was given to the mother for skin-to-skin contact.

At 45 minutes of age, the baby was found to be unresponsive, floppy and grey in colour. No heart sounds were heard and the baby was not making any respiratory effort. Intermittent positive pressure ventilation (IPPV) with cardiac compression was commenced by the obstetrician and midwife. The paediatric team arrived within a minute of the incident. Full resuscitation was initiated, including IPPV, cardiac compression, intravenous fluid bolus and antibiotics. At five minutes of resuscitation, as the baby was not making any respiratory effort, endotracheal intubation was initiated. The newborn clinically improved, with a good heart rate and oxygen saturation. After stabilising, the baby was transferred to the special care nursery (SCN).

In the SCN, the baby’s oxygen requirement decreased. The baby clinically improved, with good respiratory efforts, and was extubated to high-flow respiratory support within an hour. Throughout the event, the infant maintained normal blood sugar and body temperature. During the stay at SCN, the baby continued to clinically improve, the high-flow support was gradually reduced and, within ten hours of age, the baby was comfortably breathing in air without any respiratory distress. The blood investigations, chest x-ray and head ultrasound scan results were normal.

In the SCN, the baby remained clinically stable. There were no dysmporphic features noted and other clinical examination was unremarkable. Enteral feeds were introduced on day two and full-suck feeds on day three. The baby was discharged home on day six of life, with a plan of follow-up appointments in the paediatric outpatient clinic.

Discussion

SUPC or ALTEs in the maternity ward within the first day of life have received increased attention. These events can affect an apparently healthy newborn in the delivery room during the first hours of life, especially during early skin-to-skin contact with the mother. Though ALTEs are rare, the consequences are grave, with death reported in half of the cases and permanent disability in a majority of the surviving infants.

From various studies published, the majority of reported incidents occur within two hours of birth, often at the time of the first breastfeeding attempt or when the infant was in a prone position on his or her mother’s abdomen during early skin-to-skin contact. In most cases, the mother was a primigravida.

There are many benefits of early skin-to-skin contact between mother and baby and breastfeeding in the delivery room. However, in view of the risk of ALTE, surveillance of newborns is needed. Perinatal medical personnel (obstetrician-gynaecologists, midwifes, nurses and paediatricians) should be aware of ALTEs and carefully monitor and ensure proper positioning of healthy neonates during this delicate period of mother-infant attachment, in particular for primigravida mothers.

Guidelines for safe postnatal care of infants should include appropriate vigilance of infants, particularly where mothers are primiparous or where their ability to assess the baby may be impaired.

Further reading

Andres V, Garcia P, Rimet Y et al. Apparent Life-Threatening Events in Presumably Healthy Newborns During Early Skin-to-Skin. Arch Dis Child Fetal Neonatal Ed. 2012; 97:F30-F34. doi:10.1136/F30 adc.2010.208736.
Pejovic N, Herlenius E. Unexpected collapse of healthy newborn infants: risk factors, supervision and hypothermia treatment. Acta Paediatr. 2013; 102(7):680-8. doi: 10.1111/apa.12244. Epub 2013 Apr 30.