Resuscitating a non-vigorous meconium infant — OSCE

Station brief (8–10 minutes)

A term infant is born through thick meconium-stained liquor. He is limp and apnoeic. You are the registrar leading the resuscitation, with a skilled neonatal nurse present. Demonstrate the first 60 seconds, decide whether to intubate and suction, manage escalation, and plan post-resuscitation stabilisation. State guideline doses and thresholds and name the source. [1] [4]

Tasks for the candidate

1. Perform the first 60 seconds: warmth, drying, stimulation, and assessment of tone, breathing and heart rate. [1]
2. Decide and justify whether to intubate and suction the trachea for the meconium. [1] [4]
3. Begin and describe positive-pressure ventilation: rate, pressure and starting oxygen for a term infant. [1]
4. State the heart-rate triggers for chest compressions and for adrenaline, and quote the adrenaline dose by both microgram per kilogram and millilitre per kilogram of the correct concentration. [1]
5. Outline the post-resuscitation plan: temperature target, glucose, surveillance for encephalopathy, and the cooling referral criteria and time window. [9]

Expected performance

Must hit. Warms, dries and stimulates; assesses tone, breathing and heart rate; correctly states that routine tracheal suction and intubation are no longer recommended for the non-vigorous meconium infant and that the baby is resuscitated per the standard algorithm; starts positive-pressure ventilation at 40 to 60 breaths per minute in air (21%) using the lowest pressure giving chest rise; states that compressions begin when the heart rate is under 60 despite effective ventilation, in a 3:1 ratio; quotes adrenaline as 0.01 to 0.03 mg per kilogram intravenously (0.1 to 0.3 mL per kilogram of 1:10,000); targets normothermia at 36.5 to 37.5 degrees; refers an eligible term infant with encephalopathy for cooling within six hours. [1] [4]

Merit. Names the MR SOPA corrective sequence before escalating; explains physiologically why ventilation comes first (failed aeration keeps the circuit fetal); uses pre-ductal pulse oximetry interpreted against the saturation nomogram; raises oxygen toward 100% only when compressions begin; distinguishes hypovolaemia (needs volume) from routine asphyxia; and explains why hyperthermia as well as hypothermia must be avoided. [1] [10]

Fail. Routinely intubates and suctions for meconium before ventilating; starts in 100% oxygen for a term infant; compresses before confirming effective ventilation; quotes the wrong adrenaline concentration or route; gives volume routinely without evidence of hypovolaemia; begins uncontrolled cooling locally instead of referring; or cannot state the cooling time window. [1] [9]

Sample candidate structure

"This baby is apnoeic and limp, so he is on the resuscitation pathway. I would start the clock, warm and dry him, clear any obvious secretions from the mouth, and begin positive-pressure ventilation in air at 40 to 60 breaths per minute. The 2015 change means I do not routinely intubate and suction the trachea for a non-vigorous meconium infant — I resuscitate him by the standard algorithm. I would watch for chest rise, apply pre-ductal oximetry and an ECG, and recheck the heart rate at 30 seconds. If it were under 60 despite effective ventilation, I would add compressions in a 3:1 ratio and raise the oxygen, then give adrenaline at 0.1 to 0.3 mL per kilogram of the 1:10,000 concentration intravenously. Once he is stable I would hold his temperature at 36.5 to 37.5 degrees, check his glucose, watch for encephalopathy, and refer him for cooling within six hours if he is 36 weeks or more with moderate or severe encephalopathy." [1] [9]