Case 2: Newborn with Persistent Apnea

A female neonate is born via spontaneous vaginal delivery to a 19-year-old primiparous woman at 35 1/7 weeks of gestation at a rural hospital following an uncomplicated pregnancy. The neonate initially cries at delivery but soon becomes apneic and bradycardic. She is resuscitated with positive pressure ventilation, chest compressions, and a dose of epinephrine via emergent umbilical vein catheter. Her heart rate is subsequently stable in a normal range for age. During the resuscitation, endotracheal intubation is not successful so she receives ventilation via laryngeal mask airway. Her Apgar scores are 1, 1, 4, 5, and 7 at 1, 5, 10, 15, and 20 minutes, respectively. Her physical examination findings immediately after resuscitation are pertinent for diffuse hypotonia and decreased responsiveness. Her blood gas shows a severe mixed acidosis with pH 6.7, partial pressure of carbon dioxide 68 mm Hg (9 kPa), and base deficit 27. She undergoes intubation and passive cooling, and is transferred to the nearest NICU. She has moderate-to-severe encephalopathy on admission and undergoes therapeutic hypothermia for …