What is the next step in management for a full-term baby delivered by cesarean section (C-section) with respiratory distress and fluid in pulmonary fissures, without desaturation?

Management of Full-Term Infant with Transient Tachypnea After Cesarean Section

The next step is to withhold oral feeds (keep nil per mouth) and start IV fluids, as this infant has respiratory distress with fluid in pulmonary fissures consistent with transient tachypnea of the newborn (TTN). 1

Immediate Management Priorities

Feeding and Hydration Management:

• Withhold oral feeds immediately and initiate IV fluids when the respiratory rate exceeds 60-70 breaths/min or when significant work of breathing is present, which is the case with respiratory distress. 1
• Administer IV glucose to prevent hypoglycemia, as respiratory distress increases metabolic demands. 1
• Monitor capillary glucose in the first hour and according to protocol. 1

Respiratory Support Strategy:

• Provide warmth, drying, stimulation, and airway positioning as initial steps. 2
• Titrate supplemental oxygen to maintain preductal saturations ≥95%, starting with room air (21% oxygen) for term infants. 1, 2
• Do NOT routinely initiate CPAP for this term infant with TTN, as evidence shows increased air-leak syndromes without clear benefit. 3, 1, 2
• Observation with supplemental oxygen as needed is appropriate for spontaneously breathing infants who are tachypneic. 1

Why This Approach

The clinical presentation—full-term infant, cesarean delivery, respiratory distress without desaturation, and fluid in pulmonary fissures on chest X-ray—is classic for TTN. 4, 5 This condition results from delayed clearance of fetal lung fluid, particularly common after cesarean section. 5, 6

Key Management Principles:

• TTN typically resolves within 24-72 hours as lung fluid is reabsorbed. 1
• The primary risk during this period is aspiration if oral feeds are continued with tachypnea >60-70 breaths/min. 1
• IV fluids maintain hydration and glucose homeostasis while oral feeds are withheld. 1

What NOT to Do

Avoid Routine CPAP:

• The 2022 International Consensus on Cardiopulmonary Resuscitation found insufficient evidence to support routine CPAP use in term infants with respiratory distress. 3
• Meta-analysis showed CPAP increased air-leak syndromes (133 more cases per 1000 infants) without reducing mortality. 3
• CPAP should be reserved for infants failing supportive care, not used as first-line therapy. 3, 1

Avoid Premature Escalation:

• Do not start with 30-40% oxygen routinely; begin with room air and titrate based on oxygen saturation monitoring. 1, 2
• Intubation is reserved for failed positive pressure ventilation or severe respiratory failure unresponsive to less invasive measures. 2

Antibiotic Consideration

While antibiotics are not the primary next step, consider them if:

• Clinical signs suggest sepsis or pneumonia (fever, lethargy, poor perfusion). 4
• Blood cultures should be obtained if infection is suspected. 4
• However, the presentation described (post-cesarean, fluid in fissures, no desaturation) is most consistent with TTN, not infection. 4, 5

Monitoring Parameters

• Continuous heart rate and oxygen saturation monitoring via pulse oximetry. 1
• Serial assessment of respiratory rate and work of breathing. 1
• Capillary glucose monitoring to prevent hypoglycemia. 1
• Expect improvement within 24-72 hours; if not improving, reassess for alternative diagnoses. 1

Answer: B. Keep Nil per mouth (with IV fluids)