Hydrops Fetalis, Structural CHD, and Multiple Gestation

Hydrops fetalis presents with abnormal fluid accumulation across two or more compartments - typically pleural effusions, pericardial effusion, ascites, and subcutaneous edema. The resuscitation challenge is consistent regardless of etiology: fluid compresses the lungs and impairs cardiac filling, making both ventilation and cardiac output difficult to establish.

Delivery room preparation should include pleural and pericardial drainage equipment immediately available, a designated third provider for drainage separate from the airway and compression team, and anticipation that PPV may be ineffective until pleural effusions are drained. Significant haemodynamic instability should be expected even after drainage.

Structural congenital heart disease

Structural congenital heart disease varies widely in presentation and severity. In the delivery room context, the key concern is duct-dependent lesions, where systemic or pulmonary blood flow depends on patency of the ductus arteriosus. In these infants, administration of high FiO₂ will cause ductal constriction and may precipitate cardiovascular collapse.

Duct-dependent lesions should be suspected when an infant fails to respond to resuscitation despite adequate airway management and chest compressions, particularly if there is no other explanation for the poor response. Where structural CHD is suspected, FiO₂ should be kept to the minimum required to maintain a clinically acceptable SpO₂ - 21-30% rather than 100%. Prostaglandin E1 to maintain ductal patency is a post-stabilisation intervention managed in the NICU, not the delivery room.

Multiple gestation

Multiple births require one fully equipped resuscitation team per infant. Twins born at 24 weeks (both requiring advanced resuscitation) represent a simultaneous clinical emergency that one team cannot manage safely. Staffing for multiple births must be arranged antenatally. Equipment must be duplicated: two radiant warmers, two complete airway sets, two drug preparations. If staffing is insufficient for simultaneous full resuscitation of each infant, a priority decision must be made based on clinical presentation, ideally informed by antenatal discussion with the family.

Congenital anomalies incompatible with life

Some congenital anomalies, such as anencephaly, confirmed trisomy 13 or 18, confirmed renal agenesis (Potter sequence), have no potential for survival. Where these are identified antenatally, a pre-birth family communication should establish the agreed approach: non-initiation of resuscitation and a comfort care pathway. This pathway focuses on warmth, skin-to-skin contact, pain management, and family presence, and does not involve resuscitative interventions. Documentation of the pre-birth discussion and family consent is essential.