So let’s go through that resuscitation process.
In the first step, we have initial stabilization.
Then, we engage in assessing the airway, the breathing and the circulation,
just like adults but it’s a little bit different.
Next, we may need to do chest compressions if that child is bradycardic.
And lastly, we may need to administer epinephrine
or volume expansion depending on the clinical circumstances.
We will go through that now.
First, let’s talk about the initial stabilization.
The most important thing when a baby is handed off
to the pediatrician is not the airway,
it’s maintaining the temperature and drying the baby.
So the first thing we do before we do anything else
is we vigorously dry the baby and place them under the warmer.
We have to keep that baby warm and dry.
The warmer is very useful
because we don’t need to keep the baby swaddled under the warmer,
so we can engage in other activities such as the ABCs.
It is often through just the drying process alone
that a baby wakes up, starts crying and looks much better,
and our job is almost done.
However, if the baby does not wake up or does not interact in a way that we expect,
we may have to further investigate with airway, breathing, and circulation.
It is important to keep the neck in a neutral or a slightly extended position
as the structures to the airway can themselves prevent adequate
oxygenation or ventilation.
The first thing we’ll often do is suck out the nose and mouth
with a bulb or a suction catheter.
It’s important then to check the circulation.
The best place to feel a pulse on a baby is actually the umbilical stump.
You can easily feel the pulse pulsating through that umbilical stump
and that’s where you can check that heart rate.
Often times, if there are multiple practitioners,
one will be doing the airway,
the other will be tapping out the pulse on the table
so that the airway operator can have the sense of what is that pulse.
Now, here’s what we do when things go wrong.
If the patient has apnea or the heart rate is less than 100,
we’re going to give some positive pressure ventilation.
That's done through effective ventilation with a bag and mask.
Remember, the baby’s head should be a little bit back or a little bit forward.
If they're crunched over like this,
you won’t necessarily be able to get the mask over it and fit it well.
When you are giving these bags, you need to watch for chest rise.
Without chest rise, you probably aren’t doing it right.
There may be a leak.
Next, if the heart rate goes below 60
despite 30 seconds of positive pressure ventilation,
the time has come to start chest compressions
and we’re also going to administer oxygen.
CPAP is effective often in helping a baby breathe.
Usually, what we can do is first, we vigorously dry the baby.
If they’re still not breathing, we may just provide a little bit of CPAP.
Most delivery rooms have a Mapleson bag.
A Mapleson bag is that floppy one that requires an active air outlet from the wall.
Eventually, the Mapleson bag is we can get a sense from it of how much CPAP
we're providing because we don’t want to give too much CPAP,
because then you could cause pulmonary problems.
Generally, around 5 is adequate.
Next, we’re going to intubate
especially if the bag mask is ineffective or the chest compressions are required.
We will give epinephrine if the heart rate is remaining persistently below 60
to try and bring up that heart rate.
Normal saline or blood transfusion may be indicated
in a patient where there was excessive blood loss,
for example, if the patient had placenta previa in utero.
And we used to intubate for all meconium and suck out the meconium,
that’s really no longer recommended.
Centers are just starting to come around to that.
You may have learned in the center where they intubate for meconium,
but the guidelines clearly say that’s no longer necessary.
Okay.
One important aspect of the delivery room is being able to describe accurately
how sick a baby is at the time of delivery.
This invention was made by Virginia Apgar.
Virginia Apgar was a famous physician who described a way of assessing babies
and the Apgar score, which is named after Virginia Apgar,
is measured at one, five and ten minutes.
Let’s go through how we calculate the Apgar score.
What’s convenient is, is we can use the letters of Virginia Apgar’s name
as a reminder of what the five types of measurements are in the Apgar score.
So the A stands for appearance.
If a child is completely blue, they get zero points.
If they had just blue hands and feet, they get one point.
And if they are completely pink, they get two points.
In all the Apgar scores I’ve seen,
this is the one I think that’s the hardest to get two points on.
Usually, kids are a little bit blue in their extremities.
The P in Apgar stands for pulse.
If a patient has no pulse at all, they get zero points.
If their pulse is present, but less than 100, they get one point
and if it’s over 100, they get two points.
The G stands for grimace which is really just the response to stimulation.
If you’re stimulating and they do nothing, they get zero points.
If they grimace and cry and fuss, they get one point.
If they cough, sneeze and vigorously cry, and are present with you,
that’s two points.
A stands for activity.
If they’re silent, zero points.
Whimpering, one point.
Or crying, which we love, two points.
R is for respiration.
If they have no respiratory effort, zero.
An irregular respiratory effort, one.
Or regular effort, two.
This is something that takes a little bit of experience.
The first few times you’re in the delivery room,
try to volunteer to do the Apgar score and see if the other practitioner agrees.
Sometimes there is agreement, that’s okay.
This is just getting a rough idea of what is the patient’s Apgar.
Remember, 10 points is perfect.
It’s very rare that patients are a 10.
So now we have done the Apgar score, we’ve resuscitated the baby.
Let’s say this baby is continuing to have problems with respiration.
I wanted to talk about one of the most common
causes of respiratory distress in a newborn baby
and that is transient tachypnea of the newborn.
This usually goes away on its own within a day or so.
So this is a really common problem in infants
and it’s particularly common in infants who are a C-section.
This is because the process of squeezing through that birth canal
which is so powerful that it deforms the child’s head.
It’s pain for that child and it wakes them up
and it gets them going and it also causes a stress response
that allows these infants to breathe better.
Without that stress response,
if they’re just pulled out of the uterus through C-section,
they don’t get the opportunity to clear out those lungs and breathe more comfortably.
This is a failure of fetal alveolar fluid to clear the airway
which is mediated by stress response.
It results in a respiratory distress of an infant
and usually resolves perfectly well within the first 24 hours of life.
Sometimes these infants require supportive treatment
in the neonatal intensive care unit.
They may require CPAP or extra oxygen,
but it would be rare for them to need a frank intubation.
So that’s my review of neonatal resuscitation and the Apgar score
and transient tachypnea of the newborn.
Thanks for your time.