Pediatric Case of the Week 20 Oh baby the "Fear-icle" of Life

There are few phrases that cause a well trained Emergency Physician to stop everything and rapidly soil his or her undergarments. "She's 40 weeks and having vigorous contractions" or "the baby is blue and not moving" are just a couple that readily come to mind...

You are working an overnight shift at the "frontier site" when, during those wee morning hours when most normal human beings are fast asleep, you overhear the triage nurse say in a panic stricken voice;

"She thinks she's about 40 weeks, no prenatal care, her contractions started about 3 hours ago and are now coming about every minute. She thinks her water broke on the way in. She's looks really uncomfortable."  

You immediately jump up to evaluate a 30 year old female who is breathing heavily through clenched front teeth. She's in noticeable distress.  You stare into her eyes trying desperately to use your best  Jedi mind tricks to make all of this go away.

It doesn't. 

You recall delivering a baby 10+ years ago. (You can do this.) You put some gloves on.  You vaguely remember what a dilated (or is it effaced) cervix feels like and what the head, rumpus, and/or foot of a baby should feel like. You feel head (that's good.)  You are pretty sure that the liquid, which seems to coming from everywhere, is amniotic fluid and not your own tears. No significant bleeding (that's good too.)

You ask your excellent nursing staff to establish an IV.  You ask your superb EMT for a bulb syringe, scissors, and a "couple of clamps."  Your spirituality and religiosity have dipped in recent years but you offer up a prayer..."Holy mother of all things...God help us."




After a few pushes and some screaming (yours included) out comes baby.  You suction the mouth and clamp the cord in two places.  Cut in between.  You hand off the baby to the excellent overnight nurse who swaddles the baby in a warm towel.


You then focus on delivering the placenta.  Still no major bleeding (that's good.)  You are about to massage the uterus when the nurse says (you guessed it), "the baby is blue and not moving."





What additional points of the Emergency Department newborn delivery are important to remember?

What other bad things can happen during an ED delivery and what would you do about it?

What are the basics of neonatal resuscitation and how would you manage this "blue baby" who is "not moving?"  What would you do first? Second? Third?

Do you have any good precipitous delivery stories you'd like to share?

Know any good PTSD counselors?

Do you own any DEPEND undergarments?












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WEEKEND UPDATE 



Most newborn deliveries occur without the need for neonatal resuscitation.  Occasionally (roughly 10% of the time) the transition from intrauterine to extrauterine life requires assistance. This is important because over 80% of newborn deliveries in the United States take place in non-teaching, non-affiliated Level 1 or 2 hospitals. Most rural facilities do not have the resources available to dedicate a high risk delivery room and/or neonatal resuscitation team.

A brief review of neonatal physiology illustrates the fact that most neonatal emergencies are RESPIRATORY in nature.  The fetal lungs progress through various stages of development in preparation for the first breath.  However, the lungs remain fairly lazy throughout the fetal period as O2 exchange is performed wholly by the placenta.

With that first neonatal breath an amazing complex series of physiologic events takes place.  Tiny fetal lungs must generate a strong negative pressure to overcome the viscosity of the fetal lung tissue and the resistance of fluid filled lungs.   There are a number of physiologic factors that precede this event which  help to make it possible. Yet, when it fails, we need to be ready to assist.

The stimuli for the first breath is multifactorial: tactile, thermal, auditory, and visual (light).  Each of these stimululate the neonate to enter this world with a grand inhalation.  We can most readily augment this process with vigorous tactile stimulation. Drying the newborn, specifically, rubbing the back or slapping the soles of feet should immediately elicit a crying response.  This should be your first action when confronted with an unresponsive neonate.  If this fails, we need to assist with breathing: "Ay is Fah AYAWAY"

Neonatal Resuscitation Supplies (the basics):

-Warm blankets (neonatal warmer if available)
-Bulb syringe
-O2
-Neonatal bag and mask(s)
-Neonatal endotracheal tubes (sizes 2.5-4)
-Laryngoscope size 0-1 blades
-IV catheters (22g)
-Umbilical catheter
-Dextrose 10% in water
-Epinephrine 1:10000

Following warming and vigorous tactile stimulation, suction the nose and the mouth with a bulb syringe.  (There has been a movement away from deep airway suctioning due to the profound neonatal vagal response which can induce further apnea, bradycardia, hypotension, and laryngospasm.)

If warming, vigorous stimulation, and bulb syringe suctioning do not stimulate a response, Positive Pressure Ventilation (PPV) should be initiated with neonatal bag and mask.  MOST neonates will respond after these basic measures.  Many consider this basic neonatal care.  Infants who have heart rate higher than 100 beats per minute and adequate respiratory effort, but remain cyanotic may require "blow by oxygen" via oxygen tubing or mask.

If the neonates respiratory effort is poor: Intubate.   Here is a video that is a little long, but worthwhile. http://www.youtube.com/watch?v=23ArsJyJzvg  Remember that the neonatal occiput is large and you should place a roll of towels under the shoulders to line up the posterior pharynx with the glottis.  Use the straight Miller blade; size 0-1. Auscultate for bilateral breath sounds and get a chest X-ray to confirm tube placement.

If the neonates HR is less than 60 bpm 30 seconds after positive pressure ventilation: initiate compressions.  Encircle the chest with your hands and apply pressure to the sternum with both thumbs. You should compress about one third the diameter of the chest. (You may also use the two finger technique.)  Allow for recoil. 90 compressions every minute. If intubated, neonate should receive one breath every 3 compressions.  If not, the ratio of compressions to ventilation is 15 to 2.  (Think "stayin' alive" sung by the chipmunks.)

If you find yourself giving prolonged chest compressions, administer epinephrine.  Dose: 0.01-0.03 mg/kg (0.1-0.3 ml of the 1:10000 solution).  IV route is preferred but if you cannot establish IV access, Epinephrine can be given down the ET tube at 3x the IV dose.

Finally, if you cannot establish IV access or if you want to establish more reliable access you could insert an umbilical venous catheter.  Remember: 2 arteries, 1 vein.  See umbilical catheter video: https://vimeo.com/49987868

In summary: VENTILATION, VENTILATION, VENTILATION

SEE NEONATAL RESUSCITATION ALGORITHM BELOW: