So let’s go through that
In the first step, we have
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
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
The first thing we’ll often do
is suck out the nose and mouth
with a bulb or a
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
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
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
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.
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.