Neonatal Resuscitation

by Brian Alverson, MD

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    00:01 So let’s go through that resuscitation process.

    00:05 In the first step, we have initial stabilization.

    00:08 Then, we engage in assessing the airway, the breathing and the circulation, just like adults but it’s a little bit different.

    00:16 Next, we may need to do chest compressions if that child is bradycardic.

    00:21 And lastly, we may need to administer epinephrine or volume expansion depending on the clinical circumstances.

    00:29 We will go through that now.

    00:31 First, let’s talk about the initial stabilization.

    00:34 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.

    00:44 So the first thing we do before we do anything else is we vigorously dry the baby and place them under the warmer.

    00:51 We have to keep that baby warm and dry.

    00:55 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.

    01:04 It is often through just the drying process alone that a baby wakes up, starts crying and looks much better, It is important to understand that stimulation during the first 30 seconds of life, usually with warming and drying vigorously rubbing the baby is incredibly important for getting that kid going.

    01:23 And usually that will in of itself do a lot towards getting the child off of breathing normally and having a normal heart rate.

    01:30 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.

    01:40 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.

    01:50 The first thing we’ll often do is suck out the nose and mouth with a bulb or a suction catheter.

    01:57 It’s important then to check the circulation.

    02:00 The best place to feel a pulse on a baby is actually the umbilical stump.

    02:05 You can easily feel the pulse pulsating through that umbilical stump and that’s where you can check that heart rate.

    02:12 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.

    02:24 One could obtain the heart rate by 2 major methods either auscultation but also another easy way to do it is simply grasping the umbilical stump with your thumb and forefinger and you can very easily feel the pulse.

    02:38 Usually one person will tap it out while the other person is doing other things, so everyone in the room can see what the heart rate of that infant is.

    02:47 Now, here’s what we do when things go wrong.

    02:50 If the patient has apnea or the heart rate is less than 100, we’re going to give some positive pressure ventilation.

    02:57 That's done through effective ventilation with a bag and mask.

    03:01 Remember, the baby’s head should be a little bit back or a little bit forward.

    03:04 If they're crunched over like this, you won’t necessarily be able to get the mask over it and fit it well.

    03:10 When you are giving these bags, you need to watch for chest rise.

    03:13 Without chest rise, you probably aren’t doing it right.

    03:16 There may be a leak.

    03:18 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.

    03:32 CPAP is effective often in helping a baby breathe.

    03:36 Usually, what we can do is first, we vigorously dry the baby.

    03:40 If they’re still not breathing, we may just provide a little bit of CPAP.

    03:44 Most delivery rooms have a Mapleson bag.

    03:49 A Mapleson bag is that floppy one that requires an active air outlet from the wall.

    03:56 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.

    04:06 Generally, around 5 is adequate.

    04:09 Next, we’re going to intubate especially if the bag mask is ineffective or the chest compressions are required.

    04:17 We will give epinephrine if the heart rate is remaining persistently below 60 to try and bring up that heart rate.

    04:25 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.

    04:35 When you're looking to see if there is good chest rise during ventilation, a good mnemonic is Mr.

    04:41 SOPA or MRSOPA.

    04:44 That's a good way of knowing whether your ventilations are effective.

    04:47 M stands for Mask.

    04:49 Do you have the mask on the baby, or is the reposition where you're going to reposition the head? So the head is slightly extended so you can get the air in S is suction, always open the mouth and look around.

    05:02 P is make sure there's adequate pressure and then a is advanced airway.

    05:06 If you're really stuck and nothing else can be done, you need to innovate the baby or obtain a better airway.

    05:14 And we used to intubate for all meconium and suck out the meconium, that’s really no longer recommended.

    05:22 Centers are just starting to come around to that.

    05:24 You may have learned in the center where they intubate for meconium, but the guidelines clearly say that’s no longer necessary.

    05:31 Okay.

    05:33 One important aspect of the delivery room is being able to describe accurately how sick a baby is at the time of delivery.

    05:44 This invention was made by Virginia Apgar.

    05:48 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.

    06:01 Let’s go through how we calculate the Apgar score.

    06:04 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.

    06:16 A stands for activity.

    06:18 If they’re silent, zero points. Whimpering, one point.

    06:22 Or crying, which we love, two points.

    06:25 The P in Apgar stands for pulse.

    06:29 If a patient has no pulse at all, they get zero points.

    06:33 If their pulse is present, but less than 100, they get one point and if it’s over 100, they get two points.

    06:38 The G stands for grimace which is really just the response to stimulation.

    06:44 If you’re stimulating and they do nothing, they get zero points.

    06:48 If they grimace and cry and fuss, they get one point.

    06:51 If they cough, sneeze and vigorously cry, and are present with you, that’s two points.

    06:58 A stands for appearance.

    06:59 If a child is completely blue, they get zero points.

    07:04 If they had just blue hands and feet, they get one point.

    07:07 And if they are completely pink, they get two points.

    07:09 In all the Apgar scores I've seen, this is the one I think that's the hardest to get two points on.

    07:16 Usually, kids are a little bit blue in their extremities.

    07:19 R is for respiration.

    07:21 If they have no respiratory effort, zero.

    07:24 An irregular respiratory effort, one.

    07:26 Or regular effort, two.

    07:29 This is something that takes a little bit of experience.

    07:31 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.

    07:39 Sometimes there is agreement, that’s okay.

    07:41 This is just getting a rough idea of what is the patient’s Apgar.

    07:46 Remember, 10 points is perfect.

    07:48 It’s very rare that patients are a 10.

    07:52 So now we have done the Apgar score, we’ve resuscitated the baby.

    07:57 Let’s say this baby is continuing to have problems with respiration.

    08:01 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.

    08:09 This usually goes away on its own within a day or so.

    08:13 So this is a really common problem in infants and it’s particularly common in infants who are a C-section.

    08:20 This is because the process of squeezing through that birth canal which is so powerful that it deforms the child’s head.

    08:29 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.

    08:41 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.

    08:51 This is a failure of fetal alveolar fluid to clear the airway which is mediated by stress response.

    08:58 It results in a respiratory distress of an infant and usually resolves perfectly well within the first 24 hours of life.

    09:06 Sometimes these infants require supportive treatment in the neonatal intensive care unit.

    09:12 They may require CPAP or extra oxygen, but it would be rare for them to need a frank intubation.

    09:19 So that’s my review of neonatal resuscitation and the Apgar score and transient tachypnea of the newborn.

    09:28 Thanks for your time.

    About the Lecture

    The lecture Neonatal Resuscitation by Brian Alverson, MD is from the course Neonatology (Newborn Medicine).

    Included Quiz Questions

    1. Blood pressure
    2. Skin color appearance
    3. Response to tactile stimulation
    4. Limb movement
    5. Respiratory effort
    1. Neutral and slightly extended
    2. Neutral and slightly flexed
    3. Extended
    4. Flexed
    1. Heart rate < 60/min after 30 seconds of adequate ventilation
    2. Heart rate < 100/min after 30 seconds of adequate ventilation
    3. Heart rate < 60/min before initiation of ventilation
    4. Heart rate < 100/min before initiation of ventilation
    5. Only when no heart rate is detected

    Author of lecture Neonatal Resuscitation

     Brian Alverson, MD

    Brian Alverson, MD

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    Excellent lecture
    By Jalil Z. on 15. August 2020 for Neonatal Resuscitation

    Excellent lecture as usual on a very important topic. I particularly liked that TTN was included in this lecture.

    Thank you very much Dr. Alverson
    By Juan M. on 10. August 2020 for Neonatal Resuscitation

    It is a very important topic for our medical career, and you helped us a lot. Thank you very much.

    interesting lecture presentation
    By Neuer N. on 04. January 2018 for Neonatal Resuscitation

    talking in a soft tone attract to concentrate, precise, well aware of the information , many thx dr

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