00:01
So let's talk about what happens
right when the baby
takes their first breath.
00:06
So this is the review of
the fetal circulation video
that we did earlier
in this lecture series.
00:12
So it's right here.
00:13
I want you to go back,
watch this and make sure
that you have a good understanding
of what fetal circulation
looks like.
00:21
So as we move to adult circulation,
you've got that fresh in your mind.
00:26
There are three very important
concepts to keep in mind
as we discuss fetal circulation.
00:32
First,
in fetal circulation,
the umbilical vein
carries the oxygen rich blood
and the umbilical artery
carries the deoxygenated blood
back to the placenta.
00:43
This is the exact opposite of
what happens in adult circulation.
00:47
Number two, because the placenta
takes care of oxygenating the blood
and filtering out
the waste products,
the liver and the lungs
are not fully functional
in fetal circulation.
00:59
And the third point
to preserve oxygen
for fetal development
and neurological functioning,
there are three shunts
that alter the flow of blood
away from certain organs.
01:10
Number one,
the ductus venosus.
01:13
Number two,
the foramen ovale.
01:15
Number three,
the ductus arteriosus.
01:18
When we talk more about birth,
and the newborn assessment,
if you'll remember these
elements of fetal circulation,
the kinds of assessments that we do
will make so much more sense.
01:31
So let's review
the points to remember.
01:34
There are two umbilical arteries
and one umbilical vein.
01:40
Oxygen rich blood is carried from
the placenta via the umbilical vein,
and deoxygenated blood
is carried back to the placenta
via the umbilical artery.
01:52
The ductus venosus shunts blood
away from the liver.
01:56
The foramen ovale
and the ductus arteriosus
shunt blood away from the lungs.
02:03
The pulmonary system
and adult circulation
is a relatively low pressure system.
02:08
But in fetal circulation,
the pulmonary system
is a high pressure system
to help shunt the blood
away from the lungs.
02:17
So now you've got
fetal circulation down again,
let's talk about what happens when
the baby takes their first breath.
02:24
So after the very first breath,
the lungs expand,
and all that fluid that
was filling up the lungs.
02:31
Remember, it didn't matter because
the baby wasn't breathing oxygen,
that placenta took care of all that.
02:36
All that fluid is
going to be pushed out,
that's going to allow
the lungs to expand,
which is ultimately going to
decrease the pulmonary resistance.
02:44
So everything in
fetal circulation was geared
towards keeping blood flow
out of the lungs,
because we didn't need it.
02:50
Now we need to get
oxygen to the lungs.
02:53
So we're going to experience
increased pressure
in the left atrium.
02:57
And that increased pressure
is going to lead to
closure of the foramen ovale.
03:03
When the court is clamped,
we lose the placenta.
03:06
So that loss of placenta
is going to lead
to an increase in
systemic resistance.
03:12
And that systemic resistance
increase
is going to cause the pressure
in the right atrium
to actually decrease.
03:20
And so once that happens,
that right to left shunt
is going to close.
03:25
And then when we have closure
of the right to left shunt,
we're going to have increased oxygen
levels in pulmonary circulation.
03:33
This is what we need,
because we need more oxygen
to come from the lungs.
03:37
This is all about breathing air,
because the placenta is gone.
03:41
Then we experienced closure
of the ductus arteriosus.
03:45
And that is going to complete
that transition
to extra uterine breathing.
03:50
So we've gone from
placenta doing all the work
to clean us in their lungs
doing all the work.
03:57
Now, let's talk about
one of the very first assessments
that we will perform
on our brand new baby.
04:02
It's called an APGAR
or APGAR Score.
04:05
The APGAR Score was developed
by an anesthesiologist named
Virginia Apgar.
04:10
And she developed this system
as a way to really be able to tell
when we engage in
any sort of infant resuscitation
if it's going well or not.
04:20
But we still use this
as a way of really noticing
whether the baby
is transitioning well
to extra uterine life.
04:26
So the APGAR Score is an
assessment of five things:
Appearance, pulse, grimace,
activity, and respiration.
04:35
Now, let's break down
that APGAR Score.
04:38
You can see on the vertical axis
we have our mnemonic.
04:42
Appearance, Pulse, Grimace,
Activity, and Respirations.
04:46
And on the horizontal axis,
we have the scoring system
0, 1, or 2.
04:51
So appearance just refers to color.
04:54
So zero points would be a baby
that is blue everywhere.
04:58
In the central area,
hands, feet, ever thing.
05:01
However, a baby
that has acrocyanosis,
or maybe
just blue hands and feet,
but the center part
of the baby is pink,
then they would receive a score
of one.
05:11
Now, very rarely are babies
all the way pink.
05:14
That's just not typical,
but if they were,
they would earn a score of two.
05:20
Pulse stands for the heart rate.
05:21
If they have a heart rate of zero,
they earn zero points.
05:25
If the heart rate is less than
100 beats per minute,
they earn one.
05:30
If the heart rate is
100 or greater
than they earn two points for that.
05:36
Grimace is not just a purple man
from a fast food restaurant.
05:40
Grimace refers to a
response to stimulation
or a kind of like a
little face like this,
can you do that?
A grimace that would be
a zero point means
that if I suction the baby
or stimulate the baby,
I don't get a face.
I don't get anything.
05:55
The baby just lies limb.
05:57
If the baby however,
does make a slight face,
when I suction the baby
or use a bulb syringe,
then they would earn
a point of one.
06:06
If, however,
the baby is crying vigorously,
then they earn a score of two.
06:12
Activity refers to movement.
06:14
If again,
the baby is limp and not moving,
they would on a score of zero.
06:18
If they have some flexion,
they move just a little bit,
but not really an exciting
or aggressive way,
then that would be one.
06:25
And if they're really moving,
and kicking, and screaming
and moving blankets,
then they would clearly
get a score of two.
06:32
And finally respirations.
06:34
So a baby that makes
no respiratory effort at all
would earn a score of zero.
06:39
A baby that has some response
and some respiratory effort,
but maybe they're using
some accessory muscles
in order to do so
would earn a score of one.
06:49
And then a baby that is actively
crying or breathing well
and it's unlabored,
then they would earn
a score of two.
06:58
To interpret the APGAR Score,
the provider will then
add up all the points
for each of those assessments.
07:04
A score of seven or greater
will indicate that the baby
is transitioning well
to extra uterine life.
07:10
So typically, for this baby that
might be doing kangaroo care,
this baby will be fine
to continue to stay there.
07:17
A baby on the other hand,
that scores a three or less,
that baby clearly is having
a difficult time transitioning
and will absolutely need
some supportive assistance
in order to breed.
07:29
Babies that are in the middle
will likely also need some support,
and they will be watched
under the monitor.
07:34
But hopefully will transition
up to a 7, 8, 9, or 10.
07:40
APGAR Scores are scored
at one minute,
also at five minutes.
07:44
And for any babies
that are experiencing
any sort of difficulty,
an APGAR Score
may be taken again at 10 minutes.
07:53
Now, let's practice
and see how well you do
at calculating APGAR Scores
on your own.
07:58
A neonatal client has a pink color,
a pulse rate of 102,
a respiratory rate of 27.
08:07
The baby grimaces
in response to stimuli
and has limited muscle movement.
08:13
Think for a minute
about what you think
that score will be.
08:17
And if you need to go back
and use the APGAR chart
in order to calculate your result,
feel free to do that.
08:26
Let's go over our answer.
08:28
So what we have
from the clues here
is that we have a baby
that's pink in color.
08:34
So it doesn't mention
APGAR cyanosis.
08:36
So technically, we'd have to
go with a 2 for this score.
08:39
The pulse rate is 102.
08:42
It's above 100.
08:43
So we would also
give a score of 2 for that.
08:46
The respiratory rate is 27.
08:48
Doesn't say anything about
any sort of accessory muscles
or it being difficult.
08:53
So let's read further to decide
what we're going to give the baby
for this respiratory rate.
08:58
The baby does grimace
in response to stimuli
but it doesn't sound like
it's an aggressive response
and the baby has
limited muscle movement.
09:06
So let's go back through.
2 for color 2 for pulse.
09:11
Based on the rest
of our information,
we may go with
1 for respiratory rate,
1 in response to stimuli,
so the grimace,
and limited muscle movement
would also be a one.
09:22
So if we add that together,
we have 2, 4, 5, 6, 7
as an APGAR Score.
09:30
Okay.
09:33
Let's try a second one.
09:35
A newly delivered infant has a
pink trunk and blue hands and feet.
09:40
A pulse rate of 60
and does not respond to your
attempts to stimulate them.
09:46
The baby also appears to be limp
and taking slow gasping breaths.
09:51
Think about this one for a minute.
09:52
It's a little bit more tricky.
09:58
Okay, let's go through it.
10:00
So we have a pink trunk
and blue hands and feet.
10:03
So although this part is typical,
the baby's still
only going to earn a one for this.
10:08
The pulse rate is 60.
So it's less than 100.
10:12
So the baby only
earns a point for that.
10:15
The baby does not respond
to any attempts to stimulation.
10:18
So, grimace
going to be zero for that.
10:21
The baby also appears to be limp.
10:23
That's going to be a 0
and taking slow gasping breaths.
10:27
So there is
respiratory effort here.
10:30
But it's not
a solid respiratory effort.
10:31
So we're going to give
a 1 for that.
10:34
So the APGAR Score for this baby
would be a three.
10:37
How'd you do?
Now, I want to talk about
one of the most important actions
that we perform
as the baby transition.
10:44
And that is skin-to-skin care.
10:46
Now, maybe you're asking yourself,
well, didn't we just do
an APGAR Assessment?
And that would mean the baby
would have to be on the warmer.
10:53
But that's not true.
10:54
Unless the baby is experiencing
some sort of difficulty,
we can do the APGAR Score
with the baby in skin-to-skin care.
11:02
So sometimes this is called
kangaroo care.
11:05
If you've ever seen
a little baby kangaroo,
and you'll see how close it stays
to the mother after it's born,
it does that to keep warm.
11:12
And the same thing
works for humans.
11:14
So, skin-to-skin or kangaroo.
11:17
And what we would do
is we would first dry the infant.
11:20
We want the baby to be warm.
11:22
And if you've ever gotten out
of the shower or out of the tub,
you know it's really cold.
11:26
What's the first thing you do?
You dry off.
11:28
so we want to dry the baby
and then place the baby directly
on the parents bare chest
not on top of the gown.
11:36
We want to move the gown
and do skin-to-skin care.
11:39
And that skin-to-skin care should be
uninterrupted for one to two hours.
11:43
Now, of course, if the baby's
having any difficulty transitioning,
then we're going to need
to interrupt that care.
11:49
But short of that,
then we need to have
skin-to-skin, uninterrupted.
11:54
Now, maybe the birthing person
can't do the skin-to-skin
for some reason.
11:58
A partner or someone else can.
12:00
It doesn't matter who that is.
12:02
But skin-to-skin care
is so important.
12:04
We know that infants
that receive skin-to-skin
transition easier
to extra uterine life.
12:10
So remember, all those things
that had to happen
in order for Cletus
to take that breath
and maintain adult circulation,
skin-to-skin
makes it happen easier.
12:19
It helps to stabilize respiration,
and glucose, and temperature.
12:24
It also for clients who are going to
chest feed or breastfeed,
it makes it easier to do that.
12:30
They're actually some instinctual
things that the baby has
that lets them know,
"Hey, I'm born. It's time to eat."
And they will actually move
to the breast, on their own.
12:41
Also, the birthing person
can gain more confidence
about just taking care of the baby
by holding the baby
and being the first one to do so.
12:49
And sometimes we have found
that birthing persons who are
allowed to practice skin-to-skin
have an easier time
transitioning into breastfeeding.
12:57
So skin-to-skin is so important.
13:00
Now, I also want to make this point
that just because a birthing person
does not experience
a vaginal delivery
is no reason not to initiate
skin-to-skin.
13:08
So even in the operating room
skin-to-skin care
immediately after delivery
is possible and it should be
encouraged.