Mothers and Babies: Emergent Delivery and Pediatric Resuscitation

Mothers and Babies: Emergent Delivery and Pediatric Resuscitation is an ACEP Scientific Assembly Lab that focuses on two anxiety-producing scenarios for even the most practiced emergency physician: the emergent difficult newborn delivery followed by neonatal resuscitation. For the delivery portion, participants rotated through multiple high-fidelity stations and practiced skills including normal vaginal delivery, management of nuchal cord, breech presentation, and shoulder dystocia. Nuchal cords are common and present in about 30% of births. Fortunately, the cord is often loose and can be easily reduced by bringing the looped cord over the baby's head. Breech presentation is less common, and the incidence decreases with gestational age. When managing a vaginal breech delivery, the most important point to remember is to keep “hands off the breech.” If the presenting fetal part is anything other than a head, the physician should step back and await events. Breech delivery is best managed by allowing spontaneous delivery at least to the level of the fetal umbilicus. Participants practiced maneuvers for assisted delivery of the fetal legs, arms, and head while not applying traction as the fetus should never be pulled from below. Participants also practiced management of shoulder dystocia—a true obstetrical emergency. Shoulder dystocia occurs when the fetal anterior shoulder impacts against the maternal pelvic inlet (usually the pubic symphysis), causing a bone-on-bone impaction. If the anterior shoulder does not deliver after the usual downward traction, the physician should assume there is shoulder dystocia and immediately call for help. The patient should be placed in the McRoberts position, which involves hyperflexing the maternal thighs toward the abdomen. This is best performed with two assistants, each helping to position a maternal leg. One assistant can then apply suprapubic pressure. In most cases, the combination of McRoberts maneuver plus suprapubic pressure will relieve the dystocia. Additional maneuvers include various rotational maneuvers and the delivery of the posterior fetal arm. The pediatric half of the lab includes several stations that allow participants to run a high-fidelity simulated resuscitation of a newborn utilizing the Neonatal Resuscitation Program (NRP) algorithm. Fortunately, most newborns do not require resuscitation, and those who do typically only require brief positive pressure ventilation (PPV). Immediately after birth, the baby should be warmed, dried, and stimulated. If the baby is apneic, gasping, or has a heart rate less than 100 within the first 60 seconds of life despite warming, drying, and stimulation, then PPV is recommended utilizing either bag mask ventilation or T-piece resuscitator. There are T-piece resuscitators, such as the NeoTee®, that are disposable and do not require the use of an oxygen blender. If the heart rate does not adequately improve with ventilation, the next step is corrective ventilation techniques – aka – MR SOPA. This stands for Mask Adjustment, Reposition Airway, Suction (bulb or catheter), Open the Mouth, Pressure Increase (increase PIP in small increments to a max of 40 mmHg) Alternate Airway—ie, supraglottic airway or endotracheal tube. If the heart rate remains below 60 despite MR SOPA (including supraglottic airway or intubation), then chest compressions are indicated. These compressions should be in a 3:1 ratio with ventilation, as compared to continuous compressions done in pediatric advanced life support (PALS) after intubation, to maximize ventilation. It is important to note that postnatal saturations are not expected to be over 95% until after 10 minutes of life. A good rule of thumb is that normal neonatal saturations at 1, 3, and 5 minutes of life should be approximately 60%, 70%, and 80%, respectively. To meet these saturation goals, term infants undergoing PPV should be started on room air (21% FiO2), infants 32 to 35 weeks, on 21% to 30% FiO2 and very preterm infants (<32 weeks) from 30% to 100% FiO2, and only once intubation or supraglottic airway has been placed should all infants be placed on 100% FiO2. Lastly, heat management is important as both hypothermia and hyperthermia can lead to morbidity in neonatal resuscitation, particularly preterm infants. All infants should be placed in a radiant warmer with a temperature probe on, a hat placed, and if the infant is <32 weeks' gestation, that infant should be placed in plastic wrap or bag from the neck down to be kept warm. The priority in newborn resuscitation is ventilation; do not delay ventilation to place in the bag.1,2 Participants also practiced emergency umbilical line placement. The supplies needed are betadine, a scalpel, umbilical tape (large suture is an adequate substitute), mosquito forceps (or any small hemostats), a 3.5 Fr or 5 Fr umbilical line (a 5 Fr feeding tube will work if your emergency department (ED) does not stock umbilical catheters), a 3-way stopcock, and saline-filled syringe. The procedure includes cleaning the cord with betadine, applying the umbilical tape lightly initially for hemostasis, and cutting the cord. The line then needs to be prepped and flushed before it is inserted into the identified umbilical vein. Emergency lines should be placed no further than 4-5 cm to avoid entering the portal circulation. Once confirmed with adequate blood return, the umbilical tape can be tightened, the line taped down and medications infused.3 This line will ultimately be replaced with a sterile catheter when the infant arrives to the neonatal intensive care unit (NICU). Precipitous or difficult delivery followed by resuscitation of a distressed infant are among the most stressful scenarios an emergency physician can encounter. To ensure your ED is well prepared for these high-risk situations, advanced preparation with obstetrical and neonatal colleagues is critical. This includes stocking necessary delivery and pediatric-sized equipment and ensuring that staff are comfortable using it, having emergency delivery protocols in place, and lastly utilizing simulation to practice these high-risk, low-frequency events to increase team comfort.4