Delivery Room

Emergencies
AMANDA LOUISE DU, MD, DPPS, DPSNBM
PEDIATRICIAN-NEONATOLOGIST
Disorders Of Respiration

 CNS Failure
 Depression or failure of the respiratory center

 Peripheral respiratory difficulty

 Interference with the alveolar exchange of oxygen
and carbon dioxide

 Respiratory distress
 Do a chest x-ray
Apnea

 Cessation of breathing for greater than 15 to 20

seconds

 Primary Apnea
 Responds to stimulation

 Secondary Apnea
 Need ventilatory assistance
 A result of asphyxia or neuromuscular disorders or
prematurity
Neonatal
Resuscitation
Neonatal Resuscitation

 Reestablish adequate spontaneous respiration and cardiac

output

 High-risk situations should be anticipated from the history

 Infants who are born limp, cyanotic, apneic, or pulseless

require immediate resuscitation before the 1-min APGAR
score
 All newborns require initial assessment to
determine whether resuscitation is required
Prepare Materials

Request for an extra person

for delivery
 Early Intrapartum
Newborn Care
 The 4 core steps:

1. Immediate and thorough drying

2. Immediate skin-to-skin contact

3. Clamping the cord after pulsations stop,

cutting the cord with a sterile instrument

4. Initiating exclusive breastfeeding when

cues occur
Kangaroo mother care
(KMC)
 Promotes early, continuous and prolonged skin-to-skin contact
between the mother and the baby

 It is initiated in hospital and can be continued at home

 Small babies can be discharged early

 Mothers at home require adequate support and follow-up

 It is a gentle, effective method that avoids the agitation

routinely experienced in a busy ward with preterm infants
 KMC benefits Philippine
evidence
- Mortality
+ Weight - Hospital
Stay
gain

- Nursing
- Hypoglycemia
load

- Sepsis
- Hypothermia

+ exclusive - By 50% duration

breastfeeding for of CPAP and
first 6 months oxygen support

+prolactin
Increase +Transport
Safe for
levels
PGH and breastmilk + Both
Intermittent &
Fabella production
Continuous
MMMMC KMC beneficial
Kangaroo mother care
(KMC)
 Maternal Criteria

1. Freedom from any active, communicable disease

2. Willingness to lactate & breastfeed

3. Emotional stability

4. Commitment to the KMC technique

5. Ease & comfort in KMC 24 hours/day in the KMC room

Kangaroo mother care
(KMC)
 Neonatal Criteria

1. Weight at enrolment <2,500gm

2. Clinical stability for holding with or without feeding

3. Prior to transfer to room/ward, ability to breastfeed in a

coordinated fashion
 I. Thorough drying Apnea / NO
Birth and gasping
quick assessment or limp?

YES
1. Call for help
2. Change wet linen
3. Clamp and cut the cord
4. Transfer to warmer
5. Position airway
6. Clear secretions if needed

7. PPV
8. SpO2 monitoring
Bag And Mask Ventilation
Important points

 Keep in a sniffing/neutral position

 Landmarks: bridge of the nose to the tip of the chin

 Respirations: ≈40-60 breaths per minute at 15-20cm H2O

(breath-2-3)

 Use room air in term infants

 Preterm infants use low oxygen 21 to 30%

Important points

 Effective PPV will improve:

 Color and oxygen saturation
 Muscle tone
 Spontaneous breathing
 Assisting ventilation

NO NO
Apnea / gasping Labored breathing or
or HR < 100 bpm? persistent cyanosis?

YES YES

9. Ventilation corrective steps a. Position and clear airway

10. Intubate if needed b. SpO2 monitoring
c. Supplemental O2 as needed
d. Consider CPAP
MR. SOPA

 M =Mask reposition

 R =Reposition airway (sniffing position)

 S =Suction mouth and nose

 O =Open mouth

 P =Pressure increase

 A =Alternative airway (intubation)

Circulation

If heart rate <60 bpm

despite adequate ventilation for 30
seconds

NO
HR < 60 bpm?

YES
10. Intubate if not already done
11. Coordinated PPV and chest compressions
12. 100% O2
13. Consider UVC insertion
 Endotracheal Tube Size

Tube Size (mm Depth Of Insertion

Internal Diameter) From Upper Lip (cm) Weight (g) Gestation (Wk)
2.5 6.5-7 <1,000 <28
3 7-8 1,000-2,000 28-34
3/3.5 8-9 2,000-3,000 34-38
3.5/4.0 ≥9 >3,000 >38

*1-2kgs ET size 3 (1-2-3)

*Level at the lip: Weight + 6

Correct Placement of ET
Tube
 Improvement of vital signs (HR, color, activity)
 Presence of exhaled CO2 using a CO2 detector
 Breath sounds over both lung fileds but decreased of absent over
the stomach
 No gastric distention with ventilation
 Vapor in the tube during exhalation
 Chest movement with each breath
 Tip-to-lip measurement (wt in kgs + 6)
 Chest x-ray
 Direct visualization of the tube passing between the vocal cords
Chest Compression With
PPV
Important Tips

 Landmarks: in between the nipple line on the lower 1/3 of the

sternum

 Compress the sternum 1/3 of the AP diameter

(1 and 2 and 3 and breath and)

 Preferred 2 thumb technique

 90 compressions:30 breaths (3:1)

 120 events per minute
Drug

If heart rate <60 bpm

despite adequate ventilation
and chest compressions

NO
HR < 60 bpm?

YES
14. IV epinephrine
15. Consider hypovolemia
16. Consider pneumothorax
 Epinephrine

 Concentration: 1:10,000 (0.1mg/ml)

 Route and dose:
IV at 0.1-0.3ml/kilo
ET at 0.3-1ml/kilo
dose repeated every 3-5mins
Other medications:

 Naloxone hydrochloride (0.1 mg/kg)

 Infant has respiratory depression and mother
received analgesic narcotic drug 4 hrs prior to
delivery

 Volume expanders (PNSS, LR, O-Rh negative blood)

 10-20ml/kg over 5 to 10 minutes

 Sodium bicarbonate 4.2%

 2mEq/kg or 1mEq/kg/min
 Given with adequate ventilation
Other medications:

 Dopamine or dobutamine
 5-20 µg/kg/min via continuous infusion
 Cardiogenic shock

 Epinephrine drip
 0.1-1.0 µg/kg/min via continuous infusion
 Severe shock
Emergency Cases
Pneumothorax

 1-2% of infants have pneumothorax at birth

 0.05-0.07% have symptoms

 Higher risk:
 Need PPV
 Meconium stained amniotic fluid
Pneumothorax
Pneumothorax
 Bilateral
Choanal Atresia

 Good respiratory movements

but unable to ventilate when
mouth is closed

 Mouth should be open and

clear of secretions

 Place an oropharyngeal airway

EXIT procedure

Teratoma and Critical High Airway Obstruction Syndrome

(CHAOS)
Abdominal Wall Defects

Gastroschisis Omphalocele
Injury During Delivery
 Liver

 Hepatic rupture may result in the formation of a subcapsular

hematoma

 Normal for the 1st 1-3 days

 Nonspecific signs related to loss of blood into the hematoma

 Mass palpable on the right upper quadrant and abdomen or

inguinal area may appear blue
 Hepatic Rupture

 Diagnosis: ultrasound

 Supportive therapy

 May require surgical repair

Adrenal Hemorrhage

 Due to trauma, anoxia, or severe stress (overwhelming

infection)

 Present with profound shock and cyanosis

 Mass may be present in the lank along with overlying

skin discoloration

 Diagnosis: Ultrasound

 Treatment of acute adrenal failure

Clavicular Fractures

 Fractured during labor or difficult delivery

 Does not move the arm freely on the affected side and
absent Moro reflex

 Crepitus and bony irregularity and discoloration

 Excellent prognosis

 Treatment is immobilization of the arm and shoulder

Extremity Fracture

 Long bone fracture will present with pseudoparalysis

 Absent moro reflex on affected side

 Fractured humerus immobilize for 2-4wks

 Femoral fracture immobilize with spica cast

 Excellent prognosis
Thank you!!!