The attending just stepped out to get coffee. You are the only resident in the critical care area. You just endorsed the only active patient to the medical admitting resident. As you are about to check your Instagram, the EMS rolls in a 34-year-old female s/p extramural delivery just 2 minutes prior to arrival. As you are about to run away, the EMS hands you the blue baby.
After delivery, what is the first priority in the care of the newborn? The infant must be dried as soon as possible to prevent body heat loss. If available, place the infant on the radiant warming unit. Then the baby’s mouth and nose should be suctioned by nasal syringe.
After the infant is dried, suctioned, and placed under the warmer, what further intervention is needed? If the infant is crying and is active and does not have central cyanosis (i.e. truncal or periorbital cyanosis), you can be assured that the infant has a heart rate of greater than 100; further resuscitative measures are seldom needed. If the infant has central cyanosis, apnea, low oxygen saturation, or heart rate of less than 100, assist ventilation with bag-valve-mask. The heart rate should respond quickly with BVM ventilation, especially when the infant is near-term.
How do you measure heart rate in a newborn infant? You can either palpate the umbilical artery or listen to the heart with your stethoscope. Count the heartbeats in 6 seconds and multiply it by 10. As you are counting, you can tap your hand gently on the side of the bed, so that others involved in the resuscitation can calculate as well.
What is APGAR score? Despite limitations, APGAR score remains the standard. The score is calculated at 1 and 5 minutes. In cases of ongoing resuscitations, at every 5-minute interval thereafter.
When should you start chest compressions? If the heart rate remains less than 60/min after adequate positive pressure ventilation, chest compressions should be started. When do I need vascular access? What vessel should I use? If the infant is not responding to supportive measures, and you are considering using drugs or volume expanders, an umbilical venous line should be attempted. (Recall that umbilical cord has two arteries, one vein) (Procedure Tip: You can advance the catheter to approximately one-tenth of the infant’s size) What drugs are usually used in neonatal resuscitation? Epinephrine (1:10,000 dilution) Dose: 0.1-0.3 cc/kg Route: Ideally via the umbilical vein; However, can be given via ET tube as well. Volume expanders If blood loss is suspected, especially in cases of maternal placental abruption, normal saline can be given via umbilical vein catheter. Dose: 10 ml/kg Bonus Question: Besides maintaining the airway, what is the most important thing to do? Consult NICU and OB as soon as possible. Thanks to Dr. DeSouza 
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