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SA: Hello, and welcome to Master the MRCPCH. In this series, we tap into the expertise here at Great Ormond Street Hospital to give you an overview of a topic on the RCPCH exam curriculum. So whether you're revising for an exam or just brushing up on a need to know topic, hopefully this podcast can give you the information that you need.
I'm Dr. Sarah Ahmed, a paediatric registrar and the current digital learning education fellow here at GOSH.
In today’s episode, I'll be talking to Dr. Sadaf Bhayat, a consultant neonatologist at both Great Ormond Street Hospital and UCLH. We're going to be talking about neonatal resuscitation, which corresponds to learning outcomes in the neonatology section of the exam curriculum.
Sadaf, thank you very much for taking the time to talk with us today.
SB: Thank you.
SA: So, before we delve into detail, what would you like people to get out of listening to this podcast?
SB: I think there are a few things. The first thing is understanding what happens to a baby at the time of birth and then to be able to know and to anticipate the sick babies. And the third thing would be how to stabilize the newborn baby.
SA: That all sounds really doable and hopefully we'll cover everything in the next 30 minutes or so.
So neonatal resuscitation. I have very distinct memories of going to my first resuses and being absolutely terrified that something bad was going to happen.
Do we have a sense of how many babies actually need resuscitation when they're born?
SB: Yes, there are statistics out there. I think it's really scary, isn't it? When you first start off attending these deliveries and not knowing if the baby's going to be well or unwell and not knowing if what you're going to do is going to help. I still get stressed when I attend high risk deliveries and thinking, is it going to be okay or not?
But the facts are that actually about only 1 in 2000 deliveries would need resuscitations in terms of if we're talking about ventilation and chest compressions. About 15 percent of all newborns will not breathe in the first 30 seconds. But actually out of those 15%, there'll only about 3 percent who will need some form of positive pressure ventilation. So, bagging, for example, but most of them will start breathing within the first kind of 30 seconds ish of you starting to get that positive pressure ventilation.
And out of those 15%, the most common thing that makes the baby breathe is just drying and stimulation. There's only the 1 in 2000 who would really need a full, full blown resus in terms of chest compressions and ventilation.
SA: I do think it's really helpful hearing the numbers because it's sometimes like seeing the wood for the trees because we only go to the ones where we're needed. And sometimes I think we forget to take a step back and remember that there are all those deliveries that we don't go to. And you're right so many babies need so little and that's why I try and tell the SHOs.
Thinking a little bit about why a baby might need resuscitation. Before we talk through the algorithm, I think it's worth talking a little bit about the physiological basis behind resuscitation. And I'm sure I've heard resus described as kind of like guided transition. So can we talk a little bit about the physiological changes that happen when a baby is born?
SB: Yes, I think you're right. So when we talk about resus in any other context, it's talking about life saving assistance when someone stops breathing but birth is quite unique, isn't it? Because actually you're thinking that we're helping the babies to start breathing. They've never established effective breathing in order for them to stop. You're just helping them to start breathing. So often it is just assisting transition. And as we mentioned early on, very few actually need full resuscitation.
When you think about how labour works, there are regular contractions, and so during those contractions, that gas exchange to the placenta is interrupted. In some cases, these babies don’t tolerate it well, especially, for example, the ones who have something going on, like the ones who are septic. But it also happens when babies spend a prolonged time in the birth canal. So, those are the type of babies who would need aid to transition. And we'll talk a little bit more about the physiology of transition. So when you think about what happens when the babies are in utero, they're dependent on the placenta circulation to provide gas exchange. The baby's in a fluid filled environment. And as soon as they're born, there's a huge change. The cord is clamped and we can talk a little bit more later about delayed cord clamping and things, and we expect them to breathe independently in air. So they have a complete different change of environment. The gas exchange is not dependent on the placenta cause you've cut that off, but it's now dependent on the baby's lungs.
And so if I take you a step back and let's think about what happens when gas exchange happens through the placenta. So, when you think about blood circulation through the placenta, nothing, well, not nothing, but very little is going through the lungs. And so, the right sided pressures are very high. So the pulmonary arterial pressure, so the pressures within the pulmonary arteries and the pulmonary capillary bed is very high, which then basically backtracks onto the right side, because your right side of your heart is what feeds towards your pulmonary arteries and pulmonary bed before it comes down to the left side. So, in utero, those pressures are very, very high. So we were saying that the right ventricular pressures are very high, which would mean if you have a right sided pressure, which is higher than the left sided pressure, you'd have, if there's any type of holes or communications, your shunts would all be right to left. And when we think about foetal life, there's two areas, well three, but if we talk about the two main areas we know of, the two main areas where you can have shunting of blood. One is across the PFO, which is a communication between the left and the right atrium. And that would give oxygenated blood to the left atrium. So, because your oxygenated blood is coming from your placenta to the right side. And then that would give blood to the left atrium, and then on the left atrium, as it would with any of us it would go to the left ventricle and from the left ventricle, the first vessels that arise from your aorta re your head and neck vessels. So you'd get oxygenated blood through there.
Your second shunting area is your PDA, so your patent ductus arteriosus. When the blood shunts from the right side to the left side that would, again, allow the blood to cross over to the more descending part of the aorta and to give blood to the rest of the body, mainly the abdomen and all the other lower organs. So there will be mixing of the blood as you can imagine because you're getting mixing from where the placenta is sending out oxygenated blood to that blood coming back from the rest of your body. And when you think about the saturations in a foetus, they will probably be low around 60 percent probably.
So when the baby is born, the fact that they're exposed to a cool environment, and the fact that they have this reaction against the skin, any stimulation that would help initially respiration and as soon as they breathe the lungs get aerated and all of a sudden you have a drop in those pulmonary arterial pressures and then there's increased blood flow through the lungs and then there's clearance of the lung fluid. And so you have a whole lot of different changes within those first seconds, which I think sometimes we don't appreciate. And that's often why they might need just that little extra bit of help because all of that is changing. And that's also why we give time to babies to adapt. And why we talk about saturations and differences in saturations from the time when they're born all the way up to 10 minutes.
And I know that can sound quite complicated. It's even more complicated probably just hearing it without seeing it on a picture. But there are lots of lectures that you can access on YouTube and, and lots of, even just reading the NLS manual, there's lots of little things that you can pick up on there. But that is kind of the essence of it. Your right sided pressures are much higher in foetal life. As soon as you come out, your lungs get filled with air. Those right-sided pressures drop. And then all your shunts are reversed. So then because your oxygenated blood comes from the lungs, everything goes to the left side, and that gives it to the rest of the body. It's a huge change in the whole physiology and it's probably the most change that anyone will ever get in their lives.
SA: Yeah, absolutely. Thank you for talking through that. I think it's really helpful to put into context. And I'll pop some resources in the description so people can go find some of those videos. And like you said, the NLS book lays it out really well as well.
Thinking a little bit about the actual active resuscitation, I was always taught that resus starts before the baby is born. So can you tell us a little bit about the preparation that needs to happen before you go to a resus? This is assuming that you have notice and you can prep.
SB: Yes, I think there are two different categories of babies, for example, that I would get called to as a consultant. One of them would be the very preterm infants, and one of them would be the babies with congenital abnormalities. So those are two of them where you have time often, because sometimes the preterms don't give you notice.
But if we talk a little bit about the ones with congenital abnormalities, sometimes you'll have congenital heart defects, sometimes you'll have genetic diagnoses antenatally, sometimes you'll have hydrops. When you think of the different pathologies that you can detect spina bifida, chest masses, and there's an endless list of them They can be detected at any point antenatally or they cannot be detected. If they are detected that you have a little bit more time to prep.
And I think the preparation is preparing the parents, so preparing the family, but also preparing your equipment. And when we're preparing the family, it's from the time of diagnosis. So it can be all the way from 12, 20 weeks to the time where they're coming into the hospital to give birth to their baby. I can talk for ages about antenatal counselling, but that's not the point for today. If you have a baby, a preterm baby who you have a bit of warning of, I think, again, it's important to counsel the parents. And I think if you're not confident to counsel them, that's, that's okay. But it's really useful to go with someone. Even when I counsel now, I try and take someone with me because it's always helpful. People pick up on certain things that when you're talking. So going with a nurse, going with someone who's more junior or more senior than you, and just getting feedback about your counselling, I think is quite useful.
Then again, you can talk about preparing your equipment. So, and we can talk about the specifics of having a preterm infant, but making sure the room is warm, making sure that you have all the specific equipment and making sure you have all the right people. But regardless of how senior you are, you need a team of different people. The ideal I think is two nurses, two doctors. So it's not too many people and not too little, but enough people to be able to allocate tasks to, enough people to go and update the parents, enough people to scribe, for example.
One of the things I put down is, when you're preparing is how much time do you have? Because we've talked all the way from having weeks and weeks about antenatal counselling, but sometimes you will just have 10 minutes. This woman's walked in, you know, they need an emergency section because of, for example, prolonged foetal bradycardia. So if you don't have much time, then you can just focus on equipment. If you have a bit more time, it's important to think, is this baby going to be born in the right place? So some babies with cardiac abnormalities need septostomies, for example, so it's better if they're born in the cardiac centre. So it's just about preempting what needs to be done. We know that outcomes of extremely preterm babies are much better if they're not transferred out. So, if they're born in a level 3 unit where well, in a neonatal intensive care unit, because the nomenclature has changed, but where you will have people who are used to doing it and who do it more frequently. So it's just thinking about is this baby going to be born in the right place? Do I have enough time to think where the right place would be and can I transfer them?
Some places have checklists, so being able to go through what you need for different types of babies. Unfortunately, sometimes you don't have time and you just have to rush and do it.
SA: Yeah, I would, I would say to anyone who's just starting in a new unit, talk to your seniors, find out what the protocol is in that particular place. And like you said, if there are any checklists or anything available.
Let's go through the algorithm. And so this is the, the 2021 algorithm just to, just to be clear. So my first question is delayed cord clamping, yay or nay?
SB: So for me it’s a big yes. But I think you need to know when to do it and why to do it. And why are you doing it? So, I think you always have to assume that you are going to do delayed cord clamping, unless it's contraindicated. And there are benefits for them both in term and in preterm infants.
The problem is that it's called delayed cord clamping, right, which would assume that it's not normal to do that. It's normal to do immediate cord clamping, but actually the, the most physiological thing would be to do what we call delayed cord clamping. So the advantages it has is that in a term baby, you avoid bradycardia, you improve usually the Hb and the iron stores when you look at those values later on in infancy. And when you talk about the preterm infants, someone smaller than 34 weeks, it has been shown to improve survival, improve the haemoglobin, improve cardiovascular stability with less inotropic use and overall less blood transfusions during their stay. So it's quite a big win.
But there are some cases where you have to initiate resuscitation. For example, if you have a severely compromised baby who's been bradycardic in the womb for a long time, your baby comes out completely flat. You're not going to do delayed core camping. You need to start resuscitation. Now there's some places where you can do everything at the same time, where they have very fancy little tables that you can bring towards, and you can start doing your drying, stimulating, inflation breaths. And if you're not stopping resuscitation then that would be fair, but I think that the most important thing is to initiate resuscitation if you have a really poorly baby newborn infant.
There's another couple of times I think that when I don't do delay cord clamping. One of them is having a congenital diaphragmatic hernia, because ideally I want to intubate them before they take their first breath or before they start establishing spontaneous breathing.
And when you think about the physiology of delayed cord clamping, what you're basically trying to do is you're trying to allow the baby to start using their lungs to oxygenate the blood moving away from the placenta, but still you have that dependence on the placenta. So it allows a bit more of that stability. And that's where we go back to the physiology. You're not kind of cutting and expecting a huge change within seconds, you're allowing a little bit more time for that change to happen.
Another situation when the obstetricians, and I think there's a bit of controversies about doing delayed cord clamping with that is when you have MCDA twins, because of the anatomy. And the other one, so for example, if the baby's really poorly, so if you don't want to delay starting treatments, so some of the cardiac babies. But it's quite nice to have this joint discussion with the obstetricians before the baby is delivered or with the midwives who are delivering the baby and decide what you're going to do as a team and then facilitate it accordingly. And you can always be there as a neonatologist, very close and say, okay, I'm happy for you to continue. I'm here.
SA: And you said 60 seconds. Is that how long you should delay the cord clamping for?
SB: So that's what NLS recommends. So we leave it at that. I think there's been a lot of studies doing multiple various things. Some have suggested to wait until the cord stop pulsating. We have seen effects of having delayed cord clamping, a very prolonged delayed cord clamping. So having what they call physiological cord clamping so until it stops pulsating, which can be sometimes five up to 20 minutes, I've seen babies having such delayed camping. And you have things like quite significant polycythaemia, babies needing dilutional transfusions, which ends up having more risks. Sometimes even seizures because of significant polycythaemia. So I would be quite worried to leave it for such a long time. I think the fact of having 60 seconds just allows everybody to have a kind of time frame and to allow that kind of teamwork to say that, yes, we are delaying it and 60 seconds proven to have some benefits.
SA: And so moving through the algorithm and we've, touched on this already briefly, when a baby is born and the cord has been clamped and they've been brought over to a resuscitator, what do you do first?
SB: I do a few things at the same time. The first thing I do is I dry the baby and stimulate at the same time and change my towel. While I'm drying and stimulating I'm also assessing. And I'm looking at what the colour is, what the tone is, the breathing and the heart rate. So those are things that are kind of repeated constantly in NLS: colour, tone, breathing heart rate.
Usually you can identify quite quickly. If you've been to about 10 deliveries, you can identify quite quickly the babies who are very sick and poorly because they are completely floppy and they look extremely pale. Whereas if you see a baby coming out and they're slightly flexed and the colour is not too bad, then very quickly, you can say, Okay, this baby I think is going to be okay.
And if you are worried on your first assessment and you're new, I would just say to call for help. I think it's always better calling for help earlier than, than delaying things. And most of the time help comes and it's okay if it's not needed.
SA: What I always say to SHOs is I'd so much rather turn up and not be needed at a delivery than you call me five minutes later when bad things are happening.
I think in, in those kind of initial bits as well, a lot of centres will put a pulse ox on pretty quickly. And I know the target saturations changed with the new guidance. Can you tell us a little bit about what saturations were meant to be aiming for?
SB: So when you talked about physiology, we mentioned that the foetal saturations are about 60 percent in utero. And normal baby saturation when you're thinking about a term healthy baby would be about 90, above 95%. So what we're looking at is having that transitional period. It's really difficult when you're in a resus situation to remember numbers. I'll give them to you, but it's really difficult to remember the numbers. What I tend to think is that when they're born within the first couple of minutes, that if their stats are around 60 ish, it's okay. And when we reach to 10 minutes, they're above 90% I would be happy with that. So what NLS says is at two minutes, 65%, at five minutes, 85%, and at 10 minutes 90%. And often these are values that are stuck on the resuscitaire. So you can, you can look at them but again, often it's quite a stressful situation. So to have an approximate, vague idea that it needs to be between 60% when you start off to, to above 90% by the time you're getting to 10 minutes I think it's a reasonable thing to remember.
SA: And then, and then what comes next?
SB: So once you've assessed your baby, you can put the sats monitor on if you're worried about it. You have to ensure as with any resuscitation, you go through A, B, and C. That your airway is patent. So if your baby is not crying, then you don't have any way of proving that your airway is open, except if you're going to look in, and if your baby is not breathing, what do you have to do is you have to start by giving inflation bets. And the reason we give inflation bets is when you think again of the physiology, what you're trying to do is inflate those lungs to be able to have all those changes in your pressures. So we talk about inflation bets because they're sustained inflation. So your total duration of an inflation breath should be five seconds, which would mean that you have this kind of sustained inflation for three seconds, and then you leave with positive expiratory pressure for the last couple of seconds. And you do that five times. The reason being is that sometimes you won't get chest movements on the first two or three breaths because those lungs are filled with fluid. But when you get to the fourth or the fifth breath, then what you're hoping to do is being able to have shifted a bit of that fluid and being able to see your chest rise. And you would think of giving them with pressures in a term baby of about 30 over 5, and you can set that on your, on your resuscitaire.
The most important thing in a newborn infant is the breathing. So if you're not going to get the chest to rise, you haven't filled your lungs with oxygen. And so the rest of your body will not be able to function. If your chest is not moving, you need to find different ways of moving your chest and we can talk through that in a bit more detail. And then if your chest is moving, then you need to assess what your heart rate is. And if your heart rate is still low, despite your chest moving, you need to think that I need to continue being able to aerate those lungs and get oxygen through the rest of my body. So you can adjust your your FiO2 according to your saturations, and you can go up to 100 percent if you need to.
So once you've got your chest to move, you want to continue making sure that you're getting oxygen through the rest of your body. So you continue with 30 seconds of ventilation breaths, which are much shorter breaths, which basically go at a rate of 30 per minute. If after that, your heart rate is still low, and by low, I mean less than 60, and that needs to be checked on auscultation, not on looking at the cord pulsing, because sometimes you can have your cord pulsing even if you don't have a heart rate, then you need to start your chest compressions. So you do chest compressions in neonates at a rate of three compressions to one ventilation breaths. And you have to think of doing those chest compressions of approximately two per second. Because what you're aiming for is about 120 events. So you're aiming for 90 chest compressions and 30 ventilation breaths within that one minute. And you want to reassess every 30 seconds.
If your heart rate is picked up with a round of chest compressions, then that's great. If it hasn't, then you need to consider other things. So, for example starting to have vascular access to be able to give drugs. Looking at other things, what are the other causes I could have? What else can I treat?
SA: What I would say to everyone as well is just go through the algorithm, make sure you're familiar with it. And have it on your phone as well, or just have it next to your resuscitaire and many resuscitators will have the algorithm kind of attached to it.
SB: Yeah, that's right.
SA: I just wanted to mention that the guidance changed. And so if you have a term baby, you start resuscitation in air. But if you have a preterm baby who is less than 28 weeks, you start in 30%, but if they're 28 to 31 weeks, you start in 21 to 30 percent of inspired oxygen.
SB: It's a bit confusing, isn't it? I think you just pick a number, so you decide that any baby less than 32 weeks, you're going to start in 30 percent because that range is 21 to 30, because it's easier remembering two categories than it is three. But you're right, according to the NLS manual, they've put three categories on there.
SA: You mentioned this briefly, but if you have a baby whose chest isn't moving what are the things that you can do in that situation?
SB: The first thing I would do is call for help because you need an extra pair of hands. There's different techniques to be able to get chest rise. I think one of them is we were talking the first thing we were saying is the airway open. And one of them is to think, how am I going to open this airway? If you're comfortable, you can look under direct vision and see if there's anything obstructing the airway and suction and try and see if repeating that set of inflation breathes would cause chest rise. The other techniques to open an airway is often your airways obstructed in term infants with the tongue, because in floppy infants, the tongue just flops at the back, is to do a double handed jaw thrust. But for that, you need two people. You can also have things like adjuncts. So, having things like an LMA or an iGEL, which is now on most neonatal resource choice, because that's what is recommended by NLS. You can have things like a guedel, but I think an iGEL is probably quicker and more effective than having a gudel. More and more we're teaching how to use laryngeal adjuncts rather than gudels in NLS. And if you are a proficient intubator or if you feel that you can intubate and you have the right help around you, 'cause you obviously need people to pass equipment and to help secure the tube, then by all means you can intubate the baby as well. hose are different things that you can think of How to move the chest.
If your chest is still not moving after you've intubated the baby, one of the things you can do, but I would only do that if I have someone senior around, it would be to increase your pressures to be able to see whether you can move that chest. Is there something that's obstructing that you can just move with higher pressures? But there's always a risk to that because newborn infants chests are quite stiff, and there's always a risk of provoking a pneumothorax.
SA: So we've spoken about airway, we've spoken about chest compressions. Can we talk very briefly about the end of the algorithm? So if you're thinking about vascular access and drugs, can you just talk us through that a little bit, please?
SB: Yeah, so luckily in neonates in terms of vascular access, you have your umbilical cord and your umbilical vein, which was previously connected to mom. So it's a very good central access. And you can put a UBV in fairly quickly. It's considered as an emergency procedure. So you just need to cut the cord, identify what the vein is and thread through a catheter. I've seen in some rare cases that your umbilical vein can kind of self clamp when babies are very poorly. And so sometimes you can't get it in. So it's good to have another backup and you can use intraosseus needles. I would be very reluctant in preterms, but in term infants, that is something that you can use if you're unable to get your UVC in.
And when we talk about drugs, the thing that's the most effective and what we recommend first is adrenaline and the doses for that is they've made it simpler now. It's 0.2mls of 1 in 10,000 intravenously and it's always the same dose and you would repeat that every three to five minutes.
You also have to consider the context of the babies. Often we get these babies if there's been a huge antepartum haemorrhage. So if your baby looks pale and you have that history, consider giving blood. The other drugs you can give are bicarbonate, glucose, saline bonus. Often babies don't need volume. If they need volume, it's probably that they need blood.
It's important to consider the other factors. So is there's a pneumothorax, so think of transilluminating the lungs or just listening. If you have very poor compliant lungs, so sometimes we've had babies who've had no amniotic fluid, so anhydromnios, for example. Any type of renal reasons and so they have very poor compliant lungs. We talked about blood loss. If the baby's persistently cyanosed. So if you've got a heart rate, but you have a blue baby thinking of cyanotic congenital heart diseases, but also thinking of significant pulmonary hypertension of a baby who you may need to move quite quickly and start on nitric oxide. And sometimes you'll have a baby who just won't start breathing because mom's had so many drugs in labour, especially opiates, and it's just usually the heart rate will be fine once you start ventilating them, but they just will not breathe. You can have a really difficult time, even with drugs, picking up a heart rate in the context of babies who had hydrops, and that can be antenatally diagnosed or postnatally diagnosed. So there's lots of different reasons that you can think about, but by that time you're doing that, you would've had more help around. You'll be a team. Even if you may not have a consultant around because you are in a DGH or, and you don't have someone who's on site you will still have other members of your team. And I think that's a huge value, even as a consultant to be able to know that you have just other people thinking, and it doesn't matter what their level of experience is, but just other people thinking around you. So you don't carry that burden as a sole leader.
SA: Yeah, I absolutely agree. Hopefully you'll never be in this situation, but what do you do if nothing that you've done has worked?
SB: It is quite a difficult situation. It's quite sad. I think you need to think about stopping. And when is it that you stop resuscitation? When is it that your resuscitation becomes futile? So as per NLS, they say, you need to start considering things at about, 10 minutes that if you feel that you've done everything at 10 minutes, they recommend to consider stopping at 20 minutes. So you start thinking about where are we going at 10 minutes, but actually, when you're coming to thinking of stopping, it's about 20 minutes, because they've shown statistically that babies who've had long resus over 20 minutes have very poor outcomes. And again, that's an idea that anybody within a team can suggest, but it is also a decision you make as a team. So you can consult all the other members of your team to to ask whether everybody's in agreement. Ideally, you would have spoken, you have someone speaking to the parents beforehand. It is a horrible and an extremely sad situation to be in, but unfortunately it does happen. Since I started doing paeds I don't think I have ever had to do it in a baby that I wasn't expecting to die at delivery. So without any congenital abnormalities, and it has happened to my colleagues, but it is, it is extremely rare if that can reassure you in terms of frequency.
SA: Let's say that the resus has been successful what should you do at the end of a successful resus?
SB: So I'm just going to bring you back on the successful for a second, just because I think that even if your baby dies, your resus may have been successful, but sometimes the babies have you know, have died in utero. But if your baby is alive after resuscitation, you need to think of different things. Where is this baby going to be? And I think any baby who's had chest compressions, I feel that they've been poorly enough to warrant an admission to the neonatal intensive care unit. And when you're admitting them, it's thinking about why are you admitting them? Are they intubated? But also, is there any way they've sustained quite a prolonged hypoxic event? Is there any way that we could preserve their brain? And so for that, thinking about early cooling.
So in terms of babies who've had a bit of ventilation/inflation breaths, but you could discuss that you could give them back to the parents, but with a plan of monitoring and when, how often you're going to come back to see them. So I think that's talking about what happens to your baby once you've finished your resus and you've stabilized your baby.
There's also other very important factors. So with the baby goes the parents and being able to explain to them and talk to them what has happened, find out if they have anything you want to go over again. Often they're completely shell shocked, so they will not remember anything you say. But they will remember how you made them feel. So being able to have a gentle, particular tone of voice, but without going into too much detail, and then maybe offering them a sit down the next day or a couple of days to talk to them when they've had a bit more time to think about it.
And sometimes these cases come back to you years and years down the line because of some medical legal reason. So from that perspective, it's really important to have contemporaneous documentation. So if you get a chance, and if you remember to get someone to scribe while you're doing your resus. If you don't, then documenting very quickly after is a useful thing. If you have someone that's scribing, it's also useful to upload that scribing document, even though sometimes it's not very accurate, because by the time you get down to writing something, it might be two or three hours later. But you should document as soon as possible. And if you're documenting later document, why you're documenting with so many hours of delay.
And the last thing I think is that you've all been as a team through a really difficult situation. So it's really important to debrief yourselves as a team. So having a hot debrief and sometimes in, challenging cases I think having a cold debrief weeks or days after is really helpful. It's important to remember that it's hard for every member of your team. And it's really important to support them. I remember as a, as a reg, even having someone bring me a cup of tea was, you know, the kindest thing and you can just sit and cry because of that. So I think it's a really, really important to remember that. There's the baby, there's the parents, but there's also your team and yourself that you need to look after.
SA: Yeah, I think that's really important. Can we just mention a couple of very specific situations? So the first one is meconium. So if the baby's born through meconium, what does the current guidance say you should do in that situation?
SB: So the current guidance says that you should not delay resuscitation. So if your baby's born floppy flat with meconium, go through your NLS. The important thing to know about meconium is sometimes as you could have blood and vernix, meconium can block your airway. So sometimes you would need to be able to suction and meconium can be quite thick and sticky. So to use a very wide bore suction catheter. Some places have a meconium aspirator, which is basically what you put the EDT when you put something on top and you can attach your suction to it. But I think the main message is do not delay resuscitation. So, don't try and faff around with suctioning and take minutes before you start giving your baby a breath of oxygen.
SA: It used to be that if with a meconium baby, you wouldn't stimulate, you wouldn't do inflation breaths. You'd go straight to look, and to suction, and that has changed now. And then the last specific situation I wanted to mention was preterm resus. So what are the differences when you encounter a preterm baby?
SB: That's really important because that's one of the things we encounter the most often. There are two big differences that I think I would highlight in the preterm infant. One of them is their skin because it's much more fragile and they tend to lose heat much quicker. Um, and the second thing is their lungs which are also more fragile. So in terms of skin, what they need is we need to preserve humidity and warm. So make sure the room is warm. Make sure certain gestations that they have a plastic bag around them to be able to not lose that humidity and to have them under a radiant heater. For in terms of the lungs, preterm babies would breathe, but the problem they struggle with is gas exchange. So what you need to do is give them end expiratory pressure, so PEEP, and being able to help them with their breathing as and when they need it. The more preterm the baby is, the more help they may need.
SA: Fantastic. Let's wrap up with a couple of quickfire questions. So the first question is, are there any class exam questions that could pop up about neonatal resus?
SB: The things I will think that I would want to ask would be around the physiology. And that may seem harsh, but I think it's a really important factors. Everything I've mentioned during this talk goes back to the initial question of physiology. But I think there may also be questions on the NLS algorithm. And I'm just thinking of the type of questions you'd get, the, the multiple choice questions you'd get in your NLS course. Those are the main things I would prep on.
SA: The second question is, are there any useful resources that you would recommend?
SB: My first recommendation would be to attend an NLS course, to read your NLS manual. And if you're unsure of a procedure, YouTube it. Because that is usually quite helpful. And the last thing is just throw yourself out there, go to as many deliveries as you can, normal, the ones who require resus, because the more you do it, the less, less intimidated you would feel by it. I'm not going to say less stress, because I think you always feel stress when you're called to something that you expected to do something about and that may go wrong. And that stress never leaves you, even as a consultant, even as a very senior consultant, that stress of not being able to get the best outcome is always there.
SA: Yeah, absolutely. Um, and finally, what are your three takeaway learning points?
SB: The first one would be to know the NLS algorithm. Everybody speaks the same language. It improves teamwork. It improves outcomes. When you have a preterm baby, think about adjusting your resuscitation, the thermal care and gentle ventilation. And the third thing, which I think is the most important thing is call for help early.
SA: Yeah, I completely agree. Sadaf, thank you so much. This has been really, really informative.
SB: You're very welcome.
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