Episode Transcript
Hi and Welcome to Clerkship Ready - Pediatrics - A podcast aimed at helping you excel during your clinical clerkship in Pediatrics! I am Jolene (Jody) Carlton, a Pediatric nurse practitioner on the Newborn and Breastfeeding Medicine team at UVA Children’s Hospital.
During your Pediatrics clerkship, you will get to spend some time in the newborn nursery. There are many exciting things to learn on your Newborn rotation with attendance at deliveries being one of them. Today we will talk about what to expect before attending your first delivery as part of the pediatrics team while on the Newborn rotation.
While some of you may have already done your OB rotation and attended deliveries this Newborn rotation will provide you with the delivery from the perspective of the pediatric providers taking care of the newborn infant. Many students have found this rotation provides a vastly different and informative viewpoint than what they saw on their OB rotation. You will find that each delivery is different and what is needed for each infant at the delivery can be different depending on the status of the infant at birth.
Things to keep in mind: this is a wonderful learning opportunity! We want you to learn and grow and will involve you in the care as much as we can. We encourage questions!
The Pediatric team is requested at deliveries in which it is anticipated that the infant may need any medical support immediately after birth. In most institutions with a neonatal intensive care unit (NICU), the NICU team will attend the most high-risk deliveries, including preterm infants. In this podcast, we will focus on the lower risk deliveries that you are most likely to attend during your newborn rotation.
You may ask yourself what constitutes a low-risk delivery that Pediatrics would attend. While institutions may slightly vary on this, here are some of the reasons the pediatric team is called to a delivery:
1. The infant is born late pre-term – meaning 35-36 weeks gestation and a non-emergent delivery
a. These late pre-term infants born at 35 to 36 week gestation are at higher risk of having problems in the transition after birth with respiratory status, so we attend most of these deliveries, just in case. Fortunately, these infants are
usually able to transition after birth with little intervention from the pediatric team. A healthy transition means the infant has good muscle tone, a normal respiratory rate and effort -with no increased work of breathing, and a strong cry (NRP, 2021)
2. Deliveries for fetal distress with Category 1 (one) or 2 (two) tracing
a. During deliveries, the obstetricians will often do continuous fetal monitoring to track the fetal heart rate (FHR) during uterine contractions, because the fetal heart rate during uterine contractions reflects the oxygenation status of the fetus. (Kauffmann & Silberman, 2023).” The obstetrician will look at variability of the fetal heart rate – meaning how much does it fluctuate - and the trend of the heart rate. If there is marked variability, there will be more than a 25 BPM (beats per minute) fluctuation. This suggests that there is acute hypoxia to the infant or compression of the umbilical cord. Decelerations occur naturally during uterine contractions. However, if the decelerations are variable – meaning that they do not correlate with the contraction – or late – meaning that they occur after the peak of the contraction, this is concerning, asVariable or late decelerations are caused when there is uteroplacental insufficiency meaning decreased blood flow to the placenta which decreases the amount of oxygen and nutrients the infant is receiving.
b. Fetal monitoring tracings are given progressively higher levels to describe more potential risk to the newborn. In Category I (one) tracings, there is a normal baseline FHR (fetal heart rate), moderate variability, and no variable or late decelerations. These patterns are normal. In Category II (two) tracings, there may be fetal tachycardia or bradycardia, reduced or marked variability, and/or occasional variable or late decelerations (Kauffman & Silberman, 2023).
3. Maternal substance use when the infant is at risk for withdrawal and or when mothers are receiving narcotics. This can cause the infant to have decreased tone, heart rate or respiratory rate at birth.
4. Meconium-stained amniotic fluid. Meconium is the newborn’s first bowel movement. It is sticky, thick, and dark green or black. If the infant passes meconium before birth and then aspirates – or breathes it into the lungs, it can create respiratory problems, as it clogs the airways and blocks surfactant in the lungs.
a. Meconium-stained amniotic fluid occurs in 8% to 15% of all deliveries. Out of the infants born through meconium-stained amniotic fluid, 10% to 20% are Non-vigorous (at birth) and require some intervention by the Pediatrics team.
5. Maternal risk factors for fetal infection – chorioamnionitis, prolonged rupture of membranes (which is anything over 18hrs rupture), maternal fever during labor or delivery, group B strep positive mother (GBS) that is not adequately treated with an antibiotic to the mother at least 4 hours before delivery
A note here about GBS positive mothers: they should be treated with PCN-G (penicillin G), ancef or cefazolin to provide adequate treatment for the infant at least 4hrs prior to delivery (Puopolo et al., 2019).
6. No, little or late prenatal care for the mother
If this is a multiple gestation, meaning twins, triplets, or more, often both the NICU and newborn teams attend the delivery to ensure they have enough staff to take care of these infants. You will see the Neonatal Intensive Care (NICU)team and Newborn teams coordinating care and communicating often about deliveries to make sure the right team is at the delivery. A delivery team will always have someone who is qualified to provide resuscitation to the infant which includes respiratory support, suctioning the infant’s nose and mouth, stimulation, and the ability to have someone quickly available able to intubate the infant as needed.
Many times, things move extremely fast with deliveries- if the Newborn team is moving quickly to delivery, please plan to move quickly to the delivery room or operating room. If the newborn team gets a page, the team needs to move quickly to get to the delivery as many times the baby is born sooner than expected and the pediatric team wants to be there and waiting.
On your newborn rotation you will often find that you will dress in hospital-issued scrubs. The reason we have you dress in hospital scrubs is, so you are always ready to attend a delivery in the operating room. There are many reasons that a delivery may occur in the operating room, including scheduled cesarean-sections, emergent c-sections, and when there is a multiple birth delivery. Twin or multiple birth deliveries many times are brought to the operating room to deliver in case they need to quickly transition to a c-section delivery. This is an interesting delivery to see- because you might attend in the operating room, but the mother is delivering vaginally.
Shoulder dystocia is an emergent delivery. Shoulder dystocia happens when the fetal shoulder impacts or becomes stuck on the maternal pelvic bones (Politi et al, 2010).
Shoulder dystocia is a delivery that requires additional obstetric maneuvers to release the shoulders but can present a large risk of morbidity for the infant and the mother (Politi et al., 2010). For the infant, Shoulder dystocia can cause clavicle or arm fractures, brachial plexus injuries, and hypoxia. For the mother, it can result in damage to the bladder, rectum, anal sphincter, vaginal tears and post-partum hemorrhage.
Each institution has a specific Code that is called for this type of delivery such as an Obstetric Code. This code is notification to the delivery teams (NICU/Newborn) that an infant and mother are in distress and need immediate assistance.
Each institution will also have a specific Code for infants in severe distress, such as a Neonatal code—this usually happens with deliveries but can also happen on any of the labor and delivery or postpartum units. This specific code notifies the Pediatric teams (NICU/Newborn) that an infant is in distress and needs immediate assistance.
Each healthcare institution has a specific process for paging their Pediatric (NICU/Newborn) teams for deliveries. The page notifies the teams of an impending delivery, the gestational age of the infant, whether it is a single or multiple birth, and any maternal risk factors.
Check with your resident or attending to find out which deliveries you should attend and how you will get notified.
This provides important pertinent information for the newborn team to prepare for the delivery. We can get more information from the nurse on arrival at the delivery room.
In any delivery space, The Pediatric team will stand near the radiant warmer awaiting the delivery of the infant.
You will see the pediatric team ensuring the radiant warmer is ready for the arrival of the infant. We will make sure the radiant warmer is turned on with the overhead heat on for the baby to stay warm, turn on the oxygen and suction, and set up resuscitation equipment such as a neo-puff or self-inflating bag and mask, multiple blankets, bulb syringe, suction catheters, hats, temperature probe, pulse oximetry, and EKG leads. We do not open suction catheters, pulse oximetry, temperature probes, or EKG leads unless they are needed for the infant. We will open those as needed in real time.
When the baby’s head and body have been fully delivered one of the pediatrics team members will press the “Apgar button” on the radiant warmer. This starts the timer, so we can tell how old the infant is. You will hear the team state “One minute” loudly when the timer hits the one-minute mark, so the OB team is notified that it has been
one minute since birth. This does two things: #1. The designated “Apgar assigning provider in the room,” usually the OB can assign 1-minute Apgars #2. They can then clamp and cut the umbilical cord. Please listen to our Newborn Nursery episode to learn more about Apgar scores.
This is called delayed cord clamping. Delayed cord clamping in infants who are healthy and in no distress allows time for the fetal blood and stem cells to transition from the placenta into the newborn’s circulating blood volume. It is estimated in term infants that by 1 minute of life, over 80% of the blood is redistributed to the infant, which helps to increase both the fetal hemoglobin oxygen content and cardiac output. This results in higher hematocrit levels and better iron levels in infancy. .
Additionally, delayed cord clamping may be a more physiologic transition, as it provides time for the infant to aerate the lungs and increase pulmonary blood flow before venous return from the placental circulation is lost. (Tarnow-Mordi et al., 2017).
If the OB team clamps and cuts the cord before 1 minute and brings the infant to the radiant warmer, that means that the infant is in distress and needs the Newborn teams resuscitative support.
You will be standing with the pediatric team at the radiant warmer awaiting the infant’s birth. If you see something is missing or have questions about the equipment please ask the pediatric team and we will discuss these items with you. A respiratory therapist is many times at the bedside and can provide a unique perspective on resuscitation, suctioning, and respiratory support.
Once the infant is handed off to the pediatrics team, the team will use the American Academy of Pediatrics’ Neonatal Resuscitation guidelines (NRP) (Textbook of Neonatal Resuscitation, 8th Ed. (2021). I have included this reference in the show notes.
You will see the resuscitation in real time and if the infant is stable enough you may even be able to assist with the resuscitation. The pediatrics team will stimulate the infant by rubbing their back or soles of feet, and if it is needed will suction the infant’s nose, mouth, and airway with either a bulb suction or deep suction. If the infant requires more respiratory support you will see the team provide CPAP (Continuous positive airway pressure).I If the infant is not breathing you may see PPV (positive pressure ventilation) being provided to assist the infant in breathing.
If the infant is stable enough the newborn team will invite you to auscultate the lungs/heart, visualize the three vessels in the umbilical cord (2 arteries and 1 vein) as
this is the best time to see this as the cord has just been cut. You just might be able to feel the pulse in the umbilical cord (this is exciting if you have never done this!). The Newborn team will do a quick physical exam which will include looking at the spine and ensuring the infant has a patent anus along with the infant’s tone, color, heart and lung sounds, and ensuring no overall visible abnormalities. If the infant is stable you as the medical student will be able to be involved in this physical exam of the infant.
This exam allows for a quick evaluation of the infant. A further extensive exam will be done later in the day with the Newborn Pediatric team. If the infant becomes unstable and the newborn team feels the infant needs more intensive evaluation the NICU will be notified to come and evaluate the infant.
Attending Newborn deliveries is an exciting experience in your newborn rotation. You never know what to expect as deliveries can change at any time. You will be able to visualize the expert care we provide for our newborns daily. We hope you enjoy this part of your newborn rotation experience!
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