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Identification of Peripartum Risk Factors
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Anticipating the specific clinical circumstances leading to the need for neonatal resuscitation in the delivery room is very helpful. Not enough can be said for the value of time to prepare for a sick newborn. In addition, while the basics of resuscitation do not vary from one patient to the next, certain clinical situations will require the resuscitation team to be prepared to provide specific medical care beyond the usual. For example, the needs of an uncomplicated 28-week premature infant delivered for worsening maternal preeclampsia will be quite different from a term infant with particulate meconium stained amniotic fluid, or a 36-week-old child with nonimmune hydrops fetalis. Table 24-4 shows many of the more common ante- and intrapartum conditions likely to result in the initiation of neonatal resuscitation. Some of the additional requirements of children presenting under these circumstances are shown in Tables 24-5 and 24-6. An unusual example of this is the ex utero intrapartum treatment (EXIT) procedure. This operating room procedure is used when a prenatal diagnosis is made of a fetus with airway anatomy likely to make endotracheal tube intubation difficult. The delivered infant’s umbilical cord blood flow is not interrupted until airway access is secured. This allows the intubation to proceed without immediate concern for asphyxia. In addition, if a tracheotomy is anticipated, the provision of anesthetic to the maternal circulation can provide the fetus with pain relief adequate for the procedure to be performed. Thus, advance preparation will optimize even the most complex and dire delivery room events.
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In order to function properly, each member of the resuscitation team (and back up members in the event of simultaneous resuscitations, eg, multiple gestations) should be identified for each shift. All team members should respond to high-risk deliveries and to urgent calls from the delivery room. In addition, it is standard of care for the team to attend all cesarean deliveries. A recommended team composition and delineation of responsibilities are listed in Table 24-7. Note the considerable overlap of duties. The nature of a neonatal delivery room emergency requires that all team members are capable of performing multiple tasks, as the circumstance requires. Indeed, a child who needs a thoracentesis for a spontaneous pneumothorax or large pleural effusion will need the most skilled practitioner to perform this procedure. Usually, this clinician is the one managing the airway. He/she will have to relinquish that responsibility to another to be free to emergently evacuate the chest of air or fluid. Team flexibility is a requirement rather than a luxury.
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In addition to completing and maintaining NRP certification, each team member should be responsible for participating in periodic mock codes. These training exercises are extremely valuable for evaluating the team member’s knowledge of resuscitation procedures, adequacy of communication systems and response times, and for identifying general logistical problems unique to each institution (reliability of elevators, distance to operating rooms and delivery rooms, location of personnel and adequacy of equipment, etc). After each mock and real code, a debriefing to evaluate team performance is strongly recommended. This activity creates the methodology to systematically identify and correct deficiencies noted during the code.
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Critical to successfully completing a neonatal resuscitation is getting the resuscitation team to the delivery. This may seem a trite comment to make, and, therefore, one not worth making. However, once the delivering department of a hospital comes to rely upon a designated team of individuals to provide a service, no one else is likely to provide it. A simple and effective communication means the backbone of the team’s function, notifying members of the timing and location of the anticipated need. This is accomplished by facilities in many ways.
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Some utilize broadcast paging. This method allows multiple so-called code pagers to be accessed with a single pager number entry. This minimizes the time required for contacting multiple parties but is vulnerable to pager battery life and black out areas. Others employ overhead paging that disturbs uninvolved patients and staff, is vulnerable to ambient noise interference and areas not served with speakers, and can be confusing. Many institutions use both of the above. Recent technological communication advances have increasingly permitted direct voice communication between staff members. This is accomplished both by localized FM transmitted telephone communications (zone phones), direct voice-to-voice technologies (modified walkie-talkies), or by digital cellular telephones with web-based direct connection to on-call clinicians. The latter permits user to call one telephone number and access the communication device of the clinician(s) on call using a web-based system that also permits the entry of backup providers. While dependent upon battery life and signal adequacy, direct voice-to-voice communication allows clinicians to share critical case-specific information while simultaneously proceeding to the location required (ie, time waiting for someone to return their page is mitigated).
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Once alerted, the team should be familiarized with the details of the case to allow them to adequately prepare for any needs particular to each circumstance (Tables 24-5 and 24-6). Again, adequate preparation should not be undervalued.