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Paediatric Series: Basic Principles Neonatal Life support

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Summary

This on-demand teaching session will discuss the basic principles of neonatal life support with Dr Kath Cook, an ST five in pediatrics. Learn the logical approach to neonatal resuscitation, as well as the importance of delayed cord clamping, and how to effectively use equipment to ensure a successful delivery. Get your questions answered as Dr Cook takes you through the physiology, equipment, and techniques associated with neonatal resuscitation. Don't miss this valuable opportunity to improve your medical knowledge!

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Description

Basic Principles Neonatal Life support - Kataryzna Cooke

Learning objectives

Learning Objectives:

  1. Understand the principles of neonatal resuscitation and the differences between neonatal, adult, and pediatric resuscitation.
  2. Utilize a logical approach to transition and neonatal resuscitation.
  3. Recognize different types of neonatal resuscitation equipment and understand the importance of knowing the specifics of the equipment being used.
  4. Appreciate the potential benefits and risks of delayed cord clamping in term babied.
  5. Become knowledgeable on the correct steps to take for initial baby assessments and neonatal resuscitation.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um because I couldn't do it full screen anyway. Okay, good evening everyone and welcome to our session on the basic principles of neonatal life support. Um It's my absolute pleasure to be joined by Dr Kath Cook, who is an S T five in pediatrics uh and will be leading the session this evening. This is the first out of four of our neonatal presentations this week. Um I will be running the powerpoint slides, but if you have any questions, just stick them in the chat over on the right hand side of the screen and Doctor Cook will be able to see your questions as they pop up. Ok. So over to you. Thank you. I may turn off my camera to distract myself or introduce myself again. Hello, everyone. Thank you for giving up Sunni barbecues and Gin and tonic in a garden to listen to presentation about basic principles of new later life support. My name is Cathy Cook. I'm ST five registering pediatrics currently working in neonate in Burnley Hospital being Northwest trainee myself um um privately in Mount a toddler on keen runner. Uh Very Sore as completed Great Manchester on yesterday. Um I'll do my best to go through the topic, giving as many practical aspects of neonatal of life support as the presentation um allows um please feel free to ask questions throughout. There will be a section um for questions at the end as well. Okay. So, um what is your experience of neonatal resuscitation? Um If any, everyone, um if you can just shout out in a chat, uh whether you've seen neonatal resuscitation on one of your placements, whether you're actively involved in neonatal resuscitation in everyday life, whether you've been to obstetric theater, the labor ward, um Anyone silence, that's fine BLS training. Yeah. Known apart from sim being theater to observe. So that helps me a lot to try and pitch it uh at the right level and involving PCD um unknown, right? We're going to try and even it out and I'm going to try amazing, given inflation breath, I'm going to try and um kind of take you through the process um as the baby is born on what we do and why we do it a little bit of theory at the very start. Um And objectives of he spoke to understand the principles of neonatal resuscitation and differences between um neonatal, an adult or pediatric resuscitation. Um I'll try to teach a logical approach to supporting transition and neonatal resuscitation and birth. This approach tells us that we should first open the airway and a rate the lungs and then in even of anything else being necessary, provide a brief period of chest compressions. We're going to be talking about a case of a term baby only because pre terms are completely different. Uh And um they would provide excellent topic for another uh presentation and webinar next tight, please. So this is quite a busy slide. Well, I suppose I've put it on here to um make you look at the right hand side of it. So, um we know that babies are designed for the as fictional process of normal delivery and as a part of adaptation, baby circulation, as you can see, um there are minutes at the bottom of it. Uh of the of the graph, the circulation is able to continue um and function reasonably well for more than 20 minutes of hypoxia. So um that happens because of the prime acttive if, if in case, um babies is anoxic, the primitive spinal gasping center that is in our brain stem can initiate breathing. Um even much better than um the capabilities of the normal respiratory center. This gasping can manage to inflate the length of the baby. And there's this circulation may still be sufficiently intact in the baby to distribute the oxygen first to the heart and then to the brain. And almost this is what we would call the in credible self resuscitating baby. If the baby is not breathing at birth, we know um from the evidence of physiology that the most important task for us is to arrayed baby's lungs and you're going to hear it from me over and over again through this presentation. Um In many cases, the circulation of the baby will be sufficiently intact and the long inflation alone will be sufficient uh to resuscitate baby without further Axion. Um uh in babies who would progress further along this graph. When the lung inflation will be followed by a brief period of chest compressions. It may be enough to bring the oxygenated blood back to the heart. For the heart to respond and recover. Next slide please. Equipment. Um Depending on where you're gonna work, which trust you're gonna work in what environment you're gonna work. You're going to see many different kinds of equipment and kits. Um There are two main um resuscitate earth in Britain. And one of them is pictured on the right hand side, this is the one with wide background and the one with a medical professional explaining something to the. Uh this is it, there's are equipped in light source um uh heated to aid you uh thermal regulation, um your suction and mixer of oxygen and uh in order to generate pressure to provide um inflation and ventilation breaths. Um My on the land left hand side, we have something we call livestock trolley, which is a trolley that enables us to resuscitate babies with umbilical cords being still intact, whether that's the term or preterm baby. It's also equipped in terms of regulation, this little blue mattress on the side is actually a heated mattress when it's on and has suction and everything. And that versus it does. But in compact form and on wheels, the two photos in the center actually, um the examples of kits that midwives use a delivery at home delivery. And as I said, um the equipment will vary across, um where you work and across all the areas and across all the countries. So it's important for you. Um If you are going to be involved with neonatal resuscitation to know your kid um as you would in any other um part um of medicine. Next slide, please. A word on delayed court clamping. I'm not sure whether you've heard or seen it before, but it's very fashionable. Should I say a thing in word of neon? It's and obstetrics, a phrase inward of neonatal of obstetrics and it is a delay of cold clamping carried out more than a minute, a minute and more um of the birth of the baby. Um The benefits are plenty of them. Um their immediate and long term benefits. Um I mentioned preet um and low birth weight in front as well um on this slide because they wanted to underline how important it is to reduce their comorbidities after birth. And so in terms of immediate benefits, um in our preterm babies, um it would significantly decrease the risk of uh entropic ventricular hemorrhage, late onset sepsis and a necrotizing Antara colitis and also decrease the need for immediate um blood transfusions. Sue factor, administration and prolonged mechanical ventilation. Full term infants would receive adequate blood volume and birth iron stores which then um 2 to 4 months of age on when physi physiological anemia kicks in um improves the HB and hematic right and also improve iron status of the six months of age. Long term benefits for preterm or low birth weight, infant um are also related to physiological anemia. But there is quite uh strong evidence for improvement in neuro developmental outcomes, especially in male male babies. And in the one in the babies born extremely preterm. So less than 28 weeks of gestation and all these benefits come with no effect on maternal bleeding or length of the third stage of labor for people passionate about obstetrics and gynecology. And the trials suggest that less blood field placenta shortens the third stage of labor and also decreases the incidence of retain plus center. I'm not a specialist myself, but that is what the Royal College of Obstetrics and Gynecology Obstetrics and Gynaecology uh quotes in the guidelines. Um You would uh want to probably in aspect of our neonatal care wonder whether there are many contra indications to perform delayed code camping. And amongst these, we can mention that there are very few actually requirement for immediate resuscitation, uh problems with cord. So such as um cold snapping incision on cord or limited cold length. Although that would be uh the cold length doesn't have to be an issue. Um forced up and maternal problems such as placental abruption or early separation of placenta which would massive bleeding moment can definitely affect the baby. Um uterine inversion, um monochorionic twins, and this is because the risk of placental vessel vessel anastomoses may result in draining blood from 21 to 22 during changes in pressure during delayed code camping. And any maternal concerns such as postpartum hemorrhage shock procedures would be also listed amongst um contraindications next slightly. So, um this algorithm is N L S algorithm and you'll see it through your career very frequently. Um Even if you don't choose pediatrics um as a career, which I would wholeheartedly encourage you to do. Um It's simple, it's linear and tells you what to do. So if at any point you're in a first responder. Uh And you've not done nonetheless, um This chart will be visible somewhere to age you before your help arrives. Um Reassuringly, most of the babies will require support only from airway and breathing point of view. Um And um this is um what I would say um should kind of make you feel less scared about neon aids um and resuscitation, next type, please. Um So what do we do when babies born? Um We try and do things in linear and systematic money and your initial assessment will guide the level of support and indicate whether um the delayed called camping should be done as well. Um You dry and cover the baby and put the hat on. You, assess the situation from uh point of view are very well um known to us algorithm A B C D and that doesn't change at all. Um If the baby, if you have facility to keep babies still attached to mom, during your assessment, you can try and stimulate the baby and also ensure that after your initial assessment along as you go baby, um it's warm and um COVID uh after that, um if you are giving, but then after your assessment, you should bear in mind. And as I said, I will repeat that a lot that if you're giving to the baby, there's no point in giving inflation breaths. If you haven't opened the airway, um there's no point in giving chest compression until you um your lungs have been inflated and there's no point in giving drugs until error, the oxygen is available within the lungs. And that means um that you're able to get oxygenated blood to the heart via chest compressions. So as in every resuscitation in known to medics, um there is no breathing before highway circulation before airway and drugs. Before breathing. You do everything in linear manner. Next time, please. Uh This is a funny, I always smile when I see this slide because the initial actions you have to take uh really simple all the babies are small as simple as that and all the babies are born wet and because they have a large surface area, they get cold very quickly. So your first Axion will be too dry and cover the baby and conduct your assessment throughout the warm dry towels are usually available in labor ward, there will be also available and in theaters. Um and actually in most places, unless the baby is born out of hospital, but they're more regulation is your friend. And it's very, very important. Um during this time, you assess and we're going to speak about the assessment in a following slide. Um But you should also remember that most babies need very simple things done very well and um making sure that the temperature is adequate um is very important. Um Next slide, please. So how do you start? Um If you're in the hospital, if you imagine we're labor ward babies being born and we did a quick assessment after Bane was born, midwife was happy with the baby. Um And we did delayed co camping and uh all the way around babies being born. We start the clock, baby cried, we did delayed cord clamping baby midwife brings baby um to resister drives the baby. Um and then we assess the baby or were able to assess the baby with cold remaining intact depending on what where you are and whether um the you're working conditions allow you to do that Um If you're not happy with baby stops breathing, there is slow heart rate at any point of your assessment, you need to ask yourself. Um Do you need help? Um if things are not straightforward. So the worry arises as the baby has been born, um It's really useful to know later how long it took after birth for the baby to respond and that's why we start the clock. Um If we've already said before that, it's really important that baby stays warm and that means we need to dry them, we need to apply the hat and while drying the baby applying your hat, we assess how the baby is. If the baby is clearly unwell, call for help at once. Um and ask yourself all the way through your resuscitation, whether you needed help at any point next time, please. Um Now let's focus on initial assessment of the baby. We assess four things. So just imagine babies being born, whether it's attached to the cord or delayed cord clamping has been done or you see baby on resuscitator, you pay attention to four main things. First one is a color. Um second is tone, um then breathing and heart rate go afterwards. You um most babies will be born with really good town and flex posture. And then these are the babies that if you can see them from the end of the recess it to across the room being born and there should be no problem in waiting a minute till they to allow the placental transfusion and do delayed cord clamping. And the babies that I would be worried instantly about the ones that will be unconscious and there will be just floppy um and limp as they are being born or taking out the um uh C section. Um The next um is color um which is not in any aspect measure of oxygenation because most babies will be born blue, but uh taking first breath will enable them to become rapidly pink. And um these are the babies also, you can see flexed pink blue, turning pink baby. Um I would allow for delayed cord clamping, but baby who would be born very pale as we say, shut down. This might suggest that this baby is in big trouble because uh in hypoxic or occasionally hypovolemic stress breathing. Um it's no one counts breathing no heart rate and delivery room, but we assess whether breathing is obviously adequate. So baby is crying uh um inadequate. So there is a scattered work of breathing with some respiratory distress such as recessions, um uh abdominal breathing or just very irregular breathing or non existent. And if baby's gasping, which is almost like a like a sugar, um this is not an efficient breathing pattern and this will be also the baby I would be very worried about and heart rate. We assess heart rate listening to it with a stethoscope. That's the best way. Um And the most reliable way to do it. Not many labor, labor ward rooms of theaters have um pulse oximeter handy and it takes the time to get the trace of your ears are the most reliable um, kit you have and stethoscope. And I wouldn't bother to calm the heart rate. It will be the very fast or slow. So less than 100 or very slow, less than 60 or absent. So, um it's just trying to assess how fast is it having a quick listen to it. Um So we have color tone breathing and heart rate. So if we have baby who is turning pink with flex tone screaming, uh we can presume the heart rate is good and dull ache or cramping. Uh If we have baby who is blue or pale, um limp, um There's no obvious signs of breathing or there's very irregular breathing and has a slow heart rate. That will be a baby that we would be worried about. And we would like to have the motor city as soon as possible. Next slide, please. So now we go to a part A and B part of our assessment because they are usually dealt together within a baby a needing resuscitation birth, which is uh I suppose ever so slightly different from adult resuscitation. Um The first objective is to get babies head in neutral position and um most of babies will have very large oxy, but which make which will make the head flex and impair the airway. Um If we can play video, I need to make sure the baby's not hyperflex. That could be because of a large occiput. So I might consider putting a rolled up towel under the baby's shoulders to get the neutral position and make sure that I haven't overextended the head because that would include the airway. So a nice neutral position. Yeah. So neutral position um with um surface of the face parallel to surface of the resuscitator or table that baby is on the next side, please. Excellent. Yeah. And again, you can see on the photo on your left and the chin has been lifted off the chest and face is approximately parallel to the surface on which baby is lying. And the little um picture on the right hand side shows you the position. And also um the situation was head with big occiput with which chin almost touching the chest when it's to flex or two extended. And that would be the in floppy baby. The tongue would obscure the airway in that case, next slide, please. Um After we opened the air, we're holding the head in neutral position, uh we would um come to jaw thrust in floppy baby. Not all the babies need Joe thrust, but the floppy and poorly babies will need it. Yeah. Does it play? I'm going to put my thumbs on the baby's cheek bones, use my fingers to bring the baby's jaw forward and then I'm going to roll the mask up and over the top, holding the mask in place with that draw thrust, try and bring the tongue forward and open the airway. So we are talking about situation when you're the only responder and you don't have hands to help. But as the lady did in the video, you would lift the angles of your jaw, pressing your thumbs on the cheekbones and try and lift the job um to enable baby's face being in neutral position and to make sure that we can apply the mask and give inflation breaths. Um So if we imagine um where in labor ward, baby's born is floppy, not breathing and probably has a poor rate of poor heart rate and um they have no breathe yet at all. Uh Therefore, the lungs will be full of fluid. And uh in order for us to um airy eight, these lungs, we need to use positive pressure ventilations and these breaths that we're going to administer will be prolonged um red, well, relatively prolonged um uh inspiration. It's kind of the good way to describe it is like you blow the balloon for the first time um and brief and quick ventilation breath. One work at that stage and you want a baby to expand their lungs. It has to be steady, sustained ventilation as it is on the video and give five more long's like sustained inflation breaths to inflation breaths limits three inflation, breath minutes for inflation breath release, five inflation breaths release and then I'm going to reassess. Yeah. So you could see in the video that the baby's chest was moving and that will be one of the things that we're going to look out for next slide, please. Um Short slide about inflation breaths. As I mentioned before, we need long inflation inspiration time for the for these first few breaths that are essential to ensure that other quit inflation oration of the lungs is uh successful. Your success depends on the replacement of the fluid um with uh in babies lungs that have never breathed before. And it's important as you saw the video, the lady is counting um to ensure that inflation breaths are 2 to 3 seconds long because when you count, it's easier to stick to the routine. Are supposed to give two short of breath when the adrenaline is kicking in everyone because it's a resuscitation scenario. Next slide, please. So um you've given inflation breath um and after every Axion throughout the resuscitation, you um reassess. And does anyone have any idea what would we be looking for? Um What's the first thing we'll hope to find um after giving installation breath, anyone there is a little hint in the in the icon. So um if you click James, the answer will revere that too. Yes. Chest movement. Very good. Yes, improved, improved heart rate. That's what we're looking out for, um, with, if I get you back to the baby that has just been born, this is a baby who is flopping or breathing, um, has a low heart rate because we presume that they will be poorly given their floppy and not breathing. And we are maintaining neutral position of the head with a jaw thrust and we've given the five inflation breaths and we are reassessing. So increased heart rate would be first thing I would expect if I've administered sufficient inflation breaths next tight, please. So we reassessed the heart is increased and it's now more than 100. So it's fast, but the baby's not still not breathing. The next step would be um to give ventilation breaths until the breathing of the baby is established and we would ventilate um about 30 breaths per minute until the baby takes over. It's almost like counting 1212 and reassessing after 30 seconds. Next step, please. So no, um what a question for you as well. Um When there is, you've, you've done your inflation breaths. Um and there's been no increase in heart rate. What do you think is going on? Any ideas? Yes, excellent. And there is one more answer to it if you click James, um it will reveal growth good. So you have not inflated the lungs. So we need to revisit. Well, yeah, all the help. We are far. If you remember this complicated graph from the third or second slide, the heart, we are far down along the line and the heart will need the help. We need, need our help, the respond if you click one small James. So how can you tell? Does anyone have any idea? How can you tell which one of these options are? True? True. What would suggest that we're not inflated the lungs? Because that, that is the main answer we need to give us ourselves. Um Yes. If you, if you have a pulse ox a meter handy and pair of hands to apply it on the right hand's chest movement. Yeah, absolutely. Um If you click again, yeah, these are really good answers. Always look for the chest wall movement. So just to sum up what we've said, um successful inflation breaths would make your heart pick up 100%. But if there is no change, we have two situations, we need to revisit our away techniques. So ask for help at that point, make sure that we keep baby's head in neutral position, make sure that the mask is applied correctly. And also if we think that we've elicited good chest wall movements, if we're absolutely sure that all these things are fine uh call for help because you may have to progress further down at the MLS algorithm next slightly. So once we know that the chest is moving, we would reassess and then we would do another third, we would after our inflation breaths being successful with good heart pick up. We would do 30 seconds of ventilation breaths and confirm ongoing chest movement. And then because we've done an Axion after another 30 seconds, we would reassess and if the heart rate still remains very slow, despite 30 seconds of good ventilation breaths, uh we would um comments, chest compression. So it's very important to be clear that the ventilation is effective and the chest is moving because that is our only guidance uh to tell us whether we're doing a good job with airway and breathing and whether we should be thinking of escalating our resuscitation further because if all the things we talked about are true and performed in perfect manner and there is still no response. Uh That means that the heart needs help to respond under baby is in serious trouble. Next slide, please. So, um the logic and behind chest compressions is that you want to move oxygenated blood from lungs to the coronary arteries. It's not very far. Um And it won't take long usually. Um it takes um around half a minute with efficient chest compressions to get the oxygen down too hard. And most babies will actually respond um in that time. And this is the point when for a term baby, we change, we start, I should have said that at the start, we start our resuscitation and airway maneuvers. Um in, in a row where in term for term baby on me, we're talking only about the term baby. When we make decision to commence chest compressions, we um increase our oxygen 200% on the resuscitate. Uh Just to contrast it with adult resuscitation guidelines who, which mentioned and put quite a lot of emphasis on chest compressions. Um that shows the difference between urinating an adult thinking because in an adult cardiac arrest, um uh the lungs will already contain the air and um adult in cardiac arrest is not usually grossly acidotic at the time of collapse, which is the case in our babies due to hipaa secondary to hypoxia. So our baby at birth, we'll have lungs full of fluid and be grossly acidotic and they are in serious difficulty at that time time and messaging more on exaggerated blood around the place will do nothing. So that is why again, I repeat that, that you need to make sure that your lungs are inflated and ari ated first to be able to distribute the oxygenated blood from the lungs to the coronary arteries. Next slide, please. Um So this is another video but a little commentary to it as well. Um are supposed to adult resuscitation. We're not really trying to perfuse the brain. Um You are trying to return oxygenated blood back to healthy heart in order to um facilitate that the inspired oxygen should be increased 200% if the chest compression are given. And that's the logic behind that. And as I said before, most of the babies who actually need chest compressions will respond with increase in heart rate within less than a half a minute. And the commentary in the video will tell you how we do it. So I'm going to do three compressions to one ventilation breath, which is just a short breath. I'm going to use the encircling techniques. So wrapping my hands around the baby fingers, touching at the back, thumbs are centimeter below the nipple. I'm on the stern, I'm avoiding those iffy sternum compressing a third of the depth of the chest allowing it to recall in between each one fully. And I'm going to do 15 rounds about 30 seconds of chest compression. So if you can give a breath to start, please, 123, 2 to 3323423. And you continue that providing three compressions to one ventilation at about 15 cycles every 30 seconds, reassessing every 30 seconds. Um The preferred technique is used as, as the lady did in the video 200 technique, a circling technique. Um but two finger technique is also available and that will be on the next slide. So if you see two finger technique is on your left hand side and your landmarks is one centimeter between the uh line between two nipples, not pressing on xiphisternum. So you want to press on on sternum one centimeter between the line um connecting the nipples. And um that will be the same for the sick and cycling technique which the lady did in a video and um you re evaluate the response every 30 seconds. If the heart still remains very slow or absent, we continue um the chest compressions, but we make sure that the airway is secured. So we didn't have to worry whether our ventilation is um um efficient um if we have output. So if baby baby's heart rate improves, we would then titrate our 100% oxygen. Um depending on pre ductal oxygen saturation that well. In this situation, you would very much have help around. So someone can apply um the pulse oximeter or your right hand side or your right hand wrist. Next slide please. Consideration of drugs if um are supposed to uh probably adult resuscitation, but then I'm not an expert at all. Uh adult resuscitation if drugs are necessary um in neonate, the prognosis is really poor. Um There is no specific evidence supporting any particular order drugs. Um We use adrenaline, we use dextrose, we use um sodium bicarbonate and very rarely um we use volume. Um and that would be usually o negative blood. Um adrenaline is given to increase spiritual wasn't constriction and um increased systemic vascular resistance and increase um the coronary perfusion, coronary blood flow to get um the oxygen ridge blood. Um two coronary arteries, glucose prevents hypoglycemia. Um bicarbonate reverses intracardiac acidosis. And because if the circulation is a standstill peripheral access is pointless um we administer drugs through umbilical venous catheter um that you can see being inserted on in the photo volume as blood is given quite often. For some reason. I think that people just if you get to the drug giving point, you try and do everything and try to reverse all the uh reversible causes for cardiac arrest. Um then, but it's very rarely needed. It will be needed in massive bleeding, mother, placental abruption. Um uh definitely that would be my first to, to think of to give volume, but adrenaline glucose and bicarbonate. Um we would use however, baby would be in serious trouble at that point. Um Next slide, please. Um So our pale floppy, unresponsive not breathing with low heart rate, baby has been successfully resuscitated. We didn't have to give drugs and baby is recovering and I just wanted to touch quickly on what's next after we have resuscitated the baby. Um We would still continue to reassess on regular basis, preferably 30 every 30 seconds would make sure that baby baby's temperature control is good throughout the resuscitation as well. If possible, we would prevent hypoglycemia. So we would check sugar and make sure that we don't need to treat hypoglycemia because regardless whether it's a preterm baby or a baby with low birth weight or term baby. Um The the episode of resuscitation has definitely used and the stress of it has used up all the reserves. So we would like to make sure that we maintain normal blood sugar without uh we're giving some intravenous dextrose. We would um inform parents on what happened and be prepared for questions. Um We would document everything and documentation should be very thorough and um contain times of events. That's why it's also how helpful to have a timer um started at the very um birth of baby. And um most trust you would be working at would have uh resuscitation performer. And usually there is someone scribing if there are enough people at the event and also make sure whether your senior or not to make sure that you're taking care of the team you're working with. So it's a good practice to after any resuscitation um to have a cup of tea with the team or just quick chat to have an opportunity to discuss through what happened. What went well, what could have gone better on reflect upon the events next slide, please. If baby didn't respond to our resuscitation, um we would have careful consideration um of um uh effectiveness of ongoing resuscitation and treat all the reversible factors and overall clinical picture. Um It's not a good prognostic factor. There is no heart rate at birth and still lapse in that 10 minutes of baby's life. Um, they are either likely very likely to either die or have severe neurological disability. Um, babies who have not started normal, regular breathing by 25 minutes of age have very poor prognosis and stopping recess station um is always considered and um within a team and is always made by an experience in most senior um member of the team after exclusion of all the possible reversible problems. Next, like please um we're going to go through some cases just to wake you up at the end of my presentation. Um Three cases. Let's just go quickly to summarize what it's happening. What is happening? We're having a baby that is blue, turning pink with good tone breathing regularly. Um Fast heart rate. Would we delay court cramping any, any takers? Yes, we would. Um And um, if you click James, um what would be the next Axion if you were the doctor in the room knowing that babies turning pink has a good tone is breathing regularily you can see them from the end of the room crying. Yes. Yes. And if you click James give to parents go with whole halted. Um, congratulations. Um Let's go through a second case. Absolutely. Give baby too. Mom, babies blue has moderate tone is breathing but irregularly and yeah, absolutely dry. Baby. Keep on skin to skin and has slow heart rate. Would we allow cord clamping? So his mother a tone is blue but it's breathing irregularly. Um, or nowhere. Assessment by the bedside or midwife tells you baby has slow heart rate. So 60 per minute. So that depends on where you working. Um If the baby is, I would allow the late code clamping, but only on the condition that I can stimulate baby throughout. Um So I would ask midwife to stimulate the baby. And um what I find reassuring is baby is breathing irregularly. So as long as it's not gasping, um I would say that I would allow the late cord clamping or make sure if I can assess baby at the very start, start assessing baby, make sure that the head, the head is in neutral position. And and then my next steps would be asked to bring baby to rhesus it air. Yeah, exactly. Dry and cover open the airway. So put um baby's head in neutral position, see what's happening to slow, too slow heart rate because sometimes just neutral position allows baby to pick up the heart rate because that's our first airway manoeuvre. And then if there's no difference about that on my reassessment after putting baby into neutral, uh baby's head a neutral position, consider inflation breath. Is that clear? I know it's, it's always the one that it's like people are. No. Yes, I think that the presence of breathing even though it's irregularly and the fact that really between getting the cot clamped getting mid to that's from practical point of view, getting midwife to bring the baby over um not insisting on skin to skin, that's just of the record. And practically speaking, a baby is almost a minute of age by the time they are on the resuscitate because that's a bit blue baby is not unexpected to be born. They have moderate tone. So they may be just a little bit shocked, their breathing irregularly and the heart rate is there sometimes midwife um would tell you that the heart rate is improving after stimulation. So we would still dry and cover open the airway and see what happens if there is no change. Um After putting a baby's head into neutral position, um you comments, inflation breaths as you would. And I would, whether your senior or not, I would ask for a pair of extra hands at that point. Always ask yourself whether you need help next site, please. Um Baby's born blue or pale is floppy and no breathing has slow or very slow heart rate. So less than 60 would you um clamp the code in this baby? I mean, would you immediately contact coating that baby? Yes. Yes, absolutely. Yes. And um you can leave the cord on if you have the lifestyle trolley at the very uh if you remember the equipment slide, the lifestyle trolley is exactly for this scenario when you can just put baby on it and manage your airway with babies still attached. That is an option, but it's only, well, you won't see it in any of the D G H hospitals. It would be a tertiary unit. Um Truth to be told if you're called. Um If you're a crash called to labor ward um for baby whose pale and floppy, not breathing, they would have clamped accord and commenced resuscitation at the very start. Um But with a way maneuvers. So what you would try and cover this baby, you would start the clock on your arrival or um um you would call for help, open the airway, neutral position, inflation, breaths and reassess because the heart rate might have picked up. And we are, uh, we would be in a scenario of the baby we've discussed through the presentation, right? Um That's me done. Um Any questions from anyone, I'll just show you my face for the questions. Okay. We'll just give them a, a minute or so. Just a flight delay on this thing. Thank you very much. That was really informative. Thank you. I'm just gonna send a feedback form to everyone that's in the chat or anyone that is watching later on catch up. Is there any indication for any suction if airway manoeuvre and done and ventilation successful? Yes, look. So because it's a basic principle of neonatal resuscitation. I didn't think it was very relevant for that subject to touch on. Um, suctioning usually, uh suctioning is not a standard um a part of airway manoeuvre, but there are certain, um there are certain circumstances that you would do that. And one of them is as you've written, um, if your airway maneuvers are done, your two person technique when you have a helper is done and there is no chest wall movement and no response in heart rate throughout if you're competent to do. So, you would have a look and try and suction or just suction under direct vision in case there is, um, any, um, you know, debris vernix, anything in baby's mouth that is preventing that. The other thing is when baby is born through mechanism, uh, which is again, if baby is born through thick meconium and um, we are still, uh, and it's crying, we wouldn't suction routinely. If it is having regular breathing, we wouldn't suction routinely. But if baby is born pale floppy, unresponsive, you would still do your airway maneuvers. But if there is no, um, if there is, there would be no recommendation to do routine suction of meconium. But you would always bear that in mind that if you cannot get your airway maneuvers, right? And there's no response in heart rate and your competent to use laryngoscope because that's the apart from just younger suction in the mouth, that would be what you're looking for. Whether there is any big meconium plug, uh obscuring the airway, then yes, you are very much allowed to do that, but you would definitely call for help in that situation regardless of how senior you are. Any other questions. Was that? All right? Yeah, cool. So I'm very pleased to hear that. So if James you skip two summary slide, um, we're, we're waiting for questions. So just like as a summary um of all that we've talked about cause it's quite a lot to process and we always start the timer dry and cover baby. We assess the situation. Our four things done color, um breathing and heart rate, which determines whether we allow for umbilical cord management or delayed cold camping. We then manage the airway, we uh manage airway and breathing. At the same time, we um do initial inflation, breaths and then ventilation breaths. If we get chest rise and response in heart rate, uh then chest compressions that is after 30 seconds of um adequate ventilation, breath and no response in heart rate. And then we would consider drugs. But we remember that at that point, we are all in serious trouble and we need help on board senior help on board. The algorithm like any other resuscitation are algorithm in medicine is simple linear and most of the babies you're gonna see will need on the A and B but done well and simply and um making sure that you're not skipping any of this. So it's, there's no point in giving chest compressions. If you're not aerated the lungs, there's no point in giving drugs. If there is, if the lungs are still full of fluid. Uh and um the algorithm tells you not only what to do but also how you should do it. And it's always available in labor ward always. And it's not the thing to have a look at that during uh stressful event of resuscitation. Thank you very much because I know other questions. Okay. Doesn't look like there are any further questions coming in. Uh But like I said, thank you very much for giving up your time this evening. No, no problem. My main resources for less guidelines, obscene Gynie Royal College, delayed cold camping guideline. And I hope I didn't put you to sleep and you will have your short barbecue is still bright. Thanks so much, everyone. Thank you. And please remember to fill out feedback for doctor cook session. We do read it and it's really useful for all of our presenters um uh working on these to get a review, what's kind of gone really well. But also if there's anything we can improve on, um and I've also just popped in the chat, a registration link for tomorrow's session, which is all about understanding the Nike. Uh He's going to do 90. Uh Well, the brave person just gonna be excellent. Thanks so much. Thank you, James. Thanks for your help. Thank you.