EM ReSCu Peds 9: Neonatal Delivery

Brief Narrative Description of Case

You are working a shift in your Emergency Department (ED) when you hear an overhead announcement that a woman who delivered a baby moments ago in the ambulance bay is being wheeled into the resuscitation bay. She is in notable distress, screaming in pain and yells “It happened so fast! Is the baby ok?! Oh, I’m in so much pain!” The nurses turn to you for direction.

The anticipated interventions of the Emergency Medicine (EM) resident are designed to include the ACGME milestones listed by the EM Milestone Project, listed below in bold:

  1. Team Management (ICS2): Call for stat obstetric (OB) and pediatric (Peds) help and newborn warmer bed (OB will arrive promptly leaving the EM resident to care only for the neonate until Peds arrives once the case learning objectives are met); utilization of TeamSTEPPS (see Debrief section) or other techniques for effective teamwork and communication used by your specific institution.
  2. Performance of Focused History and Physical (PC2): Assess the neonate patient per the Neonatal Resuscitation Program (NRP) protocol (see Supporting File).
  3. Emergency Stabilization (PC1) and Medical Knowledge (MK): Escalate care per NRP protocol to address the following medical and procedural learning objectives:
    • Airway Management (PC10): Respiratory distress, bradycardia, and hypoxemia requiring positive pressure ventilation (PPV) and/or continuous positive airway pressure (CPAP)
    • Pharmacotherapy (PC5), General Approach to Procedures (PC9), and Other Diagnostic and Therapeutic Procedures (PC14): Hypoglycemia that requires emergent umbilical venous catheter (UVC) placement (see Supporting File) and administration of D10 bolus; hypothermia requiring warming bed, blankets, hat
  4. Patient-Centered Communication (ICS1): Effectively and sensitively communicate with the new mom that her infant is critically ill and will be transferred to the NICU for ongoing evaluation and management

Overall topics in this scenario include: Neonatal resuscitation (NRP) (AR11), diagnosis and management of neonatal hypoglycemia (EN03), effective communication with parents (ICHP01), delivering bad news (ICHP08), recognize a sick child (SS01), basic airway maneuvers, including appropriate positioning based on pediatric anatomy (AR01), bag valve mask ventilation (AR05), and installation of umbilical artery or vein catheter (CP3_05).

Primary Learning Objectives

At the end of this simulation, participants should be able to:

  1. Demonstrate post-delivery resuscitation of a neonate following NRP guidelines (application)
  2. Demonstrate early evaluation of a critically ill patient (application)
  3. Demonstrate umbilical line placement (application)
  4. Demonstrate focused history taking from a caregiver (application)
  5. Explain diagnosis and management to caregivers (synthesis)
  6. Demonstrate teamwork and closed loop communication (application)
  7. Organize transfer to a higher level of care where needed resources are available (analysis)

Critical Actions

General:

  • Elicit a team to help with tasks, specifically: team lead, monitors and survey, airway, access, labs/medication administration, runner for help
  • Acknowledge a high-risk newborn delivery in the ED and call for stat OB and pediatrics help
  • Obtain ED newborn kit (specific to your ED), newborn warmer bed, and follow NRP algorithm
  • Identify the neonate in respiratory distress with hypoglycemia and hypothermia
  • Effectively communicate with neonatology consultants
  • Deliver the news to the parent that the neonate requires critical care support and will be taken to the Neonatal Intensive Care Unit for ongoing management

Specific roles:

  • Role: Team lead
    • Assign team roles (monitors and survey, airway, access, labs/medication administration, runner for help)
    • Elicit helper to bring newborn warmer bed, if not already located in ED
    • Acknowledge and follow NRP algorithm
    • Report initial impression of the neonate according to the first questions of NRP: Term? Tone? Breathing or crying?
    • Instruct airway role to perform maneuvers (i.e., reposition airway, suction, start PPV by 60 seconds of life)
    • Instruct monitors/survey role to apply leads and communicate exam
    • Get more history from the Mom and learn she had limited prenatal care and does not know her due date
    • Given this history, in the setting of a limp neonate, continue NRP and request fingerstick blood sugar level (BSL), acknowledge hypoglycemia (BSL <40 mg/dL), request access with emergent UVC and administration of dextrose bolus (D10W 2 mL/kg)
    • Recognize hypothermia (T <36.5oC) and request warmer, warm blankets, hat
    • Treat hypoglycemia and presumed sepsis with dextrose and antibiotics
    • Effectively give the pediatric consultant (NICU or pediatrics) a recap of patient presentation and discussion of current concerns
    • Sensitively communicate with mom that her neonate is critically ill and will be transferred to the Neonatal Intensive Care Unit (NICU) for ongoing management
  • Role: Monitors and survey
    • Place baby on newborn bed under a radiant warmer
    • Start APGAR timer
    • Record neonate’s weight from bed scale (if available) or estimate based on estimated gestational age or use length-based tools available in your institution
    • Place pulse oximeter on neonate’s right wrist (pre-ductal)
    • Apply cardiac monitors
    • Place temperature probe
    • Report loudly to group their initial impression of the neonate according to the first questions of NRP: Term? Tone? Breathing or crying?
  • Role: Airway
    • Acknowledge respiratory distress and impending
      cardiorespiratory failure
    • Comment on patient’s respiratory effort (i.e., apnea,
      gasping, etc.) and bradycardia
    • Demonstrate appropriate maneuvers according to NRP
      algorithm, start PPV by 60 seconds of life
  • Role: Access
    • Place emergency UVC
  • Role: Labs/Medication administration
    • Obtain heel stick blood sugar level (BSL), and note the patient is hypoglycemic
    • Administer D10W bolus
    • Administer antibiotics (ampicillin, gentamicin)
    • Order labs/imaging when requested, including venous point-of-care (POC) labs, cord gas, blood and urine cultures, CBC, CRP, BMP, chest/abdominal x-ray
    • If requested, naloxone, epinephrine, anti-epileptics, or other medications are “pending or being drawn up”
  • Role: Runner for help
    • Call stat OB, Peds and/or NICU help
    • Get newborn warmer bed, ED delivery kit, and UVC tray
    • Obtain ample warm blankets, hat, supplies PRN
    • Call pharmacology and radiology when requested

Case Creators

Authors

  • Khoon-Yen Tay, MD
  • Elizabeth Sanseau, MD, MS
  • Leah Carr, MD

Editors

  • Ilana Bank, MDCM, FRCPC, FAAP
  • Rebekah Burns, MD
  • Fabiana Ortiz-Figueroa, MD
  • David Rayburn, MD, MPH

Updated September 17, 2020

Setup

Chief complaint: Neonatal delivery
Patient age: Neonate of unknown gestational age
Weight: 2.5 kg

Recommended Supplies

  • Manikin/Simulated actor:
    • Neonate manikin that can be ventilated
    • Simulated patient actor to play laboring mother
  • Moulage: None
  • Resources: NRP algorithm, Broselow tape or other weight-based equipment-sizing and medication dosing reference
  • Manikin set up: Cyanotic, bradycardic, and limp infant with minimal respiratory effort delivers in ED
  • Equipment:
    • Newborn warmer bed with scale and timer (if not available, bring accessory timer and scale next to bed)
    • Warm blankets
    • Newborn hat
    • Diaper
    • Monitors: Pulse oximetry, cardiac, temperature
    • Rectal thermometer
    • Heel stick sampling kit, including alcohol wipe, lancet, portable BSL reader
    • ED delivery kit: sterile gloves, sterile towels and drapes, surgical scissors, hemostats, syringes (10 ml), needles (25 G), gauze sponge (4 x 4), rubber suction bulb, neonatal airways, cord clamps, towels (infant), placenta basin.
    • ED UVC Tray and UVC lines: Sterile drapes and gauze, scalpel (No. 11-blade), 3-0 silk suture on a curved needle, small clamps, forceps, scissors, and needle holder, curved iris forceps without teeth, umbilical tie, infusion solution (usually NS or D10W), 3-way stopcock, tegaderm and tape. UVC sizing: 5.0 Fr for term babies
    • T-piece resuscitator (e.g. Neopuff® group) or flow-inflating bag with neonatal mask
    • Suction: Bulb and wall suction (set at 80-100 mmHg)
    • Oxygen source
  • Medications:
    • Dextrose 10% (0.1 g/mL). Dose: 2 mL/kg of D10W bolus, continuous infusion of 60 mL/kg/24hrs
    • Ampicillin dose: 100 mg/kg/dose, gentamicin dose: 4 mg/ kg/dose
    • All other meds “being drawn up”:
      • Naloxone: If drawn up and given, will have no effect on clinical status
      • Epinephrine: If drawn up and given, HR and BP will increase but no change in oxygen saturation

Supporting Files

  • Neonatal Resuscitation Program (NRP) algorithm
  • Point-of-care labs
  • X-ray after UVC placement

Participants/Roles

  • Participations/learners:
    • Team leader
    • Airway manager
    • Survey physician
    • Medication preparer
    • Medication giver
    • Family liaison/history taker
  • Other:
    • Faculty or other embedded participants can play a nurse, respiratory therapist, or tech, if there are not enough learners to perform the above roles
    • Standardized patient (actor or faculty) to play patient’s parent

* Team roles may need to be adjusted in order to suit local practices and norms

Prerequisite Knowledge

  • Faculty
    • NRP protocols
    • General knowledge of emergency medicine
    • Simulation implementation and debriefing experience
  • Emergency medicine residents
    • Any stage of training
    • Completed a required obstetric and pediatric rotation in medical school
    • UVC insertion (for procedural list)
    • Neonatal intubation

Case Alternatives

  • If the participants do not follow NRP initially, the patient becomes progressively more hypoxemic and bradycardic, such that the neonate decompensates into cardiorespiratory failure requiring resuscitation.

Virtual Resus Room

This simulation case can be run virtually using Google Slides and Zoom from the Virtual Resus Room (NRP) page.

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC4. Differential Diagnoses and Management
PC5. Pharmacotherapy
PC7. Disposition
PC9. General Approach to Procedures
PC10. Airway Management
PC14. Other Diagnostic and Therapeutic Procedures
MK. Medical Knowledge
ICS1. Patient Centered Communication
ICS2. Team Management

Resources

  1. Weiner GM., et al. Textbook of neonatal resuscitation (NRP). 2019.
  2. Wing R. Emergent umbilical venous catheter (UVC) placement. Brown Emergency Medicine. 2015.
ITEMFINDING
Overall AppearanceYou arrive in time to see mother wheeled in with newborn on stretcher with cord attached. You see clear fluid without meconium. The newborn is not breathing or crying and is limp and blue.

Embedded participant: The nurse wheels the laboring mother into ED trauma bay. This embedded participant tends to the mother who is fine and will wait until OB comes to ED. The embedded participant nurse cuts the cord, wraps the newborn in a towel and passes the baby to the ED resident participant. The mother does not appear to be febrile and does not have evidence of hemorrhage. The residents do not provide medical care to the mother.

HPIThe simulated patient actor plays laboring mother is wheeled into ED trauma bay and screams in pain, yelling “It happened so fast! Is the baby ok? Oh, I’m in so much pain!”

If the learners ask about prenatal care, the actor says she had some prenatal care early in the pregnancy but lost her job and insurance. So, she has not been to the OB since early in her 2nd trimester. She believes the baby is at least a month to her due date but can’t remember. Denies taking any medication, substance use, and is unable to offer any more information due to distress of her labor.

Mother’s Past Medical/Surgical HistoryPrecipitous delivery, unknown gestational age, but mother thinks ~35 weeks. No prenatal care since 2nd trimester.
Mother’s MedicationsUnknown
Mother’s AllergiesUnknown
Family HistoryNo known family history of birth defects
Mother’s Social HistorySingle mother, unemployed, uninsured. Denies substance use.

Initial Assessment of Neonate

Start of case through start of Positive Pressure Ventilation (PPV)

Critical Actions

  • Call for OB/Peds/NICU help
  • Elicit help to gather supplies (see above recommended supplies)
  • Elicit a team to help with tasks, specifically: Team lead, monitors and survey, airway, access, labs/medication administration, runner for help
  • Acknowledge and start following NRP algorithm
  • By 60 seconds of life, start PPV

Physical Exam

ITEMFINDING
Vital SignsT: cold to touch, HR: 70, BP: unable to obtain, RR: gasping and irregular, SpO2: unknown
GeneralBlue, floppy neonate, gasping, and not crying
HEENTEyes closed
NeckFloppy
LungsCourse bilaterally, minimal respiratory effort
CardiovascularBradycardic; full body cyanosis with capillary refill delayed to 4 seconds; no murmurs, rubs, or gallops
AbdomenUmbilical cord intact, once clamped and cut noted to have 3 vessels (2 arteries, 1 vein). No omphalocele or gastroschisis.
NeurologicalLimp
SkinWet, mottled, and cool to touch
MusculoskeletalNo obvious skeletal abnormalities

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Team takes newborn from nurse, finds and turns on warmer bed, brings neonate to warmer bed, dries with blankets.Neonate remains blue, limp, with limited breathing and HR <100 despite simply drying with a towel.
Start APGAR timer.Facilitator or participant starts timer.
Participants divide into roles.If no roles delineated in group, nurse demands to know who is in charge.
Team lead delegates nurse to call stat OB, Peds, NICU consultants.Help is notified and is “en route.”
Orient to NRP algorithm and verbalize answers to the first questions:

  • Term?
  • Tone?
  • Breathing or crying?
If unable to find the NRP algorithm, the facilitator can decide if they would like to provide the algorithm. Answers to NRP questions given by facilitator when asked:

  • Term? No – late preterm ~35wks
  • Tone? Floppy
  • Breathing or crying? Minimal/none
Patient weighed in warmer bed/scale; Monitors applied to patient (pre-ductal pulse oximetry probe to right hand, cardiac monitors, temperature monitor, rectal temperature).
  • Pre-ductal SpO2: 40%
  • HR: <100
  • Rectal temp: 35oC/95oF
  • Wt: 2.5 kg
  • Limited respiratory effort
Warm, dry, stimulate babyNo change in vital signs or exam
Start PPV at 40-60 bpmWithin first 15 seconds of PPV: chest is moving symmetrically with course and symmetric breath sounds auscultated bilaterally.

Neonatal Resuscitation

Start of PPV through 120 seconds of PPV

Critical Actions

  • Continue down NRP algorithm
  • Continue PPV, and perform MR SOPA airway maneuvers
  • Note hypothermia, and provide warming maneuvers
  • Reassess respiratory effort after HR and SpO2 improve with PPV
  • Recognize the need for some ventilatory support, though no longer needs PPV
  • Initiate CPAP and request neonatal CPAP set up

Physical Exam

ITEMFINDING
Vital SignsT: 35oC, HR: 90, BP: not yet obtained, RR: gasping and irregular when not supported with PPV, SpO2: 55% on RA, 65% on 100% FiO2
Exam ChangesNeonate still has limited respiratory effort without PPV support; weak cry

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Reassess vital signs at 1 minute of life
  • Pre-ductal SpO2: 50%
  • HR: 90
  • Rectal temp: 35oC/95oF
  • Wt: 2.5 kg
  • Limited respiratory effort
PPV continuedHR to 130 gradually
FiO2 increased to 100%SpO2 increases to gradually >95%
Note hypothermia and request warming measures (blankets, turn up warmer, chemical blanket if available); Repeat rectal temp following interventionsWith warming maneuvers, temperature rises to 37oC.
After an additional 60 seconds of PPV with 100% FiO2SpO2 98%, HR 130
Stop PPV to reassess work of breathingGrunting and retractions without PPV
Provide CPAP for patient manually, ask RT for neonatal CPAP setup if available at siteWork of breathing improves if CPAP started with PEEP of 5, good breath sounds bilaterally, vital signs remain stable at SpO2 98%, HR 130s

Without CPAP, grunting retractions and RR starts to increase.

Muscle tone improves, making PPV difficult to coordinate with patient’s spontaneous breaths

After 120 sec of PPVProceed to Stage 3.

Recognition and Treatment of Life Threatening Issues

>2 minutes of life AND 120 sec of PPV through correction of hypoglycemia

Critical Actions

  • Continue CPAP, wean FiO2
  • Place emergency UVC after 2 failed PIV attempts
  • Obtain ancillary studies: POC labs, x-ray
  • Note the patient is hypoglycemic at 30 mg/dL (<40 mg/dL)
    • Administer D10W bolus at 2 mL/kg through UVC.
    • The estimated vs baby warmer scale weight is 2.5 kg, so give 5 mL bolus.
    • Following bolus, give D10W at 60 mL/kg/24hrs = ~6.25 mL/hr.
  • Consider broad differential for respiratory failure in newborn, including sepsis, respiratory distress syndrome, upper airway anatomic abnormalities (e.g., choanal atresia), intrathoracic lesions (e.g., congenital diaphragmatic hernia, congenital pulmonary airway malformation), congenital heart disease, intrauterine stroke
  • Order antibiotics: Ampicillin 100 mg/kg/dose and gentamicin 4 mg/kg/ dose
  • Call NICU for consultation and discuss the case
  • Discusses with team and pharmacy medical doses for neonatal code

Physical Exam

ITEMFINDING
Vital SignsT: 37oC, HR: 130, MAP: 35-40 mmHg, RR: 40-60 (bagged), grunting, SpO2: 98% on 100% FiO2
Exam Changes
  • Heart rate 130 bpm
  • Oxygen saturation 98%
  • Improving respiratory effort but still requires some support
  • Equally coarse bilateral breath sounds
  • Muscle tone improving

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
CPAP continued, weaning FiO2 to maintain SpO2 goals within NRP rangesMAP 35-40

  • SpO2 remains >95% if wean FiO2 from 100% to 50%.
  • SpO2 falls to 90-95% if FiO2 weaned to 30%.
  • SpO2 falls below 90% if weaned to RA
Avoiding HYPERoxia is an important learning point, especially with premature infants. In general, the team should wean FiO2 once HR stable.
Ask for a heel stick sampling kit, including alcohol wipe, lancet, portable glucometerBSL 30 mg/dL
Ask for peripheral IV accessParticipant or RN attempts and fails peripheral IV attempts x 2
Ask for an IO kitUnable to find IO kit
Ask for UVC suppliesUVC kit brought to bedside
Participant places low-lying UVCAccess is successful
Order x-rayX-ray returnsConfirm UVC is not in the liver, notable for bilateral patchy opacities and significant gastric distension
Order and give dextrose bolus (D10W @ 2 mL/kg = 5 mL) followed by D10 infusion at 60 mL/kg/24hrs =~6.25 mL/hr based on 2.5 kg weight.

Repeat heel stick BSL after D10W bolus administered.

Repeat BSL 100 mg/dL
Order labs off UVC (cord gas, blood and urine cultures, CBC, CRP, BMP)Labs “pending”
Order antibiotics: ampicillin 100 mg/kg/dose and gentamicin 4 mg/kg/doseAntibiotics “en route”
Place OG tubeOG successfully placed
Team member updates mom on planProceed to Stage 4Mom verbalizes understanding and thanks team for the care of her newborn

Case Conclusion

Correction of hypoglycemia through NICU signout

Critical Actions

  • Discussion of patient with NICU and appropriate disposition stated

Physical Exam

ITEMFINDING
Vital SignsT: 37oC, HR: 130, MAP: 35-40 mmHg, RR: 60 on CPAP, SpO2 >95% on CPAP at 50% FiO2
Exam ChangesImproved color, tone, and respiratory effort

Instructor Notes: Changes and Case Branch Points

INTERVENTION / TIME POINTCHANGE IN CASEADDITIONAL INFORMATION
Call NICU, local pediatric hospital for transport or for discussion of patient; give full patient summaryNICU accepts the patient. They make recommendations to secure the UVC access, continue D10W at maintenance rate, antibiotics, and maintain normothermia (36.5- 37.5oC).

Demonstrate post-delivery resuscitation of a neonate following NRP guidelines (application)

Learners should approach a newborn delivery in a standardized fashion, using the NRP algorithm. The emphasis is on the airway and breathing in NRP resuscitation. If the neonate continues to have decreased oxygen saturation, consider problem the following interventions:

“MR SOPA”

  • M – Adjust Mask
  • RReposition head to open airway
  • SSuction mouth then nose
  • OOpen mouth, lift jaw forward
  • P – Gradually increase Pressure until visible chest rise is noted
  • A – Use artificial Airway (ETT or LMA)

Persistent desaturations could also be indicative of a mixing heart lesion or inadequate oxygen transfer in the lungs.

Demonstrate early evaluation of a critically ill patient (application)

Learners should approach a sick neonate in a standardized fashion. Airway, breathing, and circulation should be assessed immediately. Interventions such as airway repositioning/adjuncts and starting PPV or CPAP should happen promptly. After A, B, C have been addressed, the patient should be evaluated for disability and exposed for a thorough head to toe exam and a blood sugar level should be obtained. Labs/imaging should be ordered and antibiotics and fluids administered in a timely fashion.

Demonstrate umbilical line placement (application)

See Wing’s “Emergent umbilical venous catheter (UVC) placement” blog post with Brown Emergency Medicine (2015).

Demonstrate focused history taking from a caregiver (application)

The maternal history should be focused during the initial evaluation on possible prenatal etiologies of neonatal respiratory failure. Assign a participant to get a thorough history from the mother in a sensitive manner.

Explain diagnosis and management to caregivers (synthesis)

If personnel are available, assign one member of the team to stay with the mother to gather history and explain interventions. Update the mother on the baby’s status, interventions that have been done, and what next steps are (admission to the NICU). Avoid using medical jargon.

Demonstrate teamwork and closed loop communication (application)

Teams may use different frameworks to improve team dynamics and communication. Below are a few definitions that may be helpful to discuss, adapted from the AHRQ TeamSTEPPS Pocket Guide.

  • Brief: Short session prior to start of encounter to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
  • Huddle: Ad hoc team discussion to re-establish Situation Awareness; designed to reinforce plans already in place and assess the need to adjust the plan
  • Callout: A strategy used to communicate critical information during an emergent event. Helps the team prepare for vital next steps in patient care. (Example: Leader- “Airway status?”; Surveying provider- “Airway clear”; Leader- “Breath sounds?”; Surveying provider- “Breath sounds decreased on right”)
  • Check-back: A closed-loop communication strategy that requires a verification of information ensuring that information conveyed by the sender is understood by the receiver as intended. The sender initiates the message; the receiver accepts it and restates the message. In return, the sender verifies that the re-statement of the original message is correct or amends if not. (Example: Leader- “Give dextrose with D10W: 3 mL bolus via the UVC”;
    Med Prep – “D10W 3 mL bolus giving via UVC”; Leader- “That’s correct.”)
  • SBAR: A framework for team members to structure information when communicating to one another.
    • S = Situation (What is going on with the patient?)
    • B = Background (What is the clinical background or context?)
    • A = Assessment (What do I think the problem is?)
    • R = Recommendation (What would I do to correct it?)
  • Situation monitoring: The process of continually scanning and assessing a situation to gain and maintain an understanding of what is going on around you.
  • Situation awareness: The state of “knowing what’s going on around you.”
  • Shared mental model: Result of each team member maintaining situation awareness and ensures that all team members are “on the same page.” An organizing knowledge structure of relevant facts and relationships about a task or situation that are commonly held by team members.
  • STEP: A tool for monitoring situations during complex situations. A systematic method to review Status of patient, Team members’ performance and status, Environment, and Progress towards goal.
  • Cross-monitoring: A harm error reduction strategy that involves 1. Monitoring actions of other team members 2. Providing a safety net within the team. 3. Ensuring that mistakes or oversights are caught quickly and easily. 4. “Watching each other’s back.”
  • CUS: Signal phrases that denote “I am Concerned,” “I am Uncomfortable,” and “This is a Safety Issue.” When spoken, all team members should understand clearly not only the issue but also the magnitude of the issue.

Organize transfer to a higher level of care where needed resources are available (analysis)

Give an organized and thorough patient sign-out to the transferring team (NICU/Peds/transport team). Be specific about the presenting scenario, initial evaluation, labs/imaging obtained, and what interventions were done with an update on how the patient responded to said interventions.

Neonatal Resuscitation Program (NRP): Adapted from the 2016 American Heart Association and American Academy of Pediatrics reference chart

X-ray

Download Case 9 supporting files

Notes:

  • X-Ray Interpretation: Some patchy opacities in the lung fields. Support devices seen include ECG leads, temperature probe, orogastric tube, and low-lying UVC. Image from Dr. Leah Carr.

For the embedded participant playing the patient’s mother, who just delivered her baby precipitously in the ambulance bay of your Emergency Department

Case Background Information

The case is a precipitous delivery of a newborn in the ambulance bay of a busy ED. You had limited prenatal care early in the pregnancy, but lost your job and insurance so has not been to the OB since early in the 2nd trimester. You believe the baby is close to her due date but can’t remember. Your newborn is immediately taken away to be medically resuscitated.

Who are the Learners?

The targeted learners are Emergency Medicine interns and residents. They have little prior experience delivering and resuscitating babies but do have significant experience in gathering information from patients and family members.

Standardized Patient Information

You are emotional about not being able to hold your baby upon delivery, are insistent on knowing how the baby is, and are frightened by the austere and unfamiliar ED environment. You should make it known that you are very upset and want to be with your baby, but you are calmed if someone talks to you and explains what is happening, as to not distract the residents from the neonatal resuscitation.

Meanwhile, the infant is being attended to by the medical team. The medical team resuscitates the baby by following the Neonatal Resuscitation Program (NRP) algorithm and by doing the following: breathing for and supplementing oxygen to the newborn who is having persistently low blood oxygen levels with PPV and then CPAP, obtaining IV access through the umbilical cord, giving dextrose- containing fluids to correct low blood sugar, warming the baby, and eliciting prompt specialty help from the Neonatal Intensive Care Unit (NICU).

Patient Information

(Please remember not to offer any of this information, but when asked please respond while remaining in character.)

  • CHIEF COMPLAINT (your response to open-ended questions such as “what’s going on?” or “what can we do for you? Or “what happened?”): Precipitous newborn delivery with limited prenatal care
  • AGE: 25 years old
  • ADDITIONAL HISTORY: Prenatal care limited to first trimester. Baby is estimated to be at or near term.
  • PAST MEDICAL HISTORY: None
  • SOCIAL HISTORY: Lives alone and denies substance use.
  • FAMILY HISTORY: Does not know
  • PAST SURGICAL HISTORY: None
  • MEDICATIONS: None
  • ALLERGIES: No known drug allergies
  • IMMUNIZATIONS: Up-to-date

Potential Dialogue

IMPORTANT: Do not offer unsolicited information. Please allow the learners to ask questions. Do not offer information unless they ask you.

Things you could say without being asked:

  • “How is my baby? I want to hold my baby.”
  • “Why don’t I hear crying?”
  • “Can someone tell me what’s going on?”

Things you might say triggered by events in the scenario:

EVENTYOUR POTENTIAL RESPONSE
If they ask about prenatal care“I lost my job and insurance so haven’t seen a doctor in months. I had some prenatal care early in the pregnancy, but have not been to the OB since early in her 2nd trimester. I think the baby is at least a month within my due date but can’t remember.”
If participants do not recognize that the baby is cold“Is my baby cold? The hands and feet are blue!”
If participants do not check the baby’s blood sugar level and treat hypoglycemia“My baby needs to eat something. I want to nurse my baby! How do you know she isn’t hungry?”
If participants do not recognize persistent hypoxemia and difficulty breathing“Is my baby breathing normally?”

Learners enter the room to find a precipitous newborn delivery. The neonate is cool, cyanotic, not crying, and floppy. They immediately warm the baby with blankets while simultaneously setting up a warmer bed. The heart rate and tone improve following the NRP algorithm and providing effective PPV. The neonate’s tone and color improve, the heart rate rises to a goal of >100, and the pulse oximetry improves. Without PPV, the infant’s work of breathing still increases, so CPAP should be initiated, with resultant improvement in work of breathing and continued vital signs at NRP goals. They also must recognize and treat hypothermia and hypoglycemia. They place an emergency UVC after 2 failed PIV attempts, while no IO kit can be found. They consider sepsis and order labs and antibiotics. The learners may prepare intubation equipment and accessory airways but never have to use them as the newborn is appropriately supported with non-invasive positive pressure ventilation via CPAP. The scenario concludes when the team makes an appropriate disposition decision for the infant (NICU) and updates the mother on the plan. If the participants do not follow NRP, the patient’s condition deteriorates into cardiorespiratory failure.

Anticipated Management Mistakes

  1. Failure to follow NRP: If the learners fail to follow the NRP protocol, the neonate will collapse into cardiopulmonary failure. The facilitator might guide the learners by providing the NRP algorithm and/or embed a respiratory therapist to provide effective PPV which maintains the heart rate at goal.
  2. Failure to consider hypothermia: A cold neonate will decompensate quickly. If participants do not recognize that the baby is cold, have the SP playing the mom say: “it’s cold in here and my baby looks freezing!”
  3. Failure to consider hypoglycemia: In neonatal and pediatric resuscitation, the “D” in ABCD also stands for Dextrose, and the “S” in the STABLE neonatal resuscitation course stands for Sugar. If participants do not check the baby’s glucose level and treat hypoglycemia, the patient will decompensate. As the facilitator, consider having the Mom SP say “my baby needs to eat something- I want to nurse my baby! How do you know she isn’t hungry?”
  4. Failure to obtain access with UVC: The participants fail twice while trying to obtain a peripheral IV. Getting parenteral access on this patient is of utmost importance. If they do not recall the option of getting neonatal access through the umbilical vein, consider embedding a nurse participant to grab the UVC tray and placing it next to the patient. If they are unsuccessful placing the UVC, during the debrief consider watching a video on how to place a UVC.

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