Part 2 of 3 Paramedic Discussion:
Reminder, the scenario and questions that were asked of a group of paramedic students:
You are called to the home of a 24-year-old female who is 36 weeks pregnant and in labor. You are met at the door and advised that she has had no prenatal care. You are also told that the patient has been previously admitted to the ER for an opioid overdose and that she is currently taking methadone. As you enter the bedroom you see that the baby has delivered. You find that the umbilical cord is still pulsating and begin to provide care to the newborn while the other crew assesses the mom. The newborn has an APGAR of 6 and is lethargic. The other crew finds what appear to be recent track marks and the boyfriend admits that he helped the patient shoot up with heroin to dull the pain of delivery.
Question #2 What are your primary concerns regarding oxygenation of the newborn? How will you address each of them?
Most newborns will start breathing between 15-30 seconds after birth and have heart rate 120 bpm or higher. In this instance, we know the baby is depressed because of methadone and heroin use. We are going to start working through the inverted resuscitation triangle. 
If the baby is not responding, flick the feet and rub the back and may require stimulation to encourage breathing:
- Position airway
- Drying
- Warming
- Suctioning
- Tactile stimulation
We can maximize these measures by positioning the patient supine, head down, neck slightly extended. We can achieve this by placing a folded towel under upper back. Suction both sides of posterior mouth making sure to avoid deep suctioning. If the patient does not start to improve, we need to aim blow-by oxygen at mouth and nose and dry the baby more vigorously with towels while observing for spontaneous respirations, skin color and movement. Assess heart rate at the base of umbilical cord, brachial artery, or take an apical pulse with your stethoscope. After the above measures, if the heart rate remains below 60 b.p.m. start, chest compressions and ventilations in a 3:1 every 2 seconds for 60-second increments with a reevaluation of the heart rate between sets. Do not start the 60-second timer until you and your partner are synchronized. After compressions, if we have an IV in place, we can start administering epinephrine 0.01 mg/kg every 3-5 minutes.
If you still are not at the hospital because of an extended transport time, and the patient’s condition is not improving you can discuss Narcan with online medical direction making sure you clearly inform the doctor of mom’s history of addiction.
References:
American Heart Association. (2023). Part 5: Neonatal Resuscitation. Retrieved from https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation.
CALS. (2011). Neonatal Inverted Resuscitation Triangle. Retrieved from https://calsprogram.org/manual/volume3/Section20/06-NRP5InvTriangleApgarScore13.html.
Canadiem.org. (n.d.) 2020 American Heart Association Guidelines for CPR and ECC: Neonatal Resuscitation. Retrieved from https://canadiem.org/2020-american-heart-association-guidelines-for-neonatal-resuscitation/.
