Neonatology and Perinatology: Delivery Room to Discharge
This domain tests the fetal-to-neonatal transition, delivery-room resuscitation, and the complications of prematurity. Questions usually ask you to interpret a vital sign, a bilirubin value, or a radiograph at the bedside rather than recite lists.
Delivery room
- The NRP sequence starts with three questions: term gestation, good tone, breathing or crying. Any "no" sends the infant to a warmer for 30 seconds of warming, drying, stimulation and airway positioning.
- Positive-pressure ventilation begins for apnea, gasping, or a heart rate below 100/min. The heart rate is the best monitor of effective ventilation.
- Chest compressions at a 3:1 ratio start when the heart rate stays below 60/min despite 30 seconds of effective ventilation.
- Apgar scores are recorded at 1 and 5 minutes but never drive resuscitation decisions.
Respiratory disease
- Respiratory distress syndrome affects preterm infants with surfactant deficiency: grunting, retractions, ground-glass lungs with air bronchograms. Antenatal betamethasone before 34 weeks reduces severity.
- Transient tachypnea of the newborn occurs in term or near-term infants, often after cesarean birth, and resolves within 24-72 hours with perihilar streaking and fluid in the fissures.
- Meconium aspiration affects term and post-term infants; routine intubation for suction is no longer indicated.
Jaundice and infection
- Jaundice within the first 24 hours is always pathologic. Direct (conjugated) hyperbilirubinemia persisting beyond two weeks mandates evaluation for biliary atresia.
- Early-onset sepsis (under 72 hours) is usually group B streptococcus or Escherichia coli; ampicillin plus gentamicin is standard empiric therapy.
Worked example
A 32-week infant weighing 1.4 kg grunts at 2 hours of life with SpO2 88% in room air. The radiograph shows diffuse granularity and air bronchograms. Reasoning: the early timing, prematurity and film all indicate RDS. Start nasal CPAP, give early surfactant, and titrate oxygen to 90-95% saturation.
Traps
Using Apgar scores to decide resuscitation steps; labeling jaundice at 36 hours as physiologic; giving unblended 100% oxygen to a preterm infant; and missing a direct bilirubin in a thriving breastfed baby.