Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Bridging Obstetrics and Neonatology: Saving Our Tiniest Patients
Dr. Scott Guthrie joins us to explore the significant advances in neonatal care and the critical partnership between obstetricians and neonatologists to improve outcomes for newborns. Highlights include:
• Successful implemented delayed cord clamping across Tennessee hospitals through collaborative quality improvement project
• Neonatal mortality has decreased 30% between 1999-2022 due to advances in medical care and prenatal management
• Survival rates for 22-week premature infants have improved to 30-40%, with many having normal development
• Modern ventilation strategies now allow extremely premature babies to avoid intubation completely
• Delivery room practices have shifted from routine suctioning to prioritizing effective ventilation
• Therapeutic cooling has revolutionized treatment for hypoxic ischemic encephalopathy when initiated within 6 hours
• Historical treatment of meconium stained fluid has evolved as we better understood its pathophysiology
• Neonatal intensive care advances were catalyzed by Patrick Kennedy's death from hyaline membrane disease in 1963
Join us for our continuing exploration of obstetrical and neonatal advances as we work together to improve outcomes for mothers and babies.
00:00:00 Introduction to Neonatal Care Advances
00:10:13 Neonatal Mortality Trends and Challenges
00:16:27Technological Evolution in NICU Care
00:24:07 Periviable Infants: Improved Survival Rates
00:31:09 Delivery Room Best Practices for Newborns
00:38:44 Modern Meconium Management Approaches
00:47:19 Therapeutic Hypothermia for HIE
00:55:42 Causes and Detection of Hypoxic Ischemic Encephalopathy
01:03:01 History of Neonatal Care Evolution
01:12:25 Concluding Thoughts on Collaborative Care
Follow us on Instagram @thinkingaboutobgyn.
Welcome to Thinking About OB-GYN. Today's episode features Howard Harrell and Scott Guthrie discussing advances in neonatal care.
Speaker 2:Howard.
Speaker 3:Scott.
Speaker 2:So what are you thinking about on today's episode?
Speaker 3:Well, we're going to discuss a few issues that are at the intersection of what you and I do for a living. So, for our listeners, we're happy to have Dr Scott Guthrie back on the program. So he's been on here a couple of times before and you'll recall he's a neonatologist. A few seasons ago we discussed optimal cord clamping, and then Scott and I actually worked on a project together with the Tennessee Initiative for Perinatal Quality Care to prove how many newborns throughout Tennessee received at least 60 seconds of delayed cord clamping, and so that was. We were discussing that a few seasons ago now.
Speaker 2:Yeah, so thanks again for having me on, howard. It's always a pleasure to sit down with my friends in the obstetrical world and this project we talked about this was really a significant step forward for I think the work that both of our specialties can do around Tennessee and honestly, it was a lot of fun just working with you and then working to get obstetricians and neonatologists around the state of Tennessee working together. As you mentioned, this was with the Tennessee Initiative for Perinatal Quality Care. So this is our state's PQC and this was really a huge project. We had 61,642 babies in this project just over a year. Let me say that one more time. It's a big number.
Speaker 2:This is a huge quality improvement project 61,642. We have about 80,000 births a year in the state of Tennessee and what we were able to achieve was nearly 90% compliance amongst all of our participating hospitals, with 60 seconds of delayed cord clamping. We had all of our level three and four hospitals around the state involved in this. We had a number of our level one and two facilities. Overall, nearly half of all birthing hospitals in the state of Tennessee were involved. So this is the first time this has ever been done on a state level and I love this because it's a clear example of how our specialties can collaborate together to enhance outcomes for both mothers and babies. So, howard, officially, since we're on the record now I want to thank you for your time and your effort with TIPTC for this project.
Speaker 3:Well, it was a lot of fun and hopefully we start to see the impact of this in years to come. And this resulted in a recent publication in the AAP, their journal Pediatrics, and you were the first author of that, and you and I discussed that recently on the TIPQC podcast when the article was finally published, and I'll put a link to the article in that podcast for the listeners for the listeners. But yeah, obstetricians and enatologists, we have a unique relationship where we work together to try to give these new babies the best start they possibly can. And as an obstetrician, I can say I'm very relieved when I'm no longer in charge of that newborn and instead you are.
Speaker 2:Yeah. So I really appreciate that handoff, both when you hand me the baby in the delivery room and you finally letting me talk for a change, howard. So I know you like to talk just like I do, so we may be doing a good bit of handing off. So the partnership between our two specialties is really critical and, just like our project showed, if we work together and understand what each side is actually trying to do, I think we can make a huge difference in outcomes.
Speaker 3:Yeah, and I know for you that this optimal cord clamping project was just part of a bigger push to address Tennessee's neonatal mortality in a variety of different ways and just to level set. There is a new research letter published in JAMA Pediatrics last month that looked at US neonatal mortality from perinatal causes and I'll put a link to that and the good news is that neonatal mortality on the whole has been decreasing. The authors believe that this is due to both improved medical advancements, particularly in your specialty, as well as prenatal care and medical management of both the maternal and in some cases increasingly now the pediatric patient while the mother is still pregnant. But obviously NICU care has advanced tremendously in the last 20 to 30 years. Most of these deaths that were reported are still associated with prematurity and the one area where the authors noted an increase in mortality the only area really was related to slow fetal growth and they suspected this was possibly related to impaired fetal nutrition.
Speaker 3:We look at numbers, these sort of demographic or epidemiologic numbers, a lot on this podcast and the statistics and how they, when we start to look at things over time and I wonder for this basically increased attribution to fetal growth restriction I wonder if we're just doing a better job of coding fetal growth restriction. I wonder if we're just doing a better job of coding fetal growth restriction in utero. We've changed the definition a little bit over time so that it's a little broader. You can meet the criteria a little more easily than you did 20 years ago as well, so it's possible that that's a statistical artifact, that one area of increase. It's also possible that it's related to things like increasing rates of obesity, which probably affect the placental perfusion, and things like that. Older patients with more hypertension, maybe substance abuse. But that was the only area where we seem to have slid back a little bit.
Speaker 2:Yeah, let's delve into this a little bit more, because I think this letter is a pretty critical update for us as we look at just neonatal mortality trends as a whole, and I think it's really a great starting point for our discussion that we're going to have today. It's also really important that we point out wins from both of our fields and for me and you, howard, we've got a little bit of gray hairs. This report spans nearly our entire careers, spans nearly our entire careers. It analyzed CDC wonder data all the way back from 1999 to 2022. And, as you mentioned, it reports a significant decline in neonatal mortality for perinatal causes. From my side, this overall reduction is driven by advancements in neonatal care, like surfactant therapy, better equipment, better treatments, standard resuscitation protocols. I think overall, just a general better understanding of how to take care of preterm babies, for instance, mortality from disorders related to short gestation and low birth weight. That's the leading cause that they detected and they had a crude rate of 102.10 per 100,000 live births. This decreased at an annual average percentage change of minus 4%. So hey, that's really pretty cool, pretty amazing From your side, from what my friends in obstetrics do.
Speaker 2:You all offered improved prenatal care over that time frame, you did a better job getting steroids on board. You did a better job managing maternal hypertension and diabetes, as you pointed out. You've also really improved, I think, your obstetric vigilance, so you're optimizing the delivery timing for high-risk pregnancies, and all these gains that we see with this letter. It's really our shared wins. All of what you and what I and all of our friends have done have reduced these prematurity-related deaths significantly, and that's 79.8% of the top 10 perinatal causes. Now you noticed, I think, one really important thing We've still got a 1.9% annual increase in mortality due to this slow fetal growth and this fetal malnutrition, and that's a big red flag. I think you're spot on. Y'all are doing a better job with coding this and you definitely got better definitions, like that 2016 consensus criteria using the Doppler and biometric thresholds.
Speaker 2:Likely, this contributes to this trend, and you've got better detection, better abilities to do that. You pointed out too. There are definitely maternal factors in place 30% of US moms are obese during their pregnancy. Now, diabetes, hypertension All of this is going to impair placental function. This is going to reduce the nutrient transfer to the baby and, of course, if this is going on, you're going to have an increased fetal growth restriction risk. Unfortunately, substance abuse has also been a problem, particularly with opioids In all of these things that people take when they're pregnant. There's been multiple studies that have been linking these drugs to placental insufficiency as well. So, whatever the reasons, your side needs to make sure they're carefully monitoring these babies that are showing evidence of fetal growth restriction, because they're going to be at more of a risk for a host of problems than my side has to diagnose and deal with later.
Speaker 3:The substance abuse, the opioid epidemic is really also the story of our careers and I know in some of our NICUs. As many as half the patients in the NICUs are there with a substance abuse disorder, mother with withdrawal issues and things like that abuse disorder, mother with withdrawal issues and things like that, and it's always been a problem, but it is definitely the story of our careers and is contributing to this challenge of taking care of our smallest babies.
Speaker 3:Well, the other thing again that just you're talking about the advancements and things like that in terms of NICU technology and protocols and things like that, and, as you said, this sort of encompasses our careers. We're roughly the same age but, looking back over this sort of 25, 26 year period, what do you think are the biggest things? You mentioned a couple of things, but what are the biggest things that are just different today than when I was a med student?
Speaker 2:Yeah, so this is funny. We actually got a medical student with us now and so we just came up on rounds today and I was talking to some of my nurse practitioners. She's also been doing this a few years and were brand new and just getting regularly incorporated into practice during my residency and over the years how we have used these has changed significantly. We're more apt to give these earlier. We also use different methods giving surfactant in order to minimize exposure to the ventilator. So let me speak about that just for a second, because we use non-invasive ventilation a whole lot more than when I trained.
Speaker 2:I actually had a brand new 22-weeker that weighed 420 grams on nasal intermittent positive pressure ventilation for several days a few weeks ago. For several days a few weeks ago, like I think, we hit 90, 96 hours no ventilation at all. It was absolutely amazing. In Europe this is a pretty standard thing to do. Over 40% if there are 22 weekers in the German neonatal network don't get intubated within the first 72 hours of life, then maybe not at all. Somewhere in the number of 15 to 20% of them may never get ventilated during their time in the neonatal intensive care unit. So that's pretty huge and this seems to help prevent some of the long-term lung problems we can see in the neonatal intensive care unit. So other big changes that we were talking about today that we've seen in held nitric oxide that came out during my fellowship. That's been a lifesaver for many babies, and when I trained we used sparingly and now we use it a lot sooner and even use it in the little babies, and this seems to have significant benefits. Therapeutic cooling has been another big one that's helped these kids with HIE and can help improve outcomes.
Speaker 2:I think generally, though, because we've done this longer the research that has come out and we've gotten more experience, I think we just have a general better understanding of how to keep these babies alive, especially the smaller ones. We've also got standard protocols and approaches that can help quality improvement projects, like the one you and I did together and then the one that you mentioned that we've got going on right now too, which within our collaborative, we're doing something called the tennessee's tiniest babies project, and I've been heading this up with all of our level three and four NICUs in the state. So we're like tackling IVH interventricular hemorrhage. We've tackled chronic lung disease. We're just starting necrotizing urocolitis reduction project. It'll be building out a hospital-acquired infection bundle soon.
Speaker 2:And all four of these are the biggest causes of mortality and morbidity in the neonatal intensive care unit. Multiple studies have addressed these things. There's been multiple individual quality improvement projects. So if we can do this on the state level, we're going to hope that we can see a significant improvement in our infant mortality rates. Boy, that's a long answer to your question, howard. If anybody's interested specifically in the TIPQC stuff, go to TIPQCorg and you can find the Tennessee's Tiniest Babies Project, and there'll be obstetrical projects too that some of your audience might be interested in.
Speaker 3:Okay, well, I thought we would talk about a few things today that can help improve the working relationship of obstetricians and anesthetologists and improve our understanding OB's understanding of some of the things that you all do for us and what you need from us Sounds good. So I think for a lot of obstetricians, you know we're talking about these changes. We're stuck in a time warp of whenever we trained, whether it was 10 years ago or 20 or 30 years ago. It was 10 years ago or 20 or 30 years ago, and so I'd like to just have an overview of how far we've come about improving survival for these tiniest babies. When I was a resident, something before 23 weeks was just not spoken of, it was unheard of, and obviously these gestational ages have come down. So what are we doing now in these earlier gestational ages, and how is survivability at 22, 23, 24 weeks? How has that changed?
Speaker 2:Yeah, so this is fun. I got to do this at a recent general medical conference and it was absolutely amazing to see all the faces in the audience as I was going over this information with everybody. I mentioned to you earlier about this 22-weeker that I had not too long ago. So these are those periviable infants. That's at 22 and 23 weeks and this is the biggest thing. I think over the past 10 years or so, survival rates have improved dramatically in this group.
Speaker 2:22 weeks is now I don't want to say it's routine because we still go into that with fear and trepidation, but we're seeing average survival rates on hospitals that are resuscitating 22-weekers in that 30% to 40% range. For a long time most centers wouldn't even resuscitate below 23 weeks, so a lot has changed here. It's also not uncommon at all to have intact development at this age. My NICU recently sent home a 22-weeker that had a normal brain on imaging and was on just a teeny, tiny puff of oxygen and then actually went home three weeks before their due date. So pretty incredible and would not have even resuscitated that baby several years ago. Some hospitals that have been doing this for a long time, like, I think, iowa they report survival rates of even higher than that 30% to 40% and typically report 60% survival rates. So pretty significant On average, 23 weeks. We add another week. We're looking at an average survival of 60 to 70% there, and 50 to 60% of survivors at 23 weeks are going to have intact neurodevelopmental outcomes once they reach two years old. So that means they have no severe cognitive or motor impairments, and this is the fun thing.
Speaker 2:A couple of years ago, a study came out saying well, maybe we should look at these kids like up to their 10 years old, and it's extremely surprising how outcomes continue to improve over time. In this study, 63% of kids that had moderate to severe impairments at two years get this had no impairments, or maybe just mild impairments, once they reached 10 years old. That's to me just absolutely amazing and shocking and something I love to share with our parents, especially when we see things that look concerning these advances in ventilatory strategies. Nutrition, our standardized delivery room protocols have all driven these gains and, of course, working with our obstetrical friends to make sure we can prepare properly and give these little ones the best shot possible is really a critical component. My message to your side is as soon as these mothers roll in and you think they're going to deliver. Get steroids and magnesium on board. We're doing steroids in my hospital late 21 weight.
Speaker 3:Now, if that delivery looks like it's going to happen, yeah, okay, and for these earliest gestational ages, the smallest babies that we deliver, what are some of the things that we can do at the delivery specifically to help you guys, help the newborn? So certainly things like optimal delayed cord clamping, but also just very practical things. How long should we cut the cords? How should we position the baby or hold its head, or should we be putting them immediately in a plastic bag? Or what are the things you want us to do in those first couple of minutes?
Speaker 2:Yeah, so I love this question. This is great, howard. This is a fantastic podcast. This is like the neonatologist wishlist of what happened in the delivery room. So my thing in the delivery room, what you guys do, that and gals, is absolutely critical and pivotal for these babies.
Speaker 2:We'd mentioned delayed cord clamping once and I'm going to mention it again 60 seconds when feasible. It enhances blood volume. It reduces transfusion needs. It appears to decrease interventricular hemorrhage rates. It actually is a very simple thing you can do to decrease mortality rate with a number needed to treat if in the 20s, to save one life where we're talking about these babies that are less than the 1500 grams. So do this in all babies. Let me emphasize this all babies, even the 22 and 23 weekers. That's what we did do with our 22 and 23 weekers.
Speaker 2:As far as this length of the umbilical cord, it makes our job a lot harder when we get a short umbilical cord, so please try to leave it at least five centimeters and if you can do somewhere between five and ten, that would be better, because that will make it easier for us to do our procedures. Let us cut it down to what we need and one of the things I know y'all like to do is keep the OR cool, and I appreciate that. I love a cool operating room too. I hate to get in there and sweat, but we've got to keep it toasty for these little ones. As soon as I walk into a delivery room, first thing I do is go over and turn the heat up as high as it'll possibly go as high as it'll possibly go. And that's because studies have shown that for every one degree a baby is below 36.5 degrees, there is a 28% increase in mortality rate. That is significant. So our comfort, I think, is much less important than an increase in mortality. So it's important to maintain normal thermia.
Speaker 2:This warm room helps Positioning the infant. As far as how you position it, it really doesn't matter as far as the delayed cord clamping goes, but try to do it that 60 seconds and then hand off the baby to us and we'll get the baby into a pre-warm surface, into a sterile plastic bag for those smaller babies as under 30 weeks. General handling is also key. Occasionally in like the 23 week, I know the obstetrician wants to get rid of the baby as soon as possible, but I'll see like a little bit too much aggressive stimulation or rubbing or something like that. And for those tiny babies, just remember, they've got delicate skin. They've got very delicate brains. We want to make a pretty smooth transition for those babies, so go easy on them. The neonatologist should be right over your shoulders coaching you and us, working together to see what we assess and then get the baby to us so we can do those next steps.
Speaker 3:Okay, now those are for our smallest babies, but maybe let's talk a minute about term or near-term newborn practices. Again, we all get stuck in time warps and do things the way we've done them for the longest time. But the NRP guidelines have certainly changed a few times in the last 20 years or so and sometimes it takes quite a while for some of us to adapt to those changes. So when I started training, things like deep sectioning from meconium were still common practice and even when they went away from the guidelines, the practice lingered for a while. Because, again, it's a process to change our patterns. But particularly in a day and age where we're hoping that the newborn stays hooked up to the placenta for a minute or two, what are the current guidelines support? What should we be doing for normal babies and perhaps for those babies that, the ones that are not immediately vigorous in the first minute or two? Should we, for example, be routinely sectioning out the mouth and nose anymore, or things like that?
Speaker 2:Yeah. So you are spot on. These RP guidelines have evolved significantly from the days you and I were residents, and it's important that we make sure everybody understands what these evidence-based changes are so we can optimize neonatal outcomes. So let's start with your first idea that you threw out there, and that's that vigorous term or near-term baby. These are those babies that are going to be born at 35 weeks or later. They're crying, they're breathing well, they've got good muscle tone For those newborns.
Speaker 2:The current NRP guidelines recommend against routine suctioning of the mouth or nose. This is a major shift from in the past, where we would like get that bulb suction and stick it down that mouth of that baby, begin to suction and all we realized later that we were doing was triggering the vagal nerve and causing them to have bradycardia. So probably not a really good idea. Occasionally you'd have mucosal trauma with that. There's no benefits to this at all. So instead, the focus has been on supporting the natural transition to extra uterine life. Do what your ancestors, what Hippocrates did put that baby on the skin-to-skin with the mother. Promote thermoregulation bonding it's supposed to happen what nature intended. Delay the clamping of the cord for at least 60 seconds and help enhance placental transfusion. All right. So the next group, and that's the non-recipients, those are those babies that come out limp, not breathing adequately or have poor tone, and this approach has also been streamlined by NRP. But things have a more urgency to them. So still, the same steps we're going to warm, dry, stimulate, you're going to try to encourage spontaneous breathing and if these measures don't suffice, then you go ahead and do positive pressure ventilation and you try to do all this within 60 seconds. Ideally you're going to have what we call a T-piece resuscitator, but you can use a bag mask device if that's what you have at your hospital.
Speaker 2:Routine suction here is also not advised unless you see presence of secretions that might be obstructing the airway. And this change really comes from trials which found no benefit to routine endotracheal suctioning in non-vigorous infants, even in meconium cases. We'll talk about meconium in just a second. And the reason all this was taken out is if I'm spending time trying to suction the baby and maybe do endotracheal suctioning on the baby. I'm just time trying to suction the baby and maybe do endotracheal suctioning on the baby. I'm just delaying actually what the baby needs, which is effective ventilation. Of course I want to do this quickly because if I'm not ventilating the baby quickly, then all I'm going to do is exacerbate any hypoxia that might already be occurring and if I do this, I'm going to increase the risk of complications and words like we don't like to hear, which is hypoxic ischemic encephalopathy.
Speaker 2:For obstetricians I want to emphasize your role in the delivery room is pivotal in setting the stage for us to do our job and making sure all these protocols happen like they're supposed to Ensure the infant is hand-off to us on a warm surface or directly to the mother, based on the condition of the baby. Communicate any concerns that you have with the team as they come into the delivery room or maybe right at the time of the delivery. Any fetal distress that was taking place, prolonged decelerations, meconium, stain fluid all of that stuff is so in print. I've been in deliveries before where there has been no communication and ask questions as we're working through stuff and trying to backpedal a little bit. So please communicate.
Speaker 2:Remember we don't have that suction first mindset anymore that you and I grew up with. We no longer deep suction for meconium or secretions. First things first. Stabilize the infant, support the breathing, only intervene if clinically indicated. These are the big ones. This is that streamlined approach, avoiding unnecessary intervention. Go straight to the more critical things when you need to, and this is going to help us get all of our babies the best start possible.
Speaker 3:Okay, and we mentioned meconium and the management of meconium stained amniotic fluid has really changed profoundly for both of us in our careers. So, as I mentioned, we used to do deep suctioning with a delete trap before the baby took the breath. Even before the baby was delivered, as soon as the head was out, you'd pass that delete trap up the nose and have it hooked up to wall suction and then we'd do amio infusions during the labor for meconium stained fluid with the idea that we were diluting the meconium and lessening the impact and the amount of particulate meconium the baby was born with. But this has definitely changed. I think our ideas about meconium have changed and you mentioned some of the things, but the pediatric we no longer do either of those practices in OB and for you guys, for the pediatric providers, your approach to meconium has changed quite a bit too.
Speaker 2:Yeah, man, we thought we were so smart back in the day with those amnio infusions and delay traps didn't we?
Speaker 3:Yeah, it made sense, yeah, but again.
Speaker 2:once you have the studies that can build out the evidence and you see what you need to do, you catch up to that and that's where those current NRP guidelines have done. They call up with the evidence and so no longer do we do routine amnio and or the deep suction or the delay traps, and this is again for your vigorous and non-vigorous inputs. You avoid that for both of them. For the non-vigorous inputs, once they're born, you do the things always do in a resuscitation Warm, dry, stimulate, initiate ventilation. You don't delay for suctioning and although you and I grew up on that and we did that a whole lot during our training and early career, evidence has shown that these interventions don't improve outcomes and may actually cause harm because we just delay care. Back in that day, howard I hate to say this we were doing some worthless and potentially harmful things.
Speaker 3:Yeah, our whole idea about meconium, I think, really has changed. We had a mechanical model in mind of this mechanical irritant that was causing either in the throat or in the lungs, was causing mechanical blockage or irritation or something like that, and I think we've moved to more of a molecular understanding, perhaps, or a physiology. It represents something. It represents chronic underlying fetal stress or acute stress. I think the more serious concerns are when it's representing chronic stress, and the whole idea of meconium aspiration syndrome has changed and has more to do, in my mind, with persistent pulmonary hypertension related to chronic stress and changes in the pulmonary vascular tree, than it does this mechanical blockage or irritation that we were trying to address with amnioinfusion and suctioning. So can you talk about how the pathophysiology understanding has changed?
Speaker 2:Oh yeah, this is a complex, fun problem to work through, and so we still have to worry about the chemical irritant effect. You still have to worry about the mechanical blockage. But, as you pointed out, there's a whole lot more to what's going on with meconium, and the thought used to be was that the damage occurred right at the time of the delivery. That's why you suction. The baby was going to gasp and take that first big breath and they were going to suck that meconium down into their lungs and all these things were going to happen. But as we've gotten more information, more evidence, we've realized that those interventions the amnion fusion, deep suction doesn't help at all, and so the International Liaison Committee on Resuscitation goes through all this stuff pretty regularly. So all the evidence, data, studies that have been done and reframed meconium aspiration syndrome as this complex condition. It's really driven by underlying fetal stress, and so the damage actually occurs in utero.
Speaker 2:The aspiration of the meconium actually occurs much earlier, and then this release of meconium is really a marker of these stressors, and those stressors could be chronic hypoxia, it could be some type of intrauterine infection, it could be long-standing placental insufficiency, and this meconium release is really just triggering an inflammatory cascade in the lungs that, as you mentioned, triggers the persistent pulmonary hypertension of the newborn.
Speaker 2:And then this is what impairs, after the baby's born, the oxygenation, the potential of hypoxic ischemic encephalopathy, disrupting the effective gas exchange that we want to happen in these babies. So it's not really just a simple mechanical blockage. It's a much more complex interplay of all these things and that's why these new strategies that are in the NRP guidelines going straight to effective ventilation, straight to making sure they get the oxygen that they need, hoping to avoid the pulmonary hypertension, hoping to avoid the hypoxic ischemic encephalopathy. So again, that's important to communicate with us as we're coming in, make sure that handoff is correct. So we've got the equipment there that we need, so we've got the mindset we need in order to do these things. Make sure the baby gets stabilized and improve the outcomes and really, most importantly, don't get upset if we don't ask you to suction in the perineum or you don't see us suctioning right away. That's really no longer the top priority.
Speaker 3:One thing I occasionally still see happen is a baby's doing fine. The nurse is taking care of the baby in the warmer but it's struggling a little bit with its breathing. And some of the older nurses will take an NG tube and put it in the baby and be very proud of themselves that they drew off three or four or five milliliters of fluid from the stomach. Can you comment on that practice?
Speaker 2:I'm sure it makes the nurse feel really good. It doesn't help the baby at all.
Speaker 3:Yeah, I wonder sometimes if they think that they're drawing fluid from the lungs.
Speaker 2:Yeah, and all they're doing is maybe effectively causing the baby to have a bradycardic episode.
Speaker 3:Okay, another thing that you mentioned earlier that has evolved a lot in my career is therapeutic hypothermia, so can you explain to us about cooling or therapeutic hypothermia? What is it, why is it helpful and also what goes into your decision calculus of when you're applying that to a newborn? So I do think obstetricians are taken aback when one of their newborns is all of a sudden in the NICU being cooled, especially when they thought everything was fine and everything was going well and they weren't worried about intrapartum hypoxia, and it makes us defensive. It makes us worried that something went wrong that we could have controlled, I guess.
Speaker 2:Yeah. So therapeutic hypothermia has definitely become a cornerstone in managing hypoxic ischemic encephalopathy and we've looked for a ton of things to help with neonatal neuroprotection. There's some really cool ones too. We've tried xenon gas, we've tried melatonin, we've done erythropoietin, but it really the thing that has really shown effectiveness so far has been the therapeutic tooling. Vanderbilt was involved in this when I was a fellow. My mentor cooling Vanderbilt was involved in this when I was a fellow. My mentor, bill Walsh, was actually involved in these early pivotal trials.
Speaker 2:And so what therapeutic cooling is taking your term or near-term infant, so those babies that are 36 weeks or more, and you drop their core body temperature to around 34 degrees Celsius, give or take half a degree, and you do this for 72 hours. This is time sensitive and that's the key why you may, in the delivery room or shortly after, see a lot of hustle and bustle in the NICU and hear the neonatologist talking about things and trying to work through things, and why it may be surprising because we've only got six hours to get cooling started. A lot of times, if the story is very clear, we'll do this in the delivery room, turn the temperature off to the radiant warmer, let nature do its thing and let the body temperature begin to drop right away while we're assessing the situation to see if the baby qualifies, and there's some things that we've got to look for to see if the baby qualifies, and there's some things that we've got to look for to see if the baby qualifies for cooling. They've got to have evidence of moderate to severe encephalopathy. So that's doing a careful neurologic exam on them, looking at how they respond to various stimuli, looking at the normal newborn reflexes and trying to make a decision if they're moderate to severe. We look at the cord pH, or that first blood gas. If we don't have a cord gas something below 7.0, a base deficit that's 12 or greater, a low 10-minute APGAR score typically less than 5, and then we'll look for clinical findings like seizures, lethargy or abnormal tone and all these things that we're looking for are pretty standard and be found in available guidelines. So the reason we've got to get the cooling done quickly is we've got this time window to prevent or try to limit the secondary neuronal injury following any type of insult. So time sensitive, time limited, very careful selection data that we've had for a really long time and you guys may find this surprising because HIE can't always be predicted.
Speaker 2:A baby could have had something happen during the pregnancy and have an antepartum insult or something that has left them with less fetal reserve for some reason. They could have had chronic placental insufficiency or something else that caused chronic hypoxia. They don't have enough fetal reserves available. Something else happens that a normal baby would be able to handle, but they're not able to handle that for some reason, and they may have HIE, but it may not be acute HIE. It's a huge difference. Sometimes it can be very hard to make a difference in chronic HIE and acute HIE at the time of the delivery. Just to help some understanding too and I think this is fascinating I've seen some cases of this recently where a kid has come out asystolic in the delivery room and as an obstetrician and as an enatologist in that delivery room, that is a horribly frightening thing, because you've had maybe a CAT2, maybe an early cat three strip, so you're trying to hurry things along, making the delivery happen, but the baby looked more or less the same before, and then the baby comes out asystolic and you're wondering like what in the world was going on here?
Speaker 2:How did this happen? And so in the literature there's been some fascinating descriptions of how prolonged or repetitive cord occlusions can lead to hypovolemic shock at the time of the delivery, and then that hypovolemic shock immediately follow into a systole. Think physiologically how this happens. Remember the umbilical cord you've got one vein it's very floppy, and that's getting the good blood coming back from the placenta. You've got two arteries that are very muscular. That's sending the bad blood away from the baby. And so something happens. Maybe that cord is a shoulder wrapped around the baby in some way that, with those uterine contractions that are occurring, that cord just has these periods where it's becoming occluded. And when that happens, of course the blood is being backed up in the placenta into the baby. But the baby's heart is still beating, and every time it's beating there's multiple milliliters of blood going out and going back to the placenta. Multiple milliliters of blood going out and going back to the placenta. And as the baby drops down the vaginal vault, that strong muscular wall actually acts as an anti-shock garment, and so all the blood is held in centrally, but there's very little blood that's there, and then, as soon as that baby is delivered, the blood has to flow out in the peripherally and then you have a collapse from the hypopalemic shock and a systole occurs, and this is catastrophic. Everybody involved in this situation.
Speaker 2:But let me just give you a little bit of advice from the neonatology standpoint and what to do when this happens. Because instinctivelyively you see this baby that's lifeless and not moving, and so you want to cut the cord and get the baby to me. I completely get that and I would love to have this baby too. But this baby is attached to something that it actually needs and that's the placenta and the blood in the placenta, and this is where delayed cord clamping actually can become life-saving. Once the occlusion is relieved, blood's going to start flowing again. So take a few seconds, try to let the blood get back to that baby. I mean, wait at least 30 seconds and see what happens. Still no movement or signs of life. Go ahead, strip the cord a few times You're essentially giving this baby a blood bolus and then give the baby to me.
Speaker 2:If you cut the cord immediately without doing this, it's going to be harder for your NIC team to actually resuscitate the baby, because it's going to take us several minutes to get intravenous access and all we're going to be able to do is give the baby normal saline and the baby needs blood. It needs it fast and really only you can do this. So stay calm. If you're ever in this situation and I hope you never are Remember this physiology the baby's still likely going to need to be cooled, but you've just improved the chances of survival and intact survival significantly by doing this.
Speaker 2:If it is this acute HIE, we will make sure we make a difference. So this is where we need to make sure we're communicating. So if you've seen something happen like cord prolapse, an abruption, make sure we know about that, make sure you're documenting the labor details meticulously just in case any questions come up later. And then the collaboration we both need to have in these situations and make sure we're acting swiftly, we're diagnosing things correctly. It reduces uncertainty about things and it makes certain efforts in our care, optimizing outcomes for these babies at a really difficult time.
Speaker 3:I actually had that scenario that you described happen with a category one tracing several years ago and a full-time baby?
Speaker 2:Yeah, it's terrifying.
Speaker 3:Yeah, baby did fine but, it needed all full court press.
Speaker 2:You mentioned yeah, I've had them in cat ones too, and that's when it's really expected.
Speaker 3:Yeah, totally unexpected. Yeah, you mentioned stripping or milking the cord a bit, but not for preterm babies, right?
Speaker 2:Exactly, hey, yeah, thanks for clarifying that. Yeah, this is the term near-term baby scenario. Don't do that with a preterm baby. For tiny preterm babies that could be problematic, but for the bigger babies in this situation, yeah, stripping the cord is certainly okay as you're trying to get them a blood bolus quickly.
Speaker 3:Okay, we'll talk about hypoxic ischemic encephalopathy a little bit. So the causes of HIE are more than just intrapartum asphyxia like you just described. So can you go over a little bit some of the causes and how you sort that out, how you can understand that? Maybe the timing you mentioned difficulty in acute versus chronic what are some of the evidences about the timing of when it might've happened? So, for example, if a fetus had an event the day before an intrapartum event the day before the mother presented in labor that caused damage, how can you tell the difference when you're getting this baby at delivery and how it's different acute versus chronic and how it evolves.
Speaker 2:Wow, all right, howard, you're asking for really long answers, let's go. And this is a great question. Just like meconium aspiration syndrome, ischemic encephalopathy is a really complex condition. So, simply, hie is exactly what it sounds like it is, it's just impaired cerebral blood flow or oxygen delivery, and you are 100% correct that it causes extend well beyond intrapartum asphyxia. So always when I'm teaching this, try to get people not to jump straight to HIE as the answer.
Speaker 2:Do not put that in the chart until you know you need to put it in the chart and you've ruled out everything else. Start with just a diagnosis of neonatal encephalopathy. So if you see a baby who is not moving appropriately, who might have seizure activity, that is neonatal encephalopathy. In work from there, because you've got to rule out other things that can cause encephalopathy first Infections, genetic issues, metabolic issues, structural issues, other things like that can lead to an encephalopathic infant. So, specifically for HIE, that's what you wanted us to focus on and turn to the etiology, for this can span the antepartum, intrapartum, rarely even postnatal periods. So your antepartum factors include things like the chronic placental insufficiency linked to maternal conditions, your hypertension, diabetes, smoking, all those things linked to maternal conditions, your hypertension, diabetes, smoking. All those things, and as all these things can reduce uteroplacental perfusion, can do that over weeks. Infections such as chorioamnionitis can also trigger fetal hypoxia and there's great evidence with placental path, with chorio and funicitis. The increased incidence of fetal hypoxia and developmental delays when that's present. Intrapartum events like umbilical cord compression, uterine rupture, prolonged labor, repetitive accelerations all of these things can be contributors. And this is particularly true when fetal heart rate tracing show those persistent late D-cells or the loss of variability that y'all are always looking for. Those rare post-natal causes are things like severe apnea and cardiac arrest. Again, things are uncommon, but I've seen it happen before in unstable neonates.
Speaker 2:So you're specifically asking about timing and how we try to figure out timing in this situation. This is a multifaceted approach. Clinical evolution is important and may provide some clues. So the timing of the seizures can be important. Usually if it's related to some type of acute partum event, we're going to expect to see seizures within 6 to 12 hours, unless it's really severe within 6 to 12 hours, unless it's really severe. Those delayed seizures or early seizures a lot of times happen from something else. You're also looking at the MRI. So once we get the imaging, does it show chronic changes that might be seen with chronic hypoxia. So stuff like cortical thinning or things like that may potentially have been from events that happened days earlier. The types of seizures are clues. If they're unilateral, this is probably a stroke and it's not HIE, because HIE remember that's a global event and you're going to have bilateral seizure activity with that.
Speaker 2:We look at some of our diagnostic tests that we have. Your cord blood gas analysis can be helpful. If it's low, as we've talked about before, it's going to indicate your acute asphyxia. Lysental histology is going to be really important in making sure somebody who's looked at that is skilled at looking at lysental pathology, looking for things like fetal vascular malperfusion or thrombosis that can point to long-standing issues in the placenta. Our EEG patterns can be clues to things.
Speaker 2:There are specific things like a burst suppression that's usually seen in acute HIE and some other tests that we will look for to try to give us some data is when something might have happened is something called the nucleated red blood cells. Some pretty good data out there that an elevated nucleated red blood cell at the delivery actually points to something that happened 24 hours or more. So it helps us identify that where, if it's normal and that might be a more of an acute event. So this is really a complex problem. The answer as to why something happened is also incredibly complex and every case is different.
Speaker 2:For obstetricians, proactive measures are really critical Making sure you're looking at the fetal heart rate monitoring, paying attention to that, acting on that when you need to, early recognition of those patterns, trying to judge whether you need to intervene or not to minimize any hypoxia that might be occurring For the smaller babies, those preterm babies. Making sure magnesium, making sure steroids are on board, because those things can offer neuroprotection. Making sure you're documenting things, noting sentinel events, making sure the neonatal teams are aware of this information, supporting sentinel events, making sure the neonatal teams are aware of this information. All that stuff is important and ultimately is going to help with outcomes and may reduce the risk of long-term problems.
Speaker 3:Yeah, and one more thing I was thinking of while you were describing all that you and I have both done some medical legal work in our careers, and one thing that I've seen on my side that I would add to that is a surprising number of times the tracing might be maternal, and I can't emphasize enough for OBGYNs to have the pulse ox on the mother or make sure that you're distinguishing. And unfortunately, I've seen some cases where for a very long time, a slightly tachycardic mother who's in labor not uncommon to have a pulse of 120, 130 is actually what's being presented as a fetal tracing, and so we just weren't tracing the fetus for some period of time. So things like that happen too, and so I would encourage my colleagues to if you have them on continuous fetal monitoring, do something to make sure that you're tracing the fetus, not the mother. In some of those cases, a mother with a fever, for example, very easily will have a fetal tracing that's maternal. I've even, unfortunately, seen an example of a fetal demise that was labored for hours with a beautiful tracing that was the febrile mother's tracing the whole time. So make sure you're actually tracing the fetus.
Speaker 3:Okay. Well, we talked about meconium a little bit and our mutual enemy of OBs and pediatricians for millennia probably. So we do a little history segment on here sometimes with some of the stuff that we find interesting, and so I thought we could talk about the longer term history of meconium. We talked about the recent developments in your updates there, but let's talk about the long term history of meconium from the medical literature.
Speaker 2:Yeah, that sounds great.
Speaker 3:Teach me something amazing the numbers you started with about just decreases in neonatal mortality in the last 25 years. But of course, if you look globally, maternal outcomes have made tremendous headway. Obstetric as a specialty or as a process or whatever has improved maternal mortality by 99% in the last 150 years or so. But obviously the same things happen for neonatal mortality and even just the recent improvement staggering, but let alone over the last 150 years or so. But obviously the same things happen for neonatal mortality and even just the recent improvement staggering, but let alone over the last 100 plus years. It's a more than 99% reduction.
Speaker 3:And a big part of that for the mothers and making birth safer for mothers and infants over time was coming up with ways to deliver these babies and identifying that babies needed to be delivered and all that stuff. And obviously none of that existed a while ago and we didn't have effective ways of inducing labor that were very safe or effective until the 1950s and 1960s. And cesarean delivery wasn't very safe for mothers until about the 1950s when we started using routine antibiotics or even had antibiotics available after World War II really. So a lot of these things have led to us being able to make the delivery process safer for the mother. But along that way we weren't focusing on the babies that much.
Speaker 3:And then there was no need to because we didn't have anything to do about it and we didn't really have any way of knowing whether a baby that was still inside was in any kind of danger. We didn't know if there was chronic distress. We certainly didn't have ultrasounds and things like that to monitor. For these things we didn't have fetal monitoring, and so we couldn't identify distress and we couldn't deliver the baby that we knew was distressed. And so really everything came about in the 1950s and 60s where we had accomplished a lot for the mother, and then we turned our focus on identifying these babies that needed our attention, and I think that the sort of the birth, of improving neonatal outcomes really followed that and really started around the 50s and 60s in this country.
Speaker 2:Yeah, especially the 60s. For me that was a really pivotal period for the improvements of neonatal care and that's literally with that point, with the creation of the National Institute for Child Health and Human Development. That's part of the NIH I'm going to use a little bit recently. This has really been a turning point for research and focus for many of the improvements that really have helped make a difference in neonatal care and need to be funded well, so we can continue to do that.
Speaker 2:In 1962, that's when they started, and this was really motivated by Eunice Kennedy Shriver. She had a sister, rosemary Kennedy, who had an intellectual disability, shriver, she had a sister, rosemary Kennedy, who had an intellectual disability, and Shriver was passionate about trying to understand the causes and make changes to help child health and development to prevent this for other families. Just a real quick, interesting historical side note Rosemary also had a frontal lobotomy to try to treat this. Frontal lobotomies were all the rage at this time but it is a blight on medicine. If you're curious, just Google search that. Take a moment to read about her history and about frontal lobotomies. Anyhow, I'll move on. Just got to say that because I just think that's fascinating.
Speaker 2:So in 1961, there was this task force that was created, that led ultimately to the creation of the NICHD in October of 62. And so a lot of the important work and research dollars that's gone into improving neonatal outcomes started after that point and really have been shepherded by the NICHD. Neonatal mortality has plummeted 70% since the Institute was founded in 1962. 70% percent since the institute was founded in 1962. 70 percent. They've played a big part in the safe sleep campaign, in surfactant replacement therapy, which we've talked about, hypothermia for HIE, phototherapy for jaundice, optimizing oxygen therapy for preterm infants, as well as just improving and expanding newborn screening programs. In 1986, they established the Neonatal Research Network and this is a collaborative of NICUs across the country where a lot of the most important studies occur. And there is a huge list of accomplishments from the NRA we go into, but then that would be the rest of this podcast.
Speaker 3:Yeah, well, we're starting to talk about meconium, but it's all related, I promise. And the other thing about the Kennedys in the 60s was the focus of even the Institute changed. It was originally focusing on children with disabilities and there is a lot of interesting story about Rosemary, and the family kept it a secret about the lobotomy. There's a lot there that's interesting. But the other thing that happened a year later was the president, jack Kennedy, and his wife, jacqueline. They had a child, patrick Kennedy, who was born a couple of months before the assassination at 34 weeks by cesarean delivery and died of highland membrane disease.
Speaker 3:So that was August of 63, a 34-plus week baby, delivered by the best physicians available in a state-of-the-art hospital, despite the best care available to anybody in the United States, died of highland membrane disease. And so the emphasis of the NICHD focused, the focus changed to prematurity, I think. After that, because it was very personal, obviously, and international tragedy in a sense, I actually had an aunt that was born in the late 50s, just a few years before, also at about 34 to 35 weeks, lived, I think, 11 days or something like that, and her death certificate says she also died of hyaline membrane disease. And, like both of those cases are just unthinkable today that 34 or 35 week babies are dying of lung disease.
Speaker 2:Oh, yes, most definitely. And just so your audience knows, hyaline membrane disease is an old term for respiratory distress syndrome, so surfactant deficiency is what's being described, and there are these hyaline membranes that are noted in the alveoli that cause the problem. Yeah, 1963 was a really bad year for Jackie. She had a premature baby in August and then her husband passed away in November of that year. So, patrick Bouvier-Kennedy, his death was essentially the moment that neonatology became a field, because we actually began to get funded by the NICHD. Then the March of Dimes also played a role prominently in this, because polio had pretty much gone away and they needed something to do. And March of Dimes was founded for polio and for FDR. That's why they call it the March of Dimes thing. So, hey, what better thing to take up something like another president's issues? And so they took up the story of the Kennedy baby. And if you ever go to Arlington Cemetery, been there, howard.
Speaker 3:No, I haven't.
Speaker 2:You've never been to Arlington.
Speaker 3:No.
Speaker 2:Oh man, you got to do this sometime. Anyhow, when you do and you go to JFK's area where he's buried to the left of the eternal flame, it's a little plaque that says Patrick Bouvier Kennedy and it's got his birthday and death date on it and they disinterred his body, put him next to his father after JFK was killed. So he was born Otis Air Force Base in Massachusetts. He was huge. This 34 wicker was four pounds 10.
Speaker 2:And a half ounces, he would have easily been treated, maybe not have even need to be treated at all, because obstetricians would have given him steroids Back then. We didn't know what to do, so he's transferred to Boston Children's Hospital in treatment in those days. Howard, you ready for this? Yeah.
Speaker 2:They put him in a hyperbaric oxygen chamber. Yeah, yeah, that's what we thought was the answer, and he died 39 hours later. So his death, as you mentioned, national tragedy. It spurred research, dollars in adult respiratory care, figuring out things like surfactant therapy ventilators, and it's been millions and millions of babies saved since then. And you and I are both based here in Tennessee. I'm sure your audience probably tell by our accent we're some good Southern gentlemen. So this is where Tennessee plays into this story and since I'm a Vanderbilt guy, I got to tell you a Vanderbilt story.
Speaker 2:There is a Vanderbilt legend, dr Mildred Stallman. She just died last year and was nearly 102 years old. She was this pioneering neonatologist, this woman of steel, and she had developed one of the world's first neonatal ventilators. 1961, she developed this negative pressure ventilator. It's essentially a scaled down iron lung ventilator is essentially a scaled down iron lung when she put it on a baby in 1961.
Speaker 2:And she had a NICU at Vanderbilt at the time and actually had a baby on her ventilator at the time and got this urgent request from Boston Children's Hospital hey, dr Stallman, we got the president's baby. We need you to bring your ventilator up here. And so the problem was. This baby in nashville was already on it, and the vanderbilt legend is she refused to take that baby off the ventilator because that would mean death for that baby, and she couldn't leave the babies in nashville anyhow because there would be nobody to take care of them. So so she said, hey, I'll be happy to chat with you by phone. And so the legend is that's what she did for the rest of the time the baby was born. As they were trying to talk through this thing, Wow, okay, well, well, back to meconium.
Speaker 3:So we I was getting at what are some evidences that we had back in those days and before of fetal distress or of issues like that, and we realized for a long time that when a fetus passed meconium that it would be a sign, potentially, of fetal distress, but we didn't have much to do about it and it was nonspecific. And most babies that pass meconium have no issues at all and are perfectly fine, and some have significant issues or have even passed away, are perfectly fine, and some have significant issues or have even passed away. But it used to be difficult even to diagnose fetal death in utero, let alone a disease that's subtle, like chronic distress or growth restriction or infections or things like that or some issue that would warrant expedited delivery, even when we developed a method to do so. But that first method really was forceps, and so that was something available even 250 years ago, and so people were interested in was meconium an indication to do forceps delivery if it was available to you? And then eventually we got ways of inducing labor with oxytocins and things like that. That if we could only know of a baby that needed expedited delivery, who are they and how would they benefit? So meconium has played into that story for a long time, and maybe 300 years ago the most reliable predictor for a midwife or an obstetrician that might have been available about fetal status, if you will, was just fetal movement, and absent fetal movement or decreased fetal movement was something that they were aware of and would ask some others about During labor. If the membranes were ruptured, then meconium stained fluid. We knew nearly 300 years ago was a sign or a clue that there might be fetal distress. But again, what would we do about it? And in most cases meconium isn't passed until after birth. That's the normal thing. It's normally the first stool of infants.
Speaker 3:It's composed of sterile materials that pass through the fetus's digestive system, like skin cells and mucus, lanugo, amniotic fluid and bile, which gives it its characteristic dark green color. And so the word meconium is derived from a diminutive form of the Greek word mekon, which means poppy. It was a word for the poppy, so the exact reason why it was named that is unclear. So poppy flowers themselves are red, but the raw opium seed extract that's processed to make narcotics, which is something that the ancients did as well, but was later used to make, say, morphine. Well, it does have a dark green, slimy appearance that would remind you of meconium. They also, the Greeks, called this poppy juice, and so the leftover and weaker extracts from the poppy seeds. The Greeks called that. In ancient Greek they called that meconium. It was actually the same word, and the use of the word to denote the first stool of a newborn dates from at least the early 18th century when it was borrowed.
Speaker 3:Now the true etymology may be a little bit more complicated. So a lot of articles and sources will claim that Aristotle coined the word meconium and that he did this with the belief that this poppy-like substance was responsible for keeping the fetus asleep in the uterus, was responsible for keeping the fetus asleep in the uterus. So if this were true, then it might give some insight into a historically believed reason for why fetuses who swallow meconium are often depressed at birth or in some cases have even died. But that whole story seems to be dubious. Andinterpretation of a 1957 paper by a fellow named John Emory, who made these claims about Aristotle. But they were two separate and unrelated points. So for the first part, aristotle himself doesn't claim to be the coiner of the term and he actually writes in the History of Animals, book 7, section 10,. This is a quote. Moreover, the child voids excrement, sometimes at once, sometimes a little later, but in all cases during the first day, and this excrement is unduly copious in comparison with the size of the child. It's what the midwives call the meconium, or poppy juice, if you translate it. In color it resembles blood, extremely dark and pitch-like, but later on becomes milky for the child takes it once to the breast. So Aristotle seems to indicate that it was already called that by ancient midwives Not that he coined the term, but that was what was already in common use and referred to this as meconium.
Speaker 3:And other ancient writers did as well, including Hippocrates. He doesn't speak of it in of any in utero ingestion in his text, but the next sentence that he writes seems to make the observation that the fetus makes no sound while in the uterus, and the text gives no indication that he believed this was due to meconium. So this is where the idea about the fetus being asleep if it ingested it. So that seems to be a modern extraction from it. Hippocrates noted that meconium was evidence that the fetus sucks or swallows, and that was one of the interesting things If it was born with meconium in its oropharynx or in its lungs, then it must have sucked or swallowed in the womb, and so that was an observation that the ancients made, but doesn't refer to the passage of meconium and potential aspiration in the lungs as any sign of fetal distress. They didn't have that understanding. They were just more interested in what was an in utero baby doing. Could it swallow, for example? And some have attributed to Hippocrates these claims that Aristotle supposedly made about aspirating meconium and being sleepy. But again, these false sort of etymologies seem to be related to just a poor review of primary sources and some extrapolation, probably with modern eyes, something that the ancients didn't actually appreciate.
Speaker 3:Obstetricians and midwives in the 17th century did finally, though, recognize that meconium, stained amniotic fluid, indicated potential fetal distress, but most of the time it didn't matter again, because there was no opportunity to intervene. It was just something that they noted, that outcomes tended to be worse when they saw it. So a fetus who died in labor would often pass meconium before birth. And again, nothing to do, no action to do. So what we needed was a way to determine, eventually, if a fetus was even still alive when you saw meconium pass, and the most straightforward way to do this would be to hear the fetal heart beating.
Speaker 3:But the ancients, including Hippocrates, they, recognized that the sounds of internal organs, including our adult heart, could be heard by placing your ear on the skin over the organ of interest. But you can't do this with a fetal heartbeat. So, but observations of hearing the fetal heart by this method in theory were attributed in 1650 to Philippe Lagoost. But again, maybe a full-term baby and a very thin woman. Maybe he heard it. I think there's some questions about that, but it's a very hard thing to do. Woman, maybe he heard it? I think there's some questions about that, but it's a very hard thing to do.
Speaker 3:But in 1816, we got the stethoscope, which is another interesting part of medical history invented by Rene Leneck in Paris, and eventually a friend of his, a physician named Jacques Kuradek, used his stethoscope to listen to fetal heart tones and he started to write about them and characterize them, and he actually wasn't interested in this. For that purpose he was originally wanting to investigate if the mythical vagetis uterinus was a real phenomenon or not. Vagetis uterinus you might not have heard of that before, but it supposedly is the sound of a fetus crying in the womb after ruptured membrane, so airs come into the uterus and then could they take a breath and could they cry if they had air in the womb. And so people have talked about this over the centuries, reported hearing it, and it apparently is a real thing. That's happened, thing that's happened. There are some legitimate, rare cases where this seems to be confirmed, that it is possible for air to move in and out of the lungs in that situation. And so he was trying to hear that. He didn't hear it, but what he did hear was probably the placental souffle and the fetal heartbeat with his stethoscope, and this became interesting to a lot of people, including him.
Speaker 3:And in the mid-19th century, another Kennedy, not related to the president, a man named Every Kennedy, worked out a lot of details about how to use a stethoscope to monitor the condition of the fetus in labor. And then, another century after that, we get to the 1950s and the 1960s where all of a sudden we have figured out safe ways of delivering babies that might be in trouble, and there's a new emphasis on not just having the mother survive but on having the newborn survive, and also a lot of interest then on conquering cerebral palsy, which was receiving a lot of attention and was mostly attributed at the time to problems related to intrapartum events, and so we became interested in how to use electronic fetal heart monitoring to really conquer cerebral palsy and eventually, of course, ultrasounds and all the other things that we've talked about today and that are a big emphasis now to help us identify fetuses who are struggling, which is still a complicated task.
Speaker 2:Wow, fascinating journey through the history of obstetrics. So, howard, I've got to ask.
Speaker 3:so, Faggitis uterinus, you ever heard this? No, there are legitimate case reports, and it is a rare thing that has apparently legitimately been documented.
Speaker 2:I'm going to start asking all the obstetricians I work with.
Speaker 3:Yeah.
Speaker 2:I've never heard this. I'll see how many of them know about this. Maybe they'll hear this podcast and they'll be like, oh, I just got. This has been great, I've learned a lot. It's been humbling, really to think that midwives who once relied solely on absent fetal boom or meconium stain fluid as crude markers of distress, with these limited tools to intervene. And you compare that to what we have now In this history, though, that you've just gone through so beautifully, it connects us directly to the topics we've discussed today.
Speaker 2:We've looked at that JAMA Pediatrics Research Letter that started this show and the fact that over our career we've made a difference. And in fact, howard, if we want to quantify the difference you and I have made in everybody else of our generation, we've got a 30% decline in US neonatal mortality between 99 and 22. And that's driven in advancements in my end of things like surfactant therapy and improving care in the neonatal intensive care units. And we trace all these efforts back to little baby Patrick Kennedy's death back in 1963 and all the things that came out of that, and the fact that we've been able to save more and more babies ever since. We discussed those periviable babies, those 22 and 23 weekers that are surviving now and actually thriving, which is crazy, and it's in mind in your career, howard, if anybody told you 20 years ago you're going to be delivering a 22 weeker that I was going to send home and it was going to be normal, would you believe? No, no, I wouldn't have either.
Speaker 2:But now we're doing that and we've got treatments for HAE, got a better understanding of meconium aspiration syndrome. We take all this data, all that, and we've got treatments for HAE, got a better understanding of meconium aspiration syndrome. We take all this data, all these things that we've learned. We make updates to the guidelines that we use in the delivery room every day, the guidelines, and that is a marker of the progress that we continue to make.
Speaker 2:And then you and I are working together along with every other obstetrician and neonatologist in our state with the Tennessee Initiative for Perinatal Quality Care on this cord clamping project Further with the Tennessee's Tiniest Babies, and overall we're just demonstrating how our two fields neonatology and obstetrics have to work together as a team so we can improve the protocols in our current understanding and ultimately continue to improve outcomes for the mothers and babies. So, man, howard, thank you for inviting me to join your podcast. I have enjoyed it. Hopefully your audience has learned a little something from me. I know I have learned something from you. I hope we continue to collaborate not just me and you on stuff together, but all the obstetricians. Reach out to your neonatologist and see what you can do to work on, to collaborate together, share the knowledge, work together and help to get more babies to survive and thrive.
Speaker 3:Yeah, maybe in 15 years we'll do an episode on artificial womb technologies and how that's impacted NICU technology.
Speaker 2:They've done that in animals. They've done that in sheep and in pigs. It's absolutely amazing.
Speaker 3:Human trials starting in the next couple of years, supposedly.
Speaker 2:Yep, yep, that'll be really interesting to see how that goes.
Speaker 3:The future is interesting, but yes, it is Well. Thanks for being on and we'll have you back on sometime. Maybe we should talk about neonatal abstinence syndrome and some of those things at some point too.
Speaker 2:Yep Sounds good. Hey, thank you so much, howard, appreciate it.
Speaker 1:Thanks for listening. Be sure to check out thinkingaboutobgyncom for more information and be sure to follow us on Instagram. We'll be back in two weeks.