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. 2000 Apr 1;320(7239):937.

Care of newborn infants in delivery room

Two clarifications

C Deakin 1
PMCID: PMC1117849  PMID: 10742014

Editor—Two points need clarification in the article by Hamilton on caring for newborn infants in the delivery room in the ABC of labour care.1

Firstly, the diagram entitled “Correct positioning of the laryngoscope” (p 1404) does not show the laryngoscope correctly positioned. Straightbladed paediatric laryngoscopes are designed to be inserted beyond the epiglottis, which is then lifted by the tip of the blade to expose the vocal cords. The figure shows the correct positioning using this type of straight blade.2 An alternative technique, as used in adults, is to insert the tip of the blade into the vallecula at the base of the epiglottis (further than shown in the diagram), which lifts the epiglottis to reveal the vocal cords beneath.2

Secondly, Hamilton discussed the insertion of shouldered endotracheal (Coles) tubes. These tubes have previously been widely used in neonatal resuscitation because they were thought to reduce the risk of endobronchial intubation and reduce airway resistance. However, it is now thought that the shoulder may not only accentuate cricoid oedema but also cause turbulence and therefore increase airway resistance. The use of shouldered tubes is therefore no longer recommended.2

Figure.

Figure

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Orotracheal intubation using straightblade laryngoscope2

References

  • 1.Hamilton P. Care of the newborn in the delivery room. BMJ. 1999;318:1403–1406. doi: 10.1136/bmj.318.7195.1403. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Advanced Life Support Group. Advanced paediatric life support. London: BMJ Publishing Group; 1993. [Google Scholar]
BMJ. 2000 Apr 1;320(7239):937.

Author's reply

Patricia Hamilton 1

Editor—I thank Deakin for his comments. The figure illustrating correct positioning of the laryngoscope was supposed to illustrate the second of the two acceptable techniques described by him. Perhaps the figure could have shown the blade inserted a few millimetres further, as he suggests, but some clarity would then be lost. The text makes it quite clear that both of the methods, as in Deakin's letter, are acceptable, and I do not think that we have any point of difference here. Deakin's illustration seems to me a little confusing as it does not indicate the position of the oesophagus.

With regard to shoulder tubes, I did not particularly recommend their use, but I did not wish to dissuade people from using tubes to which they are accustomed. We are merely discussing resuscitation in this instance and not prolonged ventilation. The very small tubes used for resuscitation of newborn infants are likely to have turbulence in any case. I am not aware of any evidence that resuscitation is any less successful using a shoulder tube, and indeed a study performed by the Thames Region Perinatal Group showed no difference in the incidence of subsequent subglottic stenosis in neonates who had been intubated with either shouldered or straight sided tubes (R Rivers, personal communication).

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