DISCUSSION

Premature birth can and does happen unexpectedly in the emergency department, even when the patient denies a history of pregnancy. It is estimated that for 1 in every 475 cases, the mother is unaware of the pregnancy at 20 weeks gestation.^{Reference Wessel and Buscher2} Negative sequelae can result when emergency department staff, including nurses, physicians, and respiratory therapists, are underprepared for deliveries. When birth occurs, staff must be prepared to manage both the neonate and the mother simultaneously. Emergency departments should, therefore, consider having a checklist of equipment and supplies needed, in addition to a birth delivery action plan, with separate teams assigned to the mother and neonate.^{Reference Gupta and Adler3}

Given that premature neonates are at increased risk of hypothermia, the Canadian Paediatric Society offers a variety of strategies to control thermoregulation for infants less than 32 weeks gestational age. These include using a hat, preheated radiant heater, polyethylene wrap, and a thermal mattress.^{Reference Finan, Campbell, Aziz and McNamara4} In this case, the neonate was placed in cellophane wrap until an incubator was located.

Moving forward, all personnel working in an emergency department should be up-to-date on the Neonatal Resuscitation Program offered by the Canadian Paediatric Society.⁵ The updated Neonatal Resuscitation Program algorithm should be readily available and followed during neonatal resuscitation in the emergency department. In this case report, an initial pulse was indeterminate. Research recommends that ventilation efforts need to be made before beginning CPR as neonatal resuscitation is often secondary to a respiratory etiology.^{Reference Finan, Campbell, Aziz and McNamara4,Reference Reuter, Moser and Baack6} Moreover, we recommend simulation sessions be used to help prepare emergency medicine staff to be comfortable following neonatal resuscitation guidelines; research suggests that these sessions can be an effective teaching tool.^{Reference Patel, Posencheg and Ades7,Reference Rubio-Gurung, Putet and Touzet8}

The hospital where this case took place did not have a neonatologist on staff, and the pediatrician on call was not in-house when initially consulted. Anesthesia was not involved in the intubation of this patient. The potential difficulty in managing a neonatal airway necessitates early use of the most experienced care provider. Research shows that the use of a laryngeal mask airway may be an alternative to an endotracheal tube; however, evidence for this is lacking in neonates <34 weeks’ gestational age or birth weight <1,500 g.^{Reference Wanous, Wey, Rudser and Roberts9,Reference Bansal, Caoci, Dempsey, Trevisanuto and Roehr10}

This case also exemplifies some challenges faced when working in hospitals geographically detached from larger centers. The neonate's transfer to a specialized pediatric center was delayed for more than 6 hours because of a winter storm. This highlights the importance of emergency staff who work in rural contexts to have the clinical confidence to help manage unstable neonates.