Neonatal Resuscitation Provider

VVC Perinatal Class

Neonatal Resuscitation Provider

ObjectivesIntroductionPreparing for a deliveryNRP Flow sheet/resuscitationDelivery room procedures/MeconiumPPV/Use of OxygenChest compressionsCPAPIntubationMedicationsSpecial considerations/Pre-term babiesEthical considerations

IntroductionApproximately 10% of newborns require some

assistance to begin breathing at birth. 100% of newborns require initial assessment after birth

Less than 1% require extensive resuscitative measures. Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births, a sizable number will require some degree of resuscitation.

Must decipher between primary and secondary apneaNewborns who experience secondary apnea usually

respond with an increase in heart rate after effective positive-pressure ventilation

IntroductionNormal transition to external uterine life

begins when the systemic blood pressure is increased when the low-resistance placental circuit is removed by umbilical cord clamping.

RT’s attend all high risk deliveries and also most if not all C-sections

Each decision made during a resuscitation of a newborn is done so in 30 second intervals (vastly different from PALS or ACLS)

IntroductionThe most important and effective action in a

neonate requiring resuscitation = Ventilating the lungs

When resuscitation is anticipated, additional personnel will be in the delivery room before birth, this includes RT’s, RN’s and MD’s

Evaluation and decision making during resuscitation are primarily based on: Respiration rate, heart rate, color

A cry following birth typically represents the neonate has a adequate heart rate and respiratory effort (it does not necessarily mean the ventilation/oxygenation is adequate however)

Introduction Those newly born infants who do not require resuscitation can

generally be identified by a rapid assessment of the following 3 characteristics: Term gestation?Crying or breathing?Good muscle tone?

If the answer to all 3 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing.

If the answer to any of these assessment questions is “no,” the infant should receive one or more of the following 4 categories of action in sequence:

Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate)

VentilationChest compressionsAdministration of epinephrine and/or volume expansion

Preparation Anticipation, adequate preparation, accurate evaluation, and

prompt initiation of support are critical for successful neonatal resuscitation.

At every delivery there should be at least 1 person whose primary responsibility is the newly born. This person must be capable of initiating resuscitation, including administration of positive-pressure ventilation, intubation and chest compressions.

Factors to keep in consideration at every delivery:Gestational age of baby?Age of mother?Single or multiple births?Meconium present?Prenatal care?Known risk factors (smoking, drugs, alcohol)Know congenital factors such as heart defects, gastroschisis,

CDH… Intrapartum factors such as placenta previa, abruption,

preclampsia, infection….Did the mother receive sedation…

Preparation Know history of mother before delivery: Para? Gravida? Gestational age? Infections? Sedation?

Drug Abuse? Smoke or Drink? Abnormalities already predetermined? Previa/abrution? Eclampsia? Age of mother (Old or too young)? First baby? Socioeconomic status? Vital signs?

Know if baby received steroids before delivery (beclamethosone) or Magnesium.

Know if Mother has been given antibiotics for Strep B Know presentation of baby: Breech/transverse, normal…

(breech will make for a more difficult delivery) Know L:S ratio if there is one, or PG, PC Is this a C-Section? If so why Know if mother has ruptured membranes is it PROM, is she

dilated? Is the baby effaced? Did the mother receive Tocolytic agents? Are there decels? If so what is the severity?

PreparationSetup the warmer, ensure your PPV is working

and have your supplies ready including:Endotracheal tubes (size 2.5-3.5) and blades

(Miller 00,0,1)Tape, scissors, suction supplies (5/6, 8, 10 F),

meconium aspiratorVarying sized masks (premie, normal)Pulse ox probeBulb syringeWarm blanketsETT holders and ETCO2Medication box (nurse), umbilical cord clampUVC kit (Nurse will bring)Surfactant if anticipated useVentilator, CPAP…

PreparationIf a preterm delivery (<37 weeks of gestation) is

expected, special preparations will be required. Preterm babies have immature lungs that may be

more difficult to ventilate and are also more vulnerable to injury by positive-pressure ventilation.

Preterm babies also have immature blood vessels in the brain that are prone to hemorrhage; thin skin and a large surface area, which contribute to rapid heat loss; increased susceptibility to infection; and increased risk of hypovolemic shock related to small blood volume.

Potential risk factorsProlapsed cord

The umbilical cord is delivered (passed through the cervix) before the infant. This compromises the blood flow to the infant due to the compression of the cord.

Placenta previa The placenta covers the cervical opening, preventing the

infant from passing through the cervix. A Cesarean delivery is usually required. This is usually associated with advanced maternal age, multiple gestation and prior Cesarean deliveries.

Placental abruption The placenta separates from the uterine wall before the

infant is born. This leads to bleeding from the infant and places the infant and mother at risk, (watch for DIC).

Fetal Bradycardia Deceleration of the fetus' heart rate can indicate the

impact of contractions or a more serious insult such as nuchal cord.

Neonatal Resuscitation Airway

Provide warmth. A radiant warmer should be warm and available for all deliveries.

Position the head and clear the airway as necessary. Dry and stimulate the baby to breathe (rub back vigorously or tap soles of

feet). Evaluate respirations, heart rate and color; give oxygen as needed.

Breathing If the baby is apneic, or heart rate is less than 100 bpm: Provide positive pressure ventilation with a resuscitation bag and 100%

oxygen. The resuscitation mask should be chosen based on the size of the infant.

The mask should fit from the bridge of the nose to the chin, but not covering the eyes. A good seal with the mask is necessary for resuscitation.

Circulation If the heart rate is less than 60 bpm (HR checked at umbilical stump): Give chest compressions as you continue to provide positive pressure

ventilation with 100% oxygen. Give chest compressions at a rate of 3 compressions to every

breath, resulting in 90 compressions per minute, and 30 ventilations per minute

Delivery Room Procedures

Delivery Room Procedures

To stimulate a newborn:flick soles of feetWarm with a warm blanketRub back of newborn

An apneic newborn has not responded to suctioning, drying, and rubbing of the back. What is the appropriate next action?PPV

Example Delivery room procedureA 29 year old mother with a 28 week

gestation presents to the L & D with suspected placental abruption. The mother is para 2 and gravida 1, she has moderate bleeding

What equipment would you prepare?What personnel would you want on hand?What are the possible risk factors for the

neonate?

Example Delivery room procedureThe neonate is born without a cry, he is

limp with poor muscle tone and color, HR is 89What is your first action?If HR does not increase over 100 during PPV

what is your next step of action?If the heart rate does not improve above 60

what is your next step of action? Would you consider intubation before

compressions?

Neonatal Resuscitation Initial StepsThe initial steps of resuscitation are to provide warmth by

placing the baby under a radiant heat source, positioning the head in a “sniffing” position to open the airway, clearing the airway if necessary with a bulb syringe or suction catheter, drying the baby, and stimulating breathing.

Assess respirations, muscle tone, heart rate If HR is less than 100 beats per minute (bpm), or if

newborn is apneic or gasping, begin positive pressure ventilation. If HR is more than 100 and respirations are labored, consider CPAP, especially for preterm newborns

Evaluate oxygenation (by pulse ox), right hand as needed

Neonatal ResuscitationAfter ensuring effective ventilation, if heart rate remains below 60

bpm, despite 30 seconds of effective ventilation, provide chest compressions and continue assisted ventilation.

Intubation is strongly recommended when chest compressions begin, if not already done

Increase oxygen concentration to 100% when chest compressions begin

Continue chest compressions coordinated with effective ventilation for at least 45-60 seconds before assessing heart rate (*used to be 30 sec)

If heart rate remains <60 bpm after 45-60 sec of chest compressions coordinated with effective ventilation, administer epinephrine.

Insert emergency umbilical venous catheter for administration of epinephrine

The intratracheal route of epinephrine results in lower and less predictable blood levels that are often not effective, but this route is acceptable while the umbilical venous line is being placed

If the newborn appears to be in shock and is not responding to resuscitation, administration of a volume expander may be indicated.

Meconium Aspiration

Thin-consistency meconium-stained amniotic fluid is noted in a term newborn. Following birth, you observe thenewborn to be pale and limp (low tone) without respiratory effort. What should be done next?

Meconium Aspiration Aspiration of meconium before delivery, during

birth, or during resuscitation can cause severe meconium aspiration syndrome (MAS).

Suctioning of the oropharynx before delivery of the shoulders was considered routine until a randomized controlled trial demonstrated it to be of no value.

Elective and routine endotracheal intubation and direct suctioning of the trachea were initially recommended for all meconium-stained newborns until a randomized controlled trial demonstrated that there was no value in performing this procedure in babies who were vigorous at birth.

Meconium Aspiration Although depressed infants born to mothers

with meconium-stained amniotic fluid (MSAF) are at increased risk to develop MAS, tracheal suctioning has not been associated with reduction in the incidence of MAS or mortality in these infants.

Vigorous newborns should undergo routine delivery room procedure, The term "vigorous" is defined by:Heart rate more than 100 beats per minute,

strong respiratory efforts, good muscle tonehttp://www.youtube.com/watch?v=Hx1lLopbrtY

Neonatal Resuscitation-PPV

Neonatal Resuscitation-PPVPositive Pressure Ventilation (PPV):

Indicated for Apnea/gasping, HR below 100 bpm even if breathing, persistent central cyanosis and low oxygen saturation despite free flow oxygen increased to 100%

All PPV devices require a integral pressure gauge or if there is a site for attaching a pressure gauge (manometer) it should be attached

Effective ventilation is defined by the presence of bilateral breath sounds, chest movement (HR may rise without visible chest movement, especially in preterm newborns)

Start with inspiratory pressures of about 20 cm H2O at a rate of about 40-60 breaths/minute. Avoid excessive chest movement.

A pressure release ("pop-off") valve is present on all PPV devices to avoid excessive pressure

http://www.youtube.com/watch?v=RPul1Ybr-Ro


NeoPuff: Pressure pop off set on device. Can supply CPAP when hole is not covered or blow by oxygen. The operator sets the maximum circuit pressure, peak inspiratory pressure, and positive end-expiratory pressure.


Self inflating bags: They fill spontaneously after they are squeezed. If used ensure a an oxygen reservoir is attached to reach 90-100% FIO2.


Flow inflating bag: Ideal, can assess chest compliance. It fills only when gas from a compressed source flows into it. Can supply CPAP when not bagging or free flow oxygen. Possible malfunction = hole in the bag, improper seal on patient

Neonatal Resuscitation-PPVUse lowest inflation pressure necessary to maintain a heart

rate of >100 and a gradually improving oxygen saturationAssess for rising heart rate and improving oxygen saturation;

if not evident (within 5-10 breaths) assess bilateral breath sounds and chest movement.

If these are not immediately evident, perform as many ventilation corrective steps as needed. The acronym “MR SOPA” may be used to remember the sequence of ventilation steps:M: Adjust the MASK on the faceR: REPOSITION the head to ensure an open airwayS: SUCTION the mouth and noseO: Ventilate the baby’s mouth slightly OPEN and lift the

jaw forwardP: Gradually increase the PRESSURE every few breaths

(use caution, max 40 cmH2O) until there is bilateral breath sounds and visible chest movement

A: Consider airway ALTERNATIVE (ETT or LMA)


Ensure proper mask size

Neonatal Resuscitation-PPVThe NRP recommends use of 100%

supplemental oxygen when positive-pressure ventilation is required during resuscitation of term newborns.

For excessive PPV insert a OG tube:Measure the length of the feeding tube to

be inserted:Use the feeding tube to measure from the tip

of the nose to the ear lobe and from the ear lobe to a point midway between the tip of the breastbone and the navel


7 cm

12 cm

Example: For correct insertion depth of OG tube add 7 and 12 = 19 cm would be insertion depth

Neonatal Resuscitation-PPVIf HR is more than 60 bpm but less than 100 bpm,

continue to administer effective positive pressure ventilation as long as the baby is showing steady improvement

If HR is persistently more than 60 bpm, but less than 100 bpm, ensure effective ventilation, call complications such as a pneumothorax or hypovolemia

If HR is below 60 bpm despite 30 seconds of effective PPV ventilation (defined by audible bilateral breath sounds and chest movement) begin chest compressionsNote presence of CDH during

bagging

PPVThere is no physiologic improvement

and no perceptible chest expansion. What would be an appropriate action?

Reposition the headYou have performed the correct

maneuvers described in the above question and the baby is still not improving and the chest wall is not moving. What else should you do?

Recheck or replace the resuscitation bag.

Use of Oxygen and Pulse Oximetry

Compressed air source and oxygen blender and a pulse oximeter should be available in the immediate delivery area for every birth

There is ongoing controversy about how much oxygen to use during neonatal resuscitation

Resuscitation of term newborns may begin with 21% oxygen; resuscitation of preterm newborns may begin with a somewhat higher oxygen concentration (30-40%)

Use of Oxygen and Pulse Oximetry

Use of oximetry:Resuscitation is anticipatedPPV is required for more than a few breathsCentral cyanosis is persistent, or you need to confirm

your perception of central cynanosisSupplemental oxygen is administeredDo not delay resuscitation efforts for a pulse ox readingPlace probe on the newborns right hand or wrist

(measure pre-ductal saturation) Avoid saturations exceeding 95% It may take up to 10 minutes for a healthy newborn to

increase saturation to the normal range of over 90%. If persistent cyanosis is visible, confirm a low saturation with pulse ox and adjust the supplemental O2 to achieve the target values for the pre-ductal saturations

Use of Oxygen and Pulse OximetryMethods of administering free-flow

oxygen to a babyHold an oxygen mask firmly over the

baby's faceHold oxygen tubing cupped closely in

your hand over the baby's mouth and nose.

Hold a mask from a flow-inflating bag closely over the baby's mouth and nose.

Neonatal Resuscitation-Chest Compressions

Ensure effective ventilation prior to beginning chest compressions

Chest compressions are indicated whenever the heart rate is below 60 bpm, despite at least 30 seconds of effective positive pressure ventilation

The 2 techniques are the thumb technique and the 2-finger technique; however, the thumb technique is preferred and should be used in most situations

Use enough pressure to depress the sternum to a depth of approximately one third of the anterior-posterior diameter of the chest


When the HR is below 60 bpm, the oximeter may not work. Increase the oxygen concentration to 100% until the oximeter is giving a reliable signal and can guide the appropriate adjustment of supplemental oxygen

Use 3 compressions plus 1 ventilation, resulting in approximately 120 “events” per 60 seconds (90 compressions plus 30 breaths)

Chest compressions circulate blood to the vital organs

"One-and-Two-and-Three-and-Breathe-and..” Fracturing ribs is still a concern during neonatal CPR


Intubation is strongly recommended when chest compressions begin to help ensure effective ventilation

Interruption of chest compressions to check heart rate may result in decrease of perfusion pressure in the coronary arteries. Therefore, continue chest and coordinated ventilations for at least 45-60 seconds before stopping briefly to assess the HR

Assess HR at umbilical stumpIf you anticipate the need to place a UVC continue

compressions by moving the head of the bed near the newborns head and continuing the thumb technique.

Insert an umbilical catheter, administer epinephrine, and consider intubation if not already done after 30 seconds of compressions

Discontinue compressions when the HR rises above 60, continue PPV until HR is above 100

Neonatal Resuscitation-CPAP

Neonatal Resuscitation-CPAPCPAP is the administration of continuous

positive airway pressure (CPAP) to infants who are breathing spontaneously, but with difficulty, following birth

Starting infants on CPAP reduces the rates of intubation and mechanical ventilation, surfactant use, and duration of ventilation, but increases the rate of pneumothorax.

Spontaneously breathing preterm infants who have respiratory distress may be supported with CPAP or with intubation and mechanical ventilation

PPV/CPAP and CPRBreak up into two groupsGROUP 1. Practice PPV using a flow inflating bag and

maskProvide CPAP

GROUP 2. Practice chest compression and

resuscitation

Neonatal Resuscitation-Intubation

http://www.youtube.com/watch?v=fGXddPdEsu8&feature=related

Neonatal Resuscitation-IntubationYou have about 20 seconds to intubate a newbornIndicated for ineffective or prolonged bag-and-mask

ventilation and also for non-vigorous meconiumTo intubate:

Stabilize the baby's head in the "sniffing" position, deliver free-flow oxygen during the procedure, hold the laryngoscope in the left hand

Insert the tube into the sight side of the mouth, with the curve of the tube lying in the horizontal plane

Always pull up and outward, be sure not to use the newborns upper lip/teeth as a folcrum, if cords can not be seem immediately pull back on blade

Use a CO2 detector indicates the presence of expired C02.


Only experience and well practiced clinicians should attempt to intubate


Vocal cords

Glottic opening

EpiglottisValecula Space

Neonatal Resuscitation-IntubationETT Size based on size of babyThe primary methods of proper ETT placement

are an increasing heart rate and carbon dioxide detection.

Tube placement is also determined by the baby's birth weight.

Formula: add six to the baby's weight (in kg). Example: 2 kg baby

6 + 2 = 8 cm at gums

Weight ETT size

<1.0 Kg 2.5

1.0-2.0 Kg 3.0

2.0-3.0 Kg 3.5

>3.0 Kg 4.0

Intubation and Scenario PracticeBreak up into two groupsGROUP 1. Practice Intubation and oral airway

insertion

GROUP 2. Practice with labor room scenarios

Neonatal Resuscitation-DrugsDrugs

If the heart rate is less than 60 bpm after 30 seconds of assisted ventilation and another 30 seconds of chest compressions and assisted ventilation: Administer epinephrine while continuing chest

compressions and assisted ventilation. (Endotracheal intubation should be considered as prolonged ventilation becomes apparent)

Best route of administration is a UVC

Neonatal Resuscitation-DrugsIntratracheal epinephrine via the

endotracheal tube should be considered while the umbilical venous catheter is being placed

Neonatal Resuscitation-DrugsEpinephrine

If HR remains below 60 despite ongoing effective PPV and compressions after 45-60 seconds

Give as quickly/rapidly as possibleGiven preferably through UVC, may be given down ETT

while UVC is being placed IO is controversial in premature newborns but may be an

alternativeConcentration: 1:10,000 solution (0.1 mg/ml)Give rapidly/quick as possible IV dose: 0.1-0.3 ml/kg of 1:10,000 solution per UVC in a 1

ml syringeFollow with 0.5-1 ml saline flushETT dose: 0.5-1 ml/kg of 1:10,000 soln in a 3-6 ml syringeCheck HR about 1 minute after administration

Repeated every 3-5 minutes

UVC

http://www.youtube.com/watch?v=JjBJONanCYU

Neonatal Resuscitation-DrugsVolume Administration

Indicated for newborns not responding to resuscitation and newborn appears in shock

Or there is a HX of a condition associated with fetal blood loss (abruption)

May be given for persistent bradycardiaVolume expanders: NS, Ringers lactate, O Rh-

negative PRBCsDose: 10 ml/kgRoute: UVC only with large syringeOver 5-10 minutes

Neonatal Resuscitation-DrugsNaloxone: Administration of naloxone is not

recommended as part of initial resuscitative efforts in the delivery room for newborns with respiratory depression. Heart rate and oxygenation should be restored by supporting ventilation. Used for continued respiratory depression, after positive-pressure ventilation has restored a normal heart rate and color and there is a known history of maternal narcotic administration within the previous 4 hours.

Glucose: Newborns with lower blood glucose levels are at increased risk for brain injury and adverse outcomes after a hypoxic-ischemic insult. Intravenous glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia

Special ConsiderationsTherapeutic hypothermia following perinatal asphyxia

should be used only for babies >36 weeks gestation who meet previously defined criteria for this therapy

Initiated before 6 hrs after birthUsed only by centers with specialized programs

equipped to provide the therapyVery low birth weight (<1500 g) preterm infants are

likely to become hypothermic despite the use of traditional techniques for decreasing heat loss. For this reason it is recommended that additional warming techniques be used, such as covering the infant in plastic wrapping (food-grade, heat-resistant plastic) and placing him or her under radiant heat. Temperature must be monitored closely because of the slight but described risk of hyperthermia with this technique

Special ConsiderationsChoanal atresia: Placement of an oral airway

Narcotic for analgesia before delivery: PPV first, before Narcone

Pneumothorax: Identify with Transillumination, tx with percutaneous catheter or needle into the pleural space

Special Considerations

Transillumination

Special ConsiderationsCongenital diaphragmatic hernia: flat (scaphoid) abdomen, intestines fill space of left or right lung. Intubate ASAP/insert OG

Pierre Robin (or Robin) syndrome:small mandible (jaw). Place the baby prone and insert a nasopharyngeal tube

Preterm BabyHave trained personnel on hand- able to intubate,

place UVCIf facility is not equipped to handle premature

newborn have transport team ready/calledKeep preterm baby warm, increase temp of the

delivery room and area where baby will be resuscitated to approximately 25-26 C (77-79 F)

Use polyethylene plastic wrap for babies delivered at less than 29 weeks gestation (or 28 weeks or less). Use a sheet of plastic food wrap, a food grade 1-gallon plastic bag or a commercially available sheet of polyethylene plastic

Place a portable warming pad under layers of towels on the resuscitation table

Preterm BabyCommon Characteristics:

Weak muscles and surfactant deficiency, making adequate ventilation more difficult (avoid excessive pressures)

Infection post resuscitation is commonThe baby should be monitored for apnea and bradycardiaBabies who require resuscitation are at risk for deterioration

after their vital signs have returned to normal. Management includes monitoring and controlling blood

sugar, watch for IVH, ROP and sepsisAfter 5 to 10 minutes, attempt to maintain oxygen

saturations in the 85% to 95% rangeGive feedings slowly and cautiously while maintaining

nutrition intravenously

Ethical ConsiderationsDiscontinuation of life support should be

considered after 10 minutes of absent heart rate. The decision to continue beyond 10 minutes should take into considerations factors such as gestational age, etiology of arrest, complications, parents previously expressed feelings about acceptable risk

It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement.

Ethical Considerations The ethical principles should be no different from those of an

older child or adult. A consistent and coordinated approach to individual cases by the

obstetric and neonatal teams and the parents is an important goal. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely.

When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated.

GA equal to or less than 23 weeks or gestational weight less than 500 grams

Surrogate decision maker(s) for a newborn in most cases are the parents

The parents' views on either initiating or withholding resuscitation should be supported.

Mega Code and TestingThe test comprises of 9 LessonsThe mega code is done as a group followed

by a debriefing

Neonatal Resuscitation Provider

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