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Newborn Care
andResuscitation
Joseph J. Mistovich, M.Ed, NREMT-P
Chair and Professor
Department of Health Professions
Youngstown State UniversityYoungstown, Ohio
jjmistovich@ysu.edu
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Neonatal Resuscitation
Newly born
infant at time of birth
Newborn within first few hours of birth
Neonate within first 30 days of delivery
Pre-term less than 37 weeks of gestation
Term 38 to 42 weeks of gestation
Post-term (post-date) greater than 42
weeks of gestation
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General Pathophysiology and
Assessment
Approximately 10% of newborns require
assistance to begin breathing
Extensive resuscitation needed in less than 1%
of newborns Rate of complication increases as the newborn
weight and gestational agedecrease
80% of 30,000 babies born each year weighingless than 3 lbs. (1,500 grams) require
resuscitation
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Antepartum Risk Factors
Multiple gestation
Pregnant patient 35 years of age
Post-term >42 weeks
Preeclampsia, HTN,
DM
Polyhydraminos
Premature rupture of
amniotic sac (PROM)
Fetal malformation
Inadequate prenatal
care
History of prenatalmorbidity or mortality
Maternal use of drugs
or alcohol Fetal anemia
Oligohydraminos
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Intrapartum Risk Factors
Premature labor
PROM >24 hours
Abnormal
presentation
Prolapsed cord
Chorioamnionitis
Meconium-stained
amniotic fluid
Use of narcotics
within 4 hours ofdelivery
Prolonged labor
Precipitous delivery Bleeding
Placenta previa
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Fetal Transition
Rapid process that allows baby to breathe Fetal lung is collapsed and filled with fluid
Reduction in pulmonary resistance
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Causes of Delayed Fetal Transition
Hypoxia
Meconuium aspiration
Blood aspiration Acidosis
Hypothermia
Pneumonia Hypotension
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Newborn Resuscitation
Recommendations are primarily for
neonates transitioning to extrauterine life
Also applicable to neonates and infants
during the first few weeks to months
following birth
2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care
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Arrival of the Newborn
Key questions Mothers age
Length of pregnancy (due date)
Presence and frequency of contractions
Presence of or absence of fetal movement
Any pregnancy complications (DM, HTN, fever)
Rupture of membranes
When?
Color? (clear, meconium, blood)
Any medications that have been taken
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Arrival of the Newborn
Suction* when the head is delivered
Nose
Mouth
Keep the baby at the same level as the
mother
Neonate turned to side if copious
secretions
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Suctioning
Clear Amniotic Fluid Recommendation that suctioning
immediately following birth including with a
bulb syringe should only be done in babies
who have obvious obstruction tospontaneous breathing or require PPV
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care
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Suctioning
Clear Amniotic Fluid Suctioning the nasopharynx can cause
bradycardia
Suctioning the trachea in intubated babies
Decreases pulmonary compliance
Decreases oxygenation
Reduces cerebral blood flow
If secretions are present, suctioning must
be performed.2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
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Clamp and Cut Cord
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Special Consideration
Polycythemia (escessive red blood cell
count)
Delay in clamping the cord
Placing the infant below the placenta
Do not milk the cord
Destroy or distort RBCs
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Initial Assessment
Respiratory rate (Cry)
Respiratory effort (Cry)
Pulse rate Oxygenation
Color
SpO2
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Assess Neonate
Nearly 90% of newborns are vigorous termbabies
Ensure thermoregulation
Dry Warm
Place on mothers chest (skin to skin)
Suction only if necessary
Assess ventilation (cry) Asses heart rate
Assess oxygenation (color and SpO2)
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Apgar Score
Determines need and effectiveness of
resuscitation
Performed 1 minute and 5 minutes after
birth
If 5 minute Apgar is less than 7, reassess
every 5 minutes for 20 minutes
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APGAR Score
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Need for Resuscitation
Approximately 10% of newborns require
additional assistance
1% requires major resuscitation
Resuscitation
Intervene Reassess Intervene
Reassess
30 second intervals
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Initial Steps of Resuscitation
Routine Care IfYES to the followingquestions
Term gestation?
Amniotic fluid clear? Breathing or crying?
Good muscle tone? Dry
Provide warmth (skin-to-skin)
Cover
Assess color, breathing, acivity
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Initial Steps of Resuscitation
Resuscitative Care IfNOto the followingquestions
Term gestation?
Amniotic fluid clear?
Breathing or crying? Good muscle tone?
Provide warmth
Position sniffing position
Clear airway (meconium consideration)
Dry and stimulate
PPV
Chest compressions
Epinephrine or volume expansion
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Stimulate
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Initial Steps (Golden Minute)
Approximately 60 seconds to complete,
reevaluate, and ventilate if necessary
Provide warmth
Clear airway
Dry
Stimulate
Position - sniffing
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Initial Steps (Golden Minute)
Decision to proceed beyond initial steps isbased on evaluation of:
Respirations
Apnea Gasping
Labored breathing
Heart rate
Less than 100 bpm
Auscultation of precordial pulse
Palpation of umbilical pulse
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Assessment After PPV or
Supplemental Oxygenation Evaluate
Heart rate
Respirations
Oxygenation
Most sensitive indicator of successful
response is an increase in heart rate
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Assessment of Oxygen Need
and Oxygen Administration Blood oxygen levels do not reach extrauterine
values in uncompromised babies until
approximately 10 minutes after birth
Cyanosis may appear until that point (10minutes)
Skin color is very poor indicator of oxygen
saturation immediately after birth
Lack of cyanosis is a very poor indicator state of
oxygenation in uncompromised baby
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Neonatal Pulse Oximetry
New pulse oximeters with neonatal probes
Provide reliable readings within 1 to 2 minutes
following birth
Must have sufficient cardiac output to skin
SpO2 recommended
Resuscitation anticipated
PPV for more than a few breaths
Persistent cyanosis
Supplemental oxygen is administered
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Neonatal Pulse Oximetry
Probe location
Right upper extremity
Medial surface of the palm
Wrist
Attach probe to baby prior to device
More rapid acquisition of signal
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PPV and Supplemental Oxygen
100% oxygen administration is not
recommended
Titrate oxygen to SpO2 range
Initiate resuscitation with airif blended
oxygen is not available
If bradycardia persists (HR
100 bpm
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Targeted SpO2 After Birth
1 minute 60 to 65%
2 minutes 65 to 70%
3 minutes 70 to 75% 4 minutes 75 to 80%
5 minutes 80 to 85%
10 minutes 85 to 95%
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Newborn Intervention Triggers
Secretions = suction
Apnea or gasping respirations = PPV
Labored breathing or low SpO2 = oxygenor CPAP
HR< 100 bpm = PPV
HR< 60 = Chest compressions and PPV Persistent HR< 60 = epinephrine
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Evaluate Respiration, HR,
Oxygenation Breathing adequate (rate and effort)
No apnea
No gasping
No labored breathing
HR >100 bpm
SpO2 in normal range
Observe and suction only to keep airway
clear
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Evaluate Respiration, HR, Color
Breathing adequate
HR >100 bpm
Core cyanosis is persistent
Low SpO2 reading
Provide blow by oxygen
Warm and humidify oxygen
5 lpm
Do not blow directly in eyes or trigeminal area
of face
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Evaluate Respiration, HR, Color
Breathing adequate
HR >100 bpm
Acrocyanosis with normal SpO2
No intervention
If acrocyanosis with poor SpO2 provideblow-by O2
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Evaluate Respiration, HR, SpO2
Breathing inadequate Gasping or apnea
HR >100 bpm
Good pink or normal SpO2
Positive pressure ventilation Infant size (240 ml)
5 to 8 ml/kg VT Disable pop-off (30 to 40 cmH20)
40 to 60 ventilations/minute
Peak inspiratory pressure 25 cmH2O in full-term
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CPAP
Breathing spontaneously but labored
HR> 100 bpm
SpO2 normal or low
Research lacking only studied in preterm
babies
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Evaluate Respiration, HR, Color
Breathing adequate
HR
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Evaluate Respiration, HR, Color
Breathing adequate
HR < 60 bpm
SpO2 not adequate
PPV Chest compressions
Depth 1/3 of anteroposterior diameter of chest
Two thumbs over sternum with hands encircling chest
3 compressions to one ventilation Compression rate 120/minute
90 compressions and 30 ventilations in one minute
After 30 seconds of compressions andventilation consider epinephrine
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Persistent Bradycardia
Usually due to
Inadequate lung inflation
Profound hypoxemia
Primary emergency intervention
Adequate ventilation
HR remains < 60 bpm with 100% oxygen
Consider epinephrine
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Epinephrine Administration
Intravenous route is recommended only
0.01 to 0.03 mg/kg
1:10,000 dilution
If ET route is used
0.05 to 0.1 mg/kg
1:10,000 dilution
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Volume Expansion
Blood loss known or suspected
Pale skin
Poor perfusion
Weak pulse
HR not responding to other interventions
Isotonic crystalloid
10 mL/kg
Avoid rapid infusion in premature infants
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Oral Airways
Rarely used for neonates
Use tongue depressor to insert airway
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Respiratory Distress or Inadequacy
HR < 100 bpm = hypoxia
Periodic breathing (20 second or longer
period of apnea)
Intercostal retractions
Nasal flaring
Grunting
Meconium Stained Amniotic Fluid
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Meconium Stained Amniotic Fluid(MSAF)
10 to 15% of deliveries
High risk of morbidity
Passage may occur before or duringdelivery
More common in post-term infants and
neonates small for the gestational age
Fetus normally does not pass stool prior to
brith
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Meconium Stained Amniotic Fluid
Complications if aspirated Meconium
Aspiration Syndrome (MAS)
Atelectasis
Persistent pulmonary hypertension
Pneumonitis
Pneumothorax
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Meconium Stained Amniotic Fluid
Determine if fluid is thin and green or thick andparticulate
If baby is crying vigorously use standard
resuscitation criteria
If baby is depressed DO NOT dry or stimulate
Intubate trachea Attach a meconium aspirator
Apply suction to endotracheal tube
Dry and stimulate
Continue with standard resuscitation
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Apnea
Common in infants delivered before 32 weeks ofgestation
Risk factors Prematurity Infection
Prolonged or difficult labor and delivery
Drug exposure
CNS abnormalities Seizures
Metabolic disorders
Gastroesophageal reflux
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Apnea
Pathophysiology
Prematurity due to underdeveloped CNS
Gastroesophageal reflux can trigger a vagal
response
Drug-induced from CNS depression
Bradycardia is key assessment finding
Premat re and Lo Birth Weight
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Premature and Low Birth Weight
Infants Delivered before 37th week of gestation
Less than 5.5 lbs or 2,500 grams
Premature labor Genetic factors
Infection
Cervical incompetence
Abruption Multiple gestations (twins, triplets)
Previous premature delivery
Drug use
Trauma
Premature and Low Birth Weight
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Premature and Low Birth Weight
Infants
Low birth weight
Chronic maternal HTN
Smoking
Placental anomalies
Chromosomal abnormalities
Born
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Premature and Low Birth Weight
Infants
Physical appearance
Skin is thin and translucent
No cartilage in the outer ear
Small breast nodule size
Fine thin hair
Lack of creases in soles of feet
Premature and Low Birth Weight
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Premature and Low Birth Weight
Infants
High risk for respiratory distress andhypothermia Surfactant deficiency
Thermoregulation is imperative
Use minimum pressure with PPV
Brain injury may result from hypoxemia, rapidchange in blood pressure
Retinopathy from abnormal vasculardevelopment of retina May be worsened by long term oxygen administration
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Hypoglycemia
BGL
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Hypoglycemia
Glycogen stores sufficient for 8 to 12 hours afterbirth
Disorders related to Poor glycogen storage
Small birth weight
Prematurity postmaturity
Increased glucose use Infant of DM mother
Large for gestational age
Hypoxia
Hypothermia
Sepsis
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Hypoglycemia
Symptoms Cyanosis
Apnea
Irritability
Poor sucking or feeding
Hypothermia
Lethargy
Tremors
Twitching or seizures
Coma Tachycardia
Tachypnea
Vomiting
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Hypoglycemia
Check BGL heel stick
Establish good airway, ventilation,
oxygenation, and circulation
D10W -10% dextrose
2 mL/kg IV if BGL