Neonatal Resuscitation SLC 2011

7/30/2019 Neonatal Resuscitation SLC 2011

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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

[email protected]


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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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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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Breathing adequate

HR


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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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Complications if aspirated Meconium

Aspiration Syndrome (MAS)

Atelectasis

Persistent pulmonary hypertension

Pneumonitis

Pneumothorax


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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



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Infants

Low birth weight

Chronic maternal HTN

Smoking

Placental anomalies

Chromosomal abnormalities

Born


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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



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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

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Neonatal Resuscitation SLC 2011

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