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Neonatal Resuscitation Program (NRP)
practice
Questions to ask prior to birth -
- what is expected Gestational age, (preterm <38 wks, term 38-41 wks or post-term > wks)
- what is amniotic fluid color (only clear good),
- what's number of babies expected (twins mebbe more),
- are any additional risk factors (GDM, miscarriages, preeclampsia, etc.) When to clamp umbilical cord - 30-60 seconds after birth for VIGOROUS newborn Things to look for after birth -
- Is the baby term, (if no, bring baby to warmer)
- does the baby have good muscle tone, (flaccid/extended extremities are bad)
- is the baby breathing or crying? (if no crying, observe chest for breathing efforts. if vigorous crying, return to mom) 5 initial steps of care -
- Warm,
- position airway,
- clear secretions if needed,
- dry,
- stimulate Flow rate for free-flow O2 administration - 10lpm O2 level for free-flow O2 administration - 30%
Suction setting for newborn - 80-100mmHg Antepartum risk factors - gestation <36wks or >41wks, pre-eclampsia and eclampsia, maternal HTN, poly and oligohydramnios, fetal hydrops, macrosomia and IGR, fetal malformations or anomalies, no prenatal care. Inpartum - Emergency c-section, vacuum assisted delivery, breech or abnormal presentation, category II or III, maternal anesthesia, mag, or narcs, prolapse cord, shoulder dystocia, meconium staining, bleeding, placental abruption, chorioamnionitis Abnormal transition signs and symptoms - Apnea, tachypnea, bradycardia, tachycardia, decreased muscle tone, low SpO2, hypotension Preductal SpO2 at 1 min - 60-65% Preductal SpO2 at 2 min - 65-70% Preductal SpO2 at 3 min - 70-75% Preductal SpO2 at 4 min - 75-80% Preductal SpO2 at 5 min - 80-85%
10lpm O2 concentration for PPV (>35wk gestation) - 21% O2 concentration for PPV (<35wk gestation) - 21-30% Single most important step in NRP is... - Ventilation of the lungs Meaning of "MR. SOPA" - Mask adjustment, reposition head, suction airway, open mouth, pressure, alternative airway If a baby does not begin breathing in response to stimulation, you should assume they are in _______ apnea. - Secondary (At the initiation of respiratory compromise, newborns experience an initial period of attempted rapid breathing followed by primary apnea. Primary apnea results in a reduced oxygen saturation, resulting in a lower heart rate. Stimulation will usually assist a newborn in the required respiratory transition, however if a newborn does not start breathing immediately following stimulation, he/she is likely experiencing secondary apnea. Further stimulation will not help, and the newborn require positive-pressure ventilation.) Which device should be readily available as a backup wherever resuscitation may be needed, in case a compressed gas source fails? - Self-inflating bag (Unlike other bag-mask ventilation methods, self-inflating bags reinflate when released due to a pressure-release, or pop-off valve. Valves are typically set by the manufacturer to release at 30 to 40 cm H2O of pressure. This makes them the only method usable when compressed gas sources are not available. It's important to note that for newborns who have not yet taken their first breath, occlusion of the pop-off valve may be necessary to generate sufficient pressure to inflate the nonaerated lungs. However, care must be taken to avoid overinflation and creation of a pulmonary air leak.)
Where should pressure be applied when performing compressions on the newborn? - Lower third of the sternum (Chest compressions on the newborn should apply pressure to the lower one-third of the sternum, typically in line with the nipples. Downward pressure should be applied perpendicular to the chest wall to depress the sternum about one-third of the anteroposterior diameter of the chest, followed by release of pressure to allow for refilling of the heart. Providers should avoid direct pressure to the xiphoid, which can result in liver injury.) During resuscitation of a newborn, you've establish adequate ventilation with an endotracheal tube and your colleague has begun chest compressions for a heart rate under 60 bpm. Nevertheless, after 60 seconds, the heart rate has not increased. What is the most appropriate next step in management? - Administer epinephrine. (A persistent heart rate under 60 beats per minute despite chest compressions and adequate ventilation, is indication for epinephrine administration. Epinephrine should only be initiated after establishing adequate ventilation to avoid myocardial injury, as it increases myocardial oxygen consumption and workload. Guidelines recommend IV epinephrine at a dose of 0.01 to 0.03 mg/kg at a dilution of 1:10,000. Epinephrine can be given every 3 to 5 minutes with the heart rate below 60 bpm.) Air that leaks from inside the lung and collects in the pleural space is called a ________. - Pneumothorax (A pneumothorax is air present between the parietal and visceral pleura. Pneumothorax in infants may be asymptomatic, however respiratory distress can manifest as tachypnea, pallor and cyanosis. Early indication of pneumothorax can often be a rapid reduction in QRS voltage on EKG. Physical exam findings can include an asymmetric chest larger on the side of pathology, decreased breath sounds on that side, and a point of maximal impulse shift away from that side.) True or False: If a pneumothorax causes significant respiratory distress, it should be relieved by placing a percutaneous catheter or needle into the pleural space and evacuating the air. - True
(Persistent pulmonary hypertension of the newborn (PPHN) results from abnormal elevation of pulmonary vascular resistance after birth, causing right-to-left blood shunting via routes of fetal circulation. The result is severe hypoxemia that may not respond to traditional respiratory support.) A full-term baby is born by emergency cesarean delivery because of fetal bradycardia (Category III fetal heart rate tracing). The baby is limp and not breathing after initial steps. What is the next step in the resuscitation process? - initiate ppv& check for rising heart rate A full-term newborn has a heart rate less than 60 beats per minute despite 30 seconds of positive- pressure ventilation that moves the chest. Your team plans to intubate. Which of the following is a true statement regarding the procedure? - The baby should be positioned on a flat surface with the neck slightly extended Which statement describes recommended practice when using a pulse oximeter in the delivery room? - place pulse oximeter on right hand and use minute by minute specific O2 SAT TARGET A baby is born at term with a bilateral cleft lip and palate and a very small mandible. She requires positive-pressure ventilation because she is not breathing. You are unable to achieve a seal with bag and mask. Which intervention is indicated? - insert a laryngeal mask The steps of intubation should ideally be completed within which duration? - 30 seconds What is the most effective maneuver to establish spontaneous breathing in a baby that is apneic after initial steps? - POSITIVE PRESSURE VENTILATION You are at the resuscitation of a newborn who is gasping and has a heart rate of 60 beats per minute. What is the most important action you can take? - Provide PPV (positive pressure ventilation).
You have determined a baby needs resuscitation at birth. What are the initial steps of newborn care?
- Provide warmth, position head and neck to open the airway, clear secretions from the airway if needed, dry, stimulate A baby is born at 34 weeks' gestation. After the initial steps of resuscitation, the baby is not breathing (apneic). What are the next steps? - Initiative positive-pressure ventilation, place a pulse oximeter sensor on the right hand or wrist, evaluate heart rate. Remembering MR. SOPA helps your team correct problems with ventilation. Which of the following steps are included in MR. SOPA? - Adjust Mask and Reposition head and neck; Suction mouth then nose and Open the mouth; increase Pressure; insert Alternative airway You have been called to attend a birth and are the only healthcare provider responsible for the management of the newborn in the room. When should you first call for additional help? - Before birth, when you have identified the presence of a perinatal risk factor that increases the likelihood of requiring neonatal resuscitation. After the initial steps of newborn care, a baby is apneic. What is the most important and effective action to take in the resuscitation of this baby? - Provide positive pressure ventilation. During the resuscitation of a newborn, you auscultate the apical pulse and count 10 beats over a 6 second period. What heart rate do you report to your team? - 100 beats per minute Your team attends an emergency cesarean delivery of a term baby because of chorioamnionitis, meconium-stained amniotic fluid, and fetal heart rate decelerations. At delivery, the newborn is term as expected, with very poor tone and he is not breathing (apneic). You quickly perform initial steps, but the newborn is still not breathing. What is the most appropriate next step of resuscitation? - Start positive-pressure ventilation and check heart rate response after 15 seconds Effective team functioning is critical in ensuring the best performance. Which of these characteristics is critical in team leaders? -
A full-term baby is born in the hospital lobby. He is not breathing (apneic), despite positioning his head in sniffing position, clearing his airway, drying, and providing tactile stimulation. You have emergency equipment including a self-inflating bag. You should start positive-pressure ventilation - Immediately Your hospital is planning Neonatal Resuscitation Program® training and trying to decide who should be included. For every delivery, what is the minimum requirement for care of the newborn at birth? - Someone capable of initiating neonatal resuscitation should be present at every delivery whose only responsibility is management of the newborn. Which statement best describes normal transitional physiology at the time of birth? - Babies may take as long as 10 minutes after birth to increase their oxygen saturation to greater than 90%. A baby born at 36 weeks' gestation was apneic after birth and required positive-pressure ventilation and oxygen supplementation in the delivery room. He continues to require supplemental oxygen after birth. Which of the following statements is true? - His blood glucose level should be checked soon after resuscitation and then at regular intervals until stable and normal. When a newborn has a high risk of mortality and there is a significant burden of morbidity among survivors, what should be included in your discussion with the parents concerning options for resuscitation? - The option of providing comfort care can be considered. When coordinating positive-pressure ventilation with chest compressions, how many events are performed each minute? - 30 breaths, 90 compressions What time frame should be used to administer intravenous epinephrine? - Rapid push, as quickly as possible What is the preferred method for assessing heart rate during chest compressions? - Electronic cardiac (ECG) monitoring
Which of the following may be associated with delayed cord clamping in vigorous preterm newborns? - Decreased need for blood transfusions You attend the birth of a baby with prenatally diagnosed congenital diaphragmatic hernia. After birth, you should - Intubate the trachea and insert an orogastric tube into the stomach Which of the following is the best indication for volume expansion after resuscitative efforts that included intubation, chest compressions, and IV epinephrine? - The baby's heart rate remains 50 beats per minute after resuscitative efforts and pulses are weak. After chest compressions with coordinated ventilations are started, the heart rate should be assessed: - After 60 seconds You are in the delivery room caring for a preterm newborn at 27 weeks' gestation. Resuscitation has been completed and the baby is ready to be transported to the neonatal intensive care unit. Which of the following is a true statement about the baby's subsequent care? - Monitor blood glucose levels because of the risk of hypoglycemia after birth. Which statement best describes the ethical principle(s) that guide the resuscitation of a newborn? - The approach to decisions in the newborn should be guided by the same principles used for adults and older children. A baby required ventilation and chest compressions. After 60 seconds of chest compressions, the electronic cardiac monitor indicates a heart rate of 70 beats per minute. What is your next action? - Stop chest compressions; continue positive-pressure ventilation. A newborn requires complex resuscitation. You have intubated and are administering positive- pressure ventilation and chest compressions. Which 3 signs are used to evaluate the effectiveness of your actions, and the need to continue one or both of these measures? - Respirations, heart rate, oxygen saturation
After what duration of time might it be reasonable to consider discontinuing resuscitation following complete resuscitation efforts with no detectable heart rate? - 10 minutes What is the ideal depth of chest compressions for a newborn? - One third the antero-posterior diameter of the chest Which of the following statements is true? - Intravenous administration of epinephrine results in reliable and effective absorption. Which of the following is true about a pneumothorax in the newborn? - Positive-pressure ventilation increases the risk of pneumothorax
