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NEONATAL RESUSCITATION PROGRAM-
NRP 5 INITIAL STEPS OF NEWBORN CARE
- Provide warmth
- Position head and neck to open airway
- Clear secretions if necessary
- Dry baby
- Stimulate ** Establishing Effective Ventilation of the baby’s lungs is the MOST IMPORTANT and effective action during resuscitation 4 QUESTIONS TO ASK BEFORE EVERY BIRTH
- What is expected gestational age
- Is the amniotic fluid clear
- How many babies are expected
- Are there any additional risk factors RAPID EVALUATION FOR ALL NEWBORNS IS REQUIRED—ASK IF THE BABY IS:
- Term?
- Tone? (Healthy babies should be active and flex extremities)
- Breathing/Crying? (Gasping is a sign of severely impaired gas exchange)
**If the answer is NO to any of these, the newborn should be brought to the radiant warmer for the initial steps of newborn care Fetal lungs do not participate in gas exchange but are expanded—alveoli is filled with fluid, NOT air but are still expanded—pulmonary vessels are tightly constricted Oxygenated fetal blood leaves placenta through umbilical vein—there is 1 vein, 2 arteries in the umbilicus Opening in atrium is a Patent Foramen Ovale-most blood bypasses lungs through the foramen OR flows from pulmonary artery into aorta through ductus arteriosis Right to left shunting is when blood follows a circulation path and bypasses the lungs Oligohydramnios- deficiency of amniotic fluid Polyhydramnios- excessive amniotic fluid Fetal hydrops- serious condition defined as abnormal accumulation of fluid in 2 or more compartments including ascites, pleural effusion, pericardial effusion, and skin edema
Can gently stimulate baby by rubbing back, trunk or extremities—Don't’ over stimulate—Can cause injury If newborn remains apneic, begin PPV (positive pressure ventilation)- **21% Oxygen NRP recommends that resuscitation of the baby 32 weeks and greater is initiated with 21% oxygen. If baby doesn’t have spontaneous respirations and a heart rate of 100bpm or higher within 1 minute of birth, begin PPV HR should be at least 100bpm—auscultation along the left side of the chest is the most accurate to determine HR -Palpation at the umbilical cord base may be felt but is less accurate and may underestimate the true HR -Using a stethoscope, estimate the HR by counting the number of beats in 6 seconds and multiply by 10 ie. 6 seconds x 12 beats= 120bpm If HR cannot be determined, connect ECG and/or Pulse Ox—pulse ox may not function is HR is too low or baby has low perfusion so ECG would be preferred method
After The Initial Steps Listed Above, What To Do If The Baby Is Not Breathing Or HR Is Low:
- Start PPV if baby is not breathing (apnea) OR if the baby has gasping respirations - Start PPV if the baby appears to be breathing, but the HR is below 100bpm - Call for help if alone at the warmers - If the baby has not responded to the initial steps within the first minute of life, it is NOT appropriate to continue to provide only tactile stimulation What Do You Do If The Baby Is Breathing And The Heart Rate Is At Least 100bpm, But The Baby Appears Persistently Cyanotic? _Apply a pulse oximeter_ Indications to apply a pulse oximeter:
- When resuscitation is anticipated
- To confirm your perception of persistent central cyanosis
- When supplemental oxygen is administered
- When positive-pressure ventilation is required Acrocyanosis is normal-blue hands and feet
****A healthy newborn breathing room air may take more than 10 minutes to achieve oxygen saturation greater than 90% Supplemental O2 is indicated when the oximeter remains below the target range for baby’s age** FREE FLOWING oxygen is when the oxygen is held close to the baby’s mouth and nose-CANNOT GIVE IF BABY IS NOT BREATHING!!
- **For free flowing oxygen delivery, adjust the flow meter to 10L/min *** Start free flow oxygen supplementation with the blender to set to 30% oxygen. Using the blender, adjust the oxygen concentration as needed to achieve oxygen saturation target. **Goal is to prevent hypoxia without using excess oxygen to cause hyperoxia To prevent heat loss, oxygen given to newborns for a prolonged period should be heated and humidified If the baby has labored breathing or persistently low oxygen saturation, apply CPAP **This should only be considered in the delivery room is the baby is breathing and the HR is at least 100bpm **Cannot be given using a self inflating bag
Meconium-stained fluid and a NON-VIGOROUS newborn
- If baby is born through meconium stained amniotic fluid, bring baby to the radiant warmer
- Perform initial steps of newborn care
- Use a bulb syringe to clear secretions- M to N
- If baby is not breathing or HR is less than 100bpm after initial steps are completed, proceed with PPV **Do not intubate for tracheal suction-there is insufficient evidence to continue recommending this practice PIP- peak inspiratory pressure- highest pressure administered with each breath PEEP- positive end-expiratory pressure- the gas pressure maintained in the lungs between breaths when the baby is receiving assisted breaths CPAP- continuous positive airway pressure- gas pressure maintained in the lungs between breathes when the baby is breathing spontaneously RATE- number of assisted breaths administered per minute IT- inspiratory time- time duration (seconds) of the inspiratory phase of each positive pressure breath
Avoid breaking the mask seal when the bag is refilling because it will allow the bag to refill with room air rather than with oxygen. Free flowing ventilation bag- Unlike a self-inflating bag, which looks like a soft filled football when not in use, an empty free flow inflation ventilation bag looks like a deflated balloon. A flow inflation bag requires constant fresh flow of oxygen into the bag: flow- inflation bags won’t refill if the oxygen source is empty or detached. In addition, you must maintain a good seal on the ventilation mask against the face, otherwise the bag deflates and you can’t ventilate. Flow-inflation, or inflow dependent bags, while more challenging to use, are common on anesthesia machines and in other ICU type settings because they allow finer control of tidal volume, and greater ability to assess the ventilation, and provide a higher FiO2. Because the flow-inflating bag is soft, you can easily feel lung compliance and changes in resistance. When ventilating a neonate with a 500 ml bag, extremely fine control of tidal volume is possible, even while giving tidal volumes less than 50 ml. With spontaneous ventilation, you can actually see and feel the bag partially deflate with each inhalation before it reinflates with the gas flow. The amount of deflation gives a good indication of tidal volume. To the experienced hand, you will know immediately when you have lost the seal because the bag will go flat. This is unlike a self-filling
bag that may lure you into a false sense of security because it’s always full, even if the lungs are not filling well. On the negative side, unlike self-filling bags, there must be a good seal of the mask against the face to allow a flow inflation bag to provide positive pressure. A poor seal causes the flow inflation bag to deflate like a big balloon. A novice ventilator may have difficulty maintaining the seal needed. Because flow inflation bags are dependent on an oxygen source and require more training, emergency ventilation is usually provided by self-inflating bags. T-piece resuscitator-
Dose Intravenous or Intraosseous: Recommended intravenous or intraosseous dose is 0.1-0.3ml/kg (equal to 0.01-0.03mg/kg). Baby’s weight must be estimated after birth Endotracheal: Recommended dose is 0.5-1 ml/kg (equal to 0.05-0.1 mg/kg). The higher dose is only recommended for endotracheal administration. DO NOT give the higher dose via the IV or IO route
- Assess the HR ONE minute after administration
- Continue with PPV at 100% O2 and chest compressions
- HR should increase to 60 bpm or higher within approximately 1 minute
- If HR is less than 60 bpm after the first dose of IV or IO administration, you can repeat the dose every 3- 5 minutes
PRESSURE OF THE PPV- INITIAL SETTINGS
Peek Inspiratory Pressure (PIP) (cm H2O)- Set to 20 Pop-off Pressure- set to 40 Positive End Expiratory Pressure (PEEP)- Set to 5 NRP QUESTIONS
1. A baby is born at term with a bilateral cleft lip and palate and a very small mandible. She requires positivepressure 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 2. You are at the resuscitation of a newborn that is gasping and has a heart rate of 60 beats per minute. What is the most important action you can take? Provide positive pressure ventilation
steps? Administration of positive pressure ventilation that inflates the lungs
9. A newborn of 34 weeks' gestation is not breathing (apneic) at birth, does not respond to initial steps and requires positive pressure ventilation. What concentration of oxygen should be used as you begin positivepressure ventilation? 21 30% 10. You have started positivepressure ventilation for a newborn because her heart rate is low (bradycardia). What is the most important indicator of successful positivepressure ventilation? A rising HR 11. A baby requires positivepressure ventilation because she is not breathing (apneic), but she soon establishes spontaneous respirations and a heart rate over 100 beats per minute. Her oxygen saturation is lower than the target level when in room air, so you provide freeflow oxygen. Which of the following devices cannot reliably deliver freeflow oxygen? Mask of self inflating bag 12. 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% 13. 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 positivepressure ventilation, place a pulse oximeter sensor on the right hand or wrist, evaluate heart rate.
14. A fullterm 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 positive pressure ventilation and check for increasing HR 15. What is the appropriate technique to stimulate a baby to breathe? Gently rub the babies back or extremities 16. You are called to attend to a newborn at birth. At the time the baby is delivered, which 3 questions should you ask to evaluate whether the baby can stay with his mother or be moved to the radiant warmer for further assessment? Is the baby term? Does the baby have good muscle tone? Is the baby breathing or crying? 17. What is the recommended way to determine if a baby requires supplemental oxygen in the delivery room? Place an oximeter sensor on the baby's right hand or wrist and assess oxygen saturation. 18. 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 19. The steps of intubation should ideally be completed within which duration? 30 seconds
capable of initiating neonatal resuscitation should be present at every delivery whose only responsibility is management of the newborn.
26. A premature newborn is born apneic and requires ongoing respiratory support and chest compressions. You and 3 colleagues provide care immediately following birth. What behavioral skills are critical to ensure successful and optimal care during resuscitation? Teamwork, leadership, communication
- A fullterm newborn has a heart rate less than 60 beats per minute despite 30 seconds of positivepressure 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. 28. 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
29. What is the preferred technique for removing secretions from the mouth and nose of a newborn that requires resuscitation? Suction the Mouth before the NoseM before N
30. A laboring woman received a narcotic medication for pain relief 1 hour before delivery. The baby does not have spontaneous respirations and does not improve with stimulation. Your first priority is to Start positive pressure ventilation 31. During resuscitation, a baby is responding to positive pressure ventilation with a rapidly increasing heart rate. Her heart rate and oxygen saturation suddenly worsen. She has decreased breath sounds on the left side and trans illumination, also reveals a bright glow on the left side. What is the most likely cause of this distress? Left side pneumothorax 32. Which of the following is true about the preparation and resources needed for a very preterm birth? Prepare the preheated radiant warmer with a thermal mattress, plastic wrap or bag, and a hat. 33. Which of the following may be associated with delayed cord clamping in vigorous preterm newborns? Decreased need for blood transfusions 34. For a newborn weighing 1 kg, what dose of 1:10, (0.1 mg/mL) concentration of intravenous epinephrine is indicated? 0.1ml
- 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.
