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Newborn Care and Resuscitation

Newborn Care and Resuscitation. Joseph J. Mistovich, M.Ed, NREMT-P Chair and Professor Department of Health Professions Youngstown State University Youngstown, Ohio jjmistovich@ysu.edu. Neonatal Resuscitation. Newly born – infant at time of birth Newborn – within first few hours of birth

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Newborn Care and Resuscitation

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  1. Newborn Care and Resuscitation Joseph J. Mistovich, M.Ed, NREMT-P Chair and Professor Department of Health Professions Youngstown State University Youngstown, Ohio jjmistovich@ysu.edu

  2. 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

  3. 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 weighing less than 3 lbs. (1,500 grams) require resuscitation

  4. Antepartum Risk Factors • Multiple gestation • Pregnant patient <16 or >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 prenatal morbidity or mortality • Maternal use of drugs or alcohol • Fetal anemia • Oligohydraminos

  5. Intrapartum Risk Factors • Premature labor • PROM >24 hours • Abnormal presentation • Prolapsed cord • Chorioamnionitis • Meconium-stained amniotic fluid • Use of narcotics within 4 hours of delivery • Prolonged labor • Precipitous delivery • Bleeding • Placenta previa

  6. Fetal Transition • Rapid process that allows baby to breathe • Fetal lung is collapsed and filled with fluid • Reduction in pulmonary resistance

  7. Causes of Delayed Fetal Transition • Hypoxia • Meconuium aspiration • Blood aspiration • Acidosis • Hypothermia • Pneumonia • Hypotension

  8. 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

  9. Arrival of the Newborn • Key questions • Mother’s 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

  10. 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

  11. SuctioningClear Amniotic Fluid • Recommendation that suctioning immediately following birth including with a bulb syringe should only be done in babies who have obvious obstruction to spontaneous breathing or require PPV 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

  12. SuctioningClear 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

  13. Clamp and Cut Cord

  14. 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

  15. Initial Assessment • Respiratory rate (Cry) • Respiratory effort (Cry) • Pulse rate • Oxygenation • Color • SpO2

  16. Assess Neonate • Nearly 90% of newborns are vigorous term babies • Ensure thermoregulation • Dry • Warm • Place on mother’s chest (skin to skin) • Suction only if necessary • Assess ventilation (cry) • Asses heart rate • Assess oxygenation (color and SpO2)

  17. 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

  18. APGAR Score

  19. Need for Resuscitation • Approximately 10% of newborns require additional assistance • 1% requires major resuscitation • Resuscitation • Intervene Reassess Intervene Reassess • 30 second intervals

  20. Initial Steps of Resuscitation • Routine Care – If YES to the following questions • Term gestation? • Amniotic fluid clear? • Breathing or crying? • Good muscle tone? • Dry • Provide warmth (skin-to-skin) • Cover • Assess color, breathing, acivity

  21. Initial Steps of Resuscitation • Resuscitative Care – If NOto the following questions • 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

  22. Stimulate

  23. Initial Steps (Golden Minute) • Approximately 60 seconds to complete, reevaluate, and ventilate if necessary • Provide warmth • Clear airway • Dry • Stimulate • Position - sniffing

  24. Initial Steps (Golden Minute) • Decision to proceed beyond initial steps is based on evaluation of: • Respirations • Apnea • Gasping • Labored breathing • Heart rate • Less than 100 bpm • Auscultation of precordial pulse • Palpation of umbilical pulse

  25. Assessment After PPV or Supplemental Oxygenation • Evaluate • Heart rate • Respirations • Oxygenation • Most sensitive indicator of successful response is an increase in heart rate

  26. 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 (10 minutes) • 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

  27. 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

  28. 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

  29. PPV and Supplemental Oxygen • 100% oxygen administration is not recommended • Titrate oxygen to SpO2 range • Initiate resuscitation with air if blended oxygen is not available • If bradycardia persists (HR <60 bpm) after 90 seconds, increase oxygen to 100% until HR > 100 bpm

  30. 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%

  31. Newborn Intervention Triggers • Secretions = suction • Apnea or gasping respirations = PPV • Labored breathing or low SpO2 = oxygen or CPAP • HR< 100 bpm = PPV • HR< 60 = Chest compressions and PPV • Persistent HR< 60 = epinephrine

  32. 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

  33. 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

  34. Evaluate Respiration, HR, Color • Breathing adequate • HR >100 bpm • Acrocyanosis with normal SpO2 • No intervention • If acrocyanosis with poor SpO2 provide blow-by O2

  35. 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

  36. CPAP • Breathing spontaneously but labored • HR> 100 bpm • SpO2 normal or low • Research lacking – only studied in preterm babies

  37. Evaluate Respiration, HR, Color • Breathing adequate • HR <100 bpm • SpO2 normal • 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 mmHg in full-term

  38. 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 and ventilation – consider epinephrine

  39. Persistent Bradycardia • Usually due to • Inadequate lung inflation • Profound hypoxemia • Primary emergency intervention • Adequate ventilation • HR remains < 60 bpm with 100% oxygen • Consider epinephrine

  40. 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

  41. 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

  42. Oral Airways • Rarely used for neonates • Use tongue depressor to insert airway

  43. Respiratory Distress or Inadequacy • HR < 100 bpm = hypoxia • Periodic breathing (20 second or longer period of apnea) • Intercostal retractions • Nasal flaring • Grunting

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