Neonatal resuscitation

Bsc nursing

1. NEONATAL RESUSCITATION

2. Approximately 10% of newborns require some assistance to begin breathing at birth. The National Resuscitation Program was developed by American Academy of Pediatrics (AAP) in conjunction with American Heart Association (AHA) According to the National Resuscitation Program, those newborns that do no require resuscitation can generally be identified by a rapid assessment of following characteristics- Term Gestation? Crying or Breathing? Good muscle tone? Good oxygen saturation? If answer to all these questions is "Yes'", the baby does not need resuscitation. Apgar scoring should be done simultaneously.

3. TABC of Resuscitation T-Maintenance of Temperature Dry the baby quickly. Remove wet linen. Place the baby under radiant warmer. A- Establish an open airway Position the infant. Suction mouth and nose ET intubation, if needed to ensure open airway. B- Initiate Breathing Tactile stimulation to initiate respiration. PPV when necessary, using either Bag and mask or Bag and ET tube. C-Circulation Chest compression Medications (if needed)  

4. Resuscitation articles Suction Equipments Mucus aspirator Meconium aspirator Mechanical suction Suction catheters, 10F or 12F Feeding tube 6F and 20 ml syringe Bag Mask Equipments Neonate resuscitation bag Face masks, newborn (size-1)and premature sizes( size-0)

5. Intubation Equipments Laryngoscope with straight blades, No. 0 (preterm) and No.1 (term) Extra bulbs and batteries for laryngoscope Endotracheal tubes: 2.5, 3.0, 3.5, 4.0 mm ID Stylet Medications Epinephrine Naloxone hydrochloride Sodium bicarbonate Normal Saline Sterile water

6. Miscellaneous Watch with seconds' hand Linen, shoulder roll Radiant warmer Stethoscope Adhesive tape Syringes 1,2,3,4,5,10,20,50 ml Gauze Umbilical catheters 3.5F, 5F Three-way stopcocks Gloves Cardiac monitor and electrodes or pulse oximeter and probe (optional for delivery room)

7. Steps of resuscitation Maintenance of Temperature Hypothermia in newborn leads to increased metabolism, increased oxygen needs and metabolic acidosis . So it is very important to prevent hypothermia in new born. In order to prevent heat loss, the baby should be dried immediately and placed under radiant warmer.

8.   Establish an open airway a. Positioning- The infant should be positioned properly to ensure open airway. The baby should be positioned on back with neck slightly extended. To maintain correct position, a rolled towel or sheet is kept under the shoulders, elevating them ¾ th to 1 inch off the mattress.

9. b. Suctioning- suctioning of mouth and nose is done using bulb syringe or mechanical suction. The mouth is suctioned first to ensure that there is nothing for the infant to aspirate if he or she gasps when nose is suctioned. While suctioning the mouth, the suction tube is inserted till, 5cm mark is at baby's lips. Next introduce the suction tube upto 3cm in each nostril. Suction pressure - <80 mmHg or < 100cm H2O Suction for less than 20 seconds.

10. Avoid stimulation of posterior pharynx during suctioning as it can lead to bradycardia and apnea If thick or particulate meconium is present in amniotic fluid, the mouth, oropharynx and hypopharynx should be suctioned as soon as the head is delivered. After delivery of baby, the trachea should be intubated and suctioned with the help of meconium aspirator (not more than 2 sec). It is recommended that the suctioning be done while the ET tube is being withdrawn. Suctio pressure at 80 mmHg or less

11. Initiate breathing A ) Tactile stimulation- Both drying and suctioning the infant produces stimulation, which is enough to induce respiration. If respiration is inadequate, tactile stimulation may be given by slapping and flicking the soles of feet and rubbing the infants back. These slaps or flicks should be given only once or twice. If the infant remains apneic, positive pressure ventilation should be started.

12. Positive Pressure Ventilation- Bag and mask ventilation is indicated if after tactile stimulation ,the infant is gasping or respiration is spontaneous but heart rate is below 100 beats/minute. PPV with supplemental oxygen (starts with 21 %oxygen and increased gradually, if needed) is provided to meet the required oxygen saturation With infants neck slightly extended to ensure open airway, place the mask on baby's face and ensure that mask forms a tight seal around chin, mouth and nose. Compress the ambu /resuscitation bag gently and ensure that chest expands with each ventilation.

13. Ventilate at a rate of 40-60 breaths per minute for 30 seconds with initial pressure at 20 mmHg Follow ‘breathe-two- three’sequence After starting ventilation with bag and mask, you should look for chest movement after ventilating two to three times to ensure adequacy of ventilation. Response to ventilation will be seen after 30 sec by- Improvement in baby's color from blue to pink. Improved respiration Heart rate rises to more than 100/minute.

14. After the infant has received 15-30 seconds of ventilation with 100% oxygen, check heart rate ( counted for 6 sec and multiply it by 10) Evaluate the heart rate by feeling the umbilical cord pulse or listening to the heart beat with stethoscope Take action as follows- HR >100, spontaneous respiration present Provide tactile stimulation and monitor HR HR>100, not breathing or gasping Continue ventilation HR 60-100 and increasing Continue ventilation HR 60-100 and not increasing or below 60 Begin chest compression

15. Maintain Circulation Chest Compression- When the infant is hypoxic; there is diminished blood and oxygen flow to the vital organs. Chest compressions are used to temporarily increase circulation and oxygen delivery Chest compression must be accompanied by ventilation with 100% oxygen, so that the blood being circulated during chest compressions gets oxygenated. Chest compressions are provided by using either thumb technique or two finger technique. During chest compressions, pressure is applied to lower third of the sternum( just below the nipple line) , depressing it 3/4 th to 1 inch.

16. About 90 chest compressions should be given in a minute. One ventilation should be given after 3 chest compression (1:3). In 1 minute, 90 chest compression and 30 positive pressure ventilations are given. Follow ‘one and two and three and breath’ sequence Check pulse rate after 30 sec, HR >60 – continue ventilation HR <60 - continue chest compressions and ventillations , consider ET intaubation and CPAP and medications

17.  b) Medications Neonates who do not improve with ventilation and chest compression, require medications These medications are administered in umbilical vein via umbilical vein catheter. Adrenaline –administered rapidly in the dose 0.1-0.3 ml/kg, if heart rate continues to be less than 60/minute even after chest compression. ( can repeat every 5 minutes)

18. 7.5 % Soda bicarb - 2 ml/kg body weight, diluted 1:1 in distil water administered at a rate of 1ml/ mt (In case of poor respiration and slow heart rate even after 5-6 minutes of resuscitation, chance of developing acidosis) Ringer lactate or 0.9 % Normal saline (volume expanders)- 10ml/kg slow IV push over 5-10 mts. (In case of peripheral shock indicated by cyanosis, absent pulse or capillary filling time of more than 3 seconds)