Neonatal Resuscitation Algorithm Initial Newborn Care Neonatal Resuscitation Algorithm

On Observation of the Neonate: In the case of infants, everything must depend upon the accurate observation of the nurse or mother…For it may safely be said, not that the habit of ready and correct observation will by itself make us useful, but that without it we shall be useless with all our devotion… If you cannot get the habit of observation one way or the other, you better give up…being a nurse, for it is not your calling, however kind and anxious you may be. Florence Nightingale On Observation of the Neonate:

Important factors to know going in to a delivery 5 things to investigate : 1) Gestational Age and multiples 2) Maternal History (Diabetes, Hypertension, Mom has an Infection, Medications, No Prenatal Care, 3) Amniotic Fluid 4) Fetal History in Labor (Signs of Distress, prolapsed cord, breech or abnormal presentation) 5) Parental wishes Gestational age Maternal hx—diabetes, HIV, group B beta strep, maternal blood type Color of amniotic fluid—thick meconium staining or thin Fetal hx in labor—decelerations or signs of distress Parental wishes—preferences for post-delivery bonding

AAP Neonatal Resuscitation (NRP) All nurses working in Obstetrics are required to be biannually certified in NRP Involves online quizzes on theory Related to neonatal physiology and nursing care Involves a simulation covering a massive resuscitation effort and debriefing. Ask your clinical instructor to review equipment used for complete NRP. To Video

NRP Demonstration Newborn Resuscitation Algorithm Kattwinkel J et al. Circulation 2010;122:S909-S919 Copyright © American Heart Association

Website for more information on Neonatal Resuscitation Program (NRP) http://www2.aap.org/nrp/ -- This is from the American Academy of Pediatrics and has all the information about the process.

Nursing Assessment Thermoregulation ABC's of CPR Dry infant Remove wet blankets Position to assess ABC’s ABC's of CPR Airway Breathing Crying Muscle tone Circulation—pulse Color

General Assessment for Gross Anomalies Done simultaneously as you are doing the drying and the ABC, muscle tone assessment.

APGAR Scoring—which is most significant? A = Appearance (color) P = Pulse (heart rate) G = Grimace (reflex irritability) A = Activity (muscle tone) R = Respiration (respiratory rate) APGAR Scoring—which is most significant? Apgar done at 1 & 5 minutes SIGN SCORE 1 2 Color Heart Rate Blue Pale Absent Body pink, extremities blue Slow, Less than 100/min Completely pink More than 100/min Reflex Irritability No response Grimace Cry or Active Withdrawal Muscle Tone Limp Some Flexion Active Motion Respirations Weak cry : Hypoventilation Good, Crying 1952 Virginia Apgar invented the scoring system (Source: Apgar,V. The newborn (apgar) scoring system, reflections and advice. Pediatric clinics of North America.13:645; 1966.)

*Apgar Score 8-10 Approximately 90% of newborns have an Apgar score between 8 and 10. The approach is drying, warmth, stimulation, positioning to drain secretions and open upper airways, and bulb suctioning of oro-nasal pharynx. Invasive maneuvers should be avoided. They should be observed and re-evaluated at 5 minutes after birth.

*Apgar Score 5-7 These newborns have usually undergone a period of intrauterine asphyxia prior to birth. The initial delivery room approach should be slightly more aggressive. Drying, warmth, suctioning and opening upper airways is immediately indicated. They generally are apneic but may respond to tactile stimulation (e.g. rubbing of the back, gentle slapping or flicking of the feet). Air or oxygen should be immediately available. If the infant fails to respond to stimulation, positive pressure ventilation/manual bagging is indicated. Bradycardia usually responds to ventilation. Vigorous stimulation and deep suctioning should be avoided. Repeat Apgar score at 10 minutes if still 5-7 at 5 minutes.

*Apgar Score 3-4 Newborns who are scored in this category at one minute or less are moderately depressed, acidotic, and have suffered more prolonged intrauterine asphyxia. In addition to the approaches provided for newborns, as indicated above, chest compressions should be initiated in tandem with manual ventilation if bradycardia. If Heart Rate remains less than 60 beats per minute (bpm) and persists beyond 60 seconds of bag/mask ventilation alone.

Apgar Score 0-3 These are the severely asphyxiated, depressed newborns. In addition to immediate drying, warmth, positioning, suctioning, Bag and mask ventilation Chest compression Drug administration Intubation may be necessary

Newborn Care Identification ID bracelets and security bracelet Footprints DNA testing (at Advocate BroMenn only) Assess umbilical cord clamp Weight and Length Vital signs Every 30 minutes per protocol Pulse, Respirations Oxygen saturation (at SJMC) for premature infants at ABMC

Prophylaxis Prophylaxis Hemorrhage Vitamin K—Phytonadione—IM L leg ABMC Infection Hepatitis vaccine—1st dose given IM during admission assessment Needs signed permit. Document Lot number, manufacturer, and expiration date. Erythromycin ophthalmic ointment in both eyes Eye ointment prophylaxis within 1 hour of delivery. State Law.   Thermoregulation: Skin-to-skin with mom 1st priority if unable wrap with blanket and place a hat on the newborn. Bonding Time!! Initiate breastfeeding ASAP with skin to skin contact!

Hypoglycemia Hypoglycemia—follow hospital protocol to do Bedside Glucose Monitoring Gestational age <37 weeks Infant of a diabetic mother Large for gestational age Small for gestational age Symptomatic such as: jitteriness or hypothermia

Daily interventions See p. 707 in the10th edition and p. 832 in the 9th addition for list of pertinent Nursing Diagnoses Complete systems assessment q 8 hrs. Maintenance of a neutral thermal environment Careful monitoring of intake and output Promotion of adequate hydration and nutrition

Newborn Care Maintenance of skin integrity and cord care. Delayed bathing at Advocate BroMenn, bathing at OSF St Joseph See link in Adaptation to Extra-uterine life Power Point. At 24 hours of age: Critical Congenital Heart Dz (CHD) Screening Check bilirubin level by Transcutaneous Bilirubin bilimeter (TCB) or serum level. Plot out using the Bilitool online calculator. Preparation for discharge: TEACH, TEACH, TEACH on all topics. Refer to other Power Point.

Critical Congenital Heart Screening Pulse-oximetry monitoring protocol based on results from the Right Hand (RH) and either foot (F). The proposed pulse-oximetry monitoring protocol based on results from the right hand (RH) and either foot (F). Kemper A R et al. Pediatrics 2011;128:e1259-e1267 ©2011 by American Academy of Pediatrics

Nourishment Breastfeeding—goal is always to attempt to breastfeed within 1 hour of delivery. Mom may nurse as long as she would like. Assess infant on mom’s chest q 30 min. Healthy People goal 81.9% for newborn to be breastfed at least once.  Formula Feeding—start with sterile water to confirm patency and ability to swallow, then offer formula. Recommend not to exceed 15 milliliters (mls or cc)at first feeding.

Circumcision Circumcision care Gomco—apply Vaseline to tip of penis   Gomco—apply Vaseline to tip of penis Plastibell—NO Vaseline is used because of risk of dislodging ring. Photo of Plastibell Pain management—newest research strongly advocates use of some form of pain control. AAP mandates that meds should be given: Sucrose on pacifier or gloved finger 2 min prior to procedure at ABMC, during at SJMC Acetaminophen 10mg/kg po prior to procedure and a second dose four hours later. Local anesthetic in dorsum penile nerve—administered by practitioner doing circumcision Encourage breastfeeding soon after procedure if allowed at institution Change diaper promptly when wet Pain assessment: NIPS Reassess for bleeding and time of first void per hospital protocol at 15 minutes and 60 min or q 15 times 4 and then q shift.

Don’t you just love being a neonatal nurse?