Neonatal Resuscitation Provider VVC Perinatal Class

Objectives Introduction Preparing for a delivery NRP Flow sheet/resuscitation Delivery room procedures/Meconium PPV/Use of Oxygen Chest compressions CPAP Intubation Medications Special considerations/Pre-term babies Ethical considerations

Introduction Approximately 10% of newborns require some assistance to begin breathing at birth. 100% of newborns require initial assessment after birth Less than 1% require extensive resuscitative measures. Although the vast majority of newly born infants do not require intervention to make the transition from intrauterine to extrauterine life, because of the large total number of births, a sizable number will require some degree of resuscitation. Must decipher between primary and secondary apnea Newborns who experience secondary apnea usually respond with an increase in heart rate after effective positive-pressure ventilation

Introduction Normal transition to external uterine life begins when the systemic blood pressure is increased when the low- resistance placental circuit is removed by umbilical cord clamping. RT’s attend all high risk deliveries and also most if not all C-sections Each decision made during a resuscitation of a newborn is done so in 30 second intervals (vastly different from PALS or ACLS)

Introduction The most important and effective action in a neonate requiring resuscitation = Ventilating the lungs When resuscitation is anticipated, additional personnel will be in the delivery room before birth, this includes RT’s, RN’s and MD’s Evaluation and decision making during resuscitation are primarily based on: Respiration rate, heart rate, color A cry following birth typically represents the neonate has a adequate heart rate and respiratory effort (it does not necessarily mean the ventilation/oxygenation is adequate however)

Introduction Those newly born infants who do not require resuscitation can generally be identified by a rapid assessment of the following 3 characteristics: Term gestation? Crying or breathing? Good muscle tone? If the answer to all 3 of these questions is “yes,” the baby does not need resuscitation and should not be separated from the mother. The baby should be dried, placed skin-to-skin with the mother, and covered with dry linen to maintain temperature. Observation of breathing, activity, and color should be ongoing. If the answer to any of these assessment questions is “no,” the infant should receive one or more of the following 4 categories of action in sequence: Initial steps in stabilization (provide warmth, clear airway if necessary, dry, stimulate) Ventilation Chest compressions Administration of epinephrine and/or volume expansion

Preparation Anticipation, adequate preparation, accurate evaluation, and prompt initiation of support are critical for successful neonatal resuscitation. At every delivery there should be at least 1 person whose primary responsibility is the newly born. This person must be capable of initiating resuscitation, including administration of positive-pressure ventilation, intubation and chest compressions. Factors to keep in consideration at every delivery: Gestational age of baby? Age of mother? Single or multiple births? Meconium present? Prenatal care? Known risk factors (smoking, drugs, alcohol) Know congenital factors such as heart defects, gastroschisis, CDH… Intrapartum factors such as placenta previa, abruption, preclampsia, infection…. Did the mother receive sedation…

Preparation Know history of mother before delivery: Para? Gravida? Gestational age? Infections? Sedation? Drug Abuse? Smoke or Drink? Abnormalities already predetermined? Previa/abrution? Eclampsia? Age of mother (Old or too young)? First baby? Socioeconomic status? Vital signs? Know if baby received steroids before delivery (beclamethosone) or Magnesium. Know if Mother has been given antibiotics for Strep B Know presentation of baby: Breech/transverse, normal… (breech will make for a more difficult delivery) Know L:S ratio if there is one, or PG, PC Is this a C-Section? If so why Know if mother has ruptured membranes is it PROM, is she dilated? Is the baby effaced? Did the mother receive Tocolytic agents? Are there decels? If so what is the severity?

Preparation Setup the warmer, ensure your PPV is working and have your supplies ready including: Endotracheal tubes (size 2.5-3.5) and blades (Miller 00,0,1) Tape, scissors, suction supplies (5/6, 8, 10 F), meconium aspirator Varying sized masks (premie, normal) Pulse ox probe Bulb syringe Warm blankets ETT holders and ETCO2 Medication box (nurse), umbilical cord clamp UVC kit (Nurse will bring) Surfactant if anticipated use Ventilator, CPAP…

Preparation If a preterm delivery (<37 weeks of gestation) is expected, special preparations will be required. Preterm babies have immature lungs that may be more difficult to ventilate and are also more vulnerable to injury by positive-pressure ventilation. Preterm babies also have immature blood vessels in the brain that are prone to hemorrhage; thin skin and a large surface area, which contribute to rapid heat loss; increased susceptibility to infection; and increased risk of hypovolemic shock related to small blood volume.

Potential risk factors Prolapsed cord The umbilical cord is delivered (passed through the cervix) before the infant.  This compromises the blood flow to the infant due to the compression of the cord. Placenta previa The placenta covers the cervical opening, preventing the infant from passing through the cervix.  A Cesarean delivery is usually required.  This is usually associated with advanced maternal age, multiple gestation and prior Cesarean deliveries. Placental abruption The placenta separates from the uterine wall before the infant is born.  This leads to bleeding from the infant and places the infant and mother at risk, (watch for DIC). Fetal Bradycardia Deceleration of the fetus' heart rate can indicate the impact of contractions or a more serious insult such as nuchal cord.

Neonatal Resuscitation Airway Provide warmth.  A radiant warmer should be warm and available for all deliveries. Position the head and clear the airway as necessary. Dry and stimulate the baby to breathe (rub back vigorously or tap soles of feet). Evaluate respirations, heart rate and color; give oxygen as needed. Breathing If the baby is apneic, or heart rate is less than 100 bpm: Provide positive pressure ventilation with a resuscitation bag and 100% oxygen. The resuscitation mask should be chosen based on the size of the infant.  The mask should fit from the bridge of the nose to the chin, but not covering the eyes.  A good seal with the mask is necessary for resuscitation. Circulation If the heart rate is less than 60 bpm (HR checked at umbilical stump): Give chest compressions as you continue to provide positive pressure ventilation with 100% oxygen. Give chest compressions at a rate of 3 compressions to every breath, resulting in 90 compressions per minute, and 30 ventilations per minute

Delivery Room Procedures

Delivery Room Procedures To stimulate a newborn: flick soles of feet Warm with a warm blanket Rub back of newborn An apneic newborn has not responded to suctioning, drying, and rubbing of the back. What is the appropriate next action? PPV

Example Delivery room procedure A 29 year old mother with a 28 week gestation presents to the L & D with suspected placental abruption. The mother is para 2 and gravida 1, she has moderate bleeding What equipment would you prepare? What personnel would you want on hand? What are the possible risk factors for the neonate?

Example Delivery room procedure The neonate is born without a cry, he is limp with poor muscle tone and color, HR is 89 What is your first action? If HR does not increase over 100 during PPV what is your next step of action? If the heart rate does not improve above 60 what is your next step of action? Would you consider intubation before compressions?

Neonatal Resuscitation Initial Steps The initial steps of resuscitation are to provide warmth by placing the baby under a radiant heat source, positioning the head in a “sniffing” position to open the airway, clearing the airway if necessary with a bulb syringe or suction catheter, drying the baby, and stimulating breathing. Assess respirations, muscle tone, heart rate If HR is less than 100 beats per minute (bpm), or if newborn is apneic or gasping, begin positive pressure ventilation. If HR is more than 100 and respirations are labored, consider CPAP, especially for preterm newborns Evaluate oxygenation (by pulse ox), right hand as needed

Neonatal Resuscitation After ensuring effective ventilation, if heart rate remains below 60 bpm, despite 30 seconds of effective ventilation, provide chest compressions and continue assisted ventilation. Intubation is strongly recommended when chest compressions begin, if not already done Increase oxygen concentration to 100% when chest compressions begin Continue chest compressions coordinated with effective ventilation for at least 45-60 seconds before assessing heart rate (*used to be 30 sec) If heart rate remains <60 bpm after 45-60 sec of chest compressions coordinated with effective ventilation, administer epinephrine. Insert emergency umbilical venous catheter for administration of epinephrine The intratracheal route of epinephrine results in lower and less predictable blood levels that are often not effective, but this route is acceptable while the umbilical venous line is being placed If the newborn appears to be in shock and is not responding to resuscitation, administration of a volume expander may be indicated.

Meconium Aspiration Thin-consistency meconium-stained amniotic fluid is noted in a term newborn. Following birth, you observe the newborn to be pale and limp (low tone) without respiratory effort. What should be done next?

Meconium Aspiration Aspiration of meconium before delivery, during birth, or during resuscitation can cause severe meconium aspiration syndrome (MAS). Suctioning of the oropharynx before delivery of the shoulders was considered routine until a randomized controlled trial demonstrated it to be of no value. Elective and routine endotracheal intubation and direct suctioning of the trachea were initially recommended for all meconium-stained newborns until a randomized controlled trial demonstrated that there was no value in performing this procedure in babies who were vigorous at birth.

Meconium Aspiration Although depressed infants born to mothers with meconium- stained amniotic fluid (MSAF) are at increased risk to develop MAS, tracheal suctioning has not been associated with reduction in the incidence of MAS or mortality in these infants. Vigorous newborns should undergo routine delivery room procedure, The term "vigorous" is defined by: Heart rate more than 100 beats per minute, strong respiratory efforts, good muscle tone http://www.youtube.com/watch?v=Hx1lLopbrtY

Neonatal Resuscitation-PPV

Neonatal Resuscitation-PPV Positive Pressure Ventilation (PPV): Indicated for Apnea/gasping, HR below 100 bpm even if breathing, persistent central cyanosis and low oxygen saturation despite free flow oxygen increased to 100% All PPV devices require a integral pressure gauge or if there is a site for attaching a pressure gauge (manometer) it should be attached Effective ventilation is defined by the presence of bilateral breath sounds, chest movement (HR may rise without visible chest movement, especially in preterm newborns) Start with inspiratory pressures of about 20 cm H2O at a rate of about 40-60 breaths/minute. Avoid excessive chest movement. A pressure release ("pop-off") valve is present on all PPV devices to avoid excessive pressure http://www.youtube.com/watch?v=RPul1Ybr-Ro

Neonatal Resuscitation-PPV NeoPuff: Pressure pop off set on device. Can supply CPAP when hole is not covered or blow by oxygen. The operator sets the maximum circuit pressure, peak inspiratory pressure, and positive end-expiratory pressure.

Neonatal Resuscitation-PPV Self inflating bags: They fill spontaneously after they are squeezed. If used ensure a an oxygen reservoir is attached to reach 90-100% FIO2.

Neonatal Resuscitation-PPV Flow inflating bag: Ideal, can assess chest compliance. It fills only when gas from a compressed source flows into it. Can supply CPAP when not bagging or free flow oxygen. Possible malfunction = hole in the bag, improper seal on patient

Neonatal Resuscitation-PPV Use lowest inflation pressure necessary to maintain a heart rate of >100 and a gradually improving oxygen saturation Assess for rising heart rate and improving oxygen saturation; if not evident (within 5-10 breaths) assess bilateral breath sounds and chest movement. If these are not immediately evident, perform as many ventilation corrective steps as needed. The acronym “MR SOPA” may be used to remember the sequence of ventilation steps: M: Adjust the MASK on the face R: REPOSITION the head to ensure an open airway S: SUCTION the mouth and nose O: Ventilate the baby’s mouth slightly OPEN and lift the jaw forward P: Gradually increase the PRESSURE every few breaths (use caution, max 40 cmH2O) until there is bilateral breath sounds and visible chest movement A: Consider airway ALTERNATIVE (ETT or LMA)

Neonatal Resuscitation-PPV Ensure proper mask size

Neonatal Resuscitation-PPV The NRP recommends use of 100% supplemental oxygen when positive-pressure ventilation is required during resuscitation of term newborns. For excessive PPV insert a OG tube: Measure the length of the feeding tube to be inserted: Use the feeding tube to measure from the tip of the nose to the ear lobe and from the ear lobe to a point midway between the tip of the breastbone and the navel

Neonatal Resuscitation-PPV 7 cm Example: For correct insertion depth of OG tube add 7 and 12 = 19 cm would be insertion depth 12 cm

Neonatal Resuscitation-PPV If HR is more than 60 bpm but less than 100 bpm, continue to administer effective positive pressure ventilation as long as the baby is showing steady improvement If HR is persistently more than 60 bpm, but less than 100 bpm, ensure effective ventilation, call complications such as a pneumothorax or hypovolemia If HR is below 60 bpm despite 30 seconds of effective PPV ventilation (defined by audible bilateral breath sounds and chest movement) begin chest compressions Note presence of CDH during bagging

PPV There is no physiologic improvement and no perceptible chest expansion. What would be an appropriate action? Reposition the head You have performed the correct maneuvers described in the above question and the baby is still not improving and the chest wall is not moving. What else should you do? Recheck or replace the resuscitation bag.

Use of Oxygen and Pulse Oximetry Compressed air source and oxygen blender and a pulse oximeter should be available in the immediate delivery area for every birth There is ongoing controversy about how much oxygen to use during neonatal resuscitation Resuscitation of term newborns may begin with 21% oxygen; resuscitation of preterm newborns may begin with a somewhat higher oxygen concentration (30-40%)

Use of Oxygen and Pulse Oximetry Use of oximetry: Resuscitation is anticipated PPV is required for more than a few breaths Central cyanosis is persistent, or you need to confirm your perception of central cynanosis Supplemental oxygen is administered Do not delay resuscitation efforts for a pulse ox reading Place probe on the newborns right hand or wrist (measure pre-ductal saturation) Avoid saturations exceeding 95% It may take up to 10 minutes for a healthy newborn to increase saturation to the normal range of over 90%. If persistent cyanosis is visible, confirm a low saturation with pulse ox and adjust the supplemental O2 to achieve the target values for the pre-ductal saturations

Use of Oxygen and Pulse Oximetry Methods of administering free-flow oxygen to a baby Hold an oxygen mask firmly over the baby's face Hold oxygen tubing cupped closely in your hand over the baby's mouth and nose. Hold a mask from a flow-inflating bag closely over the baby's mouth and nose.

Neonatal Resuscitation-Chest Compressions Ensure effective ventilation prior to beginning chest compressions Chest compressions are indicated whenever the heart rate is below 60 bpm, despite at least 30 seconds of effective positive pressure ventilation The 2 techniques are the thumb technique and the 2-finger technique; however, the thumb technique is preferred and should be used in most situations Use enough pressure to depress the sternum to a depth of approximately one third of the anterior-posterior diameter of the chest

Neonatal Resuscitation-Chest Compressions When the HR is below 60 bpm, the oximeter may not work. Increase the oxygen concentration to 100% until the oximeter is giving a reliable signal and can guide the appropriate adjustment of supplemental oxygen Use 3 compressions plus 1 ventilation, resulting in approximately 120 “events” per 60 seconds (90 compressions plus 30 breaths) Chest compressions circulate blood to the vital organs "One-and-Two-and-Three-and-Breathe-and..” Fracturing ribs is still a concern during neonatal CPR

Neonatal Resuscitation-Chest Compressions Intubation is strongly recommended when chest compressions begin to help ensure effective ventilation Interruption of chest compressions to check heart rate may result in decrease of perfusion pressure in the coronary arteries. Therefore, continue chest and coordinated ventilations for at least 45-60 seconds before stopping briefly to assess the HR Assess HR at umbilical stump If you anticipate the need to place a UVC continue compressions by moving the head of the bed near the newborns head and continuing the thumb technique. Insert an umbilical catheter, administer epinephrine, and consider intubation if not already done after 30 seconds of compressions Discontinue compressions when the HR rises above 60, continue PPV until HR is above 100

Neonatal Resuscitation-CPAP

Neonatal Resuscitation-CPAP CPAP is the administration of continuous positive airway pressure (CPAP) to infants who are breathing spontaneously, but with difficulty, following birth Starting infants on CPAP reduces the rates of intubation and mechanical ventilation, surfactant use, and duration of ventilation, but increases the rate of pneumothorax. Spontaneously breathing preterm infants who have respiratory distress may be supported with CPAP or with intubation and mechanical ventilation

PPV/CPAP and CPR Break up into two groups GROUP 1. Practice PPV using a flow inflating bag and mask Provide CPAP GROUP 2. Practice chest compression and resuscitation

Neonatal Resuscitation-Intubation http://www.youtube.com/watch?v=fGXddPdEsu8&feature=related

Neonatal Resuscitation-Intubation You have about 20 seconds to intubate a newborn Indicated for ineffective or prolonged bag-and-mask ventilation and also for non-vigorous meconium To intubate: Stabilize the baby's head in the "sniffing" position, deliver free- flow oxygen during the procedure, hold the laryngoscope in the left hand Insert the tube into the sight side of the mouth, with the curve of the tube lying in the horizontal plane Always pull up and outward, be sure not to use the newborns upper lip/teeth as a folcrum, if cords can not be seem immediately pull back on blade Use a CO2 detector indicates the presence of expired C02.

Neonatal Resuscitation-Intubation Only experience and well practiced clinicians should attempt to intubate

Neonatal Resuscitation-Intubation Vocal cords Glottic opening Valecula Space Epiglottis

Neonatal Resuscitation-Intubation ETT Size based on size of baby The primary methods of proper ETT placement are an increasing heart rate and carbon dioxide detection. Tube placement is also determined by the baby's birth weight. Formula: add six to the baby's weight (in kg). Example: 2 kg baby 6 + 2 = 8 cm at gums Weight ETT size <1.0 Kg 2.5 1.0-2.0 Kg 3.0 2.0-3.0 Kg 3.5 >3.0 Kg 4.0

Intubation and Scenario Practice Break up into two groups GROUP 1. Practice Intubation and oral airway insertion GROUP 2. Practice with labor room scenarios

Neonatal Resuscitation-Drugs Drugs If the heart rate is less than 60 bpm after 30 seconds of assisted ventilation and another 30 seconds of chest compressions and assisted ventilation: Administer epinephrine while continuing chest compressions and assisted ventilation. (Endotracheal intubation should be considered as prolonged ventilation becomes apparent) Best route of administration is a UVC

Neonatal Resuscitation-Drugs Intratracheal epinephrine via the endotracheal tube should be considered while the umbilical venous catheter is being placed

Neonatal Resuscitation-Drugs Epinephrine If HR remains below 60 despite ongoing effective PPV and compressions after 45-60 seconds Give as quickly/rapidly as possible Given preferably through UVC, may be given down ETT while UVC is being placed IO is controversial in premature newborns but may be an alternative Concentration: 1:10,000 solution (0.1 mg/ml) Give rapidly/quick as possible IV dose: 0.1-0.3 ml/kg of 1:10,000 solution per UVC in a 1 ml syringe Follow with 0.5-1 ml saline flush ETT dose: 0.5-1 ml/kg of 1:10,000 soln in a 3-6 ml syringe Check HR about 1 minute after administration Repeated every 3-5 minutes

UVC http://www.youtube.com/watch?v=JjBJONanCYU

Neonatal Resuscitation-Drugs Volume Administration Indicated for newborns not responding to resuscitation and newborn appears in shock Or there is a HX of a condition associated with fetal blood loss (abruption) May be given for persistent bradycardia Volume expanders: NS, Ringers lactate, O Rh-negative PRBCs Dose: 10 ml/kg Route: UVC only with large syringe Over 5-10 minutes

Neonatal Resuscitation-Drugs Naloxone: Administration of naloxone is not recommended as part of initial resuscitative efforts in the delivery room for newborns with respiratory depression. Heart rate and oxygenation should be restored by supporting ventilation. Used for continued respiratory depression, after positive- pressure ventilation has restored a normal heart rate and color and there is a known history of maternal narcotic administration within the previous 4 hours. Glucose: Newborns with lower blood glucose levels are at increased risk for brain injury and adverse outcomes after a hypoxic-ischemic insult. Intravenous glucose infusion should be considered as soon as practical after resuscitation, with the goal of avoiding hypoglycemia

Special Considerations Therapeutic hypothermia following perinatal asphyxia should be used only for babies >36 weeks gestation who meet previously defined criteria for this therapy Initiated before 6 hrs after birth Used only by centers with specialized programs equipped to provide the therapy Very low birth weight (<1500 g) preterm infants are likely to become hypothermic despite the use of traditional techniques for decreasing heat loss. For this reason it is recommended that additional warming techniques be used, such as covering the infant in plastic wrapping (food-grade, heat-resistant plastic) and placing him or her under radiant heat. Temperature must be monitored closely because of the slight but described risk of hyperthermia with this technique

Special Considerations Choanal atresia: Placement of an oral airway Narcotic for analgesia before delivery: PPV first, before Narcone Pneumothorax: Identify with Transillumination, tx with percutaneous catheter or needle into the pleural space

Special Considerations Transillumination

Special Considerations Congenital diaphragmatic hernia: flat (scaphoid) abdomen, intestines fill space of left or right lung. Intubate ASAP/insert OG Pierre Robin (or Robin) syndrome:small mandible (jaw). Place the baby prone and insert a nasopharyngeal tube

Preterm Baby Have trained personnel on hand- able to intubate, place UVC If facility is not equipped to handle premature newborn have transport team ready/called Keep preterm baby warm, increase temp of the delivery room and area where baby will be resuscitated to approximately 25-26 C (77-79 F) Use polyethylene plastic wrap for babies delivered at less than 29 weeks gestation (or 28 weeks or less). Use a sheet of plastic food wrap, a food grade 1-gallon plastic bag or a commercially available sheet of polyethylene plastic Place a portable warming pad under layers of towels on the resuscitation table

Preterm Baby Common Characteristics: Weak muscles and surfactant deficiency, making adequate ventilation more difficult (avoid excessive pressures) Infection post resuscitation is common The baby should be monitored for apnea and bradycardia Babies who require resuscitation are at risk for deterioration after their vital signs have returned to normal. Management includes monitoring and controlling blood sugar, watch for IVH, ROP and sepsis After 5 to 10 minutes, attempt to maintain oxygen saturations in the 85% to 95% range Give feedings slowly and cautiously while maintaining nutrition intravenously

Ethical Considerations Discontinuation of life support should be considered after 10 minutes of absent heart rate. The decision to continue beyond 10 minutes should take into considerations factors such as gestational age, etiology of arrest, complications, parents previously expressed feelings about acceptable risk It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement.

Ethical Considerations The ethical principles should be no different from those of an older child or adult. A consistent and coordinated approach to individual cases by the obstetric and neonatal teams and the parents is an important goal. Noninitiation of resuscitation and discontinuation of life-sustaining treatment during or after resuscitation are ethically equivalent, and clinicians should not hesitate to withdraw support when functional survival is highly unlikely. When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. GA equal to or less than 23 weeks or gestational weight less than 500 grams Surrogate decision maker(s) for a newborn in most cases are the parents The parents' views on either initiating or withholding resuscitation should be supported.

Mega Code and Testing The test comprises of 9 Lessons The mega code is done as a group followed by a debriefing