Care of the newborn Dr. Miada Mahmoud Rady EMS/481 Neonatal Emergencies

Initial steps of stabilizing a newborn I.Warming the newborn to prevent hypothermia. II.Positioning the newborn. III.Clearing the airway if necessary. IV.Drying and stimulating breathing.

Position of the newborn  Position on the back or side with the neck in the sniffing position (slightly extended).  Use a small shoulder roll to keep the head in this position.

Opening the Airway Wrong positioning : Right positioning

Initial steps of stabilizing a newborn I.Warming the newborn to prevent hypothermia. II.Positioning the newborn. III.Clearing the airway if necessary. IV.Drying and stimulating breathing.

Clearing The Airway 1.Using bulb syringe or suction catheter. 2.Turn the head of the to the side. 3.Gently suction the mouth first then the nose to prevent aspiration. 4.Avoid suctioning hard or deeply as it can induce a Vagal response and bradycardia. 5.Return the head to the sniffing position after suctioning.

Initial steps of stabilizing a newborn I.Warming the newborn to prevent hypothermia. II.Positioning the newborn. III.Clearing the airway if necessary. IV.Drying and stimulating breathing.

Drying and Stimulating Breathing  Dry the head and body with dry towels to provide stimulation.  Stimulate also via tactile stimulation by : 1.Slapping/flicking soles of the feet. 2.Rubbing gently on the back or trunk.

Arrival of the newborn

History Taking 1.Woman’s age 2.Length of pregnancy 3.Presence and frequency of contractions 4.Presence or absence of fetal movement 5.Any pregnancy complications 6.If membranes have ruptured ( Timing, color of fluid ). 7.Medications being taken

Resuscitation oriented history

Ambulance Delivery 1.Cover the foot of the stretcher with clean, warm blankets for the initial stabilization. 2.After confirming adequate airway, breathing, and pulse rate, place the newborn on the mother’s chest. 3.If more extensive resuscitation is necessary, transition newborn to a second ambulance with a neonatal transport incubator.

Ambulance Delivery 4.Suction the mouth, then the nose with a bulb syringe once the head is delivered. 5.Keep the newborn at the level of the mother after delivery, with head slightly lower than the body. ► ►► If the cord comes out ahead of the newborn, the blood supply to the fetus may be cut off (prolapsed cord), relieve pressure on the cord by gently moving the newborn’s body off the cord and pushing the cord back.

6.Do an initial rapid assessment simultaneous with treatment interventions. 7.Note time of delivery. 8.Monitor ABCs. 9.Assess airway patency, respiratory rate and effort, tone, pulse rate, and color. 10.Position the newborn in the sniffing position to ensure a patent airway, clear secretions, and assess the respiratory effort.

7.Newborn is at risk for hyperthermia, so ensure thermoregulation by:  Placing the newborn on prewarmed towels or radiant warmer  Drying the head and body thoroughly  Discarding wet towels and covering with a dry towel  Covering the head with a cap

Finally ………. 8.All babies are cyanotic right after birth, If the newborn stays vigorous and begins to turn pink in the first 5 minutes:  Maintain ongoing observation.  Continue thermoregulation with direct skin-to-skin contact with mother while en route.

MMR Additional resuscitation steps…..

Airway management 1.Free-flow oxygen:  If a newborn is Cyanotic Or Pale, provide supplemental oxygen, until a pulse oximetry reading can give an accurate reading.  Oxygen flow rate should be 5 L/min.  oxygen can initially be delivered through: 1.PPV (first choice unless not indicated) 2.Oxygen mask 3.Oxygen tubing cupped and held close to the newborn’s nose and mouth.

Airway management 2.Oral airways : Rarely used on newborns, but it can be life saving in Bilateral Choanal Atresia. Bilateral Choanal Atresia : Bony or membranous obstruction of the back of the nose. Management : 1.Surgical correction is definitive treatment. 2.First aid measure : keeping newborn mouth open either by oral air way or gloved finger.

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Other Conditions that may require oral airways: 1.Pierre Robin sequence 2.Macroglossia (large tongue) 3.Craniofacial defects that affect the airway

MMR Breathing

If a newborn baby fails to breathe after bulb suctioning, then Positive Pressure Ventilation With A Bag-and-mask is the single most important step in neonatal resuscitation.

Bag-mask ventilation Indicated when a newborn: 1.apneic 2.Has inadequate respiratory effort 3.Has a pulse rate of less than 100 beats/min after:  Airway is cleared of secretions.  Tongue obstruction is relieved.  Newborn is dried and stimulated.

MMR  Signs of respiratory distress suggesting need for bag-mask ventilation include: 1.Periodic breathing 2.Grunting on expiration 3.Nasal flaring 4.Intercostal retractions  The correct ventilation time (40 to 60 breaths/min) is important because a higher rate can cause: 1.Hypocapnia 2.Air trapping 3.Pneumothorax

MMR Continue PPV as long as the pulse rate is less than 100 beats/min or the respiratory effort is ineffective. If more than 1 minute of PPV is needed, hook the system to a pressure manometer. Causes of ineffective bag-mask ventilation: I.Inadequate mask seal on the face II.Incorrect head position III.Copious secretions IV.Pneumothorax V.Equipment malfunction

MMR Gently pull infant’s jaw forward to mask Use a “C-grip” to hold mask to infant’s face, using the 3 rd finger to hold jaw up to mask

MMR  Correct positioning : Watching for chest-rise- if chest is rising and falling you are performing adequate ventilation

MMR Intubation Indications : 1.Meconium aspiration. 2.Diaphragmatic hernia. 3.No response to bag-mask ventilation and chest compressions, necessitating ET administration of epinephrine 4.Prolonged PPV needed. 5.Craniofacial defects impede an adequate airway.

MMR Complications of ET tube placement include: 1.Oropharyngeal or tracheal perforation 2.Esophageal intubation with subsequent persistent hypoxia 3.Right main stem intubation Risks can be minimized by: 1.Ensuring optimal placement of laryngoscope blade 2.Noting how far the ET tube is advanced

MMR Circulation

MMR Chest compression Chest compression is indicated if pulse rate remains at less than 60 beats/min despite of : 1.Positioning. 2.Clearing airway. 3.Drying and stimulations seconds of effective PPV.

MMR Criteria of chest compression in newborn 1.Two people are needed for effective chest compressions while ventilating. 2.Two different techniques: Thumb technique. (preferred one) Two finger technique. 3.The compression depth is one third of the anteroposterior diameter of the chest.

MMR 4.Chest compressions and artificial ventilation should not be delivered simultaneously. { Coordinate 90 compressions and 30 breaths/min, equaling 120 events per minute (1/2 second each) }. 5.Pulse rate should not be assessed for at least 45 to 60 seconds after ventilation and chest compressions are established. { Interruption of chest compressions to assess the pulse may decrease perfusion of coronary arteries }.

MMR Stopping chest compression 1.If pulse rate is above 60 beats/min: Chest compressions can be stopped. Effective ventilation should continue at 40 to 60 breaths/min. Recheck pulse rate after 30 seconds. 2.If the pulse rate goes above 100 beats/min: gradually slow the rate and decrease PPV pressure.

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