1. Neonatal Resuscitation Algorithm
Initial Newborn Care
Neonatal Resuscitation Algorithm

2. 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:

3. 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

4. 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

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

6. Website for more information on Neonatal Resuscitation Program (NRP)--
This is from the American Academy of Pediatrics and has all the information about the process.

7. 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

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

9. 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.)

10. *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.

11. *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.

12. *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.

13. 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

14. 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

15. 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!

16. 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

17. 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

18. 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.

19. 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

20. 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.

21. 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.

22. Don’t you just love being a neonatal nurse?