1. Special Considerations

2. ObjectivesObjectives  Special situations that may complicate resuscitation  Subsequent management after resuscitation  How the principles of NRP can be applied beyond immediate newborn period or outside Delivery Room

3. What complications should you consider if baby does not improve Ascertain  Does the baby fail to begin spontaneous respiration  Does PPV fail to result in adequate ventilation  Does the baby remain cyanotic or have bradycardia despite good ventilation

4. When baby fails to begin spontaneous respiration  Consider Narcotic administration to the mother  Use Naloxone if mother has received narcotics within the last 4 hrs but only after: Establishing PPV and when the baby has normal heart rate and color  Do not use Naloxone if mother is addicted to narcotics or is on methadone maintenance: This may induce seizures in newborn

5. When baby fails to begin spontaneous respiration  Other maternal drugs which may cause neonatal respiratory depression: Magnesium sulfate or non-narcotic analgesics or general anesthetics  These will not respond to Naloxone  Continue PPV and transport the baby to NICU

6. NaloxoneNaloxone  Concentration: 1.0 mg/ml & 0.4mg/ml  Recommended Route: Intravenous  Not recommended for Endotracheal use  Dose: 0.1 mg/kg

7. Metabolic Acidosis  Use of Sod. Bicarb during resuscitation controversial  Ascertain ventilation is adequate before giving Sod Bicarb  Most often restoration of circulating volume and adequate oxygenation resolves acidosis  Preferably after the Blood gas analysis

8. Sodium bicarbonate  To correct metabolic acidosis  Recommended Conc. – 4.2 % Not available  Use 7.5% solution which is available  Recommended Route – Umb. Vein (NEVER Endotracheally) Dose – 2 meq/kg Rate of admn. – No faster than 1meq/kg/min

9. What if PPV fails to result in adequate ventilation of Lungs Consider Mechanical Blockage of airway  Meconium or mucus in pharynx or trachea  Choanal Atresia  Pharyngeal airway malformation (Robin Syndrome)  Other rare conditions e.g. Laryngeal web

10. What if PPV fails to result in adequate ventilation of Lungs Consider Impaired Lung Function  Pneumothorax  Congenital Pleural effusion  Congenital Diaphragmatic Hernia  Pulmonary Hypoplasia  Extreme immaturity  Congenital pneumonia

11. Choanal Atresia Congenital obstruction of posterior nasopharynx Oral Airway

12. Robin Syndrome Normal Newborn Jaw Tongue Newborn with Robin Syndrome Abnormally small Jaw Tongue airway at posterior pharynx

13. Robin Syndrome Prone positioning and a nasopharyngeal tube are often effective

14. Impaired Lung Function  Pneumothorax Breath sounds diminished Transillumination of chest X-ray chest is diagnostic  Drain it with Scalp vein Insert 21 or 23 G perpendicular to chest wall just over the top of rib 4 th IC space i.e. level of nipple in Anterior axillary line  Pleural effusion

15. Drainage of Pneumothorax  Turn the baby to side with pneumothorax side superior  A 18 or 20G catheter is inserted perpendicular to chest wall  Just over the top of the rib in the 4 th IC space (at the level of Nipples) in ant. axillary line  Aspirate with 20 ml syringe through a stopcock

16. Impaired Lung Function  Congenital Diaphragmatic Hernia Scaphoid abdomen Diminished breath sounds Persistent respiratory distress, PPHN and cyanosis  Immediate endotracheal Intubation  Avoid PPV with mask  10 F Orogastric tube to evacuate stomach contents

17. Impaired Lung Function Other Conditions  Pulmonary Hypoplasia Severe oligohydramnios may cause this, as amniotic fluid needed for lung development  Extreme Immaturity  Congenital pneumonia

18. What if Baby Remains Cyanotic or Bradycardic Despite Good Ventilation  Ensure Chest is moving adequately, breath sounds are good and 100% O 2 is being given Consider Congenital Heart Disease  Babies with CHD are seldom critically ill at birth.  Problems with ventilation are almost always the cause of a failure of successful resuscitation

19. What Should be Done after Successful Resuscitation Post Resuscitation Care : Management of  Temperature  Fluid & Electrolytes  Pneumonia, PPHN, Hypotension  Seizures & apnea  Hypoglycemia  Feeding issues

20. HypotensionHypotension  Hypoxic insult to heart muscle or decreased vascular tone  Murmur of TR may be heard  Sepsis or blood loss may be contributing factors  Monitor Heart rate and BP  Volume expansion, Blood transfusion or inotropes may be required

21. Fluid Management  Higher risk of Renal failure, SIADH  Monitor body weight, urine output, serum electrolytes & calcium  Modify fluid and electrolyte intake accordingly

22. Other Problems  Seizures or Apnea Symptoms of HIE or Hypocalcemia/ Hyponatremia Anticonvulsant (Phenobarbital): Be cautious  Hypoglycemia: Frequent Blood sugar monitorint  Feeding Problems: Risk of ileus, GI bleeding, NEC  Temperature Management: Maintain Normal body temperature Modest hypothermia experimental Avoid Hyperthermia

23. Baby born outside or beyond immediate newborn period  Baby born at home or in a vehicle  A baby who develops apnea in Nursery  A 2-week old baby with sepsis who presents to the Doctor’s clinic with shock  An intubated baby in the NICU suddenly deteriorates  Principles remain the same  Priority is to restore ADEQUATE VENTILATION

24. Baby born outside or beyond immediate newborn period  Temperature control: Baby is usually not wet Turn up the heat in the room or vehicle Dry the baby with bath towels, a blanket or clean clothing Skin to skin contact: cover both mother & baby with blanket  Clearing airway Use bulb syringe Wipe mouth & nose with clean cloth wrapped around your index finger

25. Baby born outside or beyond immediate newborn period Ventilation  Tactile Stimulation  Mouth to Mouth and nose or  Mouth to Mouth with nose pinched Vascular Access  Umbilical vein may not be an option  Cannulation of peripheral vein or  Intraosseus needle