Resuscitation of the Newborn

Lynne M. Smith, M.D.ChairDepartment of PediatricsDivision of NeonatologyHarbor-UCLA Medical CenterProfessor of PediatricsDavid Geffen School of Medicine at UCLA

Stated Goals Describe the usual measures taken for the routine

evaluation and care of the newborn. Discuss the critical features of history and physical

exam before, during, and after birth. Describe prophylactic measures to optimize a safe

delivery. Describe how neonatal resuscitation differs from that

of PALS and ACLS. Discuss daily bedside "hacks" to review neonatal

resuscitation as "thought experiments" on well children.

GOALSTo understand the steps of resuscitation for term

and preterm newborns

2-3

GOALS

Review NRP guidelines

Provide helpful pearls to allow you to confidently resuscitate the newly born baby

2-5

Rhyme

Number

Reminder

Approximately 1% of newborns require major resuscitative measures: Intubation Chest compressions Medications

Rhyme

WARM, DRY, STIMULATE

THEN YOU HAVE TO VENTILATE

CASE #1 Paramedics call stating they are transporting a woman

who delivered her baby two minutes ago en route to your facility. The baby appears term

They state the baby is: Cyanotic, breathing and with normal tone Resting on the moist towel used to deliver him

What is the biggest threat to the baby’s well being that must be addressed first?

CASE Paramedics call stating they are transporting a woman

who delivered her baby two minutes ago en route to your facility. The baby appears term

They state the baby is: Cyanotic, breathing and with normal tone Resting on the moist towel used to deliver him

Why Warm, dry, stimulate?

Avoid cold stress

Goal: 36.5-37.5 Celsius

Warmth, dry, stimulate….

Dry them off AND replace with dry blanket

Hat

Place skin-to-skin with mother

Warm, dry, stimulate….

For preterm newborns less than 32 weeks’ gestation the following are recommended:

Hat

Polyethylene Bag

Thermal mattress

http://www2.aap.org/nrp/docs/15535_NRP%20Guidelines%20Flyer_English_FINAL.pdf

Warm, Dry, Stimulate

Drying the head and body is adequate stimulation

1-15

Inappropriate/Hazardous Forms of StimulationDO NOT!! Slap back or buttocks (bruising) Squeeze rib cage (broken bones/pneumothorax) Forcing thighs onto abdomen (liver/spleen rupture) Dilating anal sphincter Hot or cold compresses or baths (burns; temperature

extremes) Shaking: Brain injury

Preterm Drying should be pat drying—not vigorous

Why stimulate?

To Avoid Primary apnea

When a fetus/newborn first becomes deprived of oxygen:1) initially attempt to rapidly breath 2) followed by apnea and dropping heart rate

Warm, Dry, Stimulate

BULB SYRINGE

From Kennan, Udaeta, Lopez and Neirmeyer. Deliver and Immediate Neonatal Carehttps://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/children-and-disasters/documents/peds-module07-eng.pdf

“Non-vigorous newborns with meconium stained fluid do not require routine intubation and tracheal suctioning”

Do not have to ask about color of the amniotic fluid

http://www2.aap.org/nrp/docs/15535_NRP%20Guidelines%20Flyer_English_FINAL.pdf

Warm, Dry, Stimulate

WARM, DRY, STIMULATE

THEN YOU HAVE TO VENTILATEIF HR <100

What other color is not part of the initial assessment?

Cyanosis

Oxygen can be toxic to the newly born baby

Cyanosis

How low?

For how long?

Oxygen Saturations

Pearl: At 60 seconds, 60% is the target.

Term or preterm newborn

Pulse Oximeter Pearl

Place pulse oximeter on theright hand (pre-ductal)

>35 weeks’ gestation, begin with room air<35 weeks’ begin resuscitation with 21-30%

http://www2.aap.org/nrp/docs/15535_NRP%20Guidelines%20Flyer_English_FINAL.pdf

At 60 seconds

Weiner, G. M., & Zaichkin, J. (2016). Textbook of neonatal resuscitation. Elk Grove Village, IL: American Academy of Pediatrics.

Warm, dry, stimulatethen you have to ventilate if HR<100

At 60 seconds

60 At 60 seconds:

Saturations should be 60% If HR <100, then you have to ventilate

POSITIVE PRESSURE VENTILATION (PPV)

The most important indicator of successful PPV is a rising heart rate

Focus on chest movement

After 15 seconds of PPV

If the chest is moving or If the HR is increasing, continue the same

If HR not increasing and chest not movinginitiate MR SOPA with the focus being on chest movement

MR SOPA

PPV is typically started at 20/5

From Kennan, Udaeta, Lopez and Neirmeyer. Deliver and Immediate Neonatal Carehttps://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/children-and-disasters/documents/peds-module07-eng.pdf

From Kennan, Udaeta, Lopez and Neirmeyer. Deliver and Immediate Neonatal Carehttps://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/children-and-disasters/documents/peds-module07-eng.pdf

Heart rate 60 or greater does not require chest compressions

MR SOPA

Chest movement

60 At 60 seconds of life:

Saturations should be 60% If HR <100, then you have to ventilate effectively for 30

seconds Heart rates of 60 or greater do not require compressions

After 30 seconds of effective ventilation

Intubation is strongly recommended prior to compressions.

After intubation, consider suctioning the trachea

MR SOPAChest movement

ETT: Estimated sizes

5-44

Tube Size Weight(g)

2.5 Below 1,000

3.0 1,000-2,000

3.5 2,000-3,000

OG tube BUT bradycardia a risk

Gauze for one second and remove

Relax wrist to the left to make room for the ETT

Consider NIPPV

Disclaimer: No data to back these up!

ETT Placement Anecdotal “tips”

After 30 seconds of effective ventilation

Significant amount of time and number of stepsafter the start of resuscitation before initiating chest compressions

MR SOPAChest movement

Chest Compressions: Thumb Technique Thumbs compress

sternum Fingers support back

4-47

Oxygen should be increased to 100%

Continue chest compressions for 60 seconds before rechecking

Chest compressions

Photo credit : www2.aap.org

60 At 60 seconds of life:

Saturations should be 60% If HR <100, then you have to ventilate effectively for 30

seconds

Heart rates of 60 or greater do not require compressions

After initiating chest compressions, continue for 60 seconds before checking the heart rate

From Kennan, Udaeta, Lopez and Neirmeyer. Deliver and Immediate Neonatal Carehttps://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/children-and-disasters/documents/peds-module07-eng.pdf

Weiner, G. M., & Zaichkin, J. (2016). Textbook of neonatal resuscitation. Elk Grove Village, IL: American Academy of Pediatrics.

Epinephrine

One dose via ETT at 1 ml/kg is may be given

IV/UV/IO preferred: 0.1 ml/kg

Repeated does every 3-5 minutes (except for the first IV dose after ETT dose of epinephrine)

Rhyme

Number

WARM, DRY, STIMULATE

THEN YOU HAVE TO VENTILATEIF HR <100

60 At 60 seconds of life:

Saturations should be 60% If HR <100, then you have to ventilate effectively for 30

seconds

Heart rates of 60 or greater do not require compressions

After initiating chest compressions, continue for 60 seconds before checking the heart rate

My True Goal for the Talk

Reference: Weiner, G. M., & Zaichkin, J. (2016). Textbook of neonatal resuscitation. Elk Grove Village, IL: American Academy of Pediatrics