Principles of Neonatal Resuscitation

Outline

Routine care for all newborns ABCs of neonatal resuscitation Neonatal resuscitation guidelines Review questions

Routine Care of Newborns at Delivery Most babies require only simple, supportive care The following steps should be taken to provide

supportive care to all newborns at the time of delivery: Dry baby with clean towel, including head, and keep infant

warm! Check for: good muscle tone, good crying effort and/or adequate

breathing, pink central color If needed, help baby establish breathing! Give baby to mother as soon as possible for skin to skin contact Cover the baby to prevent heat loss Initiate breast-feeding within 1 hr

Neonatal Resuscitation In some situations, the need for resuscitation might be anticipated,

for example:Mothers with pre-eclampsiaMultiple birthsPre-term deliveryProlapsed cord

In these cases, it is CRITICAL to prepare equipment beforehand! Resuscitation staff must be present at the moment the baby is born!

But often, the need for resuscitation is not known prior to delivery, therefore:

Be prepared for resuscitation at every delivery!Every baby should be provided with routine supportive care at birth,

and be immediately assessed by a mid-wife, nurse, or doctor for the need for further interventions

ABCs of Neonatal Resuscitation

When approaching any sick infant or child, priority should be to assess and support airway, breathing and circulation

This is called the “ABC” approach

A: Open and stabilize the patient’s airwayB: Support patient’s efforts to breathe, or breathe for the

patient if necessaryC: Check pulse and perfusion, support cardiac output as

needed

ABC’s

This presentation will first review principles of ABC’s, then discuss recommended resuscitation guidelines

ABCs of Neonatal Resuscitation

A = Airway

Airway

Position infant in neutral position to open airwayLay baby flat on back, chin lifted upDo not hyperextend the neck as this will

compress airway

Opening the AirwayOpening the Airway

Wrong positioning:

Right positioning

Airway

Suction the Airway Oral (and nasal) secretions should be suctioned

immediately with a bulb suction or other suction device. This helps clear the airway AND provides stimulation.

Suck out debris and fluid from mouth, nose and oropharynx

Do not suck deep in the throat as this can cause apnea and bradycardia

Do not repeatedly suction nose as this can cause swelling and obstruct the airway making breathing more difficult

ABCs of Neonatal Resuscitation

B = Breathing

Breathing

Assess infant’s effort to breathe Patient should have a good cry or good respirations –

grunting breaths or weak breaths are not adequate If infant is not breathing adequately, choose a

mask that covers nose and mouth, but not the chin of the infant, in order to begin bag-and-mask ventilation Size 0 for small infants Size 1 for normal weight infant

KEY TEACHING POINT! REMEMBER THIS!

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!

Gently pull infant’s jaw forward to mask Use a “C-grip” to hold mask to infant’s face,

using the 3rd finger to hold jaw up to mask

Breathing

Check for an inadequate seal If you can hear air escaping from the mask,

reposition the mask to form a better seal between mask and face

Most commonly, air escapes from openings between nose and cheek

Hold mask gently but firmly to infant’s face

Breathing

Ventilate (bag) infant at a rate of 40-60 breaths per minute

Goal with bag and mask ventilating is to give enough air with each ventilation to move the chest Watch for chest to rise and fall

If the chest does not move with bagging: Check seal of mask Reposition infant in the neutral position Suction airway Try giving larger breaths with the bag

Correct positioning

Watching for chest-rise- if chest is rising and falling you are performing adequate ventilation

ABCs of Neonatal Resuscitation

C = Circulation

Circulation

Check for pulse on infant Feel umbilical cord or brachial pulse Or listen with stethoscope for heart rate

If heart rate is less than 60 beats/min, ensure that effective ventilation is being administered!

If so, continue ventilation and begin compressions: Give 90 compressions/minute Give in cycles: 3 compressions and 1 breath every 2 seconds,

then repeat, 3 compressions 1 breath Place two thumbs on sternum, just below nipple line Compress chest approximately 1/3 of the AP diameter

Correct position of thumbs for chest compressions on infant: two choices

Neonatal Resuscitation Guidelines:

Dry the baby with a clean cloth Check for:

Breathing or crying Pink central color Good tone

If all present, continue routine care If baby does not have good respiratory effort, pink central color AND

good tone: Position infant in neutral position Clear airway Stimulate Give oxygen if available

Neonatal Resuscitation Guidelines:

If baby responds to positioning and stimulation by turning pink and breathing, return to routine care

If baby does not respond to these measures within 30 seconds: Apply mask and ventilation bag to infant Give 5 slow breaths

If baby responds and begins breathing, continue to observe closely, return to giving routine care

If baby is not breathing after 5 slow breaths: Check position of infant Continue bag and mask ventilation Check to see if chest is rising: if there is no chest movement, suction

airway, reposition infant, then resume bag and mask ventilation

Neonatal Resuscitation Guidelines:

If not breathing after 30 seconds: Check heart rate

If heart rate is > 60 beats per minute: Continue to ventilate at 40 breaths per minute Use oxygen to ventilate if available Watch for chest rise Monitor position of infant Stop ventilation every 1-2 mins to see if HR is greater than 60

beats per minute Stop compressions if HR is > 100 beats per minute Stop ventilations when breathing is > 30 breaths per minute Continue oxygen therapy until infant is pink and has good tone

Neonatal Resuscitation Guidelines:

If heart rate is < 60 beats per minute: Continue effective Positive Pressure Ventilation and

begin chest compressions at a rate of 90 compressions/minute Continue chest compressions until HR>60 beats per minute Continue to ventilate at 40 breaths per minute Use oxygen to ventilate if available Watch for chest rise Monitor position of infant – should be neutral head position Stop ventilation every 1-2 mins to see if HR is greater than 60 beats per

minute Stop compressions if HR is > 100 beats per minute Stop ventilations when breathing is > 30 breaths per minute Continue oxygen therapy until infant is pink and has good tone

Neonatal Resuscitation Guidelines:

Cessation of resuscitation If after 20 minutes the baby is not breathing

and there is no pulse, the recommendation is to stop resuscitation efforts

Review Questions

Immediate assessment of a newborn should include which of the following?A. TemperatureB. Check if hands and feet are pinkC. Check for crying or breathingD. Check pulse by umbilical cord

Review Questions

All of the following steps should be followed for all newborn infants except:A. Drying infant thoroughly, including headB. Assessing baby for good breathing or

crying, good muscle tone, and pink central color

C. Bathing infant within first hourD. Initiating breast feeding within one hour

Review Questions

An infant is born with a weak cry, poor muscle tone and bluish color on the abdomen. After drying with a clean cloth and stimulating her, the infant has gasping breaths. The next recommended step in the resuscitation of this infant is: A. Place appropriate mask on infant and give 5 slow breaths B. Check heart rate by feeling umbilical cord pulsations C. Position head appropriately and suction airway if necessary D. Continue to stimulate infant