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Resuscitation of the Newborn Lynne M. Smith, M.D. Chair Department of Pediatrics Division of Neonatology Harbor-UCLA Medical Center Professor of Pediatrics David Geffen School of Medicine at UCLA
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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
