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Newborn Care and Resuscitation

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Newborn Care and Resuscitation Joseph J. Mistovich, M.Ed, NREMT-P Chair and Professor Department of Health Professions Youngstown State University – PowerPoint PPT presentation

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Title: Newborn Care and Resuscitation


1
Newborn Care and Resuscitation
  • Joseph J. Mistovich, M.Ed, NREMT-P
  • Chair and Professor
  • Department of Health Professions
  • Youngstown State University
  • Youngstown, Ohio
  • jjmistovich_at_ysu.edu

2
Neonatal Resuscitation
  • Newly born infant at time of birth
  • Newborn within first few hours of birth
  • Neonate within first 30 days of delivery
  • Pre-term less than 37 weeks of gestation
  • Term 38 to 42 weeks of gestation
  • Post-term (post-date) greater than 42 weeks of
    gestation

3
General Pathophysiology and Assessment
  • Approximately 10 of newborns require assistance
    to begin breathing
  • Extensive resuscitation needed in less than 1 of
    newborns
  • Rate of complication increases as the newborn
    weight and gestational age decrease
  • 80 of 30,000 babies born each year weighing less
    than 3 lbs. (1,500 grams) require resuscitation

4
Antepartum Risk Factors
  • Multiple gestation
  • Pregnant patient lt16 or gt35 years of age
  • Post-term gt42 weeks
  • Preeclampsia, HTN, DM
  • Polyhydraminos
  • Premature rupture of amniotic sac (PROM)
  • Fetal malformation
  • Inadequate prenatal care
  • History of prenatal morbidity or mortality
  • Maternal use of drugs or alcohol
  • Fetal anemia
  • Oligohydraminos

5
Intrapartum Risk Factors
  • Premature labor
  • PROM gt24 hours
  • Abnormal presentation
  • Prolapsed cord
  • Chorioamnionitis
  • Meconium-stained amniotic fluid
  • Use of narcotics within 4 hours of delivery
  • Prolonged labor
  • Precipitous delivery
  • Bleeding
  • Placenta previa

6
Fetal Transition
  • Rapid process that allows baby to breathe
  • Fetal lung is collapsed and filled with fluid
  • Reduction in pulmonary resistance

7
Causes of Delayed Fetal Transition
  • Hypoxia
  • Meconuium aspiration
  • Blood aspiration
  • Acidosis
  • Hypothermia
  • Pneumonia
  • Hypotension

8
Newborn Resuscitation
  • Recommendations are primarily for neonates
    transitioning to extrauterine life
  • Also applicable to neonates and infants during
    the first few weeks to months following birth

2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care
9
Arrival of the Newborn
  • Key questions
  • Mothers age
  • Length of pregnancy (due date)
  • Presence and frequency of contractions
  • Presence of or absence of fetal movement
  • Any pregnancy complications (DM, HTN, fever)
  • Rupture of membranes
  • When?
  • Color? (clear, meconium, blood)
  • Any medications that have been taken

10
Arrival of the Newborn
  • Suction when the head is delivered
  • Nose
  • Mouth
  • Keep the baby at the same level as the mother
  • Neonate turned to side if copious secretions

11
Suctioning Clear Amniotic Fluid
  • Recommendation that suctioning immediately
    following birth including with a bulb syringe
    should only be done in babies who have obvious
    obstruction to spontaneous breathing or require
    PPV
  • 2010 American Heart Association Guidelines for
    Cardiopulmonary Resuscitation and Emergency
    Cardiovascular Care

12
Suctioning Clear Amniotic Fluid
  • Suctioning the nasopharynx can cause bradycardia
  • Suctioning the trachea in intubated babies
  • Decreases pulmonary compliance
  • Decreases oxygenation
  • Reduces cerebral blood flow
  • If secretions are present, suctioning must be
    performed.
  • 2010 American Heart Association Guidelines for
    Cardiopulmonary Resuscitation and Emergency
    Cardiovascular Care

13
Clamp and Cut Cord
14
Special Consideration
  • Polycythemia (escessive red blood cell count)
  • Delay in clamping the cord
  • Placing the infant below the placenta
  • Do not milk the cord
  • Destroy or distort RBCs

15
Initial Assessment
  • Respiratory rate (Cry)
  • Respiratory effort (Cry)
  • Pulse rate
  • Oxygenation
  • Color
  • SpO2

16
Assess Neonate
  • Nearly 90 of newborns are vigorous term babies
  • Ensure thermoregulation
  • Dry
  • Warm
  • Place on mothers chest (skin to skin)
  • Suction only if necessary
  • Assess ventilation (cry)
  • Asses heart rate
  • Assess oxygenation (color and SpO2)

17
Apgar Score
  • Determines need and effectiveness of
    resuscitation
  • Performed 1 minute and 5 minutes after birth
  • If 5 minute Apgar is less than 7, reassess every
    5 minutes for 20 minutes

18
APGAR Score
19
Need for Resuscitation
  • Approximately 10 of newborns require additional
    assistance
  • 1 requires major resuscitation
  • Resuscitation
  • Intervene Reassess Intervene
    Reassess
  • 30 second intervals

20
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21
Initial Steps of Resuscitation
  • Routine Care If YES to the following questions
  • Term gestation?
  • Amniotic fluid clear?
  • Breathing or crying?
  • Good muscle tone?
  • Dry
  • Provide warmth (skin-to-skin)
  • Cover
  • Assess color, breathing, acivity

22
Initial Steps of Resuscitation
  • Resuscitative Care If NO to the following
    questions
  • Term gestation?
  • Amniotic fluid clear?
  • Breathing or crying?
  • Good muscle tone?
  • Provide warmth
  • Position sniffing position
  • Clear airway (meconium consideration)
  • Dry and stimulate
  • PPV
  • Chest compressions
  • Epinephrine or volume expansion

23
Stimulate
24
Initial Steps (Golden Minute)
  • Approximately 60 seconds to complete, reevaluate,
    and ventilate if necessary
  • Provide warmth
  • Clear airway
  • Dry
  • Stimulate
  • Position - sniffing

25
Initial Steps (Golden Minute)
  • Decision to proceed beyond initial steps is based
    on evaluation of
  • Respirations
  • Apnea
  • Gasping
  • Labored breathing
  • Heart rate
  • Less than 100 bpm
  • Auscultation of precordial pulse
  • Palpation of umbilical pulse

26
Assessment After PPV or Supplemental Oxygenation
  • Evaluate
  • Heart rate
  • Respirations
  • Oxygenation
  • Most sensitive indicator of successful response
    is an increase in heart rate

27
Assessment of Oxygen Need and Oxygen
Administration
  • Blood oxygen levels do not reach extrauterine
    values in uncompromised babies until
    approximately 10 minutes after birth
  • Cyanosis may appear until that point (10 minutes)
  • Skin color is very poor indicator of oxygen
    saturation immediately after birth
  • Lack of cyanosis is a very poor indicator state
    of oxygenation in uncompromised baby

28
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31
Neonatal Pulse Oximetry
  • New pulse oximeters with neonatal probes
  • Provide reliable readings within 1 to 2 minutes
    following birth
  • Must have sufficient cardiac output to skin
  • SpO2 recommended
  • Resuscitation anticipated
  • PPV for more than a few breaths
  • Persistent cyanosis
  • Supplemental oxygen is administered

32
Neonatal Pulse Oximetry
  • Probe location
  • Right upper extremity
  • Medial surface of the palm
  • Wrist
  • Attach probe to baby prior to device
  • More rapid acquisition of signal

33
PPV and Supplemental Oxygen
  • 100 oxygen administration is not recommended
  • Titrate oxygen to SpO2 range
  • Initiate resuscitation with air if blended oxygen
    is not available
  • If bradycardia persists (HR lt60 bpm) after 90
    seconds, increase oxygen to 100 until HR gt 100
    bpm

34
Targeted SpO2 After Birth
  • 1 minute 60 to 65
  • 2 minutes 65 to 70
  • 3 minutes 70 to 75
  • 4 minutes 75 to 80
  • 5 minutes 80 to 85
  • 10 minutes 85 to 95

35
Newborn Intervention Triggers
  • Secretions suction
  • Apnea or gasping respirations PPV
  • Labored breathing or low SpO2 oxygen or CPAP
  • HRlt 100 bpm PPV
  • HRlt 60 Chest compressions and PPV
  • Persistent HRlt 60 epinephrine

36
Evaluate Respiration, HR, Oxygenation
  • Breathing adequate (rate and effort)
  • No apnea
  • No gasping
  • No labored breathing
  • HR gt100 bpm
  • SpO2 in normal range
  • Observe and suction only to keep airway clear

37
Evaluate Respiration, HR, Color
  • Breathing adequate
  • HR gt100 bpm
  • Core cyanosis is persistent
  • Low SpO2 reading
  • Provide blow by oxygen
  • Warm and humidify oxygen
  • 5 lpm
  • Do not blow directly in eyes or trigeminal area
    of face

38
Evaluate Respiration, HR, Color
  • Breathing adequate
  • HR gt100 bpm
  • Acrocyanosis with normal SpO2
  • No intervention
  • If acrocyanosis with poor SpO2 provide blow-by O2

39
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40
Evaluate Respiration, HR, SpO2
  • Breathing inadequate
  • Gasping or apnea
  • HR gt100 bpm
  • Good pink or normal SpO2
  • Positive pressure ventilation
  • Infant size (240 ml)
  • 5 to 8 ml/kg VT
  • Disable pop-off (30 to 40 cmH20)
  • 40 to 60 ventilations/minute
  • Peak inspiratory pressure 25 cmH2O in full-term

41
CPAP
  • Breathing spontaneously but labored
  • HRgt 100 bpm
  • SpO2 normal or low
  • Research lacking only studied in preterm babies

42
Evaluate Respiration, HR, Color
  • Breathing adequate
  • HR lt100 bpm
  • SpO2 normal
  • Positive pressure ventilation
  • Infant size (240 ml)
  • 5 to 8 ml/kg VT
  • Disable pop-off (30 to 40 cmH20)
  • 40 to 60 ventilations/minute
  • Peak inspiratory pressure 25 mmHg in full-term

43
Evaluate Respiration, HR, Color
  • Breathing adequate
  • HR lt 60 bpm
  • SpO2 not adequate
  • PPV
  • Chest compressions
  • Depth 1/3 of anteroposterior diameter of chest
  • Two thumbs over sternum with hands encircling
    chest
  • 3 compressions to one ventilation
  • Compression rate 120/minute
  • 90 compressions and 30 ventilations in one minute
  • After 30 seconds of compressions and ventilation
    consider epinephrine

44
Persistent Bradycardia
  • Usually due to
  • Inadequate lung inflation
  • Profound hypoxemia
  • Primary emergency intervention
  • Adequate ventilation
  • HR remains lt 60 bpm with 100 oxygen
  • Consider epinephrine

45
Epinephrine Administration
  • Intravenous route is recommended only
  • 0.01 to 0.03 mg/kg
  • 110,000 dilution
  • If ET route is used
  • 0.05 to 0.1 mg/kg
  • 110,000 dilution

46
Volume Expansion
  • Blood loss known or suspected
  • Pale skin
  • Poor perfusion
  • Weak pulse
  • HR not responding to other interventions
  • Isotonic crystalloid
  • 10 mL/kg
  • Avoid rapid infusion in premature infants

47
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49
Oral Airways
  • Rarely used for neonates
  • Use tongue depressor to insert airway

50
Respiratory Distress or Inadequacy
  • HR lt 100 bpm hypoxia
  • Periodic breathing (20 second or longer period of
    apnea)
  • Intercostal retractions
  • Nasal flaring
  • Grunting

51
Meconium Stained Amniotic Fluid (MSAF)
  • 10 to 15 of deliveries
  • High risk of morbidity
  • Passage may occur before or during delivery
  • More common in post-term infants and neonates
    small for the gestational age
  • Fetus normally does not pass stool prior to brith

52
Meconium Stained Amniotic Fluid
  • Complications if aspirated Meconium Aspiration
    Syndrome (MAS)
  • Atelectasis
  • Persistent pulmonary hypertension
  • Pneumonitis
  • Pneumothorax

53
Meconium Stained Amniotic Fluid
  • Determine if fluid is thin and green or thick and
    particulate
  • If baby is crying vigorously use standard
    resuscitation criteria
  • If baby is depressed
  • DO NOT dry or stimulate
  • Intubate trachea
  • Attach a meconium aspirator
  • Apply suction to endotracheal tube
  • Dry and stimulate
  • Continue with standard resuscitation

54
Apnea
  • Common in infants delivered before 32 weeks of
    gestation
  • Risk factors
  • Prematurity
  • Infection
  • Prolonged or difficult labor and delivery
  • Drug exposure
  • CNS abnormalities
  • Seizures
  • Metabolic disorders
  • Gastroesophageal reflux

55
Apnea
  • Pathophysiology
  • Prematurity due to underdeveloped CNS
  • Gastroesophageal reflux can trigger a vagal
    response
  • Drug-induced from CNS depression
  • Bradycardia is key assessment finding

56
Premature and Low Birth Weight Infants
  • Delivered before 37th week of gestation
  • Less than 5.5 lbs or 2,500 grams
  • Premature labor
  • Genetic factors
  • Infection
  • Cervical incompetence
  • Abruption
  • Multiple gestations (twins, triplets)
  • Previous premature delivery
  • Drug use
  • Trauma

57
Premature and Low Birth Weight Infants
  • Low birth weight
  • Chronic maternal HTN
  • Smoking
  • Placental anomalies
  • Chromosomal abnormalities
  • Born lt24 weeks and less than 1 lb poor chance
    of survival

58
Premature and Low Birth Weight Infants
  • Physical appearance
  • Skin is thin and translucent
  • No cartilage in the outer ear
  • Small breast nodule size
  • Fine thin hair
  • Lack of creases in soles of feet

59
Premature and Low Birth Weight Infants
  • High risk for respiratory distress and
    hypothermia
  • Surfactant deficiency
  • Thermoregulation is imperative
  • Use minimum pressure with PPV
  • Brain injury may result from hypoxemia, rapid
    change in blood pressure
  • Retinopathy from abnormal vascular development of
    retina
  • May be worsened by long term oxygen administration

60
Hypoglycemia
  • BGL lt40 mg/dL
  • May not be symptomatic until BGL reaches 20 mg/dL
  • Fetus received glycogen stores from mother in
    utero
  • Liver
  • Heart
  • Lung
  • Skeletal muscle

61
Hypoglycemia
  • Glycogen stores sufficient for 8 to 12 hours
    after birth
  • Disorders related to
  • Poor glycogen storage
  • Small birth weight
  • Prematurity postmaturity
  • Increased glucose use
  • Infant of DM mother
  • Large for gestational age
  • Hypoxia
  • Hypothermia
  • Sepsis

62
Hypoglycemia
  • Symptoms
  • Cyanosis
  • Apnea
  • Irritability
  • Poor sucking or feeding
  • Hypothermia
  • Lethargy
  • Tremors
  • Twitching or seizures
  • Coma
  • Tachycardia
  • Tachypnea
  • Vomiting

63
Hypoglycemia
  • Check BGL heel stick
  • Establish good airway, ventilation, oxygenation,
    and circulation
  • D10W -10 dextrose
  • 2 mL/kg IV if BGL lt40 mg/dL
  • IV infusion of D10W 60 mL/kg
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