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
• Youngstown, Ohio
• jjmistovich_at_ysu.edu

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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

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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

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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

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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

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Fetal Transition

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

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Causes of Delayed Fetal Transition

• Hypoxia
• Meconuium aspiration
• Blood aspiration
• Acidosis
• Hypothermia
• Pneumonia
• Hypotension

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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
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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

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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

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SuctioningClear 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

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SuctioningClear 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

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Clamp and Cut Cord
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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

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Initial Assessment

• Respiratory rate (Cry)
• Respiratory effort (Cry)
• Pulse rate
• Oxygenation
• Color
• SpO2

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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)

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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

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APGAR Score
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Need for Resuscitation

• Approximately 10 of newborns require additional
  assistance
• 1 requires major resuscitation
• Resuscitation
• Intervene Reassess Intervene
  Reassess
• 30 second intervals

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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

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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

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Stimulate
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Initial Steps (Golden Minute)

• Approximately 60 seconds to complete, reevaluate,
  and ventilate if necessary
• Provide warmth
• Clear airway
• Dry
• Stimulate
• Position - sniffing

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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

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Assessment After PPV or Supplemental Oxygenation

• Evaluate
• Heart rate
• Respirations
• Oxygenation
• Most sensitive indicator of successful response
  is an increase in heart rate

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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

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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

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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

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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

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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

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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

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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

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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

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Evaluate Respiration, HR, Color

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

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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

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CPAP

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

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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

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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

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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

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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

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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

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Oral Airways

• Rarely used for neonates
• Use tongue depressor to insert airway

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Respiratory Distress or Inadequacy

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

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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

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Meconium Stained Amniotic Fluid

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

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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

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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

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Apnea

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

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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

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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

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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

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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

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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

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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

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Hypoglycemia

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

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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