Transcript Neonatal Resuscitation and Neonatology

Chapter 4
Neonatal Assessment and Resuscitation
Labor and Delivery Terms
• Departments: L & D, OB, Post Partum,
Antepartum, NICU, Nursery
• APGAR: A measurement of the newborn's
response to birth and life outside the womb. The
ratings, APGAR, are based on Appearance (color),
Pulse (heartbeat), Grimace (reflex), Activity
(muscle tone), and Respiration (breathing). The
scores, which are taken at 1 and 5 minutes
following birth, range from 10 to 1, with 10 being
the highest and 1 being the lowest.
Labor and Delivery Terms
• Breech: When the fetus is positioned head up to be
born buttocks first or with one or both feet first.
• Cephalopelvic Disproportion(CPD):The baby is too
large to safely pass through the mother's pelvis.
• Cervidil: A medication used to ripen the cervix
before induction.
• Cesarean: An incision through the abdominal and
uterine walls for extraction of the fetus; it may be
vertical or more commonly, horizontal. Also called
abdominal delivery; commonly called C-Section.
Labor and Delivery Terms
• Colostrum: This is a thin, white fluid discharged from the
breasts in the early stage of milk production, and usually
noticeable during the last couple weeks of pregnancy
• Complete Breech: The baby's buttocks are presenting at the
cervix, but the legs are folded “Indian style,” making vaginal
delivery difficult or impossible.
• Contraction: The regular tightening of the uterus, working to
push the baby down the birth canal.
• Crowned/Crowning: When the baby's head has passed
through the birth canal and the top or “crown” stays visible at
the vaginal opening.
Labor and Delivery Terms
• Dilation: The extent to which the cervix has opened in
preparation for childbirth. It is measured in centimeters, with
full dilation being 10 centimeters.
• Effacement: This refers to the thinning of the cervix in
preparation for birth and is expressed in percentages. You will
be 100% effaced when you begin pushing.
• Epidural: A common method of anesthesia used during labor.
It is inserted through a catheter which is threaded through a
needle, into the dura space near the spinal cord.
• Episiotomy: An incision made to the perineum to widen the
vaginal opening for delivery.
Labor and Delivery Terms
• Fontanelle: Soft spots between the unfused sections of the
baby's skull. These allow the baby's head to compress slightly
during passage through the birth canal
• Forceps: Tong shaped instrument that may be used to help
guide the baby's head out of the birth canal during deliver
• Frank Breech: The baby's buttocks are presenting at the
cervix and the baby's legs are extended straight up to the
baby's head.
• Induced Labor: Labor is started or accelerated through
intervention, such as placing prostaglandin gel on the cervix,
using an IV drip of the hormone oxytocin (Pitocin), or by
rupturing the membranes.
Labor and Delivery Terms
• Lightening: When the baby drops in preparation for delivery
(Engagement).
• Meconium: This is the greenish substance that builds up in
the bowels of a growing fetus and is normally discharged
shortly after birth
• Nubain: Synthetic narcotic pain reliever commonly used in
labor and delivery.
• Oxytocin: Hormone secreted by the pituitary gland that
stimulates contractions and the milk-eject reflex. Pitocin is the
synthetic form of this hormone.
• Perineum: The muscle and tissue between the vagina and the
rectum.
Labor and Delivery Terms
• Phenergan: A sedative administered that also controls nausea
and vomiting.
• Placenta Previa: When the placenta partially or completely
covers the cervix.
• Prostaglandin Cream: Medication used to ripen the cervix
before induction.
• Ruptured Membranes: Usually refers to the breaking of the
fluid filled sac surrounding the baby. The fluid may come as a
gush of water or as a slow leak. Slow leaks are sometimes
mistaken as incontinence.
• Speculum: An instrument used to open the vagina slightly
wider so that the cervix can be seen more easily.
Labor and Delivery Terms
• Timing Contractions: Contractions are measured from the
beginning of one contraction until the beginning of the next
contraction.
• Tocolysis: Inhibition of contractions used to suppress
premature labor with medications, Magnesium Sulfate,
Terbutaline, Ritodrine
• Transverse: Baby's body length is horizontal in the uterus. If
the baby cannot be moved, it will have to be delivered by
cesarean .
• Vacuum Extractor: Instrument that attaches to the baby's
head and helps guide it out of the birth canal during delivery.
• Betamethasone: glucocorticoid drug which greatly
accelerates fetal lung maturity, but takes one to two days to
work.
Labor and Delivery Terms
• Chorioamnionitis : an inflammation of the fetal membranes
(amnion and chorion) due to a bacterial infection.
• Prelabor Rupture of Membranes (PROM) or Premature
Rupture of Membranes as it is sometimes known, is a
condition that occurs in pregnancy when there is rupture of
the membrane of the amniotic sac and chorion more than
one hour before the onset of labor
• Umbilical cord prolapse happens when the umbilical cord
precedes the fetus' exit from the uterus. It is an obstetric
emergency during pregnancy or labor that imminently
endangers the life of the fetus. Cord prolapse is rare
Labor and Delivery Terms
• Para – the number of births (alive or not) with a viable infant
> 22 weeks and at least 500 grams
• Gravida – the number of pregnancies
• Pre-eclampsia (toxemia)-Usually occurs at > 24 weeks
gestation, Acute hypertension, edema, renal impairment
(proteinuria), sudden weight gain, Occurs in 7% of
pregnancies, More common in low socioeconomic groups
• Eclampsia; Toxemia, seizures, coma, convulsions, hemolysis,
renal failure, 5% of women with pre-eclampsia develop
eclampsia, 15% die from complications; Associated with high
fetal mortality due to premature delivery
• Dystocia: Difficult birth
Neonatal Resuscitation
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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
• http://vimeo.com/31423498
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
Factors that indicate high risk delivery
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Factors can be divided into maternal and fetal.
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Maternal factors include age (younger than age 15, older than age 35)
weight (pre-pregnancy weight under 100 lb or obesity)
height (under five feet)
history of complications during previous pregnancies (including stillbirth, fetal loss, preterm labor
and/or delivery, small-for-gestational age baby, large baby, pre-eclampsia or eclampsia)
more than five previous pregnancies
bleeding during the third trimester
abnormalities of the reproductive tract
uterine fibroids
Hypertension
Rh incompatability
gestational diabetes
infections of the vagina and/or cervix
kidney infection
Fever
acute surgical emergency (appendicitis, gallbladder disease, bowel obstruction)
post-term pregnancy
pre-existing chronic illness (such as asthma, autoimmune disease, cancer, sickle cell anemia,
tuberculosis, herpes, AIDS, heart disease, kidney disease, Crohn's disease, ulcerative colitis, diabetes)
Factors that indicate high risk delivery
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Fetal factors include
exposure to infection (especially herpes simplex, viral hepatitis, mumps, rubella,
varicella, syphilis, toxoplasmosis, and infections caused by coxsackievirus)
exposure to damaging medications (especially phenytoin, folic acid antagonists,
lithium, streptomycin, tetracycline, thalidomide, and warfarin)
exposure to addictive substances (cigarette smoking, alcohol intake, and illicit or
abused drugs)
A pregnancy is also considered high-risk when prenatal tests indicate that the
baby has a serious health problem (for example, a heart defect). In such cases, the
mother will need special tests, and possibly medication, to carry the baby safely
through to delivery. Furthermore, certain maternal or fetal problems may prompt
a physician to deliver a baby early, or to choose a surgical delivery (cesarean
section) rather than a vaginal delivery.
The Birth Process
• At the onset of true labor, the contractions will feel like a
tightening of abdominal muscles, a dull ache or a pressure on
the lower pelvis or back.
• At about this time the baby drops down into the pelvis; this is
known as engagement because the baby has settled into its
position for birth. Another term aptly used is lightening
because the baby's new position means the mother has now
more space to breathe and digest food.
• With time the contractions start to come at a more regular
pace and the pain intensifies. The sensation is like a belt
tightening around your back which spreads round underneath
the baby. As the labor progresses the contractions last longer
and occur at decreasing intervals.
The Birth Process
• Bloody Show: A plug of mucous which seals the top
of the vagina acts as a barrier against infection from
invading the uterus. Sometimes this plug dislodges
itself before the contractions commence and you will
notice a 'show' i.e. thick vaginal discharge mixed with
blood in the patient’s underwear.
• This however is no indication that you are into
proper labor; it may be several days before the
action commences. In other instances, the
contractions begin well before the expulsion of the
mucous plug.
The Birth Process
• Water Break: In about 20% of women, the pressure
of the baby's head can puncture the amniotic bag
causing the fluids to leak out before labor. Often it
occurs in later part of labor. There is no mistaking a
rupture; the leakage is clear and watery from the
vagina and you can lose as much as 2 pints of fluid.
The water can gush out or come in a slow trickle.
• The baby is in risk of infection and chance of
umbilical cord's descent into the birth canal. Water
breaking can pose a risk in the form of infection or
the oxygen supply being affected.
The Birth Process
• other symptoms; nausea, diarrhea and
backache. Sometimes tightening the whole
day before labor begins; this is indicative of
the cervix ripening and shortening at a gradual
pace or your baby could be probably lying
with its back to your back. In the case of the
latter the tightening occurs as the baby
rotates round to assume the right position
before making its entry into the world.
Stages of Birth
• The first stage begins with the first contraction and ends when
the cervix is fully dilated. The cervix undergoes many changes:
it becomes softer, spongier, the cells thin out and the cervix
shortens. This shortening and thinning is termed effacement.
Before effacement the cervix is 1.5 inches in length and after
effacement it somewhat disappears.
Stages of Birth
• Force from the contractions combined with the pressure from
baby's head slowly compels the now 'thin' cervix opening to
widen. This is termed as dilation, which basically means the
widening of the opening. Full dilation is at 10cm, about the
width of a hand. When the cervix is beginning to dilate most
mothers will feel the contractions in the back. You will be
conscious of this ache but you can still go about with your
normal activities. If you do not experience this, the mucous
plug will soon dislodge instead.
Stages of Birth
• The rate of dilation varies; tends to be slower in first time
mothers.
• On average it will take about 9 hours for the cervix to dilate
2.5 cm (the latent phase). The time varies; some women take
longer, some with lesser time.
• Next comes the active phase which causes the cervix to dilate
from 3 - 10 cm; this phase lasts between 2 - 4 hours. Again the
time varies. The pain is intense and the urge to bear down
and push the baby out starts now.
• On average one hour is taken up for every centimeter that
the cervix dilates
Stages of Birth
• The second stage begins at full dilation and ends
when the baby makes an entry into the world.
• Uterine contractions are now even more
pronounced; they help in the dilation and force the
baby down and out. The contractions now occur
every 2-3 minutes, lasting between 1 to 1.5 minutes.
• As the baby makes its descent, the mother works
hard on the pushing. In a typical, normal situation,
first the head descends followed by the rest of the
body through the vagina.
Stages of Birth
• It takes a first baby close to an hour to make
its way down the birth canal, through the
vagina to the vulva
• The appearance of the baby's head at the
mouth of the vagina is called crowning.
• http://www.youtube.com/watch?v=vpeggjIiE9k
• Following the crowning, the doctor may make
a small cut into the area between the vagina
and the rectum; this is called episiotomy.
Episiotomy
Stages of Birth
• In the final stage, the placenta dislodges from the
uterus and is expelled.
• After the baby is delivered, the uterus sheds the
placenta
• Contractions continue even after baby is born. The
uterus begins to get smaller and its walls thicker. This
reduces the surface the placenta was attached. The
placenta then separates and is pushed down and out
of the vagina. Blood clots form immediately at the
site of separation preventing any excessive bleeding.
Bleeding is also controlled by the uterus contracting
and closing the blood vessels that previously
supported the placenta.
Antepartum Risk Factors
• Multiple gestation
• Pregnant patient <16 or
>35 years of age
• Post-term >42 weeks
• Preeclampsia, HTN, DM
• Polyhydraminos
• Premature rupture of
amniotic sac (PROM)
• Fetal malformation
(CDH, Gastroscesis…)
• Inadequate prenatal
care
• History of prenatal
morbidity or mortality
• Maternal use of drugs
or alcohol
• Fetal anemia
• Oligohydraminos
Risks of Multiple gestation
• Preterm labor and birth
About half of twins and nearly all higher-order
multiples are premature (born before 37 weeks).
The higher the number of fetuses in the
pregnancy, the greater the risk for early birth.
• pregnancy-induced hypertension
Women with multiple fetuses are more than
three times as likely to develop high blood
pressure of pregnancy. This condition often
develops earlier and is more severe than
pregnancy with one baby. It can also increase the
chance of placental abruption (early detachment
of the placenta).
Risks of Multiple gestation
• Anemia is more than twice as common in
multiple pregnancies as in a single birth. birth
defects
• Multiple birth babies have about twice the risk
of congenital (present at birth) abnormalities
including neural tube defects (such as spina
bifida), gastrointestinal, and heart
abnormalities.
Risks of Multiple gestation
• A phenomenon called the vanishing twin syndrome in
which more than one fetus is diagnosed, but vanishes
(or is miscarried), usually in the first trimester, is more
likely in multiple pregnancies. This may or may not be
accompanied by bleeding. The risk of pregnancy loss is
increased in later trimesters as well.
• twin-to-twin transfusion syndrome
Twin-to-twin syndrome is a condition of the placenta
that develops only with identical twins that share a
placenta. Blood vessels connect within the placenta
and divert blood from one fetus to the other. It occurs
in about 15 percent of twins with a shared placenta.
Age Related Complications
• >35 years more likely to have a multiple
pregnancy. The chance of having twins increases
with age. The use of assisted reproductive
technologies — such as in vitro fertilization —
also can play a role.
• You're more likely to develop gestational
diabetes. This type of diabetes occurs only during
pregnancy, and it's more common as women get
older. Tight control of blood sugar through diet,
physical activity and other lifestyle measures is
essential.
Age Related Complications
• You're more likely to develop high blood
pressure during pregnancy. Some studies suggest
that high blood pressure that develops during
pregnancy — before 20 weeks (chronic
hypertension), after 20 weeks (gestational
hypertension) or after 20 weeks and
accompanied by protein in the urine
(preeclampsia) — might be more common in
older women.
• The risk of chromosome abnormalities is higher.
Babies born to older mothers have a higher risk
of certain chromosome problems, such as Down
syndrome.
Preeclampsia, HTN, DM
• Preeclampsia is a condition that occurs only during
pregnancy. Diagnoses is made by the combination of high
blood pressure and protein in the urine, occurring after
week 20 of pregnancy. Preeclampsia may also be called
toxemia; who is at risk:
– A first-time mom
– Previous experience with gestational hypertension or
preeclampsia
– Women whose sisters and mothers had preeclampsia
– Women carrying multiple babies; women younger than 20 years
and older than age 40
– Women who had high blood pressure or kidney disease prior to
pregnancy
– Women who are obese or have a BMI of 30 or greater
Preeclampsia
• Mild preeclampsia: high blood pressure,
water retention, and protein in the urine.
• Severe preeclampsia/leading to eclampsia:
headaches, blurred vision, inability to tolerate
bright light, fatigue, nausea/vomiting,
urinating small amounts, pain in the upper
right abdomen, shortness of breath, and
tendency to bruise easily. Seizures and
associated symptoms
Placenta Previa
• Placenta Previa is a condition where the placenta lies low in
the uterus and partially or completely covers the cervix.
The placenta may separate from the uterine wall as the
cervix begins to dilate (open) during labor.
• Requires C-section Delivery
• Signs and symptoms of placenta previa vary, but the most
common symptom is painless bleeding during the third
trimester. Other reasons to suspect placenta previa would
be:
– Premature contractions
– Baby is breech, or in transverse position
– Uterus measures larger than it should according to gestational
age
HELLP Syndrome
• HELLP Syndrome is a series of symptoms that
make up a syndrome
• HELLP syndrome is thought to be a variant of
preeclampsia, but it may be an entity all on its
own. There are still many questions about the
serious condition of HELLP syndrome. The cause
is still unclear to many doctors and often HELLP
syndrome is misdiagnosed. It is believed that
HELLP syndrome affects about 0.2 to 0.6 percent
of all pregnancies.
HELLP Syndrome
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What is HELLP Syndrome?
The name HELLP stands for:
H- hemolysis ( breakdown of red blood cells)
EL- elevated liver enzymes (liver function)
LP- low platelets counts (platelets help the
blood clot)
HELLP Syndrome
• The most common symptoms of HELLP syndrome include:
– Headaches
– Nausea and vomiting that continue to get worse (this may also feel like a
serious case of the flu.)
– Upper right abdominal pain or tenderness
– Fatigue or malaise
• A woman with HELLP may experience other symptoms that often can be
attributed to other things such as normal pregnancy concerns or other
pregnancy conditions. These symptoms may include:
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Visual disturbances
High blood pressure
Protein in urine
Edema (swelling)
Severe headaches
Bleeding
HELLP Syndrome
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Hemolysis -Red blood bells
Abnormal peripheral smear
Lacatate dehydrogenase >600 U/L
Bilirubin > 1.2 mg/dl
Elevated liver Enzyme levels
Serum aspartate amniotransferase >70 U/L
Lacatate dehydrogenase >600 U/L
Low Platelets
Platelet count
How is HELLP Syndrome Treated?
The treatment of HELLP Syndrome is primarily based on the gestation of the
pregnancy, but delivery of the baby is the best way to stop this condition from
causing any serious complications for mom and baby. Most symptoms and side
effects of HELLP will subside within 2-3 days of delivery.
http://www.youtube.com/watch?v=LRWLB2T96MQ
Placental Abruption
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http://www.youtube.com/watch?v=CLI43qRqcjw
Requires C-sec delivery, fluid replacement
Complications
– PROM, Premature birth, amniotic embolism,
– Hypovolemic shock
Risk factors
– HTN, preclampsia, trauma, smoking
Fetal Alcohol Spectrum Disorders
(FASD);Fetal Alcohol Syndrome (FAS)
• Drinking alcohol during pregnancy can result in a
number of different physical, neurological and
mental effects that range in severity. These
effects fall under the term “Fetal Alcohol
Spectrum Disorders (FASD)”, which encompasses
all the problems that result from prenatal alcohol
exposure. The most known of these effects is
Fetal Alcohol Syndrome (FAS) and Fetal Alcohol
Effects (FAE). Fetal Alcohol Effects can also be
separated into two different categories: AlcoholRelated Neurodevelopmental Disorder (ARND)
and Alcohol-Related Birth Defects (ARBD).
FAS
• The effects of FAS include: mental retardation,
malformations of the skeletal system and major organ
systems (specifically the heart and brain), growth
deficiencies, central nervous system problems, poor
motor skills, mortality, and problems with learning,
memory, social interaction, attention span, problem
solving, speech and/or hearing.
• There are also facial features that are characteristic of
babies with FAS. These features include: small eyes,
short or upturned nose, flat cheeks, and thin lips.
These features fade as the child grows up, but the child
is left with a lifetime of difficulties trying to cope with
other effects.
• http://www.youtube.com/watch?v=oxGBjpGLdI
Other Antepartum risk factors
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Ectopic pregnancy
Fetal growth restriction
HIV/AIDS
Listeria
Placenta Accreta
RH Factor
Tipped Uterus
UTI
Yeast Infection
Fetal position
• Chicken Pox
• Cytomegalovirus (CMV)
infection
• Gestational Diabetes
• Group B Strep Infection
• Intrauterine Growth
Retardation (IUGR)
• STD’s/STI’s
• Toxoplasmosis
• Hyperemesis Gravidarum
Intrapartum Risk Factors
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Premature labor
PROM >24 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
Pain Control during child birth
• Two options, natural child birth (deep
breathing, laboring in water, massage…) or
pain controlled with opiates
• Opiates do not interfere with the ability to
push during delivery, does not numb the pain
like a epidural, can reduce anxiety
• Side effects of opiates: nausea, vomiting,
sedation, loss of protective airway reflexes
Fetal Transition
• Rapid process that allows baby to breathe
• Fetal lung is collapsed and filled with fluid
• Reduction in pulmonary resistance
Causes of Delayed Fetal Transition
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Hypoxia
Meconuium aspiration
Blood aspiration
Acidosis
Hypothermia
Pneumonia
Hypotension
Newborn Resuscitation
Basic Assessment
• Gestational age
• Amniotic fluid
• Respiratory effort
• Muscle tone
• Warmth and stimulation
• Oxygenation and ventilation
• Circulation
• Volume expanders
• Cardiotonic medications
Four Phases of Care
• Preparation (read charts, setup
equipment, ensure functionality of
equipment)
• Stabilization (NRP guidelines)
• Assessment (NRP guidelines)
• Resuscitation (NRP guidelines)
Preparation
• Trained/skilled personnel
• Equipment
• Perinatal history
ETT holders/neobar or Tape
ETT sizes 2.0, 2.5, 3.0 and 3.5 cuffless
Equipment at Delivery
Blade sizes 00, 0, 1
Cloth tape
Meconium aspirator
Various size bulb
syringes
5, 8, 10 F suction catheters
Vacuum at -60 to -80
Radiant warmer with warm
blankets, ensure temperature is
working
Types of Resuscitators
Prepare the room
• If it is a C-section, you will be in sterile dress
(be sure not to contaminate the nurse or
doctor), have transport isolate/ventilator
outside delivery room
• Insure suction tubing is working
Arrival of the Newborn
• Key questions
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Mother’s 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
Arrival of the Newborn
• Suction* when the head is delivered but
before shoulders. Performed by physician or
midwife
– Nose
– Mouth
• Keep the baby at the same level as the mother
• Neonate turned to side if copious secretions
Stabilization
• Position
• Warm/dry
• Head position
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
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
Meconium
• Vigorous or not
• If not, suction
Clamp and Cut Cord
Special Consideration
• Polycythemia (excessive red blood cell count)
– Delay in clamping the cord
– Placing the infant below the placenta
• Do not milk the cord
– Destroy or distort RBCs
Special Consideration
Severe prematurity:
Initial Assessment
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Respiratory rate (Cry)
Respiratory effort (Cry)
Pulse rate
Oxygenation
– Color
– SpO2
Assess Neonate
• Nearly 90% of newborns are vigorous term babies
• Ensure thermoregulation
– Dry
– Warm
– Place on mother’s chest (skin to skin)
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Suction only if necessary
Assess ventilation (cry)
Asses heart rate
Assess oxygenation (color and SpO2)
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
APGAR Score
http://www.youtube.com/watch?v=zY87wohJl9I
Need for Resuscitation
• Approximately 10% of newborns require
additional assistance
– 1% requires major resuscitation
• Resuscitation
– Intervene Reassess
– 30 second intervals
Intervene
Reassess
Asphyxia
• Hypoxia + Hypercapnia + Acidosis
• May lead to irreversible brain damage
• The necessity to resuscitate is related to the
degree of asphyxia
Causes of fetal asphyxia
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Maternal hypoxia
Insufficient placental blood flow
Blockage of umbilical blood flow
Fetal disorders
Primary vs. Secondary Apnea
• Primary
– Initial asphyxia
– Signs
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Initial period of rapid breathing
Respiratory movements cease
Heart rate and bp drop
Neuromuscular tone diminishes
Secondary Apnea
• If no resuscitation and apnea continues
• Signs
– Deep gasping respirations
– Heart rate continues to decrease
– Blood pressure begins to fall
– Infant flaccid
– PERFORM PPV
• Primary
–Stimulation and
oxygen will
usually induce
respirations
• Secondary
– Infant
unresponsive to
stimulation – must
be resuscitated
Initial Steps of Resuscitation
• Routine Care – If YES to the following
questions
– Term gestation?
– Amniotic fluid clear?
– Breathing or crying?
– Good muscle tone?
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Dry
Provide warmth (skin-to-skin)
Cover
Assess color, breathing, acivity
Initial Steps of Resuscitation
• Resuscitative Care – If NO to the following
questions
– Term gestation?
– Amniotic fluid clear?
– Breathing or crying?
– Good muscle tone?
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Provide warmth
Position – sniffing position
Clear airway (meconium consideration)
Dry and stimulate
PPV
Chest compressions
Epinephrine or volume expansion
Stimulate
Initial Steps (Golden Minute)
• Approximately 60 seconds to complete,
reevaluate, and ventilate if necessary
– Provide warmth
– Clear airway
– Dry
– Stimulate
– Position - sniffing
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
Assessment After PPV or Supplemental
Oxygenation
• Evaluate
– Heart rate
– Respirations
– Oxygenation
• Most sensitive indicator of successful
response is an increase in heart rate
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
Neonatal Pulse Oximetry
• New pulse oximeters with neonatal probes
– Place on RIGHT wrist
– Provide reliable readings within 1 to 2 minutes
following birth
– Must have sufficient cardiac output to skin
• SpO2 recommended
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Resuscitation anticipated
PPV for more than a few breaths
Persistent cyanosis
Supplemental oxygen is administered
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
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 <60 bpm) after 90
seconds, increase oxygen to 100% until HR > 100
bpm
Targeted SpO2 After Birth
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1 minute
2 minutes
3 minutes
4 minutes
5 minutes
10 minutes
60 to 65%
65 to 70%
70 to 75%
75 to 80%
80 to 85%
85 to 95%
Newborn Intervention Triggers
• Secretions = suction
• Apnea or gasping respirations = PPV
• Labored breathing or low SpO2 = oxygen or
CPAP
• HR< 100 bpm = PPV
• HR< 60 = Chest compressions and PPV
• Persistent HR< 60 = epinephrine
Evaluate Respiration, HR, Oxygenation
• Breathing adequate (rate and effort)
– No apnea
– No gasping
– No labored breathing
• HR >100 bpm
• SpO2 in normal range
• Observe and suction only to keep airway clear
Evaluate Respiration, HR, Color
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•
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•
Breathing adequate
HR >100 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
Evaluate Respiration, HR, Color
• Breathing adequate
• HR >100 bpm
• Acrocyanosis with normal SpO2
• No intervention
• If acrocyanosis with poor SpO2 provide blowby O2
Evaluate Respiration, HR, SpO2
• Breathing inadequate
– Gasping or apnea
• HR >100 bpm
• Good pink or normal SpO2
• Positive pressure ventilation
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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
CPAP
• Breathing spontaneously but labored
• HR> 100 bpm
• SpO2 normal or low
• Research lacking – only studied in preterm
babies
Evaluate Respiration, HR, Color
• Breathing adequate
• HR <100 bpm
• SpO2 normal
• Positive pressure ventilation
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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
Evaluate Respiration, HR, Color
• Breathing adequate
• HR < 60 bpm
• SpO2 not adequate
• PPV
• Chest compressions
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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
Persistent Bradycardia
• Usually due to
– Inadequate lung inflation
– Profound hypoxemia
• Primary emergency intervention
– Adequate ventilation
• HR remains < 60 bpm with 100% oxygen
• Consider epinephrine
Epinephrine Administration
• Intravenous (UVC) route is recommended only
– 0.01 to 0.03 mg/kg
– 1:10,000 dilution
• If ET route is used
– 0.05 to 0.1 mg/kg
– 1:10,000 dilution
http://www.youtube.com/watch?v=JjBJONanCYU
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
Oral Airways
• Rarely used for neonates
• Use tongue depressor to insert airway
May be used for Pierre Robin
Syndrome or Choanal Atresia
Respiratory Distress or Inadequacy
• HR < 100 bpm = hypoxia
• Periodic breathing (20 second or longer period
of apnea)
• Intercostal retractions
• Nasal flaring
• Grunting
Meconium Stained Amniotic Fluid (MSAF)
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•
•
•
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
Meconium Stained Amniotic Fluid
• Complications if aspirated – Meconium
Aspiration Syndrome (MAS)
– Atelectasis
– Persistent pulmonary hypertension
– Pneumonitis
– Pneumothorax
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
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DO NOT dry or stimulate
Intubate trachea
Attach a meconium aspirator
Apply suction to endotracheal tube
Dry and stimulate
Continue with standard resuscitation
Apnea
• Common in infants delivered before 32 weeks of
gestation
• Risk factors
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Prematurity
Infection
Prolonged or difficult labor and delivery
Drug exposure
CNS abnormalities
Seizures
Metabolic disorders
Gastroesophageal reflux
Apnea
• Pathophysiology
– Prematurity due to underdeveloped CNS
– Gastroesophageal reflux can trigger a vagal
response
– Drug-induced from CNS depression
• Bradycardia is key assessment finding
Premature and Low Birth Weight Infants
• Delivered before 37th week of gestation
• Less than 5.5 lbs or 2,500 grams
• Premature labor
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Genetic factors
Infection
Cervical incompetence
Abruption
Multiple gestations (twins, triplets)
Previous premature delivery
Drug use
Trauma
Premature and Low Birth Weight Infants
• Low birth weight
– Chronic maternal HTN
– Smoking
– Placental anomalies
– Chromosomal abnormalities
• Born <24 weeks and less than 1 lb – poor
chance of survival
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
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
Hypoglycemia
• BGL <40 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
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
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Infant of DM mother
Large for gestational age
Hypoxia
Hypothermia
Sepsis
Hypoglycemia
• Symptoms
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Cyanosis
Apnea
Irritability
Poor sucking or feeding
Hypothermia
Lethargy
Tremors
Twitching or seizures
Coma
Tachycardia
Tachypnea
Vomiting
Hypoglycemia
• Check BGL – heel stick
• Establish good airway, ventilation,
oxygenation, and circulation
• D10W -10% dextrose
– 2 mL/kg IV if BGL <40 mg/dL
– IV infusion of D10W – 60 mL/kg