Newborn Care and Resuscitation

Joseph J. Mistovich, M.Ed, NREMT-P Chair and Professor Department of Health Professions Youngstown State University Youngstown, Ohio jjmistovich@ysu.edu

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

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

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 Inadequate prenatal care History of prenatal morbidity or mortality Maternal use of drugs or alcohol Fetal anemia Oligohydraminos

Intrapartum Risk Factors

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

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

Hypoxia Meconuium aspiration Blood aspiration Acidosis Hypothermia Pneumonia Hypotension

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

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

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

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

Clamp and Cut Cord

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

Initial Assessment
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 mothers chest (skin to skin)

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

Need for Resuscitation

Approximately 10% of newborns require additional assistance
1% requires major resuscitation

Resuscitation
Intervene Reassess Reassess 30 second intervals Intervene

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

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

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
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

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

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

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 blow-by O2

Evaluate Respiration, HR, SpO2

Breathing inadequate
Gasping or apnea

HR >100 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

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

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
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 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

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

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)

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
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
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
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

Infant of DM mother Large for gestational age Hypoxia Hypothermia Sepsis

Hypoglycemia
Symptoms
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