Baby Saver II

Preparation for Neonatal Resuscitation Program

Nurses Educational Opportunities 866.266.2229

www.nursesed.net

2

The Baby Saver II 2006, 5th Edition Neonatal Resuscitation

Introduction

There are now 9 lessons in the 2006th 5th edition of the Neonatal Resuscitation Program. They are as follows:

Lesson 1 – Overview and Principles of Resuscitation Lesson 2 – Initial Steps in Resuscitation Lesson 3 – Use of the Resuscitation Devices PPV Lesson 4 – Chest Compressions Lesson 5 – Endotracheal Intubation Lesson 6 – Medications Lesson 7 – Special Considerations Lesson 8 – Resuscitation of Babies Born Preterm Lesson 9 – Ethics and Care of the End of Life

The standard-length NRP Provider Course consist of the above 9 lessons; however, you will need to work through only those lessons appropriate to your level of responsibility. If you have any questions about the level of your responsibilities during resuscitation, please consult your supervisor.

Successful completion of each lesson requires a passing score on the written evaluation for that lesson as well as successful completion of the Megacode.

The Neonatal Resuscitation Program is an educational program that introduces the concept and basic skills of neonatal resuscitation. Completion of the program does not imply that an individual has the competence to perform neonatal resuscitation. Each hospital is responsible for determining the level of competence and qualifications required for someone to assume clinical responsibility for neonatal resuscitation.

Your NEO Instructor will provide you with a new 5th edition text if you do not have one. The class includes an updated video for you to review and an instructor presentation to help you

3

understand and discuss the guidelines and the changes. A practice mega code can be part of the class if you desire.

The written test is a challenge and must be taken prior to the NEO class. This study guide will assist you in passing the test on line. The following instructions will help you navigate your computer. The test on line will cost $29 payable with a MC or VC. You will be issued a certification that you must bring to the class. You will watch the AAP video and perform the skills and be issued a NRP card. For initial certification the test will be taken in the office. For

those who are taking the recert class you can find directions on

our website. http://nursesed.net/index.php?pr=NRP

Objectives:

Upon completion of the neonatal resuscitation study guide the participant will be able to:

♥ Verbalize the risk factors that can help predict which babies will require resuscitation

♥ Verbalize and demonstrate the need to resuscitate

♥ Verbalize and demonstrate the use of the flow-inflating bag, self-inflating bag, and the T-piece resuscitator.

♥ Verbalize the need for chest compressions and demonstrate effective chest compressions

♥ Verbalize the need for endotracheal intubation and demonstrate intubation or assisting intubation if applicable for your job

♥ Verbalize the medications used in neonatal resuscitation with the indications, route, dose for each

♥ Verbalize the special considerations and subsequent management of infants beyond the immediate newborn period or outside the hospital delivery room.

♥ Verbalize the risk factor of infants born premature and the strategies to consider in their care

♥ Verbalize the ethical principles associated with end of life situations.

4

Lesson I – Overview and Principles of Resuscitation

Approximately 10% of all newborns require some

assistance to begin breathing at birth and about 1% will need extensive resuscitative measures. When resuscitation is anticipated additional personnel should be present in the delivery room at the time of the delivery. Keep in mind that 100% of all

newborns require initial assessment to determine whether resuscitation is required.

The most important resuscitative action is effective

ventilation of the newborns lungs.

When the newborn’s cord is clamped the systemic blood

pressure is increased. The increased systemic blood pressure, results in a lower pressure in the pulmonary arteries than in the systemic circulation and leads to a dramatic increase in pulmonary blood flow and decrease in flow through the ductus arteriosus.

When a fetus/newborn first becomes deprived of oxygen, an initial period of rapid breathing is followed by primary apnea. Primary apnea can be resolved by tactile stimulation. If oxygen deprivation continues, secondary apnea ensues. The heart rate continues to fall, and the blood pressure falls. Secondary apnea cannot be reversed with stimulation and assisted ventilation must be provided. Therefore, the deciding factor to determine

primary versus secondary apnea is the response to tactile

stimulation. The infant is secondary will require positive

pressure ventilation to initiate spontaneous breathing.

The ABC’s of resuscitation are the same for babies as for

adults. Ensure the Airway is open and clear. Be sure that there is Breathing, whether spontaneous or assisted. Make certain that there is adequate Circulation or oxygenated blood. Therefore,

5

evaluation of resuscitative measures are made accordingly to respiration rate, heart rate and color.

Assessing the need for resuscitation depends on the following criteria:

♥ Gestational age at the time of birth

♥ Meconium in the amniotic fluid prior to delivery

♥ Spontaneous breathing and crying at the time of delivery

♥ Muscle tone of the infant

The initial steps of resuscitation are as follows:

♥ Provide warmth

♥ Position the head and clear the airway

♥ Evaluate the heart rate

No more that 30 seconds should be taken to accomplish the following:

♥ Provide warmth

♥ Position and clear the airway

♥ Dry, stimulate and reposition

Most infants are born vigorous with no risk factors and do not need to be separated from their mothers and can be placed on the mother’s chest for routine care. Infants that require additional assistance to transition need to be monitored in observational

care. Infants that require extensive resuscitative measures are at high risk for recurrent deterioration and should be managed with post-resuscitation care.

Lesson II – Initial Steps in Resuscitation

After completing the initial steps of providing warmth, positioning the infant, clearing the airway evaluate the infants response with the following:

♥ Respirations with good chest movement. Gasping respirations are ineffective and require interventions

6

♥ Heart rate should be greater than 100 bmp by counting the heart beats in 6 seconds a multiplying by 10.

9 bests in six seconds would be 90 bpm

10 beats in six seconds would be 100 bpm

♥ Color with pink lips and pink trunk. There should not be central cyanosis which indicates hypoxemia. If central cyanosis exist, free-flow supplemental oxygen is required.

Supplemental oxygen can be provided in the following ways

♥ Holding the oxygen tubing cupped closely over the

infants mouth and nose

♥ Holding the mask of a flow-inflating bag closely over

the infants mouth and nose

♥ Holding an oxygen mask firmly over the infant’s

face

♥ You cannot give supplemental oxygen with the self-inflating bag.

Acceptable ways to stimulate an infant to breath are as follows:

♥ Drying vigorously with a warm towel

♥ Rubbing the back gently

♥ Flicking the soles of the feet

♥ Do not shake the baby!!!!!

If an infant does not respond to drying, rubbing and suctioning, the infant may be in secondary apnea and will require

positive pressure ventilations.

The best position to place an infant prior to suctioning, and/or providing PPV or intubation is the “sniffing” position. To

acquire the “sniffing” position place a rolled blanket or towel

under the shoulders.

The deciding factor that determines if an infant born in meconium stained amniotic fluid is the “vigorousness” of the infant at the time of delivery. The following criteria establishes “vigorousness:”

7

♥ Heart rate greater than 100 bpm.

♥ Strong respiratory effort

♥ Good muscle tone

If an infant with meconium stained amniotic fluid is pale,

limp, and showing poor respiratory effort you must be

prepared to intubate and suction the newborn’s trachea.

Lesson III – Use of Resuscitation Devices for Positive Pressure Ventilation

As noted in Lesson I, the single most important step in resuscitation if effective ventilation of the lungs. To evaluate effective ventilation, the infant should have a rise and fall of the chest during bag/mask ventilation. In addition, the following improvements should be noted:

♥ Improvement in skin color and tone

♥ Spontaneous breathing

♥ Increase in heart rate

It the chest does not rise with ventilation the provider should try the following interventions:

♥ Reapply the mask and lift the infant’s jaw forward.

♥ Suction the mouth and nose

♥ Reposition the head

♥ Replace the bag

The indications for administration of supplemental oxygen (free-flow oxygen) are as follows:

♥ Persistent central cyanosis

♥ Prior to and during intubation

The indications for positive pressure ventilations are as follows:

♥ Persistent cyanosis despite 100% free-flow oxygen

♥ Heart rate remains less that 100 bpm even if the baby is breathing

♥ Apnea or gasping

8

The AAP recommends use of 100% supplemental

oxygen when positive-pressure ventilation during resuscitation

of term newborns.

Providing positive pressure ventilation for greater than 4

minutes requires the insertion of an orogastric tube. Measure

the distance from the bridge of nose to the ear and then to ½

way between the xyphoid process and the umbilical cored.

Face mask should have the following characteristics:

♥ Large enough to cover the nose, mouth but not the

eyes.

There are now three types of resuscitative devices. They are as follows:

♥ Flow-inflating bags

♥ Self-inflating bags

♥ T-Piece Resuscitators

The flow-inflating bags have the following characteristics:

♥ They fill only when a gas from a compressed source

flows into it.

♥ They will not inflate if there is a hole in the bag

♥ You can deliver free-flow oxygen with these bags

♥ You can administer CPAP

♥ If there is no rise and fall of the chest when

performing PPV with this mask, the following

should be tried: Reposition the head and reapply the bag Suction the mouth Replace the bag

The indications to initiate PPV are as follows:

♥ Persistent cyanosis despite 100% free-flow oxygen

♥ Heart rate remains less than 100 bpm, even if the

baby is breathing

♥ Apnea or gasping

9

The indications of effective PPV are as follows:

♥ Improvement of color and tone

♥ Spontaneous breathing

♥ Increase heart rate

Continuous Positive Airway Pressure (CPAP) CPAP is delivered by pressing the mask of the flow-inflating bag tightly over the infant’s face with oxygen flowing through the bag. This “pops open” the alveoli. If

there is no chest wall movement ( physiologic movement) you must do PPP and NOT CPAP

The self-inflating bags have the following characteristics:

♥ They will fill spontaneously after they are squeezed

♥ They have a safety feature called “pop-off” valve

which is a pressure release valve.

♥ They will not deliver free-flow oxygen

♥ They will fill spontaneously after thy are squeezed.

T-piece resuscitators have 2 controls to adjust the inspiratory pressure. They areas as follows:

♥ The inspiratory pressure control sets the amount of pressure desired during a normal assisted breath.

♥ The maximum pressure relief control is a safety feature that prevents the pressure form exceeding a preset value

Excessive pressure also can be avoided by watching the circuit pressure gauge. The T-piece resuscitator is pictured on page 11. A manufacture name for the T-piece resuscitator is called a “Neo Puff.”

A T-piece resuscitator has many similarities to the flow-inflating bag, with the added safety of mechanically limiting airway pressures. They are as follows:

♥ Like the flow-inflating bag, the T-piece resuscitator requires a gas flow from a compressed gas source and

10

has an adjustable flow-control valve to regulate the desired amount of CPAP or PEEP.

♥ The T-piece resuscitator also requires a tight face-mask seal to deliver a breath and can reliable deliver a variable amount of FIO2 (21% to 100%).

♥ The T-piece resuscitator can deliver free-flow oxygen.

♥ The device also requires some preparation time to assemble, to turn on the gas flow and to adjust the pressure limits appropriately for the expected needs of the newborn.

The T-piece resuscitator differs from the flow-inflating bag in that the peak inspiratory pressure is regulated by a mechanical adjustment instead of by the amount of squeeze on the bag. Gas flow is directed to the baby or the environment when you alternately occlude and open the PEEP cap with your finger or thumb.

Note: The T-piece resuscitator is characterized by the following:

♥ The operator sets the maximum circuit pressure

♥ The operator sets the peak inspiratory pressure

♥ The operator sets the positive end-expiratory

pressure (PEEP)

The following are the advantages of the T-piece resuscitator:

♥ Consistent pressure

♥ Reliable control of peak inspiratory pressure and positive end-expiratory pressure

♥ Reliable delivery of 100% oxygen

♥ Operator does not become fatigued from bagging

The following are the disadvantages of the T-piece resuscitator:

♥ Requires a gas supply

♥ Compliance of the lung cannot be “felt”

♥ Requires pressures to be set prior to use

♥ Changing inflation pressure during resuscitation is more difficult

11

Lesson IV – Chest Compressions

The heart lies in the chest between the lower third of the sternum and the spine. Chest compressions circulate the blood

to the vital organs. Compressing the sternum compresses the heart against the spine and increases the pressure in the chest causing the blood to be pumped into the arteries. The following are the guidelines for providing chest compressions:

♥ Chest compressions are indicated when the heart rate remains less than 60 beats per minute after 30

seconds of effective positive-pressure ventilation to

circulate blood to the vital organs.

♥ Chest compressions must always be well coordinated

by positive-pressure ventilations.

♥ Three chest compressions should be given and interposed with one positive pressure ventilation.

♥ In a minute’s time, there should be 30 breaths and 90

compressions given.

♥ There are two acceptable techniques for providing chest compressions, the 2-finger technique and the thumb technique. The thumb technique is preferred because

it provides intrathoracic pressure.

♥ Chest compressions should be applied to the lower third of the sternum, which lies between the xyphoid and a line drown between the nipples. (One finger’s breath

below the nipple line.) The compressor coordinates

12

the resuscitation by counting out-loud “One-and-Two-

and -Three-and Breath-and…………”

♥ Chest compressions should be given to a depth of one

third the distance from the anterior to the posterior

of the infant’s chest.

♥ Chest compressions and ventilations should be given for 30 seconds before pausing to reassess. If the

heart rate remains less than 60 after 30 seconds of

chest compressions the following steps should be

taken:

Insertion of an umbilical catheter

Administration of epi via the umbilical catheter

Intubation of an endotracheal tube

Chest compressions can cause the following injuries:

♥ Laceration of the liver

♥ Fractured ribs

The thumb technique is preferred because of the following reasons:

♥ It usually is less tiring.

♥ You can generally control the depth of compressions somewhat better.

♥ This technique may be superior in generating peak systolic and coronary perfusion pressure.

♥ It also is preferable for individuals with long fingernails.

However, the 2-finger technique has the following advantages:

♥ It is more convenient if the baby is large or your hands are small.

♥ The 2-finger technique also is preferable to provide access to the umbilicus when medications need to be given by the umbilical rouge.

13

Lesson V – Endotracheal Intubation

Endotracheal tube intubation is indicated for the following situations:

♥ Infants born with poor respiratory effort, tone and a heart rate less that 100 with meconium in the amniotic fluid

♥ Ineffective or prolonged bag/mask ventilation

♥ Administration of epinephrine while the umbilical catheter is being placed

♥ Administration of surfactant

♥ Suspected diaphragmatic hernia

Preparation of endotracheal intubation includes the following:

♥ Selection of the laryngoscopy blade # 1 is used for term infants

(>37 weeks but <40 weeks) # 0 is used for preterm infants (<37 weeks) # 00 is used for extremely preterm infants Straight rather than curved blades are preferred

♥ Selection of the size of the endotracheal tube 2.5 ET for the infant less than 1,000 gram –

below 28 weeks 3.0 ET for the infant 1,000-2,000 grams –

between 28-34 weeks 3.5 ET for the infant 2,000-3,000 grams –

between 34-38 weeks 3.5-4.0 ET for the infant above 3,000 grams –

above 38 weeks

♥ Depth selection of the endotracheal tube is done by adding 6 to the weight of the infant in kg.

1 kg + 6 = 7 cm depth 2 kg + 6 = 8 cm depth 3 kg + 6 = 9 cm depth 4 kg + 6 = 10 cm depth

14

♥ Position and oxygenate the infant for intubation by: Stabilizing the head in the sniffing position Providing free flow oxygen during intubation

♥ Visualize the vocal cords with the following techniques:

Lifting the laryngoscope rather than rocking

Withdrawing the laryngoscopy if the esophagus

is visualize

Allow only 20 seconds to complete endotracheal

intubation Insert the ET tube with the right hand so the

curve of the tube lies on the horizontal plane.. Your instructor will show you what this means.

Insert the ET tube into the glottis which is “the

hole” between the vocal cords.

The following indications confirm endotracheal tube placement in the trachea and not the esophagus:

♥ Vapor in the tube when the stylett is withdrawn

♥ No epigastric gurgling with bag/mask ventilation

♥ Bilateral breath sounds with bag/mask ventilation

♥ CO2 detector indicates the presence of CO2

Only trained personal should attempt endotracheal intubation.

You may have to call for an anesthesiologist to intubate the

infant.

Lesson VI – Medications

The most significant and commonly used drug in neonatal resuscitation is epinephrine to increase heart rate and contractility.

Epinephrine can be administered with the following routes: IV through an Umbilical Venous Catheter

ET

15

The indications for epinephrine are as follows: Persistent heart rate less than 60 beats per minute

despite 30 seconds of positive pressure ventilations and

followed by an additional 30 seconds of positive

pressure ventilations and chest compressions.

The dose of epinephrine has been updated and is as follows: 0.3 to 1 ml/kg for the ET route

0.1 to 0.3 ml/kg for the IV route

Epinephrine given into the endotracheal tube may be absorbed by the lungs and enter blood that drains directly into the heart Although this may be the fastest way to give epinephrine in an intubated baby, the process of absorption by the lungs makes the response time slower and more unpredictable than if epinephrine is give directly into the blood. Research in animal models suggests that the standard intravenous dose is ineffective if given endotracheal. There is some evidence that giving a higher dose can compensate for the delayed absorption from the lungs. However, no studies have confirmed the efficacy or safety of this practice. Nevertheless, since the endotracheal route is the most readily accessible some clinicians believe that an endotracheal dose should b be considered while the intravenous route is being established. If endotracheal epinephrine is given, a larger dose will be needed and, therefore, a larger syringe will be necessary. The large syringe should be clearly labeled “For Endotracheal Use Only” to avoid inadvertently giving the higher dose intravenously. The intravascular route (umbilical

venous catheter) is recommended as the best choice.

Often infants will be born hypovolemic and will not respond to adequate ventilation, cardiac compressions, and epinephrine and will require volume replacement.

16

The signs of hypovolemia are as follows:

♥ Pale skin color

♥ Weak pulse

Acceptable solutions for volume expansion are the following:

♥ Normal Saline (0.9% NaCl)

♥ Ringer’s Lactate

♥ Type O Rh-negative packed red blood cells

The above volume expanders are given at 10 cc/kg of body weight. The following are examples of doses:

2.5 kg = 25 cc 3.0 kg = 30 cc 3.2 kg = 32 cc 3.6 kg = 36 cc

Epinephrine is given rapidly and as quickly as possible

Volume expanders are given slowly – over 5-10 minutes

Lesson VII – Special Considerations

Special situations may occur that can complicate resuscitation. On going problems can also occur after initial resuscitation. They are as follows:

♥ Choanal atresia

♥ Pierre Robin Syndrome

♥ Congenital diaphragmatic hernia

♥ Maternal narcotic administration prior to birth

♥ Hypoglycemia

♥ Persistent bradycardia and cyanosis

♥ Pneumothorax

♥ Delivery of an infant outside the hospital environment

Choanal atresia is an anatomical blockage of the nares. You will not be able to pass a catheter through one or both of the nares if an infant has choanal atresia. Babies cannot breath through their mouths easily unless they are actively crying. Babies that with

17

choanal atresia will have respiratory distress if they are not crying.. If you cannot pass a catheter through the nares, you must insert

an oral airway. An endotracheal tube may also be used as an oral airway without inserting it all the way into the trachea.

Robin Syndrome is a critical narrowing of the pharyngeal airway for babies that are born with a very small mandible. This causes the tongue to fall back into the pharynx and obstruct the airway just above the larynx. Placing the infant prone will relieve the

problem initially and then insert a nasopharyngeal airway.

Congenital diaphragmatic hernia is an infant born with a scaphoid (flat abdomen ) appearance.. The abdominal contents of the stomach and intestines and sometimes even the liver can herniated through the diaphragm and can be found in the chest. This will inhibit chest expansion and the infant will show obvious signs of respiratory distress. If positive pressure is delivered and then enters the stomach and/or the intestines, respiratory distress increases because of the abnormal location of the gastrointestinal organs. Babies expected with diaphragmatic hernia should not receive prolonged resuscitation with positive pressure by mask. Intubation of the trachea and placement of a large orogastric

catheter to evacuate the stomach contents is required.

Maternal narcotic administration within 4 hours of delivery can inhibit the respiratory drive and activity of the newborn. Giving a

narcotic antagonist such as naloxone (also known as narcan) should be given only if the maternal mother is not suspected of addiction to narcotics or is on methadone maintenance. This will result in infant seizures. The following are indications for giving naloxone:

♥ Continued respiratory depression

♥ In addition, continued respiratory depression after

positive-pressure ventilation has restored a normal heart rate and color. This statement may be confusing. What it means - for any infant with respiratory distress you must provide PPV. If the PPV has restored normal heart rate and color but when you

18

stop providing PPV the infant deteriorates then naloxone is indicated.

♥ A history of maternal narcotic administration with

the past 4 hours prior to birth.

All babies should be monitored for the following:

♥ Blood Sugar is often a complication of resuscitation because metabolism under conditions of oxygen deprivation consumes more glucose than metabolism under normal circumstances.

♥ Blood pressure is another complication of resuscitation because of ineffective circulating blood volume.

♥ Oxygenation can result from complications of resuscitation. Monitoring the infant with pulse oximetry and blood gasses is essential for appropriate interventions.

Persistent bradycardia and cyanosis are not necessarily indications of a congenital heart disease. Confirmation is made with x-rays, ECGs, and echocardiograms. Babies with congenital heart disease are seldom critically ill immediately following birth. Problems with resuscitation are almost always due to failure to

successfully ventilate.

Hyperthermia can be injurious to a baby. It is important not to overheat the baby during and following resuscitation. This statement should not be confused with recent studies that have evaluated the potential neuroprotective role of hypothermia in post resuscitation care

Pneumothorax is not uncommon to develop as the lung of the newborn fills with air. If a pneumothorax causes significant

respiratory distress, it should be relieved by placing

percutaneous catheter, needle, or chest tube into the pleural space. A small pneumothorax will usually absorb spontaneously.

Delivery of an infant outside the hospital can be challenging without the familiar airway adjuncts and warming equipment. The following are ways to resuscitate these infants:

19

♥ Maintain temperature by placing the baby skin-to-

skin with the mother

♥ Consider mouth-to-mouth or mouth-to-nose

ventilation for administration of PPV

♥ Clear the airway with a cloth such as a handkerchief wrapped around your finger.

Lesson VIII – Resuscitation of Babies Born Premature

Preterm infants are defined as infants born less than 37 weeks gestational age. When birth occurs before term, there are numerous additional challenges that the fetus must overcome to make this difficult transition. The likelihood that the preterm baby will need your help becomes greater as the degree of prematurity increases. The following are factors that place the preterm infant at additional risk for requiring resuscitation:

♥ They have a large body-surface area that increases

the risk of hypothermia

♥ Weak muscles and surfactant deficiency, making

adequate ventilation more difficult.

♥ Underdeveloped lungs that are easily injured

♥ A lack of lack of blood vessels development than

increases the risk of intracranial hemorrhage.

Additional personnel as well as additional equipment are needed in resuscitation of a preterm infant. The following are required for the resuscitation of preterm infants:

♥ Additional personnel including someone with

expertise in performing endotracheal intubation.

♥ Additional means of maintaining body temperature

(polyethylene bags and a portable warming pads)

♥ A pulse oximeter and an oxygen blender

Additional concerns for postresuscitation care for the preterm infant are as follows:

♥ 100% FIO2 is not well tolerated in the first 5-10

minutes of life for the preterm infant. The AAP now

20

recommends less FIO2 initially and then increase the FIO2 if the O2 sats are not rising. .

♥ Increase suspicion for infection. All preterm infants are transferred to the NICU for antibiotic therapy because of their immature immune mechanisms.

Premature infants are at risk of brain injury during resuscitation. The following criteria is essential to prevent brain injury in the premature infant:

♥ Handle the baby gently which is often overlooked in effort to handle resuscitation quickly and effectively.

♥ Avoid placing the baby in a head-down (Trendelenburg) position. The resuscitation table should be flat.

♥ Avoid excessive positive pressure or CPAP. Sufficient pressure to achieve a rise in heart rate and adequate ventilation should be provided, but excessive inflation pressure or too much. CPAP can restrict venous return from the head or create a pneumothorax, both of which have been associated with an increased risk of intraventricular hemorrhage.

♥ Use an oximeter and blood gases to adjust ventilation and oxygen concentration gradually and appropriately. Rapid changes in CO2 result in corresponding changes in cerebral flow, which can increase the risk of bleeding.

♥ Do not give rapid infusion of fluid. If volume expansion becomes necessary avoid giving the hypertonic solutions intravenously. If intravenous dextrose is indicated to treat hypoglycemia, try initially to avoid using concentrations greater than approximately 10%.

♥ After 5-10 minutes, attempt to maintain oxygenation saturations between 85%-95% to avoid hyeroxia.

21

Babies born significantly preterm have immature lungs that may be difficult to ventilate and more easily injured with positive-pressure ventilation. The following are special considerations for assisting ventilation of preterm infants:

♥ Consider giving CPAP. CPAP cannot be delivered

with a self-inflating bag. You must use a flow-inflating bag or a T-piece resuscitator. If you are using a T-piece resuscitator the flow-control valve (the PEEP valve) must be set to the desired pressure. Generally, 4-6 cm H2O is an adequate pressure.

♥ If intermittent positive-pressure ventilation is required use the lowest inflation pressure necessary to achieve an adequate response. PPV pressures of 20-25 cm H2O is adequate for most preterm infants.

♥ Consider surfactant if the baby is significantly preterm. Studies have shown that babies born less than 30 weeks’ gestation will benefit from being given surfactant after resuscitation.

Lesson IX – Ethical Considerations

The ethical principles of neonatal resuscitation are no different from those of any other child or adult. They are as follows:

♥ The ethical principles of beneficence,

nonmaleficence, autonomy, and justice apply to a

neonate as they do for all patients. Beneficence is the act of benefiting others.

Nonmaleficence is the act of avoiding unnecessary harm

Autonomy is the act of making changes that affect life.

Justice refers to the act of treating others fairly.

♥ The parents have the primary role in determining the goals of care delivered to their newborn. However, informed consent should be based on complete and reliable information, and this may not be available until after delivery and perhaps no until several hours after birth. Parents’ views on either initiating or

withholding resuscitation should be supported.

22

♥ There is no federal law mandating delivery room resuscitation in all circumstances. In most circumstances, it is ethically and legally acceptable to

withhold or withdraw resuscitation efforts if the

parents and health professionals agree that further medical intervention would be futile, would merely prolong dying, or would not offer sufficient benefit to justify the burdens imposed.

♥ Discontinuation of resuscitation efforts may be appropriate after 10 minutes of absent heart rate following complete and adequate resuscitation efforts.

♥ Resuscitation is not indicated for the following

situations: Newborns with gestational age

<23 weeks or a birth rate <400 grams

Anencephaly

Trisomy 13 or Trisomy 18

♥ The decision may need to be modified depending on

the condition of the baby at birth and the postnatal

gestational age assessment.

Basic Mega Code

You will be given a scenario that will include an infant with a heart rate <100 bpm with no chest movement and you will be expected to initiate positive pressure ventilations. After 30 seconds of positive pressure ventilations the heart rate will need to be checked and the infant will have a heart rate <60 bpm and you will be expected to begin chest compressions. You must demonstrate correct bag/mask ventilations and correct chest compressions. You will be asked to reevaluate your effort. You will be asked to call for a switch with the second responder. The following is a possible script that will be used:

A 37 y/o pregnant woman has contacted her obstetrician after pronounced decrease in fetal movement. She was admitted to the

23

labor/delivery unit. Persistent fetal bradycardia is noted and a decision is made to perform a C-section.

Is there anything you want to know about his infant? Is the infant term?

Is there meconium in the amniotic fluid?

How would you set up for this delivery? Preheat the radiant warmer and set up with the

following:

Warmed blankets for drying and stimulating

Catheter suction set at 80-100 mg/Hg suction

Bulb syringe

Oxygen for free-flow

Prepared bag/mask with oxygen

OG tube

ET tubes with stylet

Laryngoscope with # 0 & #1 blade

CO2 detector

Syringes for medications

Epinephrine, NS

Meconium aspirator

Blender For optional meconium resuscitation

The infant with meconium is not vigorous and is limp – How would you respond?

Call for intubation

Hand prepared laryngoscope to intubator

Hand ET tube to intubator

Attach the meconium aspirator to suction tubing

Attach the meconium aspirator to the in place ET tube

Suction

If there is no meconium present in the ET tube – how would you respond?

Demonstrate drying and stimulation

Demonstrate bulb suction mouth and then the nose

Ask if the infant is breathing

24

The baby is not breathing – how would you respond? Demonstrate bag/mask ventilation at 40-60 bpm

Demonstrate and verbalize corrective action if there is

no rise and fall of the chest.

Reapply mask

Reposition the head

Left jaw forward

Check for secretions

Open the mouth

Increase pressure

Call for assistance and ask for heart rate check The heart rate will be less than 60 bpm (or not rising) – how would you respond?

Demonstrate chest compressions interposed with

ventilations:

1/3 the distance from the anterior to posterior chest

Using the 2 finger or thumb technique

1-and-2-and-3-and breath

Call for a switch between the compressor and the

ventilator The infant will begin spontaneous respirations and the heart rate will begin to rise – how would you respond?

Discontinue chest compressions

Discontinue ventilations when the heart rate is greater

than 100 bmp

Wean to free-flow oxygen

Scoring: 0 =Not Done 1 = Done incorrectly, incompletely or out of order 2 = Done correctly

Lesson 1 Checks Bag, Mask and Oxygen Supply 0____1____2____ Asks 4 Assessment Questions (Term? Meconium? Breathing? Tone?) 0____1____2____

25

Lesson 2 If meconium is present, (optional)

determines if ET suction is indicated 0____1____2____ Positions head, suctions mouth then nose 0____1____2____ Dries, removes wet towels, and repositions 0____1____2____ Request description of breathing, HR, color 0____1____2____

Lesson 3 Indicates need for PPV (apnea, HR <100,

central cyanosis despite 02) 0____1____2____ Provides PPV at 40-60 bmp 0____1____2____ Check for improvement (no improvement will be indicated) 0____1____2____ Takes corrective action when HR not rising

and chest does not move (reapply mask, lift jaw forward reposition head, check secretions open mouth, increase pressure) 0____1____2____

Reevaluates heart rate (heart rate will remain <60) 0____1____2____ Lesson 4 Identifies need to start chest compressions HR <60 despite 30 seconds of PPV 0____1____2____ Demonstrates correct technique

(placement and depth) 0____1____2____ Demonstrates correct rate/coordination 0____1____2____ Continues/discontinues PPV appropriately or weans to free-flow oxygen 0____1____2____ Performed utilized items correctly Y____N____ Total Score ___________

Maximum score possible = 30 pts Without meconium = 28 pts Minimum passing score = 24 pts. Without meconium = 22 pts

26

Advanced Mega Code

In addition, to the above the student requiring advanced skills must identifies need for intubation and either intubates or assists intubation correctly. He or she must identify the need for epinephrine and verbalize the correct dose for the IV route and the correct dose for the ET route. If applicable the student verbalizes and demonstrates the process of umbilical vein catheterization or assisting of such and further verbalizes the need for volume expansion. The following is a possible script that may be used:

The infant shows no signs of spontaneous breaths and the heart rate remains <60 bpm despite oxygenations and ventilations - How would you respond?

Call and assist in endotracheal intubation Hand prepared laryngoscope to intubator

Hand ET tube to intubator

Confirms tube placement with the following criteria

Mist in the tube when the sylett is withdrawn

No epigastric sounds with bag/mask ventilations

Bilateral breath sounds

CO2 detector detects CO2 Heart rate remains <60 bpm – how would you respond

Identifies need for epinephrine

Prepared 0.1-0.3 ml/kg IV or 0.3-1.0 ml/kg ET

Prepared umbilical vein catheter for placement

Prepares for normal saline bolus Heart rate is now 140 bpm and rising – how would you respond? Discontinue PPV and chest compressions

Wean to free-flow oxygen

Lesson 5 Identifies need for intubation 0____1____2____ Intubates or assists intubation correctly 0____1____2____

27

Lesson 6 Identifies need for epinephrine HR<60 despite PPV/compressions 0____1____2____ Prepares correct dose of epinephrine 0.1-0.3 ml/kg IV or 0.3-1.0 ml/kg ET No Score Prepares umbilical venous catheter No Score Inserts umbilical venous catheter No Score Administrates Epi via UVC or ET No Score (optional) identifies need for volume 0____1____2____

Closure Continues/discontinues PPV appropriately Or weans to free-flow oxygen 0____1____2____

Performed utilized items correctly Y____N____ Total Score ___________ Total Score X .85 = minimum acceptable passing score

28