american-academy-of-pediatrics-american-heart-2021.pdf

July 11, 2022

Contents

LESSON

1 :

1 O:

11 :

Preface

Neonatal Resuscitation Program Provider

Course Overview

Foundations of Neonatal Resuscitation

Anticipating and Preparing for Resuscitation

lnitial Steps of Newborn Care

Positive-Pressure Ventilation

Endotracheal lntubation

Chest Compressions

Medications

Resuscitation and Stabilization of

Babies Born Preterm

Post-resuscitation Care

Special Considerations

Ethics and Care at the End of Life

117

159

179

213

231

243

265

SUPPLEMENTAL LESSONS:

LESSON

12:

13:

14:

APPENDIX:

lmproving Resuscitation Team Performance

Resuscitation Outside the Delivery Room

Bringing Quality lmprovement to

Your Resuscitation T eam

Part 5: Neonatal Resuscitation 2020 American Heart Association

Guidelines for Cardiopulmonary Resuscitation and Emergency

279

289

307

Cardiovascular Care (Reprint) 321

1 N D E X : 355

Foun ations o Neonata

R esuscitation

What you will learn

Why neonatal resuscitation skills are important

Physiologic changes that occur during and after birth

The format of the Neonatal Resuscitation Program®

Algorithm

Communication and teamwork skills used by effective

resuscitation teams

How implementing quality improvement methods can

improve outcomes

Used with permission of Mayo Foundation for Medical Education and Research.

FOUNDATIONS OF NEONATAL RESUSCITATION

Key Points

O Most newborns make the transition to extrauterine life without

intervention.

f.) Before birth, pulmonary blood vessels in the fetal lungs are tightly

constricted, and the alveoli are filled with fluid, not air.

Q Newborn resuscitation is usually needed because of respiratory

failure.

9 The most important and effective step in neonatal resuscitation is

to ventilate the baby's lungs.

0 Very few newborns will require chest compressions or medication.

O Teamwork, leadership, and communication are critica! to

successful resuscitation of the newborn.

The Neonatal Resuscitation Program

The Neonatal Resuscitation Program (NRP

) will help you learn the

cognitive, technical, and teamwork skills that you need to resuscitate

and stabilize newborns. Most newborns make the transition to

extrauterine life without intervention. Within 30 seconds after

birth, approximately 85% of term newborns will begin breathing.

An additional 10% will begin breathing in response to drying and

stimulation. To successfully transition, approximately

• Five percent of term newborns will receive positive-pressure

ventilation (PPV).

• Two percent of term newborns will be intubated.

• One to 3 babies per 1,000 births will receive chest compressions or

emergency medications.

The likelihood of requiring these lifesaving interventions is higher

for babies with certain identified risk factors and those born before

full term. Even though the majority of newborns do not require

intervention, the large number of births each year means that timely

intervention can save many newborn lives. Because the need for

assistance cannot always be predicted, health care providers need to be

prepared to respond quickly and efficiently at every birth.

During your NRP course, you will learn how to evaluate a newborn,

make decisions about what actions to take, and practice the steps

involved in resuscitation. As you practice together in simulated cases,

your team will gradually build proficiency and speed. The most

gratifying aspect of providing skillful assistance to a compromised

newborn is that your efforts are likely to be successful. The time that

you devote to learning how to resuscitate 11ewborns is time very well

spent.

Why do newborns require a dif f erent approach to

resuscitation than adults?

Most often, adult cardiac arrest is a complication of coronary artery

disease. It is caused by a sudden arrhythmia that preve11ts the heart

from effectively circulating blood. As circulation to the brain decreases,

the adult victim loses consciousness and stops breathing. At the time

of arrest, the adult victim's blood oxygen and carbon dioxide ( C0 2)

content is usually normal and the lungs remain filled with air. During

adult resuscitation, chest compressions maintain circulation until

electrical defibrillation or medications restore the heart's function.

In contrast, most newbor11s requiring resuscitation have a healthy

heart. When a newborn requires resuscitation, it is usually because

respiratory failure interferes with oxygen and C0 2 exchange.

• Before birth, fetal respiratory function is performed by the placenta

instead of the fetal lungs. When the placenta is functioning

normally, it transfers oxygen from the mother to the fetus and

carries C0 2 away from the fetus to the mother. A healthy fetus

makes breathing movements, which are important for normal lung

growth.

• When placenta! respiration fails, the fetus receives an insufficient

supply of oxygen and C0 2 cannot be removed. Acid increases in

the fetal blood as cells attempt to function without oxygen and C0 2

accumulates.

• Fetal monitoring may show a decrease in activity, loss of heart rate

variability, and heart rate decelerations. If placenta! respiratory

failure persists, the fetus will make a series of reflexive gasps

followed by apnea and bradycardia.

• If the fetus is born in the early phase of respiratory failure, tactile

stimulation may be sufficient to initiate spontaneous breathing and

recovery. If the fetus is born in a later phase of respiratory failure,

stimulation alone will not be sufficient and the newborn will require

assisted ventilation to recover. The most severely affected newborns

may require chest compressions and epinephrine. At the time of

birth, you may not know if the baby is in an early or a late phase of

respiratory failure.

FOUNDATIONS OF NEONATAL RESUSCITATION

• After birth, the baby's lungs must take over respiratory function.

They must be filled with air to exchange oxygen and C0 2•

Respiratory failure can occur if the baby does not initiate or cannot

1naintain effective breathi11g effort.

• If respiratory failure occurs either before or after birth, the primary

problem is a lack of gas exchange. Therefore, the focus of neonatal

resuscitation is effective ventilation of the baby's lungs.

Many concepts and skills are taught in this program. Establishing

effective ventilation of the baby's lungs during neonatal resuscitation is

the single most important concept emphasized throughout the program.

Ventilation of the newborn's lungs is the single most important

and effective step in neonatal resuscitation.

What happens during the transition f rom fe tal to neonatal

circulation?

Understanding the basic physiology of the cardiorespiratory transition

from intrauterine to extrauterine life will help you understand the steps

of neonatal resuscitation.

• Before birth, the fetal lungs are filled with fluid, not air, and they

do not participa te in gas exchange. All of the oxygen used by the

fetus is supplied from the mother's blood by diffusion across the

placenta. The oxygenated fetal blood leaves the placenta through the

umbilical vein (Figure 1.1).

• Blood vessels in the fetal lungs (pulmonary vessels) are tightly

constricted and very little blood flows into them. Instead, most

of the oxygenated blood returning to the fetus from the placenta

via the umbilical vein flows through the foramen ovale or ductus

arteriosus and bypasses the lungs. Because blood flows directly from

the right side of the heart to the left side without entering the lungs,

it is called a right-to-left shunt. In utero, this right-to-left shunt

allows the most highly oxygenated blood to flow directly to the fetal

brain and heart.

• After birth, a series of events culminate in a successful transition

from fetal to neonatal circulation.

- As the baby takes deep breaths and cries, fluid is absorbed from

the air sacs (alveoli) and the lungs fill with air (Figure 1.2).

- Air in the lungs causes the previously constricted pulmonary

vessels to relax so that blood can flow to the lungs and reach the

alveoli where oxygen will be absorbed and C0 2 will be removed

(Figure 1.3).

Superior

vena cava

Open

Foramen

ovale

Right --..µ_,

atrium

Right---:"'

ventricle

Inferior ---í

vena cava

venosus

From placenta

To placenta

ductus

arteriosus

Fluidfilled

lung

Umbilical

ve,n

Pulmonary

artery

ventricle

--- Descending

aorta

Umbilical

arteries

Figure 1.1. Fetal Circulation Path: Oxygenated blood (red) enters the right

atrium from the umbilical vein and crosses to the left side through the foramen

ovale and ductus arteriosus. Only a small amount of blood flows to the lungs.

There is no gas exchange in the fluid-filled lungs.

Fetal

lung

fluid

Air

First

breath

Figure 1.2. Air replaces fluid in the alveoli.

Air

Subsequent

breaths

Air

FOUNDATIONS OF NEONATAL RESUSCITATION

Constricted blood

vessels before birth

Figure 1.3. Blood vessels in the lungs open.

Dilated blood

vessels after birth

--Airin

alveoli

- Oxygenated blood returning from the baby's lungs helps to

fill the baby's heart and ensure that the heart and brain will

receive adequate blood flow once the umbilical cord is clamped

(Figure 1.4).

Right

atrium

Closing ductus

arteriosus

Closed

foramen ovale

Right -

ventricle

Inferior

vena cava

Pulmonary Airartery filled

lung

-- Left

ventricle

Descending

aorta

Figure 1.4. Transitional Circulation Path: The baby breathes, pulmonary

vessels relax, and blood flows to the air-filled lungs. Blood returning to the left

side of the heart from the lungs has the highest oxygen saturation.

- Clamping the umbilical cord increases the baby's systemic blood

pressure, decreasing the tendency for blood to bypass the baby's

lungs.

Although the initial steps of transition occur within a few minutes of

birth, the entire process may not be completed for hours or days. For

example, it may take up to 10 minutes for a healthy term newborn to

achieve an oxygen saturation greater than 90%. It may take severa! hours

for fluid in the lungs to be completely absorbed, and complete relaxation

of the pulmonary blood vessels occurs gradually over severa! months.

How does a newborn respond to an interruption in normal

transition?

If normal transition <loes not occur, the baby's organs will not receive

enough oxygen, acid will accumulate in tissues, and blood vessels in

the baby's intestines, kidneys, muscles, and skin may constrict.

Temporarily, a survival reflex maintains blood flow to the baby's heart

and brain to preserve function of these vital organs. If inadequate

gas exchange continues, the heart begins to fail and blood flow to ali

organs decreases. The lack of adequate blood flow and oxygen may lead

to organ damage. Table 1-1 summarizes sorne of the clinical findings

associated with an interruption in normal transition.

Table 1 • I • Clinical Findings of Abnormal Transition

• Irregular breathing, absent breathing (apnea), or rapid breathing

(tachypnea)

• Slow heart rote (bradycardia) or rapid heart rate (tachycardia)

• Decreased muscle tone

• Pale skin (pallor) or blue skin (cyanosis)

• Low oxygen saturation

• Low blood pressure

How is the Neonatal Resuscitation Program Algorithm

structured?

The NRP Algorithm (Figure 1.5) describes the steps that you will

follow to evaluate and resuscitate a newborn. It is divided into 5 blocks

beginning with birth and the initial assessment. Throughout the

Algorithm, hexagons indicate assessments and rectangles show actions

that may be required. Although it is important to work quickly and

efficiently, you must ensure that you have adequately performed the

steps of each block befare moving on to the next block. Assessments are

FOUNDATIONS OF NEONATAL RESUSCITATION

Antenatal counseling.

Team briefing.

Equipment check.

'-. ,,

Birth

' ,

Term gestation? Yes , ....

Stay with mother for initial steps, Good tone? -

routine care, ongoing evaluation. Breathing or crying? ,

' •

·-

.....

Warm, dry, stimulate, position

' -

airway, suction if needed .

' •

Apnea or gasping? No Labored breathing or

HR <100 bpm? - persistent cyanosis?

Yes

' ' ' ,

, ' '

PPV. Position airway, suction if needed.

Pulse oximeter. Pulse oximeter.

Consider cardiac monitor. Oxygen if needed.

'" , Consider CPAP.

' •

- HR <100 bpm? No

Yes

' • ' , ' ,

, ' , ....

Ensure adequate ventilation. Post-resuscitation care.

Consider ETT or laryngeal mask. Team debriefing.

, Cardiac monitor.

'-. ,,

' •

No HR <60 bpm?

Target Oxygen Saturation Table

Yes 1 min 60%-65

' ,

r '

ETT or laryngeal mask.

2 min 65%-70%

Coordinate with PPV-100% oxygen.

uve. 4 min 75%-80

'-. ,,

•

5 min 80%-85

No HR<60 bpm? 10 min 85%-95

Yes

lnitial oxygen concentration for PPV r

IV epinephrine every 3-5 minutes.

lf HR remains < 60 bpm, - 35 weeks' GA 21% oxygen

• Consider hypovolemia.

• Consider pneumothorax. <35 weeks' GA 21%-30% oxygen

'-. ,

Figure 1.5. Neonatal Resuscitation Program Algorithm

repeated at the end of each block and will determine if you need to

proceed. The details of each block are described in subsequent lessons.

• Rapid Evaluation: Determine if the newborn can remain with

the mother or should be moved to a radiant warmer for further

evaluation.

• (A) Airway: Perform the initial steps to establish an open Airway

and support spontaneous respiration.

• (B) Breathing: Positive-pressure ventilation is provided to assist

Breathing for babies with apnea or bradycardia. Other interventions

(continuous positive airway pressure [CPAP] or supplemental

oxygen) may be appropriate if the baby has labored breathing or low

oxygen saturation.

• (C) Circulation: If severe bradycardia persists despite assisted

ventilation, Circulation is supported by performing chest

compressions coordinated with PPV.

• (D) Drug: If severe bradycardia persists despite assisted ventilation

and coordinated chest compressions, the Drug epinephrine is

administered as coordinated PPV and chest compressions continue.

Take a moment to familiarize yourself with the layout of the NRP

Algorithm (Figure 1.5). Neonatal Resuscitation Program Essentials

learners will focus on the Rapid Evaluation, Airway, and Breathing

steps of the Algorithm. Neonatal Resuscitation Program Advanced

learners will study the entire Algorithm.

Why are teamwork and communication emphasized

throughout this program?

Effective teamwork and communication are essential skills during

neonatal resuscitation. A Joint Commission investigation found that

poor teamwork and communication were the most common root

causes for potentially preventable infant deaths in the delivery room.

During a complex resuscitation, providers need to perform multiple

procedures without delay. Confusion and inefficiency may occur

because severa! teams of caregivers are working in a confined space at

the same time. Even though each individual may have the knowledge

and skills to perform a successful resuscitation, each person's skills will

not be used optimally without effective coordination.

Neonatal Resuscitation Program Key Behavioral Skills

The 10 NRP Key Behavioral Skills, described in Table 1-2, are adapted

from previously described models of effective teamwork ( Center for

FOUNDATIONS OF NEONATAL RESUSCITATION

Table 1-2. Neonatal Resuscitation Program Key Behavioral Skills

Behavior Example

Know your

environment.

Use available

information.

Anticípate and plan.

Clearly identify a

team leader.

Communicate

effectively.

Delegate workload

optimally.

Allocate attention

wisely.

Use available

resources.

Call for additional

help when

needed.

Maintain

professional

behavior.

• Know the location of resuscitation equipment and how to access it.

• Know how to call for help and who is available.

• Know the prenatal and intrapartum history, including maternal complications, maternal

medications, and other risk factors.

• Perform a pre-resuscitation team briefing to ensure ali team members know the clinical

situation.

• Assign roles and responsibilities.

• Discuss an action plan in the event of complications.

• ldentify the team leader before the birth.

• Effective leaders

- Clearly articulate goals.

- Delegate tasks as appropriate while monitoring the distribution of workload.

- lnclude other team members in assessment and planning.

- Think out loud.

- Maintain situation awareness.

- Hand over leadership to another team member if they must become involved in a

procedure.

• Call team members by name.

• Share information actively.

• lnform your team if you identify a problem, error, or patient safety concern.

• Order medications by name, dose, and route.

• Use concise, clear language.

• Use closed-loop communication.

• Verify information.

• Ensure that changes in information or assessments are shared with ali team members.

• lnclude family members in communication as appropriate.

• Do not duplicate work or use more resources than necessary.

• Change task assignments depending on skill sets and what is required at the moment.

• Do not allow one person to become overloaded with tasks.

• Do not allow the team to become fixated on a single task.

• Maintain situation awareness by scanning and reassessing the clinical situation frequently.

• Monitor each other's skill performance to ensure patient safety.

• Know what personnel are available.

• Know what additional or special supplies are available and how to access them.

• Anticípate the need for additional team members based on risk factors and the progress of

the resuscitation.

• Call for additional help in a timely manner.

• Know how you will call for additional help and the process for getting the right kind of

assistance.

• Use respectful verbal and nonverbal communication.

• Actively seek and offer assistance.

• Support and promete teamwork.

• Respect and value your team.

Advanced Pediatric & Perinatal Education [CAPE], Lucile Packard

Children's Hospital at Stanford University). In each of the lessons that

follow, we will highlight how effective teams use these behavioral skills.

Improving your teamwork and communication requires deliberate

practice under conditions that are as realistic as possible. As you review

each lesson and participate in simulation, think about how these

behavioral skills can be used to improve your own team's performance.

Remember that every member of the team has a responsibility to speak

up to inform the leader and other team members of observations or

information that will improve the resuscitation in progress.

How can quality improvement methods improve the outcome

for newborns that require resuscitation?

The NRP course helps you acquire the knowledge and skills that you

need to save babies' lives, but knowledge alone <loes not guarantee

improved outcomes. Completing an NRP course is only the first step in

improving the quality of care that you give.

• Making a difference in clinical outcomes requires a commitment

to quality improvement (QI). Providers who are committed to

quality improvement set goals, measure outcomes, identify areas for

improvement, and make changes that improve care.

• Carefully look at the systems and processes used in your own

delivery room setting to determine how best to put your knowledge

and skills into practice.

• As you read the lessons in the textbook, think about opportunities

to improve care in your own delivery room setting. In the lessons

that follow, note the measurable processes and outcomes that may

identify opportunities for improvement. Additional QI resources are

included in Supplemental Lesson 14.

LESSON 1 REVIEW

1. Before birth, the alveoli in the fetal lungs are filled with (fluid)/

(air).

2. Before birth, oxygen is supplied to the fetus by (the placenta)/

(the fetal lungs).

3. Before birth, most fetal blood (enters the fetal lungs)/(bypasses

the fetal lungs).

1 1

FOUNDATIONS OF NEONATAL RESUSCITATION

4. After birth, air in the alveoli causes vessels in the baby's lungs to

( constrict) / (relax).

5. When resuscitating newborns, chest compressions and

medication are (rarely)/(frequently) needed.

6. Members of an effective resuscitation team (share information)/

(work quietly and independently).

Answers

1. Before birth, the alveoli in the fetal lungs are filled with fluid.

2. Before birth, oxygen is supplied to the fetus by the placenta.

3. Before birth, most fetal blood byp asses the fetal lungs.

4. After birth, air in the alveoli causes vessels in the baby's lungs to

relax.

5. When resuscitating newborns, chest compressions and

medication are rarely needed.

6. Members of an effective resuscitation team share information.

or Resuscitation

What you will learn

Risk factors that can help predict which babies will

require resuscitation

Four key questions to ask the obstetric provider before

birth

How to determine who should attend a birth

How to perform a pre-resuscitation team briefing

How to assemble and check resuscitation supplies and

equipment

Why accurate documentation is important

••

ANTICIPATING AND PREPARING FOR RESUSCITATION

Key Points

O Identify risk factors by asking the obstetric provider these 4

questions before birth: ( 1) What is the expected gestational age?

(2) Is the amniotic fluid clear? (3) Are there any additional risk

factors? (4) What is our umbilical cord management plan?

f) Sorne newborns without any apparent risk factors will require

resuscitation.

8 Every birth should be attended by at least 1 qualified individual

who can initiate resuscitation and whose only responsibility is

management of the newly born baby.

C, If risk factors are present, at least 2 qualified individuals should be

present solely to manage the baby. The number and qualifications

of these individuals will be determined by the risk factors.

0 A qualified team with full resuscitation skills should be identified

and immediately available for every resuscitation. The fully

qualified resuscitation team should be present at the time of birth

if the need for advanced resuscitation measures is anticipated. Ali

supplies and equipment necessary for a complete resuscitation

must be readily available and functional for every birth.

Case: Preparing f or a birth with peri natal risk f actors

A 30-year-old woman enters the hospital in labor at 36 weeks'

gestation. She has insulin-requiring gestational diabetes and

hypertension. She is found to have ruptured membranes with clear

amniotic fluid. Fetal heart rate monitoring shows a Category II pattern

(indeterminate pattern requiring evaluation, surveillance, and possibly

other tests to ensure fetal well-being). Labor progresses rapidly

and a vaginal birth is imminent. The obstetric provider calls your

resuscitation team to attend the birth.

You ask the obstetric provider 4 brief questions and determine that

there are several perinatal risk factors. You assemble a team composed

of enough people with qualified skills to manage the interventions that

may be needed. The team clearly identifies the team leader, performs

a pre-resuscitation team briefing, discusses roles and responsibilities,

and performs a complete equipment check. As your team enters the

room, you introduce yourselves to the mother and the obstetric team

and take your positions near the preheated radiant warmer.

Why is it important to anticipate the need f or resuscitation

before every birth?

At every birth, you should be prepared to resuscitate the newborn.

Table 2-1 describes risk factors that increase the likelihood that

the newborn will require support with transition or resuscitation.

Thoughtful consideration of these risk factors will help you identify

the correct personnel to attend the birth. Although attention to these

risk factors is helpful and will identify most newborns that require

resuscitation after birth, sorne newborns without any apparent risk

factors will require resuscitation.

Table 2-1 • Perinatal Risk Factors lncreasing the Likelihood of Neonatal Resuscitation

Antepartum Risk Factors

Gestational age less than 36 0/7 weeks

Gestational age greater than or equal to 41 0/7 weeks

Preeclampsia or eclampsia

Maternal hypertension

Multiple gestation

Fetal anemia

lntrapartum Risk Factors

Emergency cesarean delivery

Polyhydramnios

Oligohydramnios

Fetal hydrops

Fetal macrosomia

lntrauterine growth restriction

Significant fetal malformations or anomalies

No prenatal care

lntrapartum bleeding

Forceps or vacuum-assisted delivery Chorioamnionitis

Breech or other abnormal presentation

Category II or 111 fetal heart rote pattern*

Maternal general anesthesia

Opioids administered to mother within 4 hours of delivery

Shoulder dystocia

Meconium-stained amniotic fluid

Maternal magnesium therapy Prolapsed umbilical cord

Placenta! abruption

*See Appendix 3 in this lesson for description of fetal heart rote categories.

What questions should yo u ask bef ore every birth?

It is important for the obstetric and newborn health care providers to

coordinate care by establishing effective communication. Before every

birth, review the antepartum and intrapartum risk factors described in

Table 2-1 and ask the following 4 pre-birth questions:

O What is the expected gestational age?

f) Is the amniotic fluid clear?

Q Are there any additional risk factors?

8 What is our umbilical cord management plan?

ANTICIPATING AND PREPARING FOR RESUSCITATION

Based on the responses to these questions, assemble the necessary

personnel and equipment. You will learn more about the timing of

umbilical cord clamping and establishing a plan for umbilical cord

management in Lesson 3.

What personnel should be present at delivery?

The number and qualifications of personnel will depend on your risk

assessment. Consider creating a written policy for how many people

should attend a birth, what qualifications they should have based on

assessment of perinatal risk, and how to call for additional help if needed.

• Every birth should be attended by at least 1 qualified individual,

skilled in the initial steps of newborn care and positive-pressure

ventilation (PPV), whose only responsibility is management of

the newly born baby. When a birth is attended by only 1 qualified

individual, the likelihood of resuscitation should be low. In the

event of unanticipated resuscitation, this team member will initiate

resuscitation and call for additional help.

• If risk factors are present (Table 2-1), at least 2 qualified people

should be present solely to manage the baby. The number and

qualifications of personnel will vary depending on the anticipated

risk, the number of babies, and the hospital setting.

• A qualified team with full resuscitation skills, including endotracheal

intubation, chest compressions, emergency vascular access, and

medication administration, should be identified and immediately

available for every resuscitation.

- The fully qualified resuscitation team should be present at the

time of birth if the need for advanced resuscitation measures is

anticipated.

- It is not sufficient to have the team with these advanced skills

on call at home or in a remote area of the hospital. When

resuscitation is needed, it must begin without delay.

For example, a nurse at an uncomplicated birth might evaluate gestational

age, muscle tone, and respirations, and provide tactile stimulation. If the

newborn <loes not respond appropriately, the nurse would position and

clear the airway, start PPV, and initiate an emergency call for immediate

assistance. Quickly, a second person comes to the warmer to assess the

efficacy of PPV and places a pulse oximeter sensor. Another provider with

full resuscitation skills, including intubation and umbilical venous catheter

insertion, is in the immediate vicinity and arrives to assist the team.

In the case of an anticipated high-risk birth, such asan extremely

preterm baby or prolapsed umbilical cord, a team with sufficient

personnel to provide PPV, intubate the trachea, perform chest

compressions, obtain emergency vascular access, prepare medications,

and document events should be assembled before the birth. Depending

on the setting, this will likely require 4 or more qualified providers.

Each hospital must develop and practice a system for assembling its

resuscitation team. Identify how the team will be alerted if risk factors

are present, who will be called, and how additional help will be called if

necessary. Practice a variety of scenarios to ensure that you have sufficient

personnel immediately available to perform ali of the necessary tasks.

How do yo u perf orm a pre-resuscitation team briefing?

Once your team is assembled, perform a pre-resuscitation team

briefing to review the clinical situation and any management plans

developed during antenatal counseling. Identify a team leader,

delegate tasks, identify who will document events as they occur,

determine what supplies and equipment will be needed, and identify

.how to call for additional help (Figure 2.1). Use ali of the available

perinatal information to anticipate potential complications and plan

your response (Table 2-2). For example, if the obstetric provider tells

you that the mother has just received narcotic analgesia, you will be

prepared for a sedated baby that may require assisted ventilation.

Discuss who will perform the initial assessment, who will stimulate the

baby, who will start PPV if needed, and who will document the events.

The pre-resuscitation team briefing is important even for

well-established teams. A common analogy is to compare the medical

team's pre-resuscitation briefing toan airline pilot's preflight check.

Even pilots that have flown the same flight many times perform their

preflight check to ensure their passengers' safety.

Fi g u re 2. 1. Neonatal resuscitation team briefing

ANTICIPATING AND PREPARING FOR RESUSCITATION

Table 2-2. Pre-resuscitation Team Briefing

• Assess risk factors.

• ldentify team leader.

• Anticipate potential complications and plan a team response.

• Delegate tasks.

• ldentify who will document events as they occur.

• Determine what supplies and equipment will be needed.

• ldentify how to call for additional help.

What supplies and equipment should be available?

All supplies and equipment necessary for a complete resuscitation must

be readily available and functional for every birth. When a high-risk

newborn is expected, ali appropriate supplies and equipment should be

ready for immediate use. It is not sufficient to simply look at what is on

the radiant warmer. It is much more effective to establish an organized

routine using a standardized checklist before every birth. In this way,

you will confirm what is ready for immediate use and identify which

pieces of equipment are missing.

The appendices of this lesson include 2 lists.

• The Neonatal Resuscitation Program® (NRP

®) Quick Equipment

Checklist is a tool that you can use during your briefing to check the

most essential supplies and equipment. It follows the steps of the

NRP Algorithm. Consider keeping this checklist near the radiant

warmer so it is accessible before every birth.

• The Neonatal Resuscitation Supplies and Equipment List is a

comprehensive inve11tory of the supplies and equipment that should

be available within the resuscitation area.

What are the characteristics of an eff ective team leader?

Every resuscitation team needs to have a team leader. Any team

member who has mastery of the NRP Algorithm and effective

leadership skills can be the team leader. The leader <loes not have to

be the most senior member of the team or the individual with the

most advanced degree. That person may have technical skills that will

be required during the resuscitation and may not be able to maintain

their full attention on the baby's condition. If you are the person with

sole responsibility for management of the baby at birth and the baby

unexpectedly requires resuscitation, you become the team leader and

direct your assistants to help you until the full resuscitation team

arr1ves.

• Effective team leaders exemplify good communication skills by

giving clear directions to specific individuals, sharing information,

delegating responsibilities to ensure coordinated care, and

maintaining a professional environment.

• A skilled leader effectively uses resources by allowing all team

members to contribute their unique talents to the resuscitation

process.

• It is important for the team leader to remain aware of the entire

clinical situation, maintain a view of the "big picture;' and not

become distracted by a single activity. This is called situation

awareness.

• If the leader is involved in a procedure that diverts their attention,

the leader may need to appoint another qualified person to assume

the leadership role. If the person in the leadership role changes

during the resuscitation, a clear verbal statement should be made so

that all team members know who is leading the team.

What is closed-loop communication?

Although the team has a leader, each team member shares

responsibility for ongoing assessment and ensuring that interventions

are performed in the correct sequence with the correct technique.

Successful coordination requires team members to share information

and communicate with each other. Closed-loop communication is a

technique that ensures instructions are heard and understood.

When you give an instruction,

• Direct the request to a specific individual.

• Call your team member by name.

• Make eye contact.

• Speak clearly.

• After giving an instruction, ask the receiver to report back as soon

as the task is completed.

• After receiving an instruction, repeat the instruction back to the

sender.

The following 2 examples demonstrate requests and questions directed

to a specific individual, clear and concise language, and closed-loop

communication.

ANTICIPATING AND PREPARING FOR RESUSCITATION

Example 1 Example 2

Ni cole: Nicole:

"Lou, I need a three-point-five-millimeter

endotracheal tube, with a stylet, and

a I aryngoscope with a size-one blade

now. Tell me when they' re ready. "

"Lou, auscultote the heort rote ond tell me íf it's increasíng."

Lou:

"The heart rote is seventy beats per minute ond it is not increosing."

Ni cole:

Lou:

"You need a three-point-five-millímeter

endotracheal tube, with a stylet, and a

laryngoscope with a size-one blade."

"Is the chest moving?"

Lou:

"No, the chest is not moving."

Ni cole:

"Correct."

Once the equipment is ready,

Lou:

"Lou, opply o pulse oximeter now. Tell me when it's workíng."

Lou:

"You want o pulse oxímeter."

Ni cole:

"Nicole, a three-point-fíve-millímeter

endotracheal tube, with a stylet, and a

size-one laryngoscope are ready for you

now."

"Correct."

When the pulse oximeter is applied and working,

Lou:

"The pulse oximeter is on the right hand ond reading sixty-fíve percent.

Why is accurate documentation important?

During an emergency, highly effective teams accurately document the

series of events as they occur. Complete and accurate documentation

is important for clinical decision-making andas a source for quality

improvement data.

The sense of urgency surrounding resuscitation can make accurate

documentation challenging, but preparation can make this essential task

easier. If your hospital uses paper documentation, consider keeping a hard

copy of your hospital's neonatal code documentation sheet on a clipboard

at every radiant warmer. If your hospital uses electronic documentation,

consider keeping a device that can rapidly enter your electronic medical

record system near every radiant warmer. Practicing documentation skills

warrants the same preparation as any other resuscitation skill and should

be practiced during mock codes and simulation.

• During your tean1 briefing, assign someone to be the scribe who

will document events. Ideally, this should be an experienced team

member who knows what is important to record, is comfortable

communicating with team members, and can provide decision

support to the team leader. For example, the scribe may remind the

team leader how much time has passed since chest compressions

were started or epinephrine was administered. Without experience,

the scribe may have difficulty deciding what is important to record

and providing decision support to the team leader.

• Use a single time reference to document when events occur. If team

members use different watches or clocks during a resuscitation, it

may cause confusion or documentation errors.

• Because multitasking can disrupt observation and communication,

and increase medication errors, the scribe should not be responsible

for performing other critical tasks.

• To assist the scribe, team members need to clearly announce their

assessments and when interventions are performed.

• Consider using a paper form or electronic template designed

specifically for neonatal resuscitation. Well-designed forms that

follow the NRP Algorithm enable rapid data entry, allowing

the scribe to assist the team leader by providing prompts for

the next intervention and identifying delayed assessments. The

NeoLog, available on the NRP website, is one example of a code

documentation form designed specifically for neonatal resuscitation.

• After the event, consider supplementing the resuscitation record

with a narrative summary that clarifies decision -making.

What are the benefits of a post·resuscitation team debriefing?

A post-resuscitation team de briefing is a constructive review of actions

and thought processes that promotes reflective learning. Performing

a debriefing after the resuscitation reinforces good teamwork

habits and helps your team identify areas for improvement. A quick

debriefing can be performed immediately after the event, while a more

comprehensive debriefing may be scheduled a short time afterward.

Your debriefings do not have to find major problems to be effective.

You may identify a series of small changes that can result in significant

improvement in your team's performance and clinical outcomes.

Focus on Teamwork

The preparation phase of neonatal resuscitation highlights severa!

opportunities for effective teams to use the NRP Key Behavioral Skills.

Behavior Example

Know your environment. Know how the resuscitation team is called and how additional personnel and resources

can be summoned.

Know how to access additional supplies and equipment for a complex resuscitation.

Use available Ask the obstetric provider the 4 pre-birth questions to identify risk factors.

information.

Antici pote and plan. Know which providers are qualified to attend the birth based on the identified risk factors.

Perform a standardized equipment check before every birth.

Assign roles and responsibilities.

Clearly identify a team lf risk factors are present, identify a team leader before the birth and perform a pre-resuscitation

leader. team briefing to ensure that everyone is prepared and responsibilities are defined.

Use available resources. Prepare additional supplies and equipment, as necessary, based on identified risk factors.

ANTICIPATING AND PREPARING FOR RESUSCITATION

Quality lmprovement Opportunities

Ask yourself the following questions and begin a discussion with your

team if you find a difference between the NRP recommendations and

what is currently done in your own hospital setting. Consider using the

suggested process and outcome measures to guide your data collection,

identify areas for improvement, and monitor if your improvement

eff orts are working.

Quality improvement questions

O Who is responsible for ensuring that supplies and equipment are

ready befo re every birth?

f) Is the table of risk factors accessible in your delivery setting?

Q Is a supplies and equipment checklist available at every warmer?

8 Do you have a designated paper form or electronic template

designed specifically for neonatal resuscitation readily available for

use at every birth?

0 How is the resuscitation team mobilized when a newborn without

risk factors needs resuscitation?

Process and outcome measures

O What percentage of providers involved in the care of newborns

have completed the NRP course?

f) What percentage of births have a qualified provider present who is

only responsible for the newborn?

Q What percentage of births have a standardized supplies and

equipment checklist completed?

C, What percentage of births attended by 1 NRP provider require

additional team members for an unanticipated resuscitation?

Frequently Asked Questions

What is the ideal number of people to have on the resuscitation team?

There is no single correct answer to this question. You must have

sufficient personnel immediately available to perform all of the

necessary tasks without delay. The personnel required at any particular

birth will depend on the identified risk factors, the qualifications

of the individuals on the team, and the setting. Simulate different

scenarios to ensure that you have sufficient personnel on your team to

perform all necessary procedures quickly and efficiently. For a complex

resuscitation, this will likely require 4 or more people.

What if I am concerned that we do not hove the correct team

configuration (number of people or qualifications) to attend a birth?

This problem usually can be avoided by having a clearly written

hospital protocol to determine the number and qualifications of people

who should attend a birth based on a standardized assessment of risk

factors and effective team communication. Remember that safety is the

top priority in decision-making. Following the concepts outlined in the

NRP Key Behavioral Skills, use the available information to identify

the safety concern, use effective communication and professional

behavior to express your concern, and use your knowledge of the

available resources to suggest an alternative. Start by saying, "I believe

this delivery has risk factors that require ... :' If your concern is not

acknowledged, continue with "I am concerned because ... " and suggest

an alternative course of action.

LESSON 2 REVIEW

l. What are the 4 pre-birth questions to ask the obstetric provider

befo re every birth?

2. Every delivery should be attended by at least 1 qualified person

(whose only responsibility is the management of the newborn)/

(who shares responsibility for the mother and newborn's care).

3. If a high-risk birth is anticipated, (1 qualified person)/

( a qualified team) should be present at the birth.

4. During the pre-resuscitation team briefing, (prepare for

a routine delivery because you do not know what will be

needed)/(anticipate potential complications and discuss how

responsibilities will be delegated).

5. A qualified nurse or respiratory therapist who has been trained

in neonatal resuscitation and has strong leadership skills (can)/

( cannot) be the team leader.

6. The equipment check includes ( checking that ali supplies and

equipment for a complete resuscitation are readily available and

functional only when anticipating a high-risk birth)/(checking

that ali supplies and equipment for a complete resuscitation are

readily available and functional for every birth).

ANTICIPATING AND PREPARING FOR RESUSCITATION

Answers

l. The 4 pre-birth questions are: (1) What is the expected

gestational age? (2) Is the amniotic fluid clear? (3) Are there

any additional risk factors? ( 4) What is our umbilical cord

management plan?

2. Every delivery should be attended by at least 1 qualified person

whose only responsibility is the management of the newborn.

3. If a high-risk birth is anticipated, a qualified team should be

present at the birth.

4. During the pre-resuscitation team briefing, anticípate potential

complications and discuss how responsibilities will be delegated.

S. A qualified nurse or respiratory therapist who has been trained

in neonatal resuscitation and has strong leadership skills can be

the team leader.

6. The equipment check includes checking that all supplies and

equipment for a complete resuscitation are readily available and

functional for every birth.

Appendix 1. N R P Quick Equipment Checklist

This checklist includes only the most essential supplies and equipment

needed at the radiant warmer for most neonatal resuscitations. Tailor

this list to meet your unit-specific needs. Ensure that an equipment

check has been done prior to every birth.

Warm

Clear

a1rway

Auscultate

Ventilate

Oxygenate

lntubate

Medicate

• Preheated warmer

• Warm towels or blankets

• Temperature sensor and sensor cover for prolonged

resuscitation

• Hat

• Plastic bag or plastic wrap (< 32 weeks' gestation)

• Thermal mattress (< 32 weeks' gestation)

• Bulb syringe

• 1 OF or 12F suction catheter attached to wall suction, set

at 80 to 1 00 mm Hg

• Tracheal aspirator

• Stethoscope

• Flowmeter set to 1 O L/min

• Oxygen blender set to 21 % (21 %-30% if < 35 weeks'

gestation)

• Positive-pressure ventilation (PPV) device

• Term- and preterm-sized masks

• 8F orogastric tube and 20-ml syringe

• Laryngeal mask (size 1) and 5-ml syringe (if needed for

inflation)

• 5F or 6F orogastric tube if insertion port is present on

laryngeal mask

• Cardiac monitor and leads

• Equipment to give free-flow oxygen

• Pulse oximeter with sensor and cover

• Target Oxygen Saturation Table

• Laryngoscope with size O and size 1 straight blades (size

00, optional)

• Stylet (optional)

• Endotracheal tubes (sizes 2.5, 3.0, 3.5)

• Carbon dioxide (C0 2) detector

• Measuring tape and/ or endotracheal tube insertion depth

table

• Waterproof tape or tube-securing device

• Scissors

Access to

• Epinephrine (0.1 mg/ml= 1 mg/1 O ml)

• Normal saline (100-ml or 250-ml bag, or prefilled syringes)

• Supplies for placing emergency umbilical venous catheter

and administering medications

• Table of pre-calcuated emergency medication dosages for

babies weighing 0.5 to 4 kg

ANTICIPATING AND PREPARING FOR RESUSCITATION

Appendix 2. Neonatal Resuscitation Supplies and

Equipment List

Suction equipment

Bulb syringe

Mechanical suction and tubing

Suction catheters, SF or 6F, lOF, 12F or 14F

8F orogastric tube and 20-mL syringe

Tracheal aspirator

Positive-pressure ventilation equipment

Device for delivering positive-pressure ventilation

Pace masks, term and preterm sizes

Ox y gen source

Compressed air source

Ox y gen blender to mix oxygen and compressed air with flowmeter

(flow rate set to 10 L/min) and tubing

Pulse oximeter with sensor and cover

Target Oxygen Saturation Table

Stethoscope ( with neonatal head)

Laryngeal mask (size 1) or similar supraglottic device, and 5-mL

syringe (if needed for inflation)

5F or 6F orogastric tube if insertion port present on laryngeal mask

Cardiac monitor and leads

lntubation equipment

Laryngoscope with straight blades, No. O (preterm) and No. 1 (term)

Extra bulbs and batteries for laryngoscope, if required

Endotracheal tubes, 2.5-, 3.0-, 3.5-mm internal diameter (ID)

Stylet ( optional)

Measuring tape

Endotracheal tube insertion depth table

Scissors

Waterproof tape or tube-securing device

Alcohol pads

Carbon dioxide detector or capnograph

Medications

Epinephrine (0.1 mg/mL= 1 mg/10 mL)

Normal saline for volume expansion-100-mL or 250-mL

bag, or prefilled syringes

Dextrose 10%, 250 mL ( optional)

Normal saline for flushes

Syringes (1 mL, 3 mL or 5 mL, 20-60 mL)

Three-way stopcocks or fluid-dispensing connectors

Table of pre-calculated emergency medication dosages for babies

weighing 0.5 to 4 kg

Umbilical vessel catheterization supplies

Sterile gloves

Antiseptic prep solution

Umbilical tape

Small clamp (hemostat)

Forceps ( optional)

Scalpel

Umbilical catheters (single lumen), 3.SF or SF

Three-way stopcock

Syringes (3-5 mL)

Needle or puncture device for needleless system

Normal saline for flushes

Clear adhesive dressing to temporarily secure umbilical venous

catheter to abdomen ( optional)

Miscellaneous

Timer/clock with second hand

Gloves and appropriate personal protection equipment

Radiant warmer or other heat source

Temperature sensor with sensor cover for radiant warmer (for use

during prolonged resuscitation)

Warmed linens

Hat

Tape, 1/2 or 3/4 inch

Intraosseous needle ( optional)

For very preterm babies

Food-grade plastic bag ( 1-gallon size) or plastic wrap

Thermal mattress

Size 00 laryngoscope blade ( optional)

Transport incubator to maintain baby's temperature during move to

the nursery

ANTICIPATING AND PREPARING FOR RESUSCITATION

Appendix 3. Fetal Heart Rate Categories

Category I: This is a normal tracing and is predictive of normal fetal

acid-base status at the time of the observation, and routine follow-up is

indicated.

Category 11: This is considered an indeterminate tracing. There is

currently inadequate evidence to classify these tracings as either

normal or abnormal. Further evaluation, continued surveillance, and

reevaluation are indicated.

Category 111: This is an abnormal tracing and is predictive of abnormal

fetal acid-base status at the time of the observation. A Category III

tracing requires prompt evaluation and intervention.

Reference

Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The

2008 National Institute of Child Health and Human Development

workshop report on electronic fetal monitoring: update on

definitions, interpretation, and research guidelines. Obstet Gynecol.

2008;112(3):661-666

LESSON 2: PRACTICE SCENARIO

Anticipating and Preparing for Resuscitation

Learning Ob¡ectives

O Determine the process for identifying antepartum and intrapartum

risk factors for neonatal resuscitation and identifying how the

decision is made for who will attend the birth.

f) Demonstrate a pre-resuscitation team briefing.

E) Demonstrate an organized method for performing an equipment

check prior to the birth.

8 Identify the process used to call for additional help if needed for

newborn resuscitation.

This Practice Scenario is for review / practice and evaluation.

This is the suggested Practice Scenario sequence.

O Review the Knowledge Check Questions with your Neonatal

Resuscitation Program (NRP) instructor.

a. What are the 4 key questions to ask the obstetric provider

befo re the birth? What is the purpose of these questions?

b. What is your unit's process for assessing risk factors that

increase the likelihood of newborn resuscitation? How is it

determined who will attend a birth?

c. If a newborn unexpectedly requires resuscitation at birth, what

is the system to call for help?

d. What happens ata pre-resuscitation team briefing?

e. Who is responsible for checking resuscitation supplies and

equipment before every birth?

f) Practice/review these skills with your NRP instructor.

a. Prepare the radiant warmer for use.

b. Set up the positive-pressure ventilation (PPV) device(s) for use.

If a T-piece resuscitator normally is used in the delivery room,

the learner may demonstrate proficiency with setting up that

device and check the readiness of a self-inflating bag and mask.

c. Checl< the functio11 of wall suction device(s).

d. Check the function of the laryngoscope.

ANTICIPATING AND PREPARING FOR RESUSCITATION

8 Practice this scenario with your NRP instructor until you need

little or no assistance or coaching.

8 Pass the Lesson 2 Practice Scenario evaluation by leading this

practice scenario and performing the skills relevant to your role

and responsibilities. If a technical skill included in this scenario

is not within your scope of responsibility, delegate the skill to

a qualified team member and perform the role of assistant, if

appropriate. When you can lead the scenario(s) and perform the

skills with little or no instructor coaching, proceed to the next

lesson's practice scenario.

Practice Scenario

Two variations of the scenario are offered.

• A baby of 38 weeks' gestation with no known risk factors

• A baby of 29 weeks' gestation with additional risk factors

"You are notified that a woman has been admitted to the hospital in

active labor. Prepare your team far the birth and check your supplies and

equipment. As you work, say your thoughts and actions aloud so I will

know what you are thinking and doing."

The instructor should check boxes as the learner responds correctly.

The learner may refer to the NRP Quick Equipment Checklist or use a

unit-specific checklist. Two gestational ages are offered for use.

Critical Performance Steps

Assess perinatal risk.

Assesses perinatal risk (learner asks 4 pre-birth questions and instructor ["OB provider"] responds)

What is the expected gestational age? "38 weeks' gestation." "29 weeks' gestation."

Is the amniotic fluid clear? "Clear fluid." "Clear fluid."

Are there any additional risk factors? "No known risk factors." "Preeclampsia."

What is our umbilical cord 1 will delay cord clamping. lf the baby is not crying, 1'11 take a moment

management plan? to stimulate the baby. lf there's no response, 1'11 clamp and cut the cord."

Assemble team.

Assembles team based on perinatal risk factors.

When the likelihood of resuscitation is low, l qualified individual should attend the birth.

lf risk factors are present, at least 2 qualified people should be present solely to manage the baby. The number

of team members and qualifications vary depending on risk.

Critical Performance Steps (cont)

lf the birth will be attended by l person,

Knows the answers to the 4 pre-birth questions, determines supplies and equipment needed, knows how to call

for help

lf the birth will be attended by a team, perform a pre-resuscitation briefing.

ldentifies team leader.

Assesses risk factors, discusses potential complications and the management plan, delegates tasks, identifies who

will document events, determines supplies and equipment needed, knows how to call for additional help.

Perform equipment check.

Demonstrates an organized routine to locate the most essential supplies needed for newborn resuscitation:

Warm.

• Preheated radiant warmer

• Towels or blankets

• Temperature sensor and sensor cover for use during prolonged resuscitation

• Hat

• Plastic bag or wrap (< 32 weeks' gestation)

• Thermal mattress (< 32 weeks' gestation)

Clear the airway.

• Bulb syringe

• 1 OF or 12F suction catheter attached to wall suction, set at 80 to 100 mm Hg

• Tracheal aspirator

Auscultate.

• Stethoscope

Ventilate.

• Sets flowmeter to 1 O L/min

• Sets oxygen blender to 21 % (21 %-30% if < 35 weeks' gestation)

• Checks presence and function of PPV device(s), including pressure settings and pressure pop-off valves

• Sets T-piece resuscitator at peak inflation pressure (PIP) = 20 to 25 cm H20 for term baby; PIP = 20 cm H20 for

preterm baby; positive end-expiratory pressure (PEEP) = 5 cm H20

• Term- and preterm-sized masks

• Laryngeal mask (size 1) and 5-ml syringe (if needed for inflation)

• 5F or 6F orogastric tube if insertion port present on laryngeal mask

• 8F orogastric tube and 20-ml syringe

• Cardiac monitor and leads

Oxy genate.

• Equipment to give free-flow oxygen

• Target Oxygen Saturation Table

• Pulse oximeter with sensor and sensor cover

lntubate.

• Laryngoscope with size O and size 1 straight blades and bright light (size 00, optional)

• Stylet (optional)

• Endotracheal tubes (sizes 2.5, 3.0, 3.5)

• Carbon dioxide (C0 2) detector

• Measuring tape and/ or endotracheal tube insertion depth table

• Waterproof tape or tube-securing device

• Scissors

ANTICIPATING AND PREPARING FOR RESUSCITATION

Critical Performance Steps (cont)

Perform equipment check ( cont).

Medicate.

Ensure access to

• Epinephrine (1 mg/10 ml=0.1 mg/ml)

• Normal saline ( 100- or 250-ml bag, or prefilled syringes)

• Supplies for administering medications and placing emergency umbilical venous catheter and administering

medications

• Pre-calculated medication dose chart

Other potential items to check.

• Temperature in resuscitation location (23 º

C to 25º

C [7 4º

F-77º

F] if < 32 weeks' gestation)

• Oxygen and air tanks

• Access to intraosseous needle and insertion supplies

• Access to surfactant (preterm birth)

• Transport incubator for transfer to nursery or NICU

Sample Debriefing Questions

O What factors determined your decision for who would attend the

birth(s) described in the scenario(s)?

f) If all equipment and supplies are present> how long <loes it take you

to confirm readiness f or a birth? Are there methods yo u could use

to decrease the time needed to perform the equipment check?

E) Which of the NRP Behavioral Skills are demonstrated during

preparation for resuscitation?

NRP Key Behavioral Skills

• Know your environment.

• Use available information.

• Anticipate and plan.

• Clearly identify a team leader.

• Communicate effectively.

• Delegate the workload optimally.

• Allocate attention wisely.

• Use available resources.

• Call for additional help when needed.

• Maintain professional behavior.

lnitia

What you will learn

How to perform a rapid evaluation

The initial steps of newborn care

How to determine if additional steps are required

What to do if a baby has persistent cyanosis or labored

breathing

How to use a pulse oximeter and interpret the results

How to give supplemental oxygen

When to consider using continuous positive airway

pressure

What to do when meconium-stained amniotic fluid is

present

Used with permission of Mayo Foundation for Medical Education and Research.

r ' \ Antenatal counseling.

Team briefing.

Equipment check.

'" ,

Birth

' ,

Term gestation? Yes r

Stay with mother for initial steps, Good tone? -

routine care, ongoing evaluation. Breathing or crying? ' -

<l> ' ,

e ' Warm, dry, stimulate, position ·-

airway, suction if needed.

,....

' -

' ,

Apnea or gasping? No Labored breathing or

HA <100 bpm? ' persistent cyanosis?

Yes

' ¿

r ' \ ,

PPV. Position airway, suction if needed.

Pulse oximeter. Pulse oximeter.

Consider cardiac monitor. Oxygen if needed.

'" , Consider CPAP.

' -

' ,

- HA <100 bpm? No

Yes

' , ' , ' ¿

, ' \ ,

Ensure adequate ventilation. Post-resuscitation care.

Consider ETT or laryngeal mask. Team debriefing.

Cardiac monitor. ' -

'" ,

' ,

HA <60 bpm? Target Oxygen Saturation Table

Yes

1 min 60%-65

' ,

, ' \ ETT or laryngeal mask.

2 min 65%-70%

Chest compressions. 3 min 70%-75%

Coordinate with PPV-100% oxygen.

uve. 4 min 75%-80

/o '" ,

' , 5 min 80%-85%

No HA <60 bpm?

10 min 85%-95%

"- Yes

lnitial oxygen concentration for PPV r

IV epinephrine every 3-5 minutes.

lf HA remains < 60 bpm, - 35 weeks' GA 21% oxygen

• Consider hypovolemia.

• Consider pneumothorax. < 35 weeks' GA 21%-30

/o oxygen

' -

Key Points

O For most vigorous term and preterm newborns, clamping the

umbilical cord should be delayed for at least 30 to 60 seconds.

f) Ali newborns require a rapid evaluation. Ask if the baby is term,

has good muscle tone, and is breathing or crying. If the answer

is "NO" to any of these, the newborn should be brought to the

radiant warmer for the initial steps of newborn care.

E) The 5 initial steps include the following: provide warmth, dry,

stimulate, position the head and neck to open the airway, clear

secretions from the airway if needed.

8 Use pulse oximetry and the Target Oxygen Saturation Table to

guide oxygen therapy (a) when resuscitation is anticipated, (b) to

confirm your perception of persistent central cyanosis, ( c) if you

give supplemental oxygen, or ( d) if positive-pressure ventilation is

required. Visual assessment of cyanosis is not a reliable indicator of

oxygen saturation.

0 If meconium-stained fluid is present and the baby is not vigorous,

bring the baby to the radiant warmer to perform the initial steps.

Routine laryngoscopy with or without intubation for tracheal

suction is not suggested.

Case 1 : An uncomplicated birth

A healthy woman arrives in active labor at 39 weeks' gestation. You

are the nurse assigned to care for the newborn at birth, and you must

know the answers to the 4 pre-birth questions to assess the perinatal

risk and confirm that only 1 qualified person is needed to manage this

newborn. You know that the baby is term. The mother's membranes

ruptured shortly after arrival and the amniotic fluid is clear. You

learn that her pregnancy has been uncomplicated. You complete a

standardized equipment check to ensure that neonatal resuscitation

supplies and equipment are ready for use if needed. You review the

umbilical cord management plan with the obstetric provider and

introduce yourself to the mother.

At the time of birth, the baby appears to be full term, has good muscle

tone, and cries vigorously. The baby is placed skin-to-skin on the

mother's chest and is covered with a warm blanket. You gently dry

and stimulate the baby and position the baby's head to ensure the

airway is open. One minute after birth, the cord is clamped and cut.

The baby's color becomes increasingly pink during the transition to

newborn circulation. You continue to evaluate breathing, tone, color,

and temperature to determine if additional interventions are required.

Shortly after birth, the mother positions the newborn to initiate

breastfeeding.

Case 2: Delayed transition

A woman arrives in labor at 39 weeks' gestation. Labor progresses

rapidly and the obstetric provider calls your resuscitation team to

attend the vaginal birth. You ask the obstetric provider the 4 pre-birth

questions to assess perinatal risk factors and determine who should

attend the birth. This is a term baby. Membranes are ruptured and

the fluid is clear. Additional risk factors include fetal tachycardia

and maternal fever. The mother has received intrapartum antibiotics

for suspected chorioamnionitis. Fetal heart rate monitoring shows a

Category II (indeterminate) pattern. You discuss the umbilical cord

management plan with the obstetric providers.

When you enter the room, you introduce the team to the laboring

motl1er. Your team completes a pre-resuscitation briefing and

equipment check.

Immediately after birth, the baby has poor tone and <loes not cry.

The obstetric provider holds the baby in a warm blanket, and dries

and stimulates the baby to breathe by gently rubbing the baby's back.

The baby still has poor tone and irregular respiratory effort. The cord

is clamped and cut and the baby is brought to the radiant warmer.

You position the head and neck to open the airway and use a bulb

syringe to clear secretions from the mouth and nose in anticipation

of positive-pressure ventilation (PPV) while an assistant continues

to provide gentle stimulation. A scribe documents the events as they

occur.

The baby's tone and respiratory effort quickly improve. Listening

with a stethoscope, your assistant reports that the baby's heart rate is

120 beats per minute (bpm). Five minutes after birth, central cyanosis

persists and a pulse oximeter sensor is secured on the baby's right

hand. The pre-ductal oxygen saturation (SPo2

) is below the target

described in the Target Oxygen Saturation Table, so supplemental

free-flow oxygen is administered. Documentation continues while

the oxygen concentration (F102

) is adjusted so that the SPo2

remains

within the target range. By 1 O minutes after birth, the baby is breathing

regularly and supplemental oxygen has been gradually discontinued.

The SPo2 remains normal and the baby is placed skin-to-skin on the

mother's chest to continue transition while vital signs and activity

are closely monitored for possible deterioration. Shortly afterward,

the team members conduct a short debriefing to evaluate their

preparation, teamwork, and communication.

When should the umbilical cord be clamped?

At the time of birth, a large volume of the baby's blood remains in

the placenta. If maternal blood is still flowing to the placenta and

the umbilical cord has not been clamped, placenta! gas exchange will

continue and additional oxygenated blood will be returned to the baby

through the umbilical vein. This blood may play an important role in

the newborn baby's transition from fetal to neonatal circulation.

Mark the time of birth by starting a timer when the last fetal part

emerges from the mother's body. The ideal time for clamping the

umbilical cord is the subject of ongoing research.

• In preterm newborns, potential benefits of delayed cord clamping

compared with immediate cord clamping include decreasing the

chance of needing medications to support blood pressure after birth,

requiring fewer blood transfusions during hospitalization, and

possibly improved survival.

• In term and late preterm newborns, delayed cord clamping may

improve early hematologic measurements and, although uncertain,

there may be benefits for neurodevelopmental outcomes. However,

there may also be an increased chance of needing phototherapy for

hyp erbilirubinemia.

Before birth, establish with the obstetric provider what the plan will be

for the timing of umbilical cord clamping. For most vigorous preterm

newborns, the current evidence suggests that clamping should be

delayed for at least 30 to 60 seconds. Among vigorous term newborns,

the evidence suggests that a similar delay may be reasonable. During

this time, the baby may be placed skin-to-skin on the mother's chest

or abdomen, or held securely in a warm, dry towel or blanket. Very

preterm newborns, less than 32 weeks' gestation, may be wrapped

in a warm blanket or polyethylene plastic to help maintain their

temperature. Remember, until the cord is clamped, the baby will

also be receiving warm blood from the placenta. During the interval

between birth and umbilical cord clamping, the obstetric provider and

neonatal tea.m should evaluate the baby's tone and breathing effort and

continue the initial steps of newborn care described in the remainder

of this lesson.

Early (immediate) cord clamping is indicated, or may be considered, in

certain cases.

• If the placenta! circulation is not intact, such as after a placenta!

abruption, bleeding placenta previa, bleeding vasa previa, or cord

avulsion, the cord should be clamped immediately after birth.

• Most delayed cord clamping studies have excluded multiple

gestations, so there is currently not enough evidence to evaluate the

safety of delayed cord clamping in the setting of a multiple gestation

birth.

• Other scenarios, where safety data on delayed cord clamping

are limited, may benefit from a discussion between the neonatal

and obstetric providers to plan whether cord clamping should

be delayed. These scenarios may include fetal intrauterine

growth restriction (IUGR), abnormal umbilical artery Doppler

measurements, abnormal placentation, and other situations where

utero-placental perfusion or umbilical cord blood flow are affected.

• There is not enough evidence to make a definitive recommendation

whether umbilical cord clamping should be delayed in newborns

who are not vigorous.

- If the placen tal circulation is intact, it may be reasonable to

briefly delay cord clamping while the obstetric provider gently

stimulates the baby to breathe and suctions the mouth and

nose with a bulb syringe. If the baby <loes not begin to breathe,

additional treatment may be required. Clamp the umbilical cord

and bring the baby to the radiant warmer.

- Initiating resuscitation close to the mother with the cord intact

is the subject of ongoing research that may provide additional

evidence to inform future recommendations.

How do you evaluate the newborn immediately after birth?

After birth, ali newborns should have a rapid evaluation to determine

if they can remain with their mother to continue transition or if they

should be moved to a radiant warmer for further assessment. This

initial evaluation may occur during the interval between birth and

umbilical cord clamping. You will rapidly ask 3 questions: ( 1) Does the

baby appear to be term, (2) Does the baby have good muscle tone, and

(3) Is the baby breathing or crying?

Does the baby appear to be term?

Determine if the baby's appearance is consistent with the expected

gestational age. In sorne situations, the baby's gestational age is

unknown before birth. If the baby appears to be term, proceed to the

next assessment question. If the baby appears to be preterm (less than

37 weeks' gestation), bring the baby to the radiant warmer for the

initial steps.

Preterm babies are more likely to require interventions during the

transition to extrauterine life. For example, they have more difficulty

aerating their lungs, establishing good respiratory effort, and

maintaining their body temperature.

• Because of these risks, once the cord has been clamped, preterm

babies should have the remaining initial steps of newborn care

performed under a radiant warmer.

• If the baby is born ata late-preterm gestation (34 to 36 weeks) and

appears vigorous with good respiratory effort, the baby can be

brought to the mother within severa! minutes to continue transition.

Does the baby hove good muse le tone?

Quickly observe the baby's muscle tone. Healthy term babies should

be active with flexed extremities (Figure 3.1). Newborns requiring

intervention may have flaccid extremities (Figure 3.2).

Is the baby breathing or crying?

A vigorous cry is a clear indicator of strong respiratory effort

(Figure 3.1). If the baby is not crying, observe the baby's chest for

breathing effort. Be careful not to be misled by a baby who is gasping.

Gasping is a series of deep, single or stacked inspirations that occurs in

the setting of severely impaired gas exchange. A gasping baby requires

intervention and must be brought to the radiant warmer.

A Rapid Evaluation for

Every Newborn

• Term?

• Tone?

• Breathing or crying?

Figure 3.1. Low-risk newborn: full-term, good tone,

crying. (Used with permission of Mayo Foundation for

Medical Education and Research.)

Figure 3.2. High-risk newborn: preterm, poor tone, not

cry1ng

lnitial Steps of Newborn

Care

• Provide warmth.

• Dry.

• Stimulate.

• Position the head and neck.

• Clear secretions if needed.

Once you have completed your rapid evaluation, what are

the initial steps of newborn car e?

The initial steps include providing warmth, drying, providing gentle

tactile stimulation, positioning the head and neck so that the airway

is open, and clearing the airway of secretions if needed. These steps

may be initiated during the interval between birth and umbilical cord

clamping and should be completed within approximately 30 seconds

of birth. In many cases, the initial steps are provided by more than

1 person and sorne steps may be performed simultaneously.

How do yo u pro vide the initial steps f or vigorous, term

newborns?

If the answers to all 3 rapid evaluation questions are "Yes," the baby can

remain with the mother and have the initial steps performed on the

mother's chest or abdomen.

• Warmth is maintained by direct skin-to-skin contact and covering

the baby with a warm towel or blanket (Figure 3.3).

• Dry the baby with the towel or blanket and gently stimulate the

baby.

• Position the baby on the n1other's chest or abdomen to ensure the

• • a1rway 1s open.

•

.,. ..

•,.

• .

. •

. ' -';J • •

Figure 3.3. Vigorous, term newborn. lnitial steps are performed skin-to-skin

with mother. (Used with permission of Mayo Foundation for Medica! Education

and Research.)

• If necessary, secretions in the upper airway can be cleared by wiping

the baby's mouth and nose with a cloth. Gentle suction with a bulb

syringe should be reserved for babies who are having difficulty

clearing their secretions.

• After the initial steps are completed, continue monitoring the

newborn's breathing, tone, activity, color, and temperature to

determine if additional interventions are required.

How do yo u pro vide the initial steps f or non·vigorous and

preterm newborns?

If the answer to any of the initial evaluation questions is "No," bring

the baby to a radiant warmer because additional interventions may be

required.

Provide warmth.

Place the baby under a radiant warmer so that the resuscitation

team has easy access to the baby without causing excessive heat loss

(Figure 3.4). Leave the baby uncovered to allow full visualization and

to permit the radiant heat to reach the baby.

• If you anticipate that the baby will remain under the warmer for

more than a few minutes, apply a servo-controlled temperature

sensor to the baby's skin to monitor and control the baby's body

temperature. Avoid both hyp othermia* and overheating.

• During resuscitation and stabilization, the baby's body temperature

should be maintained between 36.SºC and 37.SºC.

Dry.

Wet skin increases evaporative heat loss (Figure 3.5). Place the baby on

a warm towel or blanket and gently dry any fluid. If the first towel or

blanket becomes wet, discard it and use fresh, warm towels or blankets

for continued drying (Figure 3.6).

• Drying is not necessary for very preterm babies less than 32

weeks' gestation because they should be covered immediately in

polyethylene plastic, which reduces evaporative heat loss.

• The interventions used to reduce heat loss in very preterm babies

are described in Lesson 8.

* After resuscitation, therapeutic hypothermia is indicated for certain high-risk

newborns and is further described in Lesson 8.

Figure 3.4. Radiant warmer

used for the initial steps with

high-risk newborns

Figure 3.5. Wet skin prometes rapid body cooling. Figure 3.6. Dry the baby and remove wet linen to

prevent heat loss and stimulate breathing. Gentle tactile

stimulation may also initiate breathing. (Used with permission

of Mayo Foundation for Medical Education and Research.)

Stimulate.

Drying the baby will frequently provide enough stimulation to initiate

breathing. If the newborn <loes not have adequate respirations, brief

additional tactile stimulation may stimulate breathing.

• Gently rub the newborn's back, trunk, or extremities (Figure 3.6).

• Overly vigorous stimulation is not helpful and can cause injury.

• Never shake a baby.

Position the head and neck to open the airway.

Position the baby on the back ( supine) with theh ead and neck neutral

or slightly extended and the eyes directed straight upward toward the

ceiling in the «sniffing the morning air" position (Figure 3.7). This

position opens the airway and allows unrestricted air entry.

• Avoid hyp erextension or flexion of the neck because these positions

may interfere with air entry.

• To help maintain the correct position, you may place a small, rolled

towel under the baby's shoulders (Figure 3.8). A shoulder roll is

particularly useful if the baby has a large occiput (back of head)

from molding, edema, or prematurity.

lf needed, clear secretions from the airway.

Routine suction for a crying, vigorous baby is not indicated. Clear

secretions from the airway if the baby is not breathing, if the baby is

gasping, if the baby has poor tone, if secretions are obstructing the

airway, if the baby is having difficulty clearing their secretions, or

if you anticípate starting PPV. Secretions may be removed from the

upper airway by suctioning gently with a bulb syringe (Figure 3.9).

Fi g u re 3.7. Correct sniffing position Fi g u re 3.8. Optional shoulder roll for maintaining the

sniffing position

If the newborn has copious secretions coming from the mouth, turn

the head to the side. This will allow secretions to collect in the cheek

where they can be removed.

• Brief, gentle suction usually is adequate to remove secretions.

• Suction the mouth before the nose to ensure there is nothing for the

baby to aspirate if the baby gasps when the nose is suctioned. You

can remember «mouth before nose" by thinking «M" comes before

«N" in the alphabet.

• Be careful not to suction vigorously or deeply. Vigorous suction may

in jure tissues. Stimulation of the posterior pharynx during the

# ..

. ,.

Fi g u re 3.9. Gently suction the mouth then nose with a bulb syringe. Use

your thumb to depress the bulb syringe before placing it in the baby's mouth or

nose.

first minutes after birth can produce a vagal response leading to

bradycardia or apnea.

• If using a suction catheter, the suction control should be set so that

the negative pressure reads approximately 80 to 100 mm Hg when

the tubing is occluded.

How do you evaluate the newborn' s response to the initial

steps?

Assess the newborn's respirations to determine if the baby is

responding to the initial steps. This should take no more than an

additional 30 seconds.

Is the baby apneic or gasping?

After the initial steps, determine if the baby is crying or breathing.

If the baby is apneic, or has gasping respirations after initial steps,

proceed directly to PPV. Remember, gasping respirations are ineffective

and are treated the same as apnea. The details of providing PPV with a

face mask are described in Lesson 4.

If you are the only provider at the warmer, call for immediate

additional help.

If the baby has not responded to the initial steps within the first

minute of life, it is not appropriate to continue to provide only tactile

stimulation. For babies who remain apneic or bradycardic, delaying the

start of PPV beyond the first minute of life worsens outcomes.

Remember: Ventilation of the baby's lungs is the most important

and effective step during neonatal resuscitation.

lf the baby is breathing after the initial steps, assess the heart rote.

If the baby is breathing effectively, the heart rate should be at least

100 bpm. If the heart rate is less than 100 bpm, start PPV even if the

baby is breathing.

Your initial assessment of the heart rate will be made using a

stethoscope. Auscultation along the left side of the chest is the most

accurate physical examination method of determining a newborn's

heart rate (Figure 3.10). Although pulsations may be felt at the

umbilical cord base, palpation is less accurate and may underestimate

the true heart rate. While listening, you may tap out the heartbeat on

the bed so that your team will also know the heart rate.

• Estimate the heart rate by counting the nu1nber of beats in 6 seconds

and multiplying by 1 O. For example, if you listen for 6 seconds and

hear 12 beats, the heart rate is 120 bpm.

• Clearly report the heart rate to your team members

("The heart rate is 120 beats per minute").

If you cannot determine the heart rate by physical

examination and the baby is not vigorous, ask

another team member to quickly connect a pulse

oximeter or cardiac monitor. Other options include

the use of a handheld Doppler ultrasound or digital

stethoscope.

Cautions

...

• Pulse oximetry may not function if the baby's

heart rate is low or if the baby has poor

perfusion. In this case, determining the heart

rate with a cardiac monitor is the preferred

method.

Figure 3. 1 O. Assess the heart rote by listening with a

stethoscope. (Used with permission of Mayo Foundation

for Medical Education and Research.)

• In unusual circun1stances, a cardiac monitor may show an electrical

signal, but the heart is not actually pumping blood. This is called

pulseless electrical activity (PEA). In the newborn, PEA should be

treated the same as an absent heart rate ( asystole).

What do you do if the baby is breathing and

the heart rate is at least l 00 bpm, but the

baby appears persistently cyanotic?

The term cyanosis describes skin or mucous

membranes with a blue hue caused by poorly

oxygenated blood. Cyanosis limited to the hands

and feet ( acrocyanosis) is a common finding in the

newborn and <loes not indicate poor oxygenation

(Figure 3.11). Low oxygen saturation causing the

baby,s lips, tongue, and torso to appear blue is

called central cyanosis. Healthy babies may have

central cyanosis for several minutes after birth.

Studies have shown that visual assessment of

cyanosis is not a reliable indicator of the baby,s

Figure 3. 11. This baby has cyanosis of the hands and

feet (acrocyanosis), but the trunk and mucous membranes

are pink. Acrocyanosis is normal. Supplemental oxygen

is only needed if oxygen saturation is below the target

range.

oxygen saturation and should not be used to guide oxygen therapy.

If persistent central cyanosis is suspected, a pulse oximeter placed on

the right hand or wrist should be used to assess the baby's oxygenation.

What is a pulse oximeter?

Oxygen is carried by the hemoglobin inside red blood cells.

Hemoglobin that is carrying oxygen absorbs red light differently than

hemoglobin that is not carrying oxygen. A pulse oximeter uses a light

source and sensor to measure the absorption of

red light passing through capillaries in the skin

and estimates the percentage of hemoglobin that

is carrying oxygen (Figure 3.12). The 1nonitor

displays the oxygen saturation, which ranges

from 0% to 100%. This number is not the same

as the partial pressure of oxygen (Po2) measured

by a blood gas machine. The pulse oximeter also

displays the baby's heart rate by sensing pulsatile

blood flow in the capillaries.

Figure 3. 1 2. Pulse oximeter with sensor attached to a

baby's right hand on the hypothenar eminence

When is pulse oximetry used in the delivery

room?

lndications for Pulse Oximetry

Use pulse oximetry to guide your treatment when

resuscitation is anticipated, to confirm your

perception of persistent central cyanosis, if you

give supplemental oxygen, or if PPV is required.

• When resuscitation is anticipated

• To confirm your perception of persistent central

cyanos1s

• When supplemental oxygen is administered Where and how should the pulse oximeter

sensor be placed? • When PPV is required

In most babies, the artery supplying the baby's right arm branches from

the aorta before the patent ductus arteriosus enters the aorta. Blood

in the right arm is often called "pre-ductal" and has a similar oxygen

saturation as the blood perfusing the heart and brain. The origin of

blood flow to the left arm is less predictable. The arteries supplying

both legs branch from the aorta after the patent ductus arteriosus and

are called "post-ductal:'

• To measure the oxygen saturation of the pre-ductal blood that is

perfusing the heart and brain, place the pulse oximeter sensor on the

baby's right hand or wrist.

• The left arm and both legs may have lower oxygen saturation. They

may receive blood from the aorta that has been mixed with poorly

oxygenated venous blood that bypassed the lungs through the patent

ductus arteriosus (post-ductal).

Proper placement of the sensor is importan t. Once the sensor is

attached to the baby, watch the monitor to ensure that it is detecting

a pulse with each heartbeat. Most instruments will not display a

saturation reading until a consistent pulse is detected. If you are

monitoring the heart rate with a cardiac monitor, the heart rate

displayed on the pulse oximeter should be the same as the heart rate on

the cardiac monitor.

• The sensor must be oriented correctly so that it can detect the

transmitted red light. After placement, it may be helpful to cover the

sensor to shield it from light in the room. If the pulse oximeter is not

detecting a consistent pulse, you may need to adjust the sensor to be

sure that it is positioned opposite the light source.

• With good technique, a pulse oximeter will accurately display

the heart rate and oxygen saturation within approximately 1 to

2 minutes of birth.

• If the baby has a very low heart rate or poor

perfusion, the pulse oximeter may not be able to

detect the pulse or oxygen saturation.

What is the target oxygen saturation?

Healthy newborns undergoing normal transition

usually take several minutes to increase their blood

oxygen saturation from approximately 60%, which

is the normal intrauterine state, to more than

·-0 -

-111

e CII

e ,

100

90%, which is the eventual state of air-breathing

healthy newborns. Figure 3.13 shows the time

course of oxygen saturation changes after birth in

healthy, full-term newborns breathing room air

.__. ......... _..._.__.__.__..__....__ ................... _..._.__._ .....

(21 % oxygen). Oxygen saturation values following

cesarean birth are slightly lower than those

following vaginal birth.

When the pulse oximeter has a reliable signal,

compare the baby's pre-ductal oxygen saturation

with the range of target values in Table 3-1. These

values are based on oxygen saturations obtained

from healthy, term babies breathing room air

during the first 10 minutes of life. The ideal oxygen

saturation after birth has not been established and

there is ongoing controversy about which targets

should be used. These targets have been selected to

represent a consensus of acceptable values that can

be easily remembered.

O 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Minutes From Birth

Figure 3. 1 3. Pre-ductal oxygen saturation changes

following birth (median and interquartile range). (From

Mariani G, Dik PB, Ezquer A, et al. Pre-ductal and

post-ductal 0 2 saturation in healthy term neonates after

birth. J Pediatr. 2007; 150[4]:418-421.)

Table 3-1 • Target Pre-Ductal Oxygen Saturation

Target Oxygen Saturation Table

• m1n 60%-65%

2 min 65%-70%

3 min 70%-75%

4 min 75%-80%

5 min 80%-85%

l O min 85%-95%

Fi g ure 3.14. Free-flow oxygen given to a spontaneously

breathing baby by holding oxygen tubing close to the

baby's mouth and nose

(I)

When and how do you administer

supplemental oxygen?

Use supplemental free-flow oxygen when the pulse

oximeter reading remains below the target range

for the baby's age. Free-flow oxygen can be given

to a spontaneously breathing baby by holding

oxygen tubing close to the baby's mouth and nose

(Figure 3.14). Free-flow oxygen is not effective if

the baby is not breathing.

You may also use one of the positive-pressure

delivery devices described in Lesson 4 (Figure 3.15).

• If you are using a flow-inflating bag or T-piece

resuscitator, hold the mask close to the face but

not so tight that you make a seal and pressure

builds up within the mask.

Fi g u re 3.1 S. Free-flow oxygen given by (A) a flow-inflating bag, (B) a T-piece resuscitator, and (C) the tail of a

self-inflating bag with an open reservoir.

Note: For free-flow oxygen, the mask of a flow-inflating bag and T-piece resuscitator is NOT held tightly against the face.

• If a flow-inflating bag is used, the bag should not

ínflate when used to provide free-flow oxygen.

- An inflated bag indicates that the mask is

tight against the face and unintended positive

pressure is being delivered.

• If a T-piece resuscitator is being used, do not

occlude the opening on the T-piece cap.

- During free-flow oxygen administration, the

T-piece pressure manometer should read

(( " zero.

• Do not attempt to administer free-flow

oxygen through the mask of a self-inflating

bag (Figure 3.16) because gas <loes not reliably

flow through the mask unless the bag is being

squeezed.

- Free-flow oxygen may be administered

through the open reservoir (tail) on sorne

self-inflating bags. If your hospital has

self-inflating bags with closed reservoirs,

you will need separate oxygen tubing to

administer free-flow oxygen (Figure 3.14).

How is the concentration of supplemental

oxygen ad¡usted?

If supplemental oxygen is necessary, it is reasonable

to start with 30%. Then, guided by pulse oximetry,

adjust the F102 to maintain the baby's oxygen

saturation within the target range described in

Table 3-1. The goal is to prevent low oxygen

saturations without exposing the newborn to the

potential risk of additional, unnecessary oxygen.

Adjust the concentration and flow of supplemental

oxygen using compressed air and oxygen, a blender,

anda flowmeter (Figure 3.17).

Compressed air and oxygen

Compressed gases may be built into the wall or

obtained from portable tanks. Medical air (21 %

oxygen) is supplied from high-pressure hoses

that are color coded yellow, and 100% oxygen is

supplied from high-pressure hoses that are color

coded green.

Fi g u re 3.16. Do not attempt to give free-flow oxygen

using the mask of a self-inflating bag.

Flowmeters

•

oxygen--

-a,ender

•

Fi g

u re 3.17. Adjust the concentration and flow of

oxygen with compressed air (inflow from yellow hose),

compressed oxygen (inflow from green hose), an oxygen

blender, and a flowmeter. The image shows 2 flowmeters

attached to the oxygen blender. Your system may only

hove 1 flowmeter.

Oxy gen blender and flowmeter

The compressed gases are connected to a blender, which has a dial

that adjusts the gas mixture (21 %-100%). The blended gas travels

to an adjustable flowmeter. The flowmeter commonly has a floating

hall within a glass tube that indicates the rate of gas flow leaving the

device. Depending on the size of the flowmeter, you can adjust the dial

to achieve gas flows between O L/min and 20 L/min. The blended gas,

adjusted to the desired concentration and flow rate, is directed through

tubing to the oxygen delivery device.

• For free-flow supplemental oxygen, adjust the flowmeter to

10 L/min.

• Begin free-flow oxygen supplementation with the blender set to

30% oxygen. Using the blender, adjust the F102 as needed to achieve

the oxygen saturation target.

lf an oxygen blender is not available

If supplemental free-flow oxygen is necessary andan oxygen blender

is not available, such as when resuscitation occurs outside the delivery

room, free-flow oxygen may be delivered by using 100% oxygen from

your wall or portable oxygen source. As described previously, direct the

flow of oxygen toward the baby's mouth and nose using oxygen tubing,

a mask, or appropriate PPV device. As oxygen flows out of the tubing

or mask, it mixes with air. The concentration of oxygen that reaches

the baby's nose is determined by the amount of 100% oxygen coming

from the tubing or mask and the amount of air it must pass through to

reach the baby. The closer the tubing or mask is to the face, the higher

the concentration of oxygen breathed by the baby. Guided by pulse

oximetry, adjust the F102 by moving the tubing or mask closer to or

farther from the baby's face.

lf the baby continues to require supplemental oxygen af ter

the first few minutes, how should it be given?

Attempt to gradually decrease the F102 until the newborn can maintain

saturation within the target range without supplemental oxygen.

If respirations and heart rate are stable but the newborn continues

to require supplemental oxygen, use pulse oximetry to guide the

appropriate F102•

• Oxygen administered directly from a compressed source is cold and

dry.

• To prevent heat loss, oxygen given to newborns for a prolonged

period of time should be heated and humidified.

What do you do if the baby has labored breathing or

persistently low oxygen saturation?

If the baby has labored breathing, or the oxygen saturation cannot

be maintained within the target range despite 100% oxygen, you may

considera trial of continuous positive airway pressure (CPAP) or PPV.

CPAP is a method of respiratory support that uses a continuous low

gas pressure to keep a spontaneously breathing baby's lungs open.

CPAP may be helpful if the airway is open, but the baby has signs of

labored breathing or persistently low oxygen saturations. CPAP should

only be considered in the delivery room if the baby is breathing and the

baby's heart rate is at least 100 bpm.

• Administering CPAP may increase the chance of developing a

pneumothorax ( air leak).

• Providers should be aware of this potential complication and

prepared to address it.

If desired, a trial of CPAP in the delivery room can be given by using

a flow-inflating bag ora T-piece resuscitator attached to a mask

that is held tightly to the baby's face (Figure 3.18). CPAP cannot

be given using a self-inflating bag. The equipment and method for

administering CPAP are described in more detall in Lesson 4.

Fi g u re 3.1 8. Administering CPAP using (A) a flow-inflating bag or (B) a T-piece resuscitator. The baby must hove

spontaneous breathing and a heart rote greater than 100 bpm.

Note: For CPAP, the mask is held tightly against the face to create a seal.

Does the presence of meconium-stained amniotic fluid change

who should attend the birth or how the initial steps are

performed?

The presence of meconium-stained amniotic fluid may indicate fetal

distress and increases the risk that the baby will require resuscitation

after birth. At least 2 qualified people who can initiate resuscitation

should be present at the time of birth solely to manage the baby. An

individual with intubation sl(ills should be identified and immediately

available.

If additional risk factors indicate that an extensive resuscitation is

likely, a qualified team with full resuscitation skills should be present

at the time of birth.

Meconium-stained fluid and a vigorous newborn

If the baby is vigorous with good respiratory effort and muscle tone,

the baby may stay with the mother to receive the initial steps of

newborn care.

Meconium-stained fluid and a non-vigorous newborn

If a baby is born through meconium-stained amniotic fluid and has

depressed respirations or poor muscle tone, bring the baby to the

radiant warmer and perform the initial steps of newborn care as

described in this lesson. You will use a bulb syringe to clear secretions

from the mouth and nose. If the baby is not breathing or if the baby is

breathing and the heart rate is less than 100 bpm after the initial steps

are completed, proceed with PPV.

Routine laryngoscopy with or without intubation for tracheal

suction is not suggested. Historically, routine intubation and suction

immediately after birth was recommended in an effort to reduce the

chance of developing meconium aspiration syndrome; however, a

recent systematic review found no evidence to support this practice.

Intubation and tracheal suction may be necessary if PPV <loes not

ínflate the lungs and airway obstruction is suspected.

Focus on Teamwork

The initial steps of resuscitation highlight several opportunities for

effective teams to use the Neonatal Resuscitation Program® (NRP

) Key

Behavioral Skills.

Behavior Example

Anticípate and plan. Ensure that you have enough personnel present at the time of delivery based on the

identified risk factors.

Communicate effectively. lmmediately after birth, the obstetric and neonatal care teams need to share their

Use available information. assessment of the newborn. Subsequent interventions will be based on this assessment.

The care teams need to communicate their findings clearly and efficiently.

Know your environment. Know how the pulse oximeter, compressed air and oxygen source, oxygen blender, and

flowmeters work in your practice setting.

Know what device is available to administer CPAP in your hospital.

Know how to obtain a cardiac monitor if needed.

Use available resources. lf you cannot auscultate a heart rate and the baby is not vigorous, quickly place a pulse

oximeter sensor or cardiac monitor leads and attach them to the appropriate monitor.

Call for additional help After the initial steps, if you identify apnea, gasping, ora heart rate less than 100 bpm

when needed. and you are alone, call for additional help. Positive-pressure ventilation is required

and you will need additional personnel.

Quality lmprovement Opportunities

Ask yourself the following questions and begin a discussion with your

team if you find a difference between the NRP recommendations and

what is currently done in your own hospital setting. Consider using the

suggested process and outcome measures to guide your data collection,

identify areas for improvement, and monitor if your improvement

efforts are working.

Quality improvement questions

O Are vigorous newborns placed skin-to-skin with their mother?

8 How are the findings of the baby's initial assessment

communicated between the obstetric and pediatric providers?

8 Do vigorous newborns routinely have their mouth and nose

suctioned?

Process and outcome measures

O What percentage of vigorous newborns have umbilical cord

clamping delayed at least 30 to 60 seconds?

f) What percentage of newborns are crying or breathing after drying

and stimulation?

E) What percentage of newborns with meconium-stained fluid still

undergo laryngoscopy and tracheal suction?

Frequently Asked Questions

After birth, do all babies need to have their mouth and nose suctioned

with a bulb syringe?

No. Vigorous newborns that are breathing or crying and have good

tone do not need to have their mouth and nose suctioned. If necessary,

the upper airway can be cleared by wiping the baby's mouth and

nose with a cloth. Gentle suction should be reserved for babies with

difficulty clearing their secretions, babies with secretions obstructing

their airway, and those who are not breathing or crying, have poor

tone, or require PPV.

Does it matter if the pulse oximeter sensor is attached to the baby's hand

or wrist?

For a small baby, sorne health care providers find it easier to secure the

sensor to the baby's wrist; however, sorne manufacturers recommend

placing the pulse oximeter sensor only on the baby's hand. There

is evidence that an accurate reading can be obtained using a sensor

placed on the baby's wrist. In the studies that established the normal

progression of oxygen saturation in healthy newborns, the pulse

oximeter sensor was placed on the baby's wrist. Placement on either the

hand or wrist is acceptable as long as the transmitted light is detected

by the sensor and a reliable signal is obtained.

Previously, the Neonatal Resuscitation Program recommended routine

endotracheal intubation and suction for non-vigorous babies born

through meconium-stained amniotic fluid. Why is this no longer

recommended? Does this change who should attend the birth of the baby

with meconium-stained amniotic fluid?

Prior to each edition of the Textbook of Neonatal Resuscitation,

questions are identified by the International Liaison Committee on

Resuscitation (ILCOR) Neonatal Task Force. The scientific evidence is

reviewed using a systematic approach and treatment recommendations

are developed using a method that evaluates the strength of the

supporting evidence (GRADE). Before the Textbook of Neonatal

Resuscitation, 7

th edition (2016), the NRP recommendation for tracheal

suction was based on small observational studies that did not use

currently accepted research methods for comparing treatments. As a

result, the conclusions from those studies are subject to bias and the

strength of evidence is considered very weak.

Recently, several small randomized trials enrolling non-vigorous

newborns have been published that do not show benefit to tracheal

suction. Both the 2015 and 2019 ILCOR reviews determined that the

existing evidence did not support routine tracheal suction. A large,

properly randomized trial is still needed.

The NRP Steering Committee's values include avoiding invasive

procedures without good evidence of benefit for important outcomes.

As a result, the NRP Steering Committee <loes not currently

suggest routine laryngoscopy with or without tracheal suction for

non-vigorous babies delivered through meconium-stained fluid. If

additional evidence becomes available, the ILCOR Neonatal Task Force

and NRP Steering Committee will reevaluate this recommendation.

The presence of meconium-stained fluid is still considered a perinatal

risk factor that increases the likelihood that the newborn will require

resuscitation. At least 2 qualified people who can initiate resuscitation

should be present at the time of birth solely to manage the baby. An

individual with intubation skills should be identified and immediately

available. If additional risk factors indicate that an extensive

resuscitation is likely, a qualified team with full resuscitation skills

should be present at the time of birth.

LESSON 3 REVIEW

1. List the 3 rapid evaluation questions that determine which

newborns should be brought to the radiant warmer for the

initial steps.

2. List the 5 initial steps of newborn care.

3. You count a newborn's heartbeat for 6 seconds and count

6 beats. You report the heart rateas (36 beats per minute)/

(60 beats per minute).

4. Oxygen saturation should be 85% to 95% by (2 minutes of age)/

( 1 O minutes of age).

5. Which image shows the correct way to position a baby's head to

open the airway (A, B, or C)?

6. You have provided warmth, dried, stimulated, positioned the

head and neck, and cleared the airway of secretions. It is now

60 seconds after birth, and the baby is still apneic and limp.

What is your next action?

7. If a baby is breathing, the heart rate is greater than 100 beats

per minute, the airway is clear and correctly positioned, but the

respirations are labored, you may consider ( deep pharyngeal

suction)/continuous positive airway pressure [CPAP]).

Answers

l. Is the baby term? Does the baby have good tone? Is the baby

breathing or crying?

2. Provide warmth, dry, stimulate, position the head and neck,

clear secretions from the airway if necessary.

3. You report the heart rate as 60 beats per minute.

4. Oxygen saturation should be 85% to 95% by 10 minutes of age.

5. Image B shows the correct way to position a newborn's head to

open the airway.

6. Your next action is to start positive-pressure ventilation. Call for

help if you are alone.

7. You may consider continuous positive airway pressure (CPAP).

LESSON 3: PRACTICE SCENARIOS

lnitial Steps of Newborn Care

Learning Ob¡ectives

O Identify the newborn who requires initial steps of resuscitation at

the radiant warmer.

f) Demonstrate correct technique for performing initial steps when

the newborn stays with the mother and when the newborn is

received at the radiant warmer.

E) Demonstrate accuracy when assessing a newborn heart rate with a

stethoscope.

C, Demonstrate correct placement of the pulse oximeter sensor,

interpretation of pulse oximetry, and administration of

supplemental free-flow oxygen.

These Practice Scenarios are for review/practice and evaluation.

This is the suggested Practice Scenario sequence.

O Review the Knowledge Check Questions with your Neonatal

Resuscitation Program (NRP) instructor.

a. What are the 3 rapid evaluation questions? How do the answers

to those questions determine whether a newborn may stay with

the mother or come to the radiant warmer?

b. Which newborns receive the initial steps? What are the 5 initial

steps of newborn care?

c. When do you start the Apgar timer?

d. How do you assess a newborn's heart rate? What will you do if

the baby is not vigorous and you cannot hear the heart rate with

the stethoscope?

e. Why do you use pulse oximetry and when is it indicated?

f. What concentration of oxygen is used to initiate free-flow

oxygen?

g. What is CPAP and when is ita consideration in the delivery

room?

8 Practice/review these skills with your NRP instructor.

a. Perform initial steps of care for a baby who stays with the

mother.

b. Perform initial steps of care for a baby on the radiant warmer,

including proper use of the bulb syringe.

c. Assess heart rate using a stethoscope.

d. Apply a pulse oximeter sensor and practice using the Target

Oxygen Saturation Table to administer and wean free-flow

oxygen.

E) Practice the scenarios applicable to your role with your NRP

instructor until you need little or no assistance or coaching.

9 Pass the Lesson 3 Practice Scenario evaluation by leading practice

scenario(s) and performing the skills relevant to your role and

responsibilities. If a technical skill included in this scenario is not

within your scope of responsibility, delegate the skill to a qualified

team member and perform the role of assistant if appropriate. When

you can lead the scenario( s) and perform the skills with little or no

instructor coaching, proceed to the next lesson's practice scenario.

Practice Scenarios

Four scenario options are offered. Use the same scenario introduction

for each scenario; the answers to the 4 pre-birth questions are different

for each scenario. The number of people attending the birth and their

qualifications are determined by the instructor and based on hospital

policy.

O Vigorous term newborn who may stay with the mother for initial

steps

8 Vigorous term newborn with meconium-stained fluid and

persistent cyanosis (this scenario is designed for a 2-person team)

E) Term newborn requires initial steps at radiant warmer, returned to

mother for skin-to-skin care

9 Late preterm newborn with clear fluid, requires initial steps at

radiant warmer, remains apneic

"You are called to attend a vaginal birth. The mother is in active labor

with ruptured membranes. How would yo u prepare far the birth of this

baby and perform the initial steps of newborn care? As you work, say

your thoughts and actions aloud so I will know what you are thinking

and doing."

Option 1 : Vigorous term newborn may stay with the mother for initial steps

Critical Performance Steps

Assess perinatal risk.

Assesses perinatal risk (learner asks the 4 pre-birth questions and instructor ["OB provider"] responds)

Gestational age? "39 weeks' gestation."

Clear fluid? "Amniotic fluid is clear."

Additional risk factors? "There are no additional risk factors."

Umbilical cord management plan? "I will delay cord clamping. lf the baby is not crying, 1'11 take a moment to

stimulate the baby. lf there's no response, 1'11 clamp and cut the cord."

Assemble team.

Assembles team based on perinatal risk factors.

When the likelihood of resuscitation is low, 1 qualified individual should attend the birth.

lf the birth will be attended by 1 person,

Knows the answers to the 4 pre-birth questions, determines supplies and equipment needed, knows how to call

for help

Perform equipment check.

"The baby has been born."

Rapid evaluation.

Asks 3 rapid evaluation questions:

• Term? "Yes."

• Muscle tone? "Yes."

• Breathing or crying? "Yes, the baby is crying."

Newborn stays with mother for initial steps.

lnitial steps.

Places baby skin-to-skin with mother, dries baby and stimulates if needed, positions head and neck. Covers with

warm blanket.

End scenario.

Continues ongoing evaluation of breathing, heart rote, tone, activity, color, and temperature

Option 2: Vigorous term newborn with meconium-stained fluid and persistent cyanosis

1 Critical Performance Steps 1

Assess perinatal risk.

Assesses perinatal risk (learner asks the 4 pre-birth questions and instructor ["OB provider"] responds)

Gestational age? "41 weeks' gestation."

Clear fluid? "The fluid is meconium-stained."

Additional risk factors? "None besides meconium-stained amniotic fluid."

Umbilical cord management plan? "I will delay cord clamping. lf the baby is not crying, 1'11 take a moment to

stimulate the baby. lf there's no response, 1'11 clamp and cut the cord."

Assemble team.

Assembles team based on perinatal risk factors.

• When meconium-stained fluid is the only risk factor, at least 2 qualified people who can initiate resuscitation

should be present at the birth solely to manage the baby. An individual with intubation skills should be

identified and immediately available.

• A fully qualified resuscitation team should be present at the time of birth if additional risk factors suggest that

advanced resuscitation measures may be required.

Perform a pre-resuscitation team briefing.

ldentifies team leader.

Assesses risk factors, delegates tasks, identifies who will document events as they occur (if necessary), determines

supplies and equipment needed, knows how to call for additional help.

Perform equipment check.

"The baby has been born."

Rapid evaluation.

Asks 3 rapid evaluation questions:

• Term? "Yes."

• Muscle tone? ' es."

• Breathing or crying? "Yes."

Newborn may stay with mother for initial steps.

lnitial steps.

Places baby skin-to-skin with mother, dries baby, stimulates as needed, positions head and neck, clears secretions

if needed. Monitors breathing, tone, activity, color, and temperature to determine if additional interventions are

required.

"The newborn is 4 minutes old and remarkably cyanotic."

Checks breathing. "The baby is breathing, with no distress."

Auscultates heart rate accurately. Heart rote per auscultation = 140 bpm

Applies pulse oximeter sensor to right hand/wrist. SP02=68%

Administer free-flow oxygen.

Adjusts blender to 30% and administers free-flow oxygen using correct technique.

Monitors oxygen saturation and adjusts blender appropriately per pulse oximetry to maintain oxygen saturation

within target range. May attempt to wean supplemental oxygen. Monitors oxygen saturation with pulse

oximetry until vital signs are stable and oxygen saturation is stable within target range.

Monitors breathing, heart rate, tone, activity, color, and temperature.

Communicates with neonatal team per hospital protocol to discuss next steps.

Updates perinatal team.

Updates parents and communicates next steps, including the plan for post-resuscitation care.

End scenario.

Option 3: Term newborn requires initial steps at radiant warmer, returned to mother for skin-to-skin care

Critical Performance Steps

Preparation for resuscitation.

Assesses perinatal risk (learner asks the 4 pre-birth questions and instructor ["OB provider"] responds)

• Gestational age? "Term."

• Clear fluid? "Amniotic fluid is clear."

• Additional risk factors? "Repeated fetal heart rate decelerations have been noted in the last 15

minutes.11

Umbilical cord management plan? "I will delay cord clamping. lf the baby is not crying, 1

111 take a moment to

stimulate the baby. lf there1

s no response, 1

111 clamp and cut the cord.

Assemble team.

Assembles team based on perinatal risk factors.

At least 2 qualified people should be present solely to manage the baby because risk factors are present.

The number of team members and qualifications vary depending on risk.

Perform a pre-resuscitation briefing.

ldentifies team leader.

Assesses risk factors, delegates tasks, identifies who will document events, determines supplies and equipment

needed, knows how to call for additional help.

Perform equipment check.

Rapid evaluation.

Asks 3 rapid evaluation questions:

• Term?

• Muscle tone?

• Breathing or crying?

lnitial steps.

Receives baby at radiant warmer.

"Yes.11

"No. 11

11The baby has been born.

Dries with towel or blanket, removes wet linen.

Stimulates by rubbing back and/or extremities.

Positions airway.

Suctions mouth and nose if still apneic.

Check breathing. lf breathing, check heart rate.

Assesses breathing "The baby is crying."

Auscultates heart rote accurately Heart rate = 120 bpm

End scenario.

Wraps baby in blanket, returns baby to the mother, and places baby skin-to-skin with the mother.

Monitors breathing, tone, activity, color, and temperature to determine if additional interventions are required.

Option 4: Late preterm newborn with clear fluid, requires initial steps at warmer, remains apneic

1 Critical Performance Steps 1

Assess perinatal risk.

Assesses perinatal risk (learner asks the 4 pre-birth questions and instructor ["OB provider"] responds)

• Gestational age? "36 weeks' gestation."

• Clear fluid? "Amniotic fluid is clear."

• Additional risk factors? "The mother has a fever."

Umbilical cord management plan? "I will delay cord clamping. lf the baby is not crying, 1'11 take a moment to

stimulate the baby. lf there's no response, 1'11 clamp and cut the cord."

Assemble team.

Assembles team based on perinatal risk factors.

At least 2 qualified people should be present solely to manage the baby because risk factors are present. The

number of team members and qualifications vary depending on risk.

Perform a pre-resuscitation briefing.

ldentifies team leader.

Assesses risk factors, delegate tasks, identifies who will document events as they occur (if necessary), determines

supplies and equipment needed, knows how to call for additional help.

Perform equipment check.

"The baby has been born."

Rapid evaluation.

Asks 3 rapid evaluation questions:

• Term? "No, appears 36 weeks' gestation as expected."

• Muscle tone? "No."

• Breathing or crying? "No."

lnitial steps.

Receives baby at radiant warmer.

Dries with towel or blanket, removes wet linen.

Stimulates by rubbing back and/or extremities.

Positions airway.

Suctions mouth and nose.

Check breathing. Also check heart rote if breathing.

• Breathing? "No, baby is apneic." (Heart rote= 70 bpm, if assessed)

• lndicates need for PPV

• lndicates the standardized method to call for additional help

End scenario.

Sample Debriefing Questions

O What factors determined the decisions for who would attend the

births described in these scenarios?

f) How <lid you know if the newborn required

a. Initial steps at the radiant warmer?

b. Pulse oximetry?

c. Supplemental oxygen?

E) What would you do differently when preparing for resuscitation or

performing initial steps in our next scenario?

O State an example of how you used at least one of the NRP Key

Behavioral Skills.

NRP Key Behavioral Skills

• Know your environment.

• Use available information.

• Anticípate and plan.

• Clearly identify a team leader.

• Communicate effectively.

• Delegate the workload optimally.

• Allocate attention wisely.

• Use available resources.

• Call for additional help when needed.

• Maintain professional behavior.

Positive-Pressure Venti ation

What you will learn

The characteristics of self-inflating bags, flow-inflating

bags, and T-piece resuscitators

When to give positive-pressure ventilation

How to position the newborn's head for positive-pressure

ventilation

■ How to place a resuscitation mask on the newborn's face

■ How to administer positive-pressure ventilation and assess

effectiveness

■ How to use ventilation corrective steps

■ How to insert a laryngeal mask for positive-pressure

ventilation

■ How to administer continuous positive airway pressure

■ How to insert an orogastric tube

r '

Antenatal counseling.

Team briefing.

\ .

Equipment check.

Birth

' ,

Term gestatian? Yes

Stay with mother for initial steps, Gaadtane? -

routine care, ongoing evaluation. Breathing ar crying? '" ,

Q) ' ,

e: , Warm, dry, stimulate, position ·-

airway, suction if needed.

, -

\ . ,

' ,

Apnea ar gasping? No Labared breathing ar

HR <100 bpm? , persistent cyanasis?

Yes

' , '

r ' ,

PPV. Position airway, suction if needed.

Pulse oximeter. Pulse oximeter.

Consider cardiac monitor. Oxygen if needed.

\ . , Consider CPAP.

'" ,

' ,

- HR <100 bpm? No

Yes

' , ' , '

, ,

Ensure adequate ventilation. Post-resuscitation care.

Consider ETT or laryngeal mask. Team debriefing.

Cardiac monitor.

'" ,

\ .

' ,

HR <60 bpm?

Target Oxygen Saturation Table

Yes

1 min 60%-65%

' ,

r '

ETT or laryngeal mask.

2 min 65%-70%

Chest compressions. 3 min 70%-75%

Coordinate with PPV-100% oxygen.

uve. 4 min 75%-80

\ . /o

' , 5 min 80%-85%

No HR<60 bpm?

10 min 85%-95

Yes

lnitial oxygen concentration for PPV r '

IV epinephrine every 3-5 minutes.

lf HR remains < 60 bpm, • 35 weeks' GA 21% oxygen

• Consider hypovolemia.

\ .

• Consider pneumothorax.

< 35 weeks' GA 21%-30

/o oxygen

Key Points

O Ventilation of the newborn's lungs is the single most important and

most effective step in neonatal resuscitation.

f) After completing the initial steps, positive-pressure ventilation

(PPV) is indicated if the baby is not breathing, OR if the baby

is gasping, OR if the baby's heart rate is less than 100 beats per

minute (bpm).

E) During PPV, the initial oxygen concentration (Fro2) for newborns

greater than or equal to 35 weeks' gestation is 21 %. The initial Fro2

for preterm newborns less than 35 weeks' gestation is 21 % to 30%.

9 The ventilation rate is 40 to 60 breaths per minute and the initial

ventilation pressure is 20 to 25 cm H20 .

0 The most important indicator of successful PPV is a rising heart rate.

O If the heart rate is not increasing within the first 15 seconds of

PPV and you do not observe chest movement, start the ventilation

corrective steps.

O The ventilation corrective steps (MR. SOPA) are:

a. Mask adjustment.

b. Reposition the head and neck.

c. Suction the mouth and nose.

d. Open the mouth.

e. Pressure increase.

f. Alternative airway.

0 If the baby cannot be successfully ventilated with a face mask and

intubation is unfeasible or unsuccessful, a laryngeal mask may

provide a successful rescue airway.

f) If the heart rate remains less than 60 bpm despite at least

30 seconds of face-mask PPV that inflates the lungs ( chest

movement), reassess your ventilation technique, consider

performing the ventilation corrective steps, adjust the Fro2

as indicated by pulse oximetry, insert an alternative airway

( endotracheal tube or laryngeal mask), and provide 30 seconds of

PPV through the alternative airway. After these steps, if the heart

rate remains less than 60 bpm, increase the F102 to 100% and begin

chest compressions.

4D) If you continue face-mask PPV or continuous positive airway

pressure (CPAP) for more than several minutes, an orogastric tube

should be inserted to act as a vent for gas in the stomach.

Case: Resuscitation with positive-pressure ventilation using

a resuscitation bag and mask

Your team is called to attend the birth for a woman at 36 weeks'

gestation whose pregnancy and labor are complicated by preeclampsia,

intrauterine growth restriction, and a Category II fetal heart rate

pattern. The amniotic fluid is clear. You complete a pre-resuscitation

team briefing and prepare your supplies and equipment. After birth,

the obstetrician dries and stimulates the baby, but the baby remains

limp and apneic. The umbilical cord is clamped and cut, and the baby

is moved to the radiant warmer.

You finish drying the baby, provide brief additional stimulation, and

position and clear secretions from the airway, but the baby is still

not breathing. Within 1 minute of birth, you start positive-pressure

ventilation (PPV) with 21 % oxygen (room air). An assistant reports

that the baby's heart rate is 70 beats per minute (bpm), not increasing,

and the chest is not moving. Another team member places a pulse

oximeter sensor on the baby's right hand, places cardiac monitor leads

on the baby's chest, and attaches the sensor and leads to the monitors.

Another team member documents the events as they occur.

You initiate the ventilation corrective steps. First, you reapply the

mask to the face and reposition the baby's head and neck. You restart

PPV while your assistant watches the newborn's chest. After several

breaths, the assistant reports that there is still no chest movement. You

suction the mouth and nose and open the baby's mouth. Again, you

start PPV, but there is still no chest movement. You gradually increase

the inflation pressure and the assistant calls out, "The chest is moving

now :' Within 30 seconds of achieving ventilation that inflates the

baby's lungs, the baby's heart rate is greater than 100 bpm and oxygen

saturation is 64%. The assistant adjusts the oxygen concentration

(F102

) to maintain the baby's oxygen saturation within the target

range.

You continue PPV while monitoring the baby's respiratory effort.

The baby begins to breathe, and you gradually decrease the

ventilation rate. When the baby is 4 minutes of age, there is good

spontaneous breathing effort, the heart rate is 140 bpm, and oxygen

saturation is 85%. You discontinue PPV and monitor the baby's

oxygen saturation. While your team prepares to move the baby to

the nursery for post-resuscitation care, you explain the next steps

to the mother. Shortly afterward, you meet with your team and

conduct a debriefing to evaluate your preparation, teamwork, and

communication.

Why does the Neonatal Resuscitation Program® focus on

positive-pressure ventilation?

Ventilation of the newborn's lungs is the single most important and

effective step in neonatal resuscitation. Learning how to provide PPV

is the foundation of neonatal resuscitation. This lesson focuses on

assisted ventilation through a face mask and laryngeal mask. The next

lesson describes how to provide ventilation through an endotracheal

tube.

What is the common terminology used to describe

positive-pressure ventilation?

Several terms and abbreviations are used to describe PPV (Figure 4.1).

• Peak inflation pressure (PIP): The highest pressure administered

with each breath

• Positive end-expiratory pressure (PEEP): The gas pressure maintained

in the lungs between breaths when the baby is receiving assisted

breaths

• Continuous positive airway pressure (CPAP): The gas pressure

maintained in the lungs between breaths when a baby is breathing

spontaneously

• Rate: The number of assisted breaths administered per minute

• Inflation time (IT): The time duration (seconds) of the inflation

phase of each positive-pressure breath

• Manometer: A gauge used to measure gas pressure

- 20

E 15

::::s 1 O "' "'

CII

0.. s

PEEP

PIP

' , • ►

Time (sec)-

Figure 4. 1. Pressure tracing during 3 positive-pressure

breaths. PIP = peak inflation pressure, PEEP = positive

end-expiratory pressure, IT = inflation time.

Fi g u re 4.2. Self-inflating bag

Fi g u re 4.3. Flow-inflating bag

Fi g u r e 4.4. T-piece resuscitator

What are the dif f erent types

of resuscitation devices used to

ventilate newborns?

Three types of devices are commonly used

for ventilation.

O A self-inflating bag fills spontaneously

with gas ( air, oxygen, or a blend of

both) after it has been squeezed and

released (Figure 4.2).

f) A flow-inflating bag ( also called an

anesthesia bag) only fills when gas

from a compressed source flows into

it and the outlet is sealed (Figure 4.3).

Q A T-piece resuscitator continuously

directs compressed gas toward the

baby. Pressure increases when an

opening on the top of the T-shaped

device is occluded (Figure 4.4).

Find out what kind of resuscitation device

is used in your hospital. If your hospital

uses flow-inflating bags or T-piece

resuscitators, you should still learn how

to use a self-inflating bag. A self-inflating

bag should be readily available as a

backup wherever resuscitation may

be needed in case compressed gas is

not available. The 3 devices are briefly

described in the following text. Additional

details are found in the Appendix to this

lesson. You should read those sections of

the Appendix that apply to the devices

used in your hospital.

Self-inflating bags

A self-inflating bag remains fully inflated

unless it is being squeezed (Figure 4.5).

Once you release the bag, it recoils and

draws fresh gas into the bag. If the bag is attached to an oxygen source,

it fills with gas at the supplied F102• If the bag is not attached to an

oxygen source, it fills by drawing room air (21 % oxygen) into the bag.

Because the bag self-inflates, it <loes not require compressed gas ora

tight seal at the outlet to remain inflated.

• The ventilation rate is determined by how often you squeeze the bag

and the inflation time is determined by how quickly you squeeze the

bag.

• PIP is controlled by how hard the bag is squeezed.

• PEEP may be administered if an additional valve is attached to the bag.

• Because gas does not flow out of the mask unless the bag is

being squeezed, a self-inflating bag and mask cannot be used to

administer CPAP or free-flow oxygen.

• Free-flow oxygen may be administered through the open reservoir

("tail") on sorne self-inflating bags.

Most self-inflating bags have a pressure-release val ve, also called a

pop-off valve, which limits the peak pressure. These valves are usually

set to release at 30 to 40 cm H20 pressure, but they are not reliable and

may not release until higher pressures are achieved. Sorne self-inflating

bags have a device that allows the pressure-releas e valve to be

temporarily occluded, allowing higher pressures to be administered.

Occluding the pop-off valve should be an un usual occurrence and care

must be taken not to use excessive pressure.

A B

Fi g u re 4.5. Self-inflating bags with a closed reservoir (A) and an open "tail" reservoir (B). Both bags reinflate

automatically without compressed gas.

To ensure the appropriate pressure is used, a manometer should always

be used. The manometer may be built into the bag or there may be an

attachment site for an externa! manometer. If the attachment site is left

open without a manometer attached, it will cause a large gas leak and

prevent the baby from receiving the desired inflation pressure.

Testing a self-inflating bag during the equipment check and before use

Block the mask or gas outlet with the palm of your hand and squeeze

the bag (Figure 4.6).

Figure 4.6. Testing a self-inflating bag

Testing a self-inflating bag

Block the mask or gas outlet and

squeeze the bag.

• Do you feel pressure against your

hand?

• Does the manometer register

pressure?

• Does the pressure-release valve

open when the manometer registers

30 to 40 cm H20 pressure?

• Does the bag reinflate quickly

when you release your grip?

Flow-inflating bags

lf no,

• Is there a crack or leak in the bag?

• Is the manometer missing, resulting

in an open attachment site?

• Is the pressure-release valve missing

or blocked?

A flow-inflating bag inflates only when a compressed gas source is

flowing into the bag and the outlet is sealed, such as when the mask is

applied to a baby's face (Figure 4.7 A). If compressed gas is not flowing

into the bag or the outlet is not sealed, the bag collapses and looks like

a deflated balloon (Figure 4.7B).

• The ventilation rate is determined by how often you squeeze the bag

and the inflation time is determined by how quickly you squeeze

and release the bag.

• PIP is controlled by how hard the bag is squeezed and the balance

between the amount of gas flowing into the bag and the gas escaping

through an adjustable flow-control valve.

• PEEP, CPAP, and free-flow oxygen can be administered with a

flow-inflating bag and are adjusted by the balance between the gas flow

into the bag and the gas escaping through the flow-control valve.

Similar to a self-inflating bag, a manometer should always be used to

accurately measure the gas pressure. If the manometer attachment site

is left open, it will cause a large leak and prevent the flow-inflating bag

from filling.

ea•

Figure 4.7. Flow-inflating bag inflated with compressed gas anda seal against the baby's face (A). lf compressed

gas is not flowing into the bag or the outlet is not sealed, the bag collapses (B).

Testing a flow-inflating bag during the equipment check and before use

Block the mask or gas outlet with the palm of your hand and squeeze

the bag (Figure 4.8).

Figure 4.8. Testing a flow-inflating bag

Testing a flow-inflating bag

Block the mask or gas outlet.

• Does the bag fill properly?

• Adjust the flow-control valve to

read 5 cm H20 PEEP.

Squeeze the bag 40 to 60 times per

minute.

• Does the bag reinflate quickly

when you release your grip?

• Adjust the flow-control valve to read

30 to 40 cm H20 when squeezed

firmly.

• Check to be sure that the pressure

still reads 5 cm H20 when not

being squeezed (PEEP).

T-piece resuscitators

lf the bag does not fill correctly,

• Is there a crack or hole in the bag?

• Is the flow-control valve open too

far?

• Is the manometer attached?

• Is the gas tubing connected

securely?

• Is the gas outlet sufficiently

blocked?

A T-piece resuscitator is a mechanical device that uses valves to

regulate the flow of compressed gas directed toward the patient

(Figure 4.9). Similar to the flow-inflating bag, the device requires

a compressed gas source. A breath is delivered by using a finger to

alternately occlude and release a gas escape opening on the top of the

T-piece cap. When the opening is occluded, gas is directed through the

device and toward the baby. When the opening is released, sorne gas

escapes through the cap. The position and function of control dials on

the T-piece resuscitator may vary by manufacturer. The operation of

one example is described below.

• The ventilation rate is determined by how often you occlude the

opening on the cap and the inflation time is controlled by how long

the opening is occluded.

• There are 2 control dials that are used to limit the inflation

pressure. The peak inflation pressure control limits the peak

pressure during each assisted breath. The maximum pressure

relief control is a safety feature, similar to the pop-off valve on a

self-inflating bag, which prevents the user from increasing the peak

pressure beyond a preset value. This control dial may be covered by

a removable shield.

• An adjustable dial on the T-piece cap controls how much gas is

allowed to escape between breaths and, therefore, adjusts the PEEP

and CPAP.

• A built-in manometer measures the inflation and expiratory pressure.

.f\l'.DJ

....

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•

..... -

1/Qly

, ..

Fi g u re 4.9. An example of a T-piece resuscitator (A). The T-piece resuscitator's pressure is controlled by

adjustable valves. PIP is adjusted by a dial on the machine (B) and PEEP is controlled by a dial on the T-piece cap (C).

Testing a T-piece resuscitator during the equipment check and before use

Block the mask or gas outlet with the palm of your hand or occluding

cap. First leave the opening on the T-piece cap open, then occlude the

opening with your finger (Figure 4.10).

Testing a T-piece resuscitator

Block the mask or T-piece gas outlet

without occluding the opening on

the T-piece cap.

• Does the PEEP read 5 cm H20 ?

Occlude the opening on the T-piece

cap.

• Does the peak pressure read 20 to

25 cm H20 ?

lf the pressure is not correct,

• Is the T-piece gas outlet sealed?

• Is the gas tubing connected to the

gas inlet?

• Is the gas flow set at 1 O L/min?

• Is the gas outlet (proximal)

disconnected?

• Is the maximum circuit pressure,

PI P, or PE E P i ncorrectly set?

What are the indications for positive-pressure ventilation?

After completing the initial steps, PPV is indicated if the baby is not

breathing ( apneic), OR if the baby is gasping, OR if the baby's heart rate

is less than 100 bpm (Figure 4.11). When indicated, PPV should be

started within 1 minute of birth.

g u r e 4. 1 O. Testing a T-piece

resusc itator

r Antenatal counseling.

Team briefing.

Equipment check.

Birth

Term gestation?

Good tone?

Breathing or crying?

Warm, dry, stimulate, position

" airway, suction if needed.

' •

Apnea or gasping?

HA <100 bpm?

Yes

' ,

PPV.

Pulse oximeter.

Consider cardiac monitor. "

Fi g

ur e 4. 11. lndications for PPV

In addition, a trial of PPV may be considered if the baby is breathing

and the heart rate is greater than or equal to 100 bpm, but the baby's

oxygen saturation cannot be maintained within the target range despite

free-flow oxygen or CPAP.

Immediately call for help if you are alone. Your assistant(s) will

monitor the heart rate response to PPV, watch for chest movement,

monitor the baby's oxygen saturation with pulse oximetry, and

document events as they occur.

How do you prepare to begin positive-pressure ventilation?

Position yourself at the radiant warmer.

The person responsible for positioning the airway and holding the

mask on the baby's face is positioned at the baby's head (Figure 4.12). lt

is difficult to maintain the head, neck, and mask in the correct position

when standing at the side or foot of the bed. Team members at the

side of the bed are better positioned to assess chest movement, listen

to heart rate and breath sounds, and assist with pulse oximeter and

cardiac monitor placement.

Complete the initial steps of newborn care.

If not done already, suction the mouth and nose to be certain that

secretions will not obstruct PPV.

Fi g

u r e 4. 1 2. Position yourself

at the baby's head to provide

assisted ventilation.

Fi g u r e 4.13. The sniffing

position

Position the baby's head and neck for

positive-pressure ventilation.

The baby's head and neck should be positioned

midline and neutral, or slightly extended, in the

sniffing position so that the baby's eyes are directed

straight upward toward the ceiling (Figure 4.13).

Improper positioning is one of the most common

reasons for ineffective mask ventilation. The airway

will be obstructed if the neck is excessively flexed

or extended. Because the back of a newborn's head

( occiput) is prominent, it may be helpful to lift the

shoulders slightly by placing a rolled towel or small

blanket under the baby's shoulders (Figure 4.14).

Figure 4. 14. Shoulder roll used to position the

head and neck

How do yo u position the mask on the baby' s fa ce?

Select the correct mask.

A variety of mask sizes should be available at every birth. Neonatal masks

have a cushioned or soft pliable rim and con1e in 2 shapes-anaton1ically

shaped and round (Figure 4.15). Anatomically shaped masks are placed

with the pointed part of the mask over the nose. The mask should rest

on the chin and cover the mouth and nose, but not the eyes. The correct

mask will create a tight seal on the face. If the rim of a cushioned mask is

improperly inflated, it may be difficult to achieve a good seal.

Place the mask on the baby's face.

An airtight seal between the rim of the mask and the face is necessary

to achieve the pressure that will ínflate the lungs. Ventilation will not be

successful if there is a large air leak from an improperly placed mask.

Fi g

u re 4.1 5. Correctly sized anatomic (A) and round (B) masks

One-Hand Hold

• Begin by cupping the chin in the bottom of an anatomic mask and

then bring the mask over the mouth and nose (Figure 4.16).

• The bottom of the mask should rest on the chin, not below it. The

tip of the mask should rest at or just below the nasal bridge to avoid

putting pressure on the baby's eyes or causing a large leak around

the eyes.

• Hold the mask on the face with the thumb and index finger

encircling the rim.

• Place the other 3 fingers under the bony angle of the jaw and gently

lift the jaw upward toward the mask.

• Once the mask is positioned, an airtight seal can be formed by using

even, downward pressure on the rim of the mask while holding the

head in the sniffing position (Figure 4.17).

Sorne round masl(s are designed to be placed directly over the nose and

mouth and held in place by the stem rather than the rim (Figure 4.18).

If you apply pressure to the rim of this type of mask, the mask shape

will be deformed and will leak.

Figure 4.16. (A) Cup the chin in the anatomic mask. (B) Bring the mask over the mouth and nose.

Figure 4.1 7. Maintaining a seal with the 1-hand hold

using an anatomic mask

Figure 4.1 8. Maintaining a seal with the 1-hand hold

by holding only the stem of a round mask

Two-Hand Hold With Jaw Thrust

It can be difficult to maintain a good seal and the correct head position

with 1 hand. If you cannot achieve a good seal, use both hands to hold

the mask and lift the jaw.

• Use the thumb and first finger of both hands to hold the mask

against the face.

• Place the other 3 fingers of each hand under the bony angle of the

jaw and gently lift the jaw upward toward the mask (Figure 4.19).

• While you concentrate on making a good seal and maintaining the

correct midline head position, another team member stands at the

baby's side and squeezes the bag or occludes the T-piece cap.

• A third person monitors the baby's response.

Fi g

u r e 4. 19. Two-hand hold with jaw thrust. An assistant delivers the breath.

Precautions

Care must be taken when holding the mask.

• Do not "jam,, the mask down on the face or occlude the nasal

passages. Too much pressure can obstruct the mask, cause air to leak

around the side of the mask, inadvertently flex the baby's neck, or

bruise the face.

• Be careful not to rest your hand on the baby's eyes.

• Be careful not to compress the soft tissue of the baby's neck.

• Recheck the position of the mask and the baby's head at intervals to

make sure they are still correctly positioned.

What concentration of oxygen should be used to start

positive-pressure ventilation?

Studies have shown that resuscitation started with 21 % oxygen in

term and late preterm newborns, and 21 % to 30% oxygen in preterm

newborns, is justas effective as resuscitation started with 100%

oxygen. To balance the hazards possibly associated with extremes of

oxygenation, this program recommends attempting to maintain an

oxygen saturation, measured with pulse oximetry, close to the saturation

measured in healthy babies born at term. Before birth, the fetus has a

blood oxygen saturation of approximately 60%. After birth, the oxygen

saturation gradually increases above 90%. However, even healthy term

newborns may take 1 O minutes or longer to reach this saturation.

• For the initial resuscitation of newborns greater than or equal to 35

weeks' gestation, set the blender to 21 % oxygen (Figure 4.20).

• For the initial resuscitation of newborns less than 35 weeks'

gestation, set the blender to 21 % to 30% oxygen.

• Set the flowmeter to 10 L/minute (Figure 4.20).

• An assistant should place a pulse oximeter sensor on the right hand

or wrist as soon as possible after PPV is started. Once the pulse

oximeter is reading reliably, compare the baby's pre-ductal oxygen

saturation with the range of target values summarized in Table 4-1

and adjust the F102 as needed.

What ventilation rate should be used during positive·pressure

ventilation?

Breaths should be given at a rate of 40 to 60 breaths per minute.

• Count out loud to help maintain the correct rate.

• Use the rhythm, "Breathe, two, three; breathe, two, three; breathe,

two, three:'

• Say "Breathe" as you squeeze the bag or occlude the T-piece cap and

release while you say "two, three:'

How much pressure should be used to start positive·pressure

ventilation?

After birth, fetal lung fluid within the alveoli must be replaced with

air for gas exchange to occur. If the baby has not taken a spontaneous

breath, the first few assisted breaths may require higher than usual

pressure to move fluid out of the air spaces and inflate the alveoli.

However, excessively high lung volumes and airway pressures can

cause lung injury. The goal is to use just enough pressure to ínflate and

aerate the lungs so that the heart rate and oxygen saturation increase

(Table 4-2).

• Start with a PIP of 20 to 25 cm H20 .

• Full-term babies may require a higher inflation pressure for the first

few breaths to ínflate their lungs. After the initial inflating breaths,

you may be able to decrease the inflation pressure.

• Administering PEEP with the initial inflating breaths helps to

achieve stable lung inflation more quickly, remove fluid, and prevent

the air spaces from collapsing during exhalation. When PEEP is

used, the suggested initial setting is 5 cm H20 .

Once you ínflate the lungs, you should see a gentle rise and fall of

the chest with each breath. If the baby appears to be taking very deep

breaths during PPV, you are probably using too much pressure and the

lungs may become overinflated. This increases the risk of producing an

air leak within the lung (pneumothorax). Remember that the volume

of a normal breath is much smaller than the amount of gas in a typical

resuscitation bag.

If the baby is preterm, visual assessment of chest movement may be less

reliable and there may be a greater risk of injury from overinflation.

It is possible to achieve successful ventilation without apparent chest

movement. Additional details about providing assisted ventilation to

preterm newborns are included in Lesson 8.

Table 4-2. lnitial Settings for Positive-Pressure Ventilation

Component lnitial Setting

Oxygen concentration > 35 weeks' gestation 21%

< 35 weeks' gestation 21%-30%

Gas flow 1 O L/minute

Rote 40-60 breaths/minute

PIP 20-25 cm H20

PEEP 5 cm H20

How do you evaluate the baby' s response to

positive-pressure ventilation?

The most important indicator of successful PPV is a rising heart

rate. When you start PPV, an assistant will monitor the baby's heart

rate response. The initial heart rate assessment may be made with

a stethoscope. Once PPV begins, an assistant should apply a pulse

oximeter sensor to continuously assess the baby's oxygen saturation

and heart rate. Continuous monitoring with a cardiac monitor may be

considered. If PPV was started beca use the baby had a low heart rate, it

should improve rapidly.

• Within 15 seconds of starting PPV, the baby's heart rate should be

• • 1ncreas1ng.

• Within 30 seconds of starting PPV, the baby's heart rate should be

greater than 100 bpm.

If the baby's heart rate is increasing after the first 15 seconds, continue

PPV. You will check the response again after 30 seconds of PPV.

If the baby's heart rate is not increasing after the first 15 seconds, ask

your assistant if the chest is moving.

• If the chest is moving, continue PPV while you monitor your

ventilation technique. You will check the baby's response again after

30 seconds of PPV.

• If the chest is NOT moving, you may not be ventilating the baby's

lungs. Perform the ventilation corrective steps described below until

you achieve chest movement with PPV.

What are the MR. SOPA ventilation corrective steps?

The ventilation corrective steps are a series of adjustments that you

will make if the baby's heart rate is not improving and the chest is not

moving. The most likely reasons for ineffective mask ventilation are

leak around the mask, airway obstruction, and insufficient ventilating

Table 4-3. The MR. SOPA Ventilation Corrective Steps

Corrective Step Actions

M Mask adjustment. Reapply the mask and lift the jaw forward. Consider the 2-hand hold.

R Reposition the head and neck. Place head neutral or slightly extended.

Give 5 breaths and assess chest movement. lf no chest movement, do the next steps.

S Suction the mouth and nose. Use a bulb syringe or suction catheter.

O Open the mouth. Use a finger to gently open the mouth.

Give 5 breaths and assess chest movement. lf no chest movement, do the next step.

P Pressure increase. lncrease in 5-1 O cm H20 increments to maximum recommended pressure.

• Max 40 cm H20 term

• Max 30 cm H20 preterm

Give 5 breaths and assess chest movement. lf no chest movement, do the next step.

A Alternative airway. lnsert a laryngeal mask or endotracheal tube.

Try PPV and assess chest movement and breath sounds.

pressure. The ventilation corrective steps address these common

problems and are summarized in Table 4-3.

You may use the MR. SOPA mnemonic to remember the 6 steps in order.

• Mask adjustment.

• Reposition the head and neck.

• Suction the 1nouth and nose.

• Open the mouth.

• Pressure increase.

• Alternative airway.

You will perform the corrective steps sequentially until you achieve

chest movement with assisted breaths.

Mask adjustment.

Reapply the mask to the face to form a better seal. Indicators of a

good seal while using a T-piece resuscitator and flow-inflating bag

include achieving the desired PIP, maintaining the desired PEEP on

the manometer, and rapid reinflation of a flow-inflating bag between

breaths.

• If a leak is present, lift the jaw upward but do not press down hard

on the baby's face. You may need to use a little more pressure on the

rim of an anatomic mask.

• The most common place for a leak to occur is between the cheek

and bridge of the nose (Figure 4.21).

• If you continue to have difficulty achieving a tight seal, use the

2-hand hold described previously.

Reposition the head and neck.

The airway may be obstructed because the neck is flexed too far forward

or is overextended. Reposition the baby's head and neck to ensure that it

is midline and neutral or slightly extended (the sniffing position).

Once you have adjusted the mask and repositioned the head and neck,

try PPV again and assess chest movement. If the chest is not moving,

proceed to the next 2 corrective steps.

Suction the mouth and nose.

Suction the mouth and nose with a bulb syringe. The airway may be

blocked by thick secretions. In unusual situations, thick secretions may be

blocking the trachea, and tracheal intubation for suction may be required.

.l. , -

... ,f ,

Figure 4.21 • lnadequate

mask seal on the face may result

in i neffective ven ti lation. Ai r lea k

between the cheek and bridge of

the nose is common.

Open the mouth.

Opening the baby's mouth may decrease the resistance to airflow during

PPV. Use your finger to open the baby's mouth and reapply the mask.

After suctioning the mouth and nose and opening the mouth, try

PPV again and assess chest movement. If the chest is still not moving,

proceed to the next step.

Pressure increase.

Although you have an adequate seal and an open airway, inflating the

baby's lungs may require a higher inflation pressure.

• Use the manometer to guide adjustments of the inflation pressure.

Increase the pressure by 5 to 10 cm H20 increments until you

achieve chest movement.

• The maximum recommended pressure with face-mask ventilation is

40 cm H20 for a term newborn and 30 cm H20 for a preterm newborn.

After each pressure increase, try PPV again and assess the

chest movement. If the chest is not moving with the maximum

recommended pressure, proceed to the next step.

Alternative airway.

Mask ventilation is not always sufficient to inflate the lungs. If you have

completed the first 5 corrective steps and you still cannot achieve chest

movement, you should insert an alternative airway such as a laryngeal

mask or endotracheal tube. Once an alternative airway is inserted,

begin PPV and evaluate the baby's chest movement and breath sounds.

Instructions for inserting a laryngeal mask are included in this lesson.

Endotracheal intubation is addressed in Lesson 5.

The baby' s chest started moving af ter one of the ventilation

corrective steps. Now what do you do?

Once you achieve chest movement with each assisted breath, announce,

"The chest is moving NOW" This ensures that your team is aware of your

assessment and knows that additional MR. SOPA steps are not necessary.

Continue PPV that moves the chest for 30 seconds while you monitor

your ventilation rate, pressure, and the baby's heart rate response.

If you have difficulty maintaining chest movement during this time,

repeat the ventilation corrective steps as needed. Insert an alternative

airway if you have persistent difficulty maintaining effective ventilation

with a face mask.

What do yo u do af ter 30 seconds of positive-pressure

ventilation that ventilates the lungs?

After 30 seconds of PPV that ventilates the lungs, as indicated by an

increasing heart rate or chest movement, you will check the baby's

heart rate response again.

• The heart rate is greater than or equal to 100 bpm.

Assisted ventilation has been successful.

- Continue ventilating at a rate of 40 to 60 breaths per minute.

- Monitor the baby's chest movement, heart rate, and respiratory

effort.

- Adjust the F102 as needed based on pulse oximetry.

- When the heart rate is consistently greater than 100 bpm,

gradually reduce the rate of PPV, observe for effective spontaneous

respirations, and gently stimulate the baby to breathe.

- Positive-pressure ventilation may be discontinued when the baby

has a heart rate continuously greater than 100 bpm and sustained

spontaneous breathing.

• The heart rate is at least 60 bpm but less than 100 bpm.

If the heart rate is improving, continue to administer PPV as long

as the baby is showing steady improvement. Monitor the oxygen

saturation and adjust the F102 to meet the target saturation range

indicated in the table.

If the heart rate is not improving, consider each of the following:

- Quickly reassess your ventilation technique. Is the chest moving?

Are you ventilating at a rate of 40 to 60 breaths/minute? Do

you hear breath sounds? If necessary, perform the ventilation

corrective steps.

- Adjust the F102 to meet the target saturation.

- If not already done, consider placing cardiac monitor leads for

continuous monitoring.

- If not already done, consider inserting a laryngeal mask or

endotracheal tube.

- If available, call for additional expertise to help problem solve this

situation.

• The heart rate is less than 60 bpm.

This uncommon situation occurs when the heart cannot respond

to ventilation alone and requires additional support to bring

oxygenated blood to the coronary arteries.

Figure 4.22. Carbon dioxide

detector used with face mask during

ventilation corrective steps. Yellow

color on the device as shown

suggests ventilation of the lungs.

Consider each of the following:

- Quickly reassess your ventilation technique. Is the chest moving?

Are you ventilating at a rate of 40 to 60 breaths/minute? Do you

hear breath sounds? If necessary, perform ventilation corrective

steps.

- If the pulse oximeter has a reliable signal, adjust the F102

to meet

the target saturation.

- If not already done, place cardiac monitor leads and begin

continuous monitoring.

- If not already done, insert a laryngeal mask or endotracheal tube.

- If available, call for additional expertise to help problem solve this

situation.

- If the baby's heart rate remains less than 60 bpm after at least

30 seconds of PPV that moves the chest, preferably through an

alternative airway, increase the F102 to 100% and begin chest

compressions as described in Lesson 6.

While perf orming the ventilation corrective steps, can a

carbon dioxide detector help assess the eff ectiveness of

ventilation?

Using a carbon dioxide ( C0 2

) detector during the ventilation

corrective steps can provide a visual cue that helps you and your team

identify when you have achieved ventilation that inflates and aerates

the lungs. Place a C0 2 detector between the PPV device and mask. If

the lungs are being effectively ventilated and gas exchange is occurring,

C0 2 should be exhaled through the mask.

• If you are effectively ventilating the lungs, you should see the

detector turn yellow during each exhalation (Figure 4.22).

• If the C0 2 detector is purple and turns yellow after a corrective step,

the step was effective and the baby's heart rate will likely improve

quickly.

- If the C0 2 detector <loes not turn yellow, your face-mask

ventilation attempts may not be ventilating the lungs.

- If the detector remains purple after the first 5 corrective steps

and the heart rate has not improved, it may be another indication

that you have not achieved effective ventilation and an alternative

airway is needed.

• Caution: If the baby's heart rate is very low or not pumping blood,

the detector may not change color because C0 2

is not being carried

to the lungs even though you are ventilating the lungs.

What is a laryngeal mask?

A laryngeal mask is a small mask attached to an

airway tube (Figure 4.23). The mask is inserted into

the baby's mouth and advanced into the throat until

it makes a seal over the entrance to the baby's trachea

(the glottis) (Figure 4.24). The laryngeal mask makes

a better seal than a face mask and may improve the

effectiveness of ventilation. Unlike endotracheal

intubation, no instruments are required to insert Figure 4.23. Examples of neonatal laryngeal masks

a laryngeal mask and you do not need to visualize

the baby's vocal cords during insertion. If the baby

cannot be successfully ventilated with a face mask and

intubation is unfeasible or unsuccessful, a laryngeal

mask may provide a successful rescue airway.

Severa! variations are available, including devices

with an inflatable mask, a soft-gel mask that <loes

not require inflation, a pre-curved airway tube, and a

port for a gastric drainage tube. The laryngeal mask

is an effective alternative airway when attempts at

face-mask ventilation or intubation are unsuccessful;

Figure 4.24. Laryngeal mask forming a seal over

the glottis

however, its use in preterm newborns is limited because

even the smallest laryngeal mask may be too large for very preterm

newborns.

To learn more about limitations of the laryngeal mask, see the

Frequently Asked Questions section in this lesson on page 96.

How do you insert a laryngeal mask?

The following instructions and images apply to one example of a

disposable laryngeal mask with a pre-curved airway tube anda soft-gel

mask that <loes not require inflation. It is intended for use in babies

weighing 2 to 5 kg. Devices vary by manufacturer and you should refer

to the manufacturer's instructions for the specific device used at your

institution.

O If not already done, attach cardiac monitor leads for accurate

assessment of the baby's heart rate.

f) Using clean technique, remove the device from the sterile package

and protective container. You may place a thin layer of water-based

lubricant onto the back and sides of the mask, but this may not be

necessary because newborns often have sufficient oral secretions to

lubricate the device (Figure 4.25).

Figure 4.25. Remove the device and lubricate the back and sides (optional).

Figure 4.26. Preparing for

insertion

Figure 4.27. lnsert the mask into

the baby's mouth.

E) Stand at the baby's head and position the baby in the sniffing position.

O Hold the device along the airway tube with the closed bottom of

the mask facing the baby's palate and the open bowl of the mask

facing toward the baby's chin (Figure 4.26).

0 Open the baby's mouth by pressing gently downward on the baby's

chin.

O Insert the leading tip of the mask into the baby's mouth, on top of

the tongue, with the bottom of the mask pressed against the baby's

palate (Figure 4.27).

O Glide the device downward and backward, following the contour

of the palate, with a continuous but gentle push until you feel

definitive resistance (Figure 4.28).

6) Holding the tube in place, attach a C0 2 detector and PPV device.

Begin PPV and secure the device in place (Figure 4.29).

O If the laryngeal mask is correctly inserted and you are providing

ventilation that inflates the lungs, you should detect exhaled C0 2

within 8 to 10 positive-pressure breaths. You should see chest wall

movement and hear equal breath sounds when you listen with a

stethoscope. You should not hear a large leak of air coming from

the baby's mouth or see a growing bulge in the baby's neck.

Figure 4.28. Advance the device

following the contour of the mouth

and palote.

Figure 4.29. Start PPV and

confirm placement.

When should you remove the laryngeal mask?

The airway can be removed when the baby establishes effective

spontaneous respirations and the device is no longer needed or when

an endotracheal tube can be inserted successfully. Babies can breathe

spontaneously through the device, and crying and grunting sounds

may be audible.

• When you decide to remove the laryngeal mask, suction secretions

from the mouth and throat before you remove the device.

• If the device has an inflatable rim, deflate the rim before removal.

What do you do if the baby is breathing spontaneously and has

a heart rate of at least 1 00 bpm, but has labored breathing or

low oxygen saturation despite free-flow oxygen?

If the baby is breathing spontaneously and has a heart rate of at least

100 bpm, but has labored or grunting respirations or low oxygen

saturation, CPAP may be considered. CPAP is NOT appropriate if the

baby is apneic or gasping or if the baby's heart rate is less than 100 bpm.

CPAP is a technique for maintaining pressure within the lungs of a

spontaneously breathing baby. CPAP keeps the lungs slightly inflated

at ali times and may be helpful for preterm babies whose lungs are

surfactant deficient, causing the alveoli to collapse at the end of

each exhalation. When CPAP is provided, the baby <loes not have

to work as hard to ínflate the lungs with each breath. Using early

CPAP for preterm newborns may avoid the need for intubation and

mechanical ventilation. Administering CPAP may increase the chance

of developing a pneumothorax (air leak). Providers should be aware of

this potential complication and be prepared to address it.

How do you administer CPAP during the initial stabilization

period?

CPAP is administered by making a seal between the baby's face anda

mask attached to either a T-piece resuscitator ora flow-inflating bag.

CPAP cannot be administered with a self-inflating bag even if a PEEP

valve has been placed. The desired CPAP is achieved by adjusting the

PEEP dial on the cap of the T-piece resuscitator or the flow-control

valve on the flow-inflating bag (Figure 4.30).

• Test the amount of CPAP before applying the mask to the baby's

face by holding the mask tightly against your hand and reading the

pressure on the manometer (pressure gauge).

• Adjust the PEEP cap or the flow-control valve so that the

manometer reads 5 to 6 cm H20 pressure.

MAX

l'tKSSUttl

1111.IIF

• ••••• •

,,,,,

¿p

PEAi<

INSl'IRATOIIY

PIIISSUIII

••••• •

,,,

Figure 4.30. Adjust the CPAP pressure by turning the cap on a T-piece resuscitator (A). The resulting CPAP pressure is

shown on the manometer (B). Adjust the CPAP pressure using the flow-control valve on a flow-inflating bag (C). The resulting

CPAP pressure is shown on the manometer (D). For both, adjust the CPAP before placing the mask on the baby's face.

After you have adjusted the CPAP to the desired pressure, place it

firmly against the baby's face (Figure 4.31) using the 2-hand hold with

jaw thrust.

• Lift the baby's jaw into the mask instead of pushing the baby's head

down into the mattress.

• Check that the pressure is still at the selected level. If it is lower, you

may not have an airtight seal of the mask on the baby's face.

• You may adjust the CPAP depending on how hard the baby is

working to breathe. Do not use more than 8 cm H20 .

Fi g u r e 4.31. Administering face-mask CPAP with a T-piece (A) and flow-inflating bag (B). The manometer shows the

amount of CPAP administered. An airtight seal must be maintained with the mask.

• During CPAP, you do NOT occlude the T-piece cap or squeeze the

flow-inflating bag.

• If the baby cannot maintain a heart rate of at least 100 bpm with

spontaneous respirations, you need to give PPV breaths instead of CPAP.

If CPAP will be administered for a prolonged period, you will use nasal

prongs ora nasal mask (Figure 4.32). After the initial stabilization,

CPAP can be administered with a bubbling water system, a dedicated

CPAP device, or a mechanical ventilator.

When should you insert an orogastric tube?

During CPAP or PPV using a face mask or laryngeal mask, gas enters

the esophagus and stomach. Gas in the stomach may interfere with

ventilation. If a newborn requires CPAP or PPV for longer than

several minutes, consider placing an orogastric tube and leaving it

uncapped to act as a vent for the stomach.

Equipment needed

• 8F orogastric tube

• 20-mL syringe

• Tape

Figure 4.32. CPAP administered

to a preterm newborn with nasal

prongs. (Used with permission

of Mayo Foundation for Medica!

Education and Research.)

Fi g u r e 4.33. Measuring the correct insertion depth for an orogastric tube. In

this example, the tube should be inserted 28 cm.

lnsertion steps

O Measure the distance from the bridge of the nose to the earlobe

and from the earlobe to a point halfway between the xiphoid

process (the lower tip of the sternum) and the umbilicus. Note

the centimeter mark at this place on the tube (Figure 4.33).

To minimize interruption of ventilation, measurement of the

orogastric tube can be approximated with the mask in place.

Fi g u r e 4.34. lnsertion of an orogastric tube (A), aspirating the orogastric

tube (B), open i ng the orogastric tube to vent (C), and securi ng the orogastric

tube with tape (D)

f) Insert the tube through the mouth (Figure 4.34A). Ventilation can

be resumed as soon as the tube has been inserted. Reassess the

face-mask seal.

8 Once the tube is inserted the desired distance, attach a syringe and

remove the gastric contents (Figure 4.34B).

8 Remove the syringe from the tube and leave the end of the tube

open to provide a vent for air entering the stomach (Figure 4.34C).

0 Tape the tube to the baby,s cheek (Figure 4.34D).

Focus on Teamwork

Providing PPV highlights several opportunities for effective teams to

use the Neonatal Resuscitation Program (NRP®) Key Behavioral Skills.

Behavior Example

Anticípate and plan. Ensure that you hove enough personnel present at the time of birth based on the risk

factors you identified.

Delegate workload optimally.

Call for additional help

when needed.

Communicate effectively.

Know your environment.

Use available resources.

During your pre-resuscitation team briefing, determine who performs PPV, auscultates

the heart rote, assesses chest movement, places the pulse oximeter and cardiac

monitor, and documents events as they occur.

lf PPV is required, at least 2 or 3 qualified providers are needed to perform all of the

tasks quickly.

lf you hove difficulty maintaining a good seal, the 2-hand hold may be required,

which requires a second person to administer the assisted breath and a third

person to evaluate the response.

You may need to call for additional help if intubation is required.

The individuals providing PPV and assessing the effectiveness of ventilation must

share information and communicate with each other.

lf the ventilation corrective steps are required, frequent information sharing after each

step is crucial.

lt is important to announce when chest movement has been achieved ("Chest is moving

NOW") so that the team knows that the heart rote should be assessed in 30 seconds.

Know how to operate and troubleshoot your PPV device.

Know how to obtain a laryngeal mask and cardiac monitor.

Quality lmprovement Opportunities

Ask yourself the following questions and begin a discussion with your

team if you find a difference between the NRP recommendations and

what is currently done in your own hospital setting. Consider using the

suggested process and outcome measures to guide your data collection,

identify areas for improvement, and monitor if your improvement

efforts are working.

Quality improvement questions

O Who provides PPV in your delivery room setting?

f) Who monitors the baby's heart rate response during PPV?

E) Is a cardiac monitor for the newborn readily available in your

delivery room setting?

8 How often do providers in your delivery room setting practice PPV?

0 Do providers know where to find a laryngeal mask and how to

insert it?

Process and oukome measures

O How often is PPV given in your delivery room setting?

f) How often do newborns without any risk factors require PPV?

E) When PPV is required, how often is a second trained provider

present at the time of birth?

8 How often are the MR. SOPA steps performed in your delivery

room setting?

0 How often are chest compressions performed in your delivery

room setting?

O How often is a complete resuscitation record completed for

newborns that have received PPV?

Frequently Asked Questions

What are the advantages and disadvantages of each resuscitation

device?

The self-inflating bag is often considered easier to use than the

other devices and requires little time to set up. It <loes not require a

compressed gas source and can be used in an emergency setting when

compressed gas may not be readily available. Because it fully reinflates

even without a seal, you will be less likely to know if you have a large

leak between the mask and the baby's face. It is difficult to control the

inflation time with a self-inflating bag. In addition, the mask cannot be

used to administer free-flow oxygen or CPAP to a baby.

The flow-inflating bag is more complicated to set up than the other

devices and takes more practice to use effectively. It requires a

compressed gas source and adjustments to find the correct balance

between gas inflow and outflow. The advantage is that you will know

immediately if you lose gas pressure or have a leak between the bag

and mask because the bag will deflate. Absent or partial inflation

of the bag indicates that a tight seal has not been established or the

bag has a leak. An effective face-mask seal is indicated by observing

stable PEEP/CPAP on the manometer. The inflation time can be

increased, if needed, by squeezing the bag for a longer period of time.

The flow-inflating bag can deliver CPAP, PEEP, and free-flow oxygen.

The T-piece resuscitator also requires sorne preparation time for setup

prior to use. Similar to the flow-inflating bag, it requires a compressed

gas source and adjustment to the dials controlling the PIP and PEEP.

The primary advantage of the T-piece resuscitator is that it provides

more consistent pressure with each breath than either the self-inflating

or flow-inflating bag. An effective face-mask seal is indicated by

observing stable PEEP/CPAP on the T-piece manometer. In addition,

the users may not become fatigued because they are not repeatedly

squeezing a bag. The inflation time can be increased, if needed, by

occluding the hole on the T-piece cap for a longer period of time. The

T-piece can deliver CPAP, PEEP, and free-flow oxygen.

Why not routinely use 100% oxygen during all neonatal resuscitations?

Multiple studies in both animals and humans have raised concerns

about the safety of routinely using 100% oxygen during neonatal

resuscitation. A series of human randomized and quasi-randomized

studies over the last 2 decades have demonstrated that resuscitation

with 21 % oxygen, is at least as effective as resuscitation with 100%

oxygen. In meta-analyses of these studies, mortality was decreased

among term and late-preterm babies resuscitated with 21 %

oxygen compared with 100% oxygen. Intermediate initial oxygen

concentrations, between 21 % and 100%, have not been studied.

Because oxygen relaxes pulmonary blood vessels, sorne have expressed

concern that babies resuscitated with lower oxygen concentrations will

be more likely to develop pulmonary hypertension. Animal studies

have shown that pulmonary vascular resistance decreases appropriately

with 21 % oxygen, and that resuscitation with 21 % oxygen may actually

prevent rebound pulmonary hypertension and preserve the response to

inhaled nitric oxide if pulmonary hypertension develops.

In preterm newborns, there was no difference in outcomes between

those resuscitated with low oxygen (21 %-30%) and high oxygen

(60%-100%). Although no difference was found, the recommendation

to start with low oxygen and titrate upward as needed using pulse

oximetry reflects a preference to avoid exposing preterm newborns

to additional oxygen without evidence demonstrating a benefit for

important outcomes. The ideal initial F102

for resuscitating preterm

newborns is still unknown, but the majority of preterm newborns

enrolled in studies required sorne oxygen supplementation during the

first minutes of life.

Can a nurse or respiratory therapist insert a laryngeal mask?

Each health care provider's scope of practice is defined by their state

licensing board, and each hospital determines the level of competence

and qualifications required for licensed providers to perform clinical

skills. Although laryngeal mask insertion is consistent with the general

guidelines for nurse and respiratory therapist practice, you must check

with your state licensing board and institution.

What are the limitations of a laryngeal mask?

Laryngeal masks have several limitations to consider during neonatal

resuscitation.

• The device has not been studied for suctioning secretions from the

a1rway.

• If you need to use high ventilation pressures, air may leak through

the seal between the pharynx and the mask, resulting in insufficient

pressure to inflate the lungs.

• Few reports describe the use of a laryngeal mask during chest

compressions. However, if tracheal intubation is unsuccessful, it is

reasonable to attempt compressions with the device in place.

• There is insufficient evidence to recommend using a laryngeal mask

to administer intratracheal medications. Intratracheal medications

may leak from the mask into the esophagus and not enter the lungs.

• Laryngeal masks cannot be used in very small newborns. Currently,

the smallest laryngeal mask is intended for use in babies who weigh

more than approximately 2 kg. Many reports describe its use in

babies who weigh 1.5 to 2.5 kg. Sorne reports have described using a

laryngeal mask successfully in babies who weigh less than 1.5 kg.

LESSON 4 REVIEW

1. The single most i1nportant a11d most effective step in neonatal

resuscitation is (aggressive stimulation)/(ventilation of the lungs).

2. After the initial steps, positive-pressure ventilation is indicated

ifthe baby is ___ , OR ifthe baby is ____ , OR ifthe

baby's heart rate is less than ___ beats per minute. (Fill in the

blanks.)

3. A baby is born limp and apneic. You place the baby under a

radiant warmer, dry and stimulate, position the head and neck

to open the airway, and suction the mouth and nose. It has been

1 minute since birth and the baby remains apneic. The next step

is to (stimulate more)/(begin positive-pressure ventilation).

4. For positive-pressure ventilation, adjust the flowmeter to (5 L/

min)/(10 L/min).

5. Administer positive-pressure ventilation ata rate of (20 to

25 breaths per minute)/(40 to 60 breaths per minute).

6. Begin positive-pressure ventilation with an inflation pressure of

(20 to 25 cm H20 )/(40 to 60 cm H20 ).

7. Ventilation of the term newborn begins with (21 % oxygen)/

(100% oxygen).

8. If you are using a device that administers positive

end-expiratory pressure (PEEP), the recommended initial

pressure is (5 cm H20 )/(10 cm H20 ).

9. You have started positive-pressure ventilation for an apneic

newborn. The heart rate is 40 beats per minute and is not

improving. Your assistant <loes not see chest movement. You

should (start the ventilation corrective steps)/(proceed to chest

compressions).

1 O. Inflation and aeration of the lungs is suggested by a C0 2

detector that turns (yellow)/(purple).

11. You have started positive-pressure ventilation for an apneic

newborn. The heart rate has remained 40 beats per minute

despite performing all of the ventilation corrective steps and

ventilating through an endotracheal tube for 30 seconds. Your

assistant sees chest movement with positive-pressure ventilation.

You should (increase the ventilation rate to 100 breaths/minute)/

(proceed to chest compressions).

12. A laryngeal mask is inserted into the baby's mouth and

advanced into the throat until it (passes between the baby's vocal

cords)/(makes a seal over the entrance to the baby's trachea).

13. To insertan orogastric tube, measure the distance from the

bridge of the nose to the earlobe and from the earlobe ( to the

nipples)/(to a point halfway between the xiphoid process and

the umbilicus).

Answers

l. The single most important and most effective step in neonatal

resuscitation is ventilation of the lungs.

2. After the initial steps, positive-pressure ventilation is indicated

if the baby is apneic, OR if the baby is gasping, OR if the baby's

heart rate is less than 100 beats per minute.

3. The next step is to begin positive-pressure ventilation.

4. For positive-pressure ventilation, adjust the flowmeter to 10 L/

m1n.

5. Administer positive-pressure ventilation ata rate of 40 to

60 breaths per minute.

6. Begin positive-pressure ventilation with an inflation pressure of

20 to 25 cm H20 .

7. Ventilation of the term newborn begins with 21 % oxygen.

8. If you are using a device that administers positive

end-expiratory pressure (PEEP), the recommended initial

pressure is 5 cm H20 .

9. You should start the ventilation corrective steps.

10. Inflation and aeration of the lungs is suggested by a C0 2

detector that turns yellow.

11. You should proceed to chest compressions.

12. A laryngeal mask is inserted into the baby's mouth and

advanced into the throat until it makes a seal over the entrance

to the baby's trachea.

13. Measure the distance from the bridge of the nose to the earlobe

and from the earlobe to a point halfway between the xiphoid

process and the umbilicus.

Appendix

Read the section(s) that refers to the type of device used in your hospital.

A. Self-inflating resuscitation bag

What are the parts of a self-inflating bag?

There are 8 basic parts to a self-inflating bag (Figure 4A.l).

O Gas outlet

f) Positive end-expiratory pressure (PEEP) valve (optional)

E) Manometer

9 Pressure-releas e valve

0 Gas inlet

O Gas tubing

O (A) Oxygen reservoir (closed type), (B) Oxygen

reservo ir ( open type)

0 Valve assembly

The self-inflating bag reexpands after being

squeezed and fills with gas from 3 locations. As

the bag reinflates, air from the room is drawn in

from openings in the back of the bag. Gas from the

blender and flowmeter travels through gas tubing

and enters the bag at the gas inlet. Gas from the

blender collects in the oxygen reservoir and provides

a third source for gas to fill the bag. Oxygen

tubing <loes not need to be attached for the bag to

provide positive-pressure ventilation (PPV) with

21 % oxygen. Oxy gen tubing must be attached to a

compressed gas source to deliver more than 21 %

oxygen. The gas outlet is where gas exits from the

bag to the baby and where a face mask, laryngeal

mask, or endotracheal tube is attached.

♦

I ......._,

••

s t

k'-'78

A manometer (pressure gauge) measures the

inflating pressure used during PPV Sorne bags will

have a built-in manometer and others will need one

attached. The attachment site is usually close to the Figure 4A.1. Self-inflating bags with a closed (7 A)

and open (7B) reservoir

Pressure

from bag

Patient outlet

Exhaled

a1r

From patient

patient outlet. If the .manometer attachment site is

left open, without a manometer attached, air will

leak out and prevent you from achieving inflation

pressure. Do not attach the oxygen inflow tubing to

the manometer attachment site. This could generate

undesired high pressure. Most self-inflating bags

also have a pressure-release (pop-off) valve. These

valves are usually set to release at 30 cm to 40 cm

H20 pressure, but they are not reliable and may not

release until higher pressures are achieved.

Self-inflating bags have a valve assembly

positioned between the bag and the patient outlet

(Figure 4A.2). When the bag is squeezed during

ventilation, the valve opens and directs gas to

the patient. When the bag reinflates, the valve

is closed. This prevents the patient's exhaled air

from entering the bag and being rebreathed. Sorne

self-inflating bags also have an adjustable PEEP

Figure 4A.2. Valve assembly within a self-inflating bag valve.

100

Why is an oxygen reservoir used on a self-inflating bag?

An oxygen reservoir is an appliance that can be placed over the bag's

air inlet. Gas from the blender collects in the reservoir. At very low

flow rates, the reservoir prevents blended gas from being diluted with

room air. Several different types of oxygen reservoirs are available, but

they all perform the same function. Sorne have open ends (

((

tails") and

others look like a bag covering the air inlet.

B. Flow-inflating resuscitation bag

What are the parts of a flow-inflating bag?

There are 6 parts to a flow-inflating bag (Figure 4A.3).

O Gas outlet

f) Manometer

E) Gas inlet

8 Pressure-release valve (optional)

0 Gas tubing

O Flow-control valve

3 4

. , , í i

Fi g u r e 4A.3. Parts of a flow-inflating bag

Compressed gas from the blender and flowmeter enters the bag

through oxygen tubing attached to the gas inlet. The gas outlet is where

gas exits from the bag to the baby and where a face mask, laryngeal

mask, or endotracheal tube is attached. Even if you plan to use 21 %

oxygen for PPV, you must have a compressed gas source to fill the

flow-inflating bag.

The flow-control valve provides an adjustable leak that allows you to

regulate the pressure in the bag. The adjustable leak allows excess gas

to escape rather than overinflate the bag or be forced into the patient.

The flow-control valve adjusts both the peak inflation pressure (PIP)

and the PEEP.

Flow-inflating bags have a site for attaching a manometer. The

attachment site usually is close to the patient outlet. A manometer

must be attached or the site will be a source of leak and the bag will not

inflate properly. A pressure release (pop-off) valve may also be present.

How does a flow-inflating bag work?

For a flow-inflating bag to work properly, there must be adequate

gas flow from the source and a sealed system. The bag inflation is

controlled by the balance between gas entering the bag, gas exiting

the adjustable flow-control valve, and gas exiting the gas outlet. A

flow-inflating bag will not ínflate adequately if the mask is not properly

sealed; if flow from the gas so urce is insufficient, disconnected, or

occluded; if there is a hole in the bag; if the flow-control valve is

open too far; or if the mano meter attachment site has been left open

(Figure 4A.4).

101

102

------

-, --

Figure 4A.4. Reasons for insufficient inflation of a flow-inflating bag:

(A) inadequate mask seal with leak, (B) insufficient gas inflow, (C) hole in bag,

(D) flow-control valve open too far, (E) manometer attachment site open

How do you adjust the inflation of a flow-inflating bag?

There are 2 ways that you can adjust the pressure in the bag a11d thus

the amount of inflation of the bag.

• By adjusting the incoming gas from the flowmeter, you regulate how

much gas enters the bag.

• By adjusting the flow-control valve on the bag, you regulate how

much gas escapes from the bag.

The flowmeter and flow-control valve should be set so that the bag

is inflated to the point where it is comfortable to handle and <loes

not completely deflate with each assisted breath (Figure 4A.5A). An

overinflated bag (Figure 4A.5B) is difficult to n1anage and may deliver

high pressure to the baby; a pneumothorax or other air leak may

Fi g u re 4A.5. Correct flow-inflating bag inflation (A), overinflation (B), and underinflation (C)

develop. An underinflated bag (Figure 4A.SC) makes it difficult to

achieve the desired inflation pressure. With practice, you will be able

to make the necessary adjustments to achieve a balance. If there is a

good seal between the baby's face and the mask, you should be able to

maintain the appropriate amount of inflation with the flowmeter set at

8 to 10 L/min.

C. T-piece Resuscitator

What are the parts of a T-piece resuscitator?

There are 9 parts to a T-piece resuscitator (Figure 4A.6). The position

and function of control dials on the T-piece resuscitator may vary by

manufacturer. The parts and operation of one example is described below.

O Gas tubing

8 Gas inlet

E) Maximum pressure-relief control

8 Manometer

0 Inflation pressure control

O Gas outlet (proximal)

O T-piece gas outlet (patient)

O T-piece PEEP adjustment dial

f) Opening on T-piece cap

How does a T-piece resuscitator work?

tí

Fi g

u re 4A.6. Parts of a T-piece resuscitator

Gas from a compressed source enters the T-piece resuscitator through

gas tubing at the gas inlet. Gas exits the control box from the gas outlet

(proximal) and travels through corrugated tubing to the T-piece gas

outlet (patient), where a face mask, laryngeal mask, or endotracheal tube

103

attaches. When the opening on the T-piece cap is occluded by the operator,

the preset inflation pressure is delivered to the patient for as long as the

T-piece opening is occluded. On the device in Figure 4A.6, the maximum

pressure that can be used is regulated by the maximum pressure relief

control valve. PEEP is adjusted using a dial on the T-piece cap.

How do you prepare the T-piece resuscitator for use?

Assemble the parts of the T-piece resuscitator as instructed by

the manufacturer. Occlude the patient outlet ( using a test lung,

outlet-occluding cap, or palm). Connect the device to the compressed

gas source using gas tubing.

Adjust the pressure settings as follows:

• Adjust the blended gas flowmeter on the wall to regulate how much

gas flows into the T-piece resuscitator. In most cases, 10 L/min is

appropriate.

• Set the maximum pressure-relief control by occluding the T-piece cap

with your finger and adjusting the maximum pressure relief dial to a

selected value ( 40 cm H20 is the recommended maximum for term

newborns, 30 cm H20 is the recommended maximum for preterm

newborns). Sorne manufacturers recommend that the maximum

relief control be adjusted toan institution-defined limit when the

device is put into original service and not be readjusted during

regular use.

• Set the desired peak inflation pressure (PIP) by occluding the

T-piece cap with your finger and adjusting the inflation pressure

control to the selected pressure (Figure 4A.7).

• Set the PEEP by removi11g your finger from the T-piece cap and

adjusting the dial on the cap to the desired setting (5 cm H20 is

recommended) (Figure 4A.8).

MAJI

' ZlfUIJ

....

•••

•

Figure 4A.7. Adjusting the peak inflation pressure (PIP)

104

Figure 4A.8. Adjusting the PEEP

&OiJ

NAlC

FE -Ptw

•••••••

,,,,,

When the device is used to ventilate the baby, either by applying the

mask to the baby's face or by connecting the device to a laryngeal mask

or endotracheal tube, you administer a breath by alternately covering

and releasing the opening on the T-piece cap. The inflation time is

controlled by how long your finger covers the opening. Be careful

not to become distracted and inadvertently cover the opening on the

T-piece cap with your finger for a prolonged time.

How do you ad¡ust the concentration of oxygen in a T-piece resuscitator?

The concentration of oxygen delivered by the T-piece resuscitator is

controlled by the oxygen blender.

4►

_,or,

fSlHUN

•••

105

106

LESSON 4: PRACTICE SCENARIOS

Positive-Pressure Ventilation, Laryngeal Mask, Orogastric

Tube, and (optional} Continuous Positive Airway Pressure

Comprehensive Skills Test Scenarios for Neonatal Resuscitation Program

(NRP) Essentials Providers

Learning Objectives

O Identify the newborn that requires positive-pressure ventilation (PPV).

f) Demonstrate correct technique for delivering PPV.

E) Demonstrate the steps for assessing response to PPV.

9 Demonstrate ventilation corrective steps (MR SOPA).

0 Identify indications and method for discontinuing PPV.

O Identify indications for continuous positive airway pressure

(CPAP) in the delivery room and demonstrate correct technique

for administering CPAP.

O Identify uses and limitations of the laryngeal mask.

C) Demonstrate the correct technique for inserting and removing a

laryngeal mask.

O List pertinent NRP Key Behavioral Skills related to successful PPV.

These Practice Scenarios are for review / practice and evaluation. The

scenarios may also be used as the Comprehensive Skills Test ("test out'')

option during a Provider Course.

This is the suggested Practice Scenario sequence.

O Review the Knowledge Check Questions with your NRP instructor.

a. What are the indications for PPV? When can you stop PPV?

b. What is PIP? PEEP? How is CPAP different than PPV?

c. What is the recommended oxygen concentration for beginning

PPV for a newborn greater than or equal to 35 weeks' gestation?

For a newborn less than 35 weeks' gestation?

d. What is the recommended initial ventilation pressure and rate

for a term newborn?

e. What is the most important indicator of successful ventilation?

f. What are the MR. SOPA ventilation corrective steps?

g. What are the indications for CPAP? (optional)

h. What is the purpose of an orogastric tube?

i. What are the indications for a laryngeal mask? What are the

limitations of a laryngeal mask?

j. At what point should you proceed to chest compressions?

8 Practice/review these skills with your NRP instructor.

a. Safety check a self-inflating bag prior to use. (Ensure that the

pressure-release valve is not occluded.)

b. Safety check a T-piece resuscitator prior to use. (Ensure that

pressures are correctly set prior to initiating PPV on the

newborn.)

c. Position the newborn's head and neck in sniffing position.

d. Position the correct-sized mask on the newborn's face.

e. Perform the ventilation corrective steps (MR. SOPA).

f. Deliver PPV at the correct rate, pressure, and oxygen

concentration per pulse oximetry.

g. Use the 2-hand hold with jaw thrust.

h. Discontinue PPV by decreasing rate and pressure as the baby

begins to breathe.

i. Insert and remove a laryngeal mask (if this skill is within your

scope of responsibility).

j. Measure and insertan orogastric tube to decompress the

stomach.

k. Administer CPAP with a T-piece resuscitator and/or a

flow-inflating bag using correct technique (if this skill is within

your scope of responsibility).

8 Practice the scenarios applicable to your role with your NRP

instructor until you need little or no assistance or coaching.

O Pass the Lesson 4 Practice Scenario evaluation by leading practice

scenario(s) and performing the skills relevant to your role and

responsibilities. If a technical skill included in a scenario is not

within your scope of responsibility, delegate the skill to a qualified

team member and perform the role of assistant if appropriate.

107

0 When you can lead the scenario(s) and perform the skills with little

or no instructor coaching, NRP Advanced learners may proceed

to the next lesson's practice scenario. The NRP Essentials learners

may proceed to the Simulation and Debriefing component of the

Provider Course.

Note: If the institution's policy is that a T-piece resuscitator normally is

used in the delivery room, the learner should demonstrate proficiency

with that device. However, the learner also should demonstrate ability

to use a self-inflating bag and mask.

Practice Scenarios

Three scenario options are offered. The number of people attending

the birth scenarios and their qualifications are determined by the

instructor and based on hospital policy.

O Term newborn with risk factors requires PPV. (CPAP and

orogastric tube insertion are optional in this scenario.)

f.) Term newborn without known risk factors unexpectedly requires

PPV.

Q Term newborn is difficult to ventilate with a face mask and

requires a laryngeal mask.

"You are called to attend a vaginal birth. Labor is progressing rapidly.

Demonstrate how you would prepare for the birth of this baby. As you

work, say your thoughts and actions aloud so I will know what you are

thinking and doing."

Option 1: Term newborn with risk factors requires PPV. (CPAP and orogastric tube insertion are optional.)

Critical Performance Steps

Assess perinatal risk.

Assesses perinatal risk (learner asks 4 pre-birth questions and instructor ["OB provider"] responds)

Gestational age?

Clear fluid?

"38 weeks' gestation."

"Amniotic fluid is clear."

Additional risk factors? "Mom has pregnancy-induced hypertension, and her labor has been induced at 38

weeks' gestation. Several late decelerations of fetal heart rote hove been noted."

Umbilical cord management plan? "1 will delay cord clamping. lf the baby is not crying, 1'11 take a moment to

stimulate the baby. lf there's no response, 1'11 clamp and cut the cord."

Assemble team.

108

Assembles team based on perinatal risk factors.

lf risk factors are present, at least 2 qualified people should be present solely to manage the baby.

The number of team members and qualifications vary depending on risk.

Critical Performance Steps (cont)

Perform a pre-resuscitation briefing.

ldentifies team leader.

Assesses risk factors, delegates tasks, identifies who will document events as they occur, determines supplies and

equipment needed, identifies how to call for additional help.

Perform equipment check.

"The baby has been born."

Rapid evaluation.

Asks 3 rapid evaluation questions:

• Term? 'rves."

• Muscle tone? "No."

• Breathing or crying? "No, not breathing or crying."

lnitial steps at radiant warmer.

Receives baby at radiant warmer, dries and removes linen, stimulates briefly by rubbing the baby's back,

positions airway, suctions mouth and nose

Assess breathing. lf breathing, check heart rote.

Is the baby breathing? "No." (Heart rote= 60 bpm, if assessed)

lndicates need for PPV

Begin PPV within 60 seconds of birth.

Applies mask correctly

Starts PPV in 21 % oxygen (room air) at 20 to 25 cm H20 (PEEP of 5 cm H20 if using T-piece resuscitator,

flow-inflating bag, or self-inflating bag with PEEP valve); rote 40 to 60 breaths/min

Requests assistant to place pulse oximeter sensor on baby's right hand or wrist

"Pulse oximeter has no signal."

Requests cardiac monitor (optional)

Within 15 seconds of beginning PPV, requests heart rote check to assess if heart rote is increasing

Heart rate=40 bpm, not increasing

Assesses chest movement

"No chest movement."

Ventilation corrective steps (MR. SOPA).

Instructor determines how many MR. SOPA steps are needed before PPV can result in chest movement.

• Mask adjustment

• Repositions the head and neck

Gives 5 breaths and asks assistant to assess chest movement

"No chest movement."

• Suctions the mouth and nose

• Opens the mouth

Gives 5 breaths and asks assistant to assess chest movement

"No chest movement." Heart rote= 40 bpm "Pulse oximeter has no signal."

• lncreases Pressure by 5 to l O cm H20 increments to maximum 40 cm H20 for term baby

Gives 5 breaths and asks assistant to assess chest movement

"Chest moves with PPV." (Note: lf instructor states that the chest is not moving with PPV after this MR. SOPA step,

the learners should inserta laryngeal mask. See Option 3.)

The learner's assistant announces, "The chest is moving NOW. Continue PPV for 30 seconds."

109

Critical Performance Steps (cont)

Deliver PPV that moves the chest.

Delivers PPV x 30 seconds.

(Learner gradually discontinues PPV if baby has a heart rote greater than 100 bpm and críes before 30 seconds

of PPV.)

Assesses heart rote after 30 seconds of PPV that moves the chest

Heart rote= 120 bpm 5P02= 64% "Occasional respiratory effort."

Continues PPV, adjusts oxygen concentration per pulse oximetry, monitors heart rote and respiratory effort

Heart rote= 140 bpm SP02 = 74%

"The baby has increasing spontaneous respiratory effort and improving muscle tone."

Gradually discontinues PPV

Heart rote= 140 bpm SP02 = 72% "The baby has strong and continuous respiratory effort."

Free-flow oxygen.

Discontinues PPV.

Assesses need for free-flow oxygen to maintain oxygen saturation within target range.

Heart rote= 140 bpm 5P02 = 70% "The baby has good spontaneous respiratory effort."

lnitiates free-flow oxygen correctly.

Assesses heart rote, oxygen saturation, respiratory status.

Heart rote= 140 bpm 5P02 = 90% "The baby has good respiratory effort."

End scenario.

Weans and discontinues free-flow oxygen and maintains oxygen saturation within target.

Monitors heart rote, breathing, oxygen saturation, temperature.

Plans post-resuscitation care.

Communicates with perinatal team and parents.

Debriefs the resuscitation.

Optional: CPAP and orogastric tube.

"After discontinuing PPV and free-flow oxygen, the newborn has labored breathing and grunting respirations."

Heart rote= 140 bpm SP02 = 80%

Administer CPAP and insert orogastric tube.

Applies CPAP at 5 cm H20 pressure.

Adjusts oxygen concentration per pulse oximetry.

Heart rote= 140 bpm SP02 = 85%

Continues CPAP, adjusts oxygen concentration per pulse oximetry

Heart rote= 140 bpm SP02 = 90%

"The baby is_ minutes old. Breathing effort has improved."

Measures insertion depth for orogastric tube while CPAP is in progress

• Places the distal end of the orogastric tube at the bridge of the nose and measures to the earlobe and from the

earlobe to a point halfway between the xiphoid process and the umbilicus. Notes the centimeter mark on the

tube. lnserts the tube through the mouth. Resumes CPAP.

• Attaches a syringe and removes the gastric contents. Removes the syringe from the tube and leaves the end

open as an air vent.

• Tapes the tube to the baby's cheek.

End scenario.

Monitors heart rote, breathing, oxygen saturation, temperature.

Plans post-resuscitation care.

Communicates with perinatal team and parents.

Debriefs the resuscitation.

11 O

Option 2: Term newborn without known risk factors unexpectedly requires PPV. (This scenario is designed for

attendance by 1 person assigned to manage newborn care at birth.)

Critical Performance Steps

Assess perinatal risk.

Assesses perinatal risk (learner asks 4 pre-birth questions and instructor ["OB provider"] responds)

Gestational age? "39 weeks' gestation."

Clear fluid? "Amniotic fluid is clear."

Additional risk factors? "There are no additional risk factors."

Plan for umbilical cord management? "I will delay cord clamping. lf the baby is not crying, 1'11 take a moment to

stimulate the baby. lf there's no response, 1'11 clamp and cut the cord."

This birth will be attended by 1 qualified individual.

Knows the answers to the 4 pre-birth questions, determines supplies and equipment needed, knows how to call for help.

Perform equipment check.

"The baby has been born."

Rapid evaluation.

Asks 3 rapid evaluation questions:

• Term? "Yes, as expected."

• Muscle tone? "No."

• Breathing or crying? "No, not breathing or crying."

lnitial steps at radiant warmer.

Receives baby at radiant warmer, dries and removes linen, stimulates briefly by rubbing the baby's back,

positions airway, suctions mouth and nose

Assess breathing. lf breathing, assess heart rate.

Is the baby breathing? "No." (Heart rate = 70 bpm, if assessed)

lndicates need for PPV

Uses standardized process to call for resuscitation team

Begin PPV by 60 seconds after birth.

Positions head in sniffing position

Applies mask correctly

Starts PPV in 21 % oxygen (room air) at 20 to 25 cm H20 (PEEP of 5 cm H20 if using T-piece resuscitator,

flow-inflating bag, or self-inflating bag with PEEP valve); rote 40 to 60 breaths/min

Requests additional help until resuscitation team arrives

Requests pulse oximeter sensor placement on baby's right hand or wrist

Requests cardiac monitor (optional)

Within 15 seconds of beginning PPV, requests heart rote check to assess if heart rote is increasing

Heart rate = 70 bpm and not increasing SP02=66%

The learner asks assistant to assess chest movement

"No chest movement."

1 1 1

Critical Performance Steps (cont)

Ventilation corrective steps (MR. SOPA).

Instructor determines how many MR. SOPA steps to use before PPV can result in chest movement

• Mask adjustment

• Repositions the head and neck

Gives 5 breaths and asks assistant to assess chest movement

"No chest movement."

• Suctions the mouth and nose

• Opens the mouth

Gives 5 breaths and asks assistant to assess chest movement

"No chest movement." Heart rote= 70 bpm SP02 = 66%

• lncreases Pressure by 5 to l O cm H20 increments to maximum 40 cm H20 for term newborn

Gives 5 breaths and asks assistant to assess chest movement

"Chest moves with PPV." (Note: lf instructor states that the chest is not moving after this MR. SOPA step, the learners

should i nsert a laryngeal mask. See Option 3.)

The learner's assistant announces, "The chest is moving NOW. Continue PPV for 30 seconds."

Deliver PPV that moves the chest.

Delivers PPV x 30 seconds.

(Learner may gradually discontinue PPV if baby has a heart rote greater than 100 bpm and críes before 30

seconds of PPV.)

Assesses heart rote and assesses need for free-flow supplemental oxygen

Heart rote= 120 bpm SP02 = 72% "The baby has increasing respiratory effort."

Gradually discontinues PPV, monitors heart rote and respiratory effort

Heart rote= 140 bpm 5P02 = 75% and increasing "The baby is breathing regularly, muscle tone is improving."

End scenario.

Discontinues PPV.

Monitors heart rate, breathing, oxygen saturation, temperature.

Communicates with resuscitation team members as they arrive.

Updates parents and informs them of next steps.

Debriefs the resuscitation.

Option 3: Term newborn is difficult to ventilate with a face mask and requires a laryngeal mask.

Critical Performance Steps

Assess perinatal risk.

Assesses perinatal risk (learner asks 4 pre-birth questions and instructor ["OB provider"] responds)

Gestational age?

Clear fluid?

Additional risk factors?

"40 weeks' gestation."

"Amniotic fluid is clear."

"A few fetal heart decelerations in the last 20 minutes."

Umbilical cord management plan? "I will delay cord clamping. lf the baby is not crying, 1'11 take a moment to

stimulate the baby. lf there's no response, 1'11 clamp and cut the cord."

Assemble team.

112

Assembles team based on perinatal risk factors.

When the likelihood of resuscitation is low, 1 qualified individual should attend the birth.

lf risk factors are present, at least 2 qualified people should be present solely to manage the baby.

The number of team members and qualifications vary depending on risk.

lf the birth will be attended by 1 person,

Knows the answers to the 4 pre-birth questions, determines supplies and equipment needed, knows how to call

for help

Critical Performance Steps (cont)

lf the birth will be attended by a team, perform a pre-resuscitation briefing.

ldentifies team leader.

Assesses risk factors, delegates tasks, identifies who will document events, determines supplies and equipment

needed, knows how to call for additional help.

Rapid evaluation.

Asks 3 rapid evaluation questions:

• Term? "Yes, appears termas expected."

• Muscle tone? "No."

• Breathing or crying? "No, not breathing or crying."

lnitial steps at radiant warmer.

Receives baby at radiant warmer, dries and removes linen, stimulates briefly by rubbing the baby's back,

positions airway, suctions mouth and nose

Assess breathing. lf breathing, ossess heort rate.

Is the baby breathing? "No." (Heort rote= 70 bpm, if ossessed)

lndicates need for PPV.

Requests immediate help from 1 person and uses standardized method to call for additional help.

Begin PPV within 60 seconds of birth.

Positions head in sniffing position

Applies mask correctly

Starts PPV in 21 % oxygen (room air) at 20 to 25 cm H20 (PEEP of 5 cm H20 if using T-piece resuscitator,

flow-inflating bag, or self-inflating bag with PEEP valve); rote 40 to 60 breaths/min

Requests pulse oximeter sensor placement on baby's right hand or wrist

Requests cardiac monitor (optional at this time)

Within 15 seconds of beginning PPV, requests heart rote check to assess if heart rote is increasing

Heort rote= 70 bpm ond not increasing SP02 = 67%

Asks assistant to assess chest movement

"No chest movement."

Perform ventilation corrective steps (MR. SOPA).

Instructor determines how many MR. SOPA steps to use before PPV can result in chest movement.

• Mask adjustment

• Reposition the head and neck

Gives 5 breaths and asks assistant to assess chest movement

"No chest movement." Heart rate = 70 bpm and not increosing SP02 = 67%

• Suctions the mouth and nose

• Opens the mouth

Gives 5 breaths and asks assistant to assess chest movement

"No chest movement." Heart rate= 70 bpm and not increosing SP02 = 65%

• lncreases Pressure by 5 to l O cm H20 increments to maximum 40 cm H20 for term baby

Gives 5 breaths and asks assistant to assess chest movement

"Chest moves with PPV." (Note: lf instructor states that the chest is not moving after this MR. SOPA step, learners

will proceed with laryngeal mask insertion now.)

Learner's assistant announces, "The chest is moving NOW. Continue PPV for 30 seconds."

113

Critical Performance Steps (cont)

Deliver PPV that moves the chest.

Delivers PPV that moves the chest x 30 seconds

Requests heart rote assessment

Heart rote= 60 bpm and not increasing "Pulse oximeter has no signal."

Laryngeal mask preparation.

Calls for additional help if needed.

Places chest leads and attaches a cardiac monitor, if not already done.

Obtains a size 1 laryngeal mask (and a 5-ml syringe if mask requires inflation), and a 5F or 6F orogastric tube

if the laryngeal mask has an insertion port

Resuscitation team continues MR. SOPA steps with face mask while operator is preparing laryngeal mask

lf the laryngeal mask requires inflation,

Quickly inflates the rim with no more than 4 ml of air to test for leaks.

Withdraws air.

Lubricates back and sides of the mask with water-soluble lubricant, keeping lubricant away from the inside of the

mask (optional step for manikin use)

Laryngeal mask insertion.

Stands at the baby's head. Places baby's head in sniffing position.

Holds the device along the airway tube with the closed bottom of the mask facing the baby's palote and the

open bowl of the mask facing toward the baby's chin

Opens the newborn's mouth by gently pressing downward on the baby's chin.

lnserts the leading tip of the mask into the baby's mouth, on top of the tongue, with the bottom of the mask

pressed against the baby's palote.

Glides the device downward and backward, following the contour of the palote, with a continuous but gentle

push until definitive resistance is met

lf the laryngeal mask requires inflation,

Supports the device in place, allowing it to rise and seat while inflating the rim by injecting 2 to 4 ml of air via

the inflation valve. The pilot balloon mirrors inflation of the rim. Removes syringe.

Holds the laryngeal mask in place and attaches a C0 2 detector and the PPV device

Positive-pressure ventilation with laryngeal mask

The person holding the laryngeal mask holds the PPV device and begins PPV.

Learner and/ or the assistant confirms insertion by assessing and announces the presence of

• Symmetrical chest movement

• Bilateral breath sounds

• Color change on C0 2 detector within 8 to 1 O positive-pressure breaths

Operator continues PPV at appropriate rote and pressure for 30 seconds, monitoring heart rote and SP02

Secures laryngeal mask with waterproof tape

lf the laryngeal mask has a gastric port and will be in place for more than severa! minutes, measures for

orogastric tube insertion (described above), inserts orogastric tube down port, and decompresses stomach

contents with syringe. Leaves orogastric tube open to air as a vent. Tapes tube to baby's cheek.

114

Critical Performance Steps (cont)

Assess heart rote after 30 seconds of PPV that moves the chest.

Heart rote= 120 bpm SP02= 74%

"The baby has occasional spontaneous respirations."

Gradually decreases PPV rote and pressure. Stimulates newborn.

Requests heart rote assessment, SP02 to assess need for supplemental oxygen, and respiratory status

Heart rote= 140 bpm 5Po2 = 78% and gradually increasing "The baby is crying."

Remove laryngeal mask.

Suctions secretions from the back of the mouth and throat.

lf the mask has an inflatable rim, deflates the rim before removing.

Removes laryngeal mask.

Monitors heart rote, breathing, oxygen saturation

Heart rote= 140 bpm 5Po2 = 86% and gradually increasing

"The baby has spontaneous, regular breathing."

End scenario.

Mon itors hea rt rote, breath i ng, oxygen satu ration, tempera tu re.

Communicates with perinatal team.

Updates parents and informs them of next steps, including post-resuscitation care.

Debriefs the resuscitation.

Sample Debriefing Questions

O What is the most important issue to discuss during this debriefing?

f) What went well during this resuscitation?

E) What will you do differently when faced with this situation in a

future scenario?

8 Do you have additional comments or suggestions for your team

members? For the team leader?

0 Give me an example of how you used at least one of the NRP Key

Behavioral Skills.

If significant errors were made, consider asking the learners

O What happened? What should have happened? What could you

have done to make the right things happen?

f) What NRP Key Behavioral Skills might have been helpful in this

situation?

11 S

116

NRP Key Behavioral Skills

• Know your environment.

• Use available information.

• Anticipate and plan.

• Clearly identify a team leader.

• Communicate effectively.

• Delegate the workload optimally.

• Allocate attention wisely.

• Use available resources.

• Call for additional help when needed.

• Maintain professional behavior.

What you will learn

The indications for endotracheal intubation during

resuscitation

How to select and prepare the equipment for

endotracheal intubation

How to assist with endotracheal intubation

How to use a laryngoscope to insert an endotracheal

tube

How to determine if the endotracheal tube is in the

trachea

How to use an endotracheal tube to suction thick

secretions from the trachea

r '

Antenatal counseling.

Team briefing.

\ .

Equipment check.

Birth

' ,

Term gestatian? Yes

Stay with mother for initial steps, Gaadtane? -

routine care, ongoing evaluation. Breathing ar crying? '" ,

Q) ' ,

e: , Warm, dry, stimulate, position ·-

airway, suction if needed.

, -

\ . ,

' ,

Apnea ar gasping? No Labared breathing ar

HR <100 bpm? , persistent cyanasis?

Yes Yes

' , '

r ' ,

PPV. Position airway, suction if needed.

Pulse oximeter. Pulse oximeter.

Consider cardiac monitor. Oxygen if needed.

\ . , Consider CPAP.

'" ,

' ,

- HR <100 bpm? No

Yes

' , ' , '

, ,

Ensure adequate ventilation. Post-resuscitation care.

Consider ETT or laryngeal mask. Team debriefing.

Cardiac monitor.

'" ,

\ .

' ,

HR <60 bpm?

Target Oxygen Saturation Table

ypc.

1 min 60%-65%

T r '

ETT or laryngeal mask.

2 min 65%-70%

Chest compressions. 3 min 70%-75%

Coordinate with PPV-100% oxygen.

uve. 4 min 75%-80

\ . /o

' , 5 min 80%-85%

HR <60 bpm?

10 min 85%-95

Yes

lnitial oxygen concentration for PPV r '

IV epinephrine every 3-5 minutes.

lf HR remains < 60 bpm, • 35 weeks' GA 21% oxygen

• Consider hypovolemia.

\ .

• Consider pneumothorax.

< 35 weeks' GA 21%-30

/o oxygen

118

Key Points

O Insertion of an endotracheal tube (intubation) is strongly

recommended if the baby's heart rate remains less than 100 bpm

and is not increasing after positive-pressure ventilation (PPV) with

a face mask or laryngeal mask.

f) Insertion of an endotracheal tube is strongly recommended before

starting chest compressio11s. If intubation is not successful or

feasible, and the baby weighs more than approximately 2 kg, a

laryngeal mask may be used.

8 An endotracheal tube should be inserted for direct tracheal suction

if the trachea is obstructed by thick secretions, for surfactant

administration, and for stabilization of a newborn with a suspected

diaphragmatic hernia.

8 If PPV is prolonged, an endotracheal tube may be considered to

improve the efficacy and ease of assisted ventilation.

0 A person with intubation skills should be in the hospital and

available to be called for immediate assistance if needed. If the

need for intubation is anticipated, this person should be present in

the delivery room at the time ofbirth. It is not sufficient to have

someone on call at home or in a remote area of the hospital.

O The appropriate laryngoscope blade for a term newborn is size

No. l. The correct blade for a preterm newborn is size No. O

(size No. 00 optional for extremely preterm newborn).

O The intubation procedure ideally should be completed within

30 seconds. Effective teamwork is required to perform this

procedure quickly.

0 Demonstrating exhaled carbon di oxide ( C0 2) and observing

a rapidly increasing heart rate are the primary methods of

confirming endotracheal tube insertion within the trachea.

f) Endotracheal tube insertion depth can be estimated using the

nasal-tragus length (NTL) or the baby's gestational age; however,

the depth estímate should be confirmed by auscultating equal

breath sounds. If the tube is to remain in place, obtain a chest x-ray

for final confirmation.

119

120

4D) If a correctly inserted endotracheal tube <loes not result in PPV

with chest movement, suspect airway obstruction and suction the

trachea with a suction catheter or tracheal aspirator.

G, If a baby's condition worsens after endotracheal intubation, the

tube may have become displaced or obstructed, or there may be a

pneumothorax or PPV equipment failure (DOPE mnemonic).

0 Avoid repeated unsuccessful attempts at endotracheal intubation.

Por babies who weigh more than approximately 2 kg, a laryngeal

mask may provide a rescue airway when PPV with a face mask fails

to achieve effective ventilation and intubation is unsuccessful or

not feasible.

Case: Resuscitation with positive-pressure ventilation using

an endotracheal tube

Your team is called to attend the birth for a woman at 37 weeks'

gestation whose labor is complicated by maternal fever and

fetal tachycardia. The amniotic fluid is clear. You complete a

pre-resuscitation briefing and prepare your supplies and equipment.

After the vaginal birth, the obstetrician dries and stimulates the

baby, but the baby remains limp and apneic. The umbilical cord

is clamped and cut and the baby is moved to the radiant warmer.

You position and suction the mouth and nose while providing brief

additional stimulation, but the baby is still not breathing. You start

positive-pressure ventilation (PPV) while another team member

places a pulse oximeter sensor on the baby's right hand and another

documents the events as they occur. The baby's heart rate is 50 beats

per minute (bpm) and not increasing. You observe that the chest is

not moving with PPV breaths and begin the ventilation corrective

steps. After the first 5 corrective steps, the chest is still not moving

and the heart rate has not improved. A carbon dioxide ( C0 2) detector

placed between the PPV device and mask remains purple with assisted

breaths. You decide to insert an endotracheal tube to improve the

effectiveness of PPV.

Leads are placed on the chest and attached to a cardiac monitor. An

assistant holds a 3.5-mm endotracheal tube, provides cricoid pressure,

and monitors the procedure time while a qualified provider uses a

size 1 laryngoscope to insert the endotracheal tube. A C0 2 detector

is placed on the tube, PPV is resumed, and the detector turns yellow,

indicating that the tube is in the trachea and the lungs are being

ventilated. The baby's chest is moving and the heart rate rapidly

increases. Based on the nasal-tragus length (NTL) measurement,

the endotracheal tube is held with the 8-cm marking adjacent to the

lip. Breath sounds are equal in both axillae, the tube is secured, and

PPV continues. You adjust the oxygen concentration based on pulse

oximetry. The baby still has poor tone and irregular respiratory effort.

You quickly update the parents and transfer the baby to the nursery

for a chest x-ray and post-resuscitation care. Shortly afterward, your

resuscitation team conducts a debriefing to discuss preparation,

teamwork, and communication.

What is an endotracheal tube?

An endotracheal tube (Figure 5.1) is a thin tube that is inserted

through the glottis, between the vocal cords, and advanced into the

trachea. Although digital intubation using only the operator's finger

has been described, endotracheal intubation typically requires the use

of a lighted instrument (laryngoscope [Figure 5.2]) to visualize the

larynx and guide the insertion of the tube between the vocal cords.

When should insertion of an endotracheal tube be

considered?

• Insertion of an endotracheal tube (intubation) is strongly

recommended if the baby's heart rate remains less than 100 bpm and

is not increasing after PPV with a face mask or laryngeal mask.

• Insertion of an endotracheal tube is strongly recommended before

starting chest compressions. If intubation is not successful or

•

: 1

• l •

Fi g u re 5.1. Endotracheal tubes (size 2.5, 3.0, 3.5) Fi g u re 5.2. Laryngoscope

121

122

feasible, and the baby weighs more than approximately 2 kg, a

laryngeal mask may be used.

- Ventilation through an endotracheal tube for 30 seconds may

improve ventilation efficacy and prevent the need to proceed to

chest compressions.

- If chest compressions are needed, ventilation through an

endotracheal tube may improve coordination with compressions.

- Intubation allows the compressor to give compressions from the

head of the bed.

• An endotracheal tube should be inserted for direct tracheal suction

if the trachea is obstructed by thick secretions, for surfactant

administration, and for stabilization of a newborn with a suspected

diaphragmatic hernia.

• If PPV is prolonged, an endotracheal tube may be considered to

improve the efficacy and ease of assisted ventilation.

When endotracheal intubation is needed, it must be performed

without significant delay. A person with intubation skills should be

available to be called for immediate assistance if needed. If the need for

intubation is anticipated, this person should be present in the delivery

room at the time of birth.

What are the important anatomic landmarks in the neonatal

airway?

The anatomic landmarks are labeled in Figures 5.3 and 5.4.

O Esophagus: The passageway extending from the throat to the

stomach

8 Epiglottis: The lid-like structure overhanging the glottis

E) Vallecula: The pouch formed by the base of the tongue and the

epiglottis

C) Larynx: Portion of the airway connecting the pharynx and trachea

0 Glottis: The opening of the larynx leading to the trachea, flanked

by the vocal cords

O Vocal cords: Mucous membrane-covered ligaments on both sides

of the glottis

O Trachea: Portion of the airway extending from the larynx to the

car1na

Glottis

Larynx ---i

--- Thyroid and cricoid cartilage

L--Si-3 .)---:;:::::::::::-Trachea

Carina

Main bronchi

Figure 5.3. Airway anatomy

0 Thyroid and cricoid cartilage: Lower portion of the cartilage

protecting the larynx

O Carina: Where the trachea branches into the 2 main bronchi

E) Main bronchi: The 2 air passageways leading from the trachea to

the lungs

Tengue Vallecula

Esophagus

Figure 5.4. Laryngoscopic view of vocal cords and surrounding structures

123

124

What supplies and equipment should be available f or

intubation?

Intubation supplies and equipment should be kept together and readily

accessible. It is important to anticipate the need for intubation and

prepare the supplies and equipment before a high-risk delivery.

Each delivery room, nursery, and emergency department should have

at least 1 complete set of the following items (Figure 5.5):

O Laryngoscope handle •

• If the handle uses replaceable batteries and bulbs, an extra set

should be available.

8 Laryngoscope blades (straight Miller)*

• No. 1 (term newborn)

• No. O (preterm newborn)

• No. 00 ( optional for extremely preterm newborn)

E) Endotracheal tubes with inside diameters of 2.5, 3.0, and 3.5 mm

• Size 2.0 mm, size 4.0 mm, and tubes with inflatable cuffs are

available and may be considered for specific indications but are

not routinely used during neonatal resuscitation.

8 Stylet ( optional) that fits into the endotracheal tube

0 C0 2 detector

O Suction setup with suction catheters: size lOF or larger (for

suctioning the pharynx), size 8F, and either size 5F or 6F (for

suctioning endotracheal tubes of various sizes that become

obstructed with secretions during resuscitation)

O Waterproof adhesive tape (1/2 or 3/4 inch), or other tube-securing

device

O Measuring tape and/ or endotracheal tube insertion depth table

(Table 5-4)

f) Scissors to cut tape

'A video laryngoscope with an integrated camera that displays a magnified

view of the airway structures on a video screen is an option.

CD) Tracheal aspirator

fD Stethoscope (with neonatal head)

0 Positive-pressure ventilation device (bag or T-piece resuscitator)

and tubing for blended air and oxygen

G, Pulse oximeter, sensor, and cover

4D Laryngeal mask ( size 1) as a rescue airway

• 5-mL syringe if using a laryngeal mask with an inflatable rim

Intubation should be performed as a clean procedure. All supplies

should be protected from contamination by being opened, assembled,

and placed back in their packaging until just before use. The

laryngoscope blades and handle should be cleaned, following your

hospital's procedures, after each use.

When intubation becomes necessary, a cardiac monitor is

recommended for the most accurate assessment of the baby's heart

rate. During resuscitation, auscultation can be difficult and pulse

oximetry may not reliably detect the baby's pulse. A cardiac monitor

is a valuable tool at this point in resuscitation because an increasing

heart rate is a critica} indicator for proper endotracheal tube insertion

and because your decision to proceed with chest compressions after

intubation depends on accurate assessment of the heart rate.

•

,,,

,Q> •

•

l •

1 ...

Figure 5.5. Neonatal airway supplies and equipment. (Supplies removed

from packaging for demonstration purposes.)

125

Figure 5.6. Neonatal endotracheal tube with a uniform diameter (A). This tube has a vocal cord guide that is used

to approximate the insertion depth (B). The tube is inserted so that the vocal cords are positioned in the space between

the double line and single line (indicated by the arrows). The vocal cord guide is only an approximation and may not

reliably predict the correct insertion depth.

126

What type of endotracheal tube should be used?

The endotracheal tube should have a uniform diameter throughout the

length of the tube (Figure 5.6A). Tapered tubes are not recommended

for neonatal resuscitation. Endotracheal tubes have centimeter

markings along the side measuring the distance to the tip of the tube.

Many tubes will also have lines or markings (Figure 5.6B) near the tip

that are intended to be a vocal cord guide. When the tube is inserted

so that vocal cords are positioned between the 2 sets of lines, the tip of

the tube is expected to be above the carina; however, the location and

design of the lines varíes considerably between manufacturers. The

vocal cord guide is only an approximation and may not reliably indicate

the correct insertion depth.

How do you prepare the endotracheal tube?

Select the correct size.

Endotracheal tubes are described by the size of their interna!

diameter (mm ID). The appropriate endotracheal tube diameter is

estimated from the baby's weight or gestational age. Table 5-1 gives

the recommended endotracheal tube size for various weight and

gestational-age categories. Using a tube that is too small increases the

resistance to air flow and the chance that it will become obstructed by

secretions. Using a tube that is too large may traun1atize the airway.

Size 2.0 mm, size 4.0 mm, and tubes with inflatable cuffs are available

and may be considered for specific indications but are not routinely

used during neonatal resuscitation.

Table 5-1. Endotracheal Tube Size for Babies of Various Weights and

Gestational Ages

Weight Gestational Age Endotracheal Tube Size

Below l kg Below 2 8 weeks

1-2 kg 28-34 weeks

Greater than 2 kg Greater than 34 weeks

Consider using a stylet.

Many operators find it helpful to use a stylet

with the endotracheal tube to provide additional

rigidity and curvature (Figure 5.7 A). Use

of a stylet is optional and depends on the

operator's preference. When inserting a stylet,

it is important to ensure that the tip is not

protruding from either the end or side hole of

2.5 mm ID

3.0 mm ID

3.5 mm ID

Stylet tip

Side hole

the endotracheal tube (Figure 5.7B). If the tip

protrudes, it may cause trauma to the tissues. The

stylet should be secured with a plug, or bent at the

top, so that it cannot advance farther into the tube

during the insertion procedure. It is important to

ensure that the stylet is easily removable from the

endotracheal tube because aggressive attempts to

remove the stylet after intubation can accidentally

displace the tube.

Figure 5.7. Optional stylet for increasing endotracheal

tube stiffness and maintaining curvature during intubation

How do you prepare the laryngoscope and other equipment

you will need?

The following steps describe how to prepare the equipment used for

intubation:

O If not already done, attach cardiac monitor leads for accurate

assessment of the baby's heart rate.

f) Select the appropriate laryngoscope blade and attach it to the

handle.

a. Use a No. 1 blade for term newborns.

b. Use a No. O blade for preterm newborns. Sorne operators may

prefer to use a No. 00 blade for extremely preterm newborns.

E) Turn on the light by clicking the blade into the open position to

verify that the batteries and light are working. If the light is dim or

flickers, tighten or replace the bulb, insert a new battery, or replace

127

128

the laryngoscope. If you are using a light-bulb laryngoscope, close

the laryngoscope until ready for use to avoid overheating the light

bulb and blade.

8 Prepare the suction equipment.

a. Occlude the end of the suction tubing to ensure that the suction

is set to 80 to 100 mm Hg.

b. Connect a size lOF (or larger) suction catheter to remove

secretions from the mouth and pharynx.

c. Smaller suction catheters (size 8F and size SF or 6F) should

be available for removing secretions from an obstructed

endotracheal tube, if necessary, after insertion. Appropriate

catheter sizes are listed in Table 5-2.

d. A tracheal aspirator can be attached to the endotracheal tube to

directly suction meconium or thick secretions that obstruct the

trachea. Sorne endotracheal tubes have an integrated suction

port that can be attached directly to suction tubing and do not

require use of a tracheal aspirator.

0 Prepare a PPV device with a mask to ventilate the baby, if

11ecessary, between intubation attempts. Check the operation of the

device as described in Lesson 4.

O Place a C0 2 detector, stethoscope, measuring tape or insertion

depth table, waterproof adhesive tape (1/2 or 3/4 inch) and

scissors, or other tube-securing device within reach.

Table 5-2. Suction Catheter Size for Endotracheal Tubes of Various lnner

Diameters

Endotracheal Tube Size Catheter Size

2.5 mm ID 5F or 6F

3.0 mm ID 6F or 8F

3.5 mm ID 8F

How should you position the newborn for intubation?

Place the baby's head in the midline, the neck slightly extended in the

sniffing position, and the body straight. It may be helpful to place a

small roll under the baby's shoulders to maintain slight neck extension.

This position aligns the trachea for optima! viewing by allowing a

straight line of sight into the glottis once the laryngoscope has been

properly inserted. A team member should help to maintain good

positioning throughout the procedure.

Correct- Line of sight clear (tongue

will be lifted by laryngoscope blade) @ lncorrect - Line of sight obstructed

Fi g

u re 5.8. Correct (A) and incorrect (B and C) positioning for intubation

Both overextension and flexion of the neck will obstruct your view of

the airway. If the shoulder roll is too large or the neck is overextended,

the glottis will be raised above your line of sight. If the neck is flexed

toward the chest, you will be viewing the posterior pharynx and will

not be able to visualize the glottis (Figure 5.8).

Adjust the height of the bed, if possible, so that the baby's head is level

with the operator's upper abdomen or lower chest to bring the head

closer to the operator's eye level and improve the view of the airway.

How do you hold the laryngoscope?

Always hold the laryngoscope in your left hand with your thumb

resting on the upper surface of the laryngoscope handle and the blade

pointing away from you (Figure 5.9). The laryngoscope is designed to

be held in the left hand by both right- and left-handed users. If held

in the right hand, your view through the open, curved portion of the

blade will be obstructed.

How do yo u perf orm the intubation procedure?

The steps for endotracheal intubation are briefly described as

follows; however, proficiency requires considerable supervision and

practice. Even if you are not performing the procedure, it is helpful to

understand the steps so you can effectively assist the operator.

Get ready to insert the laryngoscope.

O Correctly position the baby. If possible, adjust the height of the bed

as needed. You may stabilize the baby's head with your right hand

(Figure 5.10) while a team member ensures that the baby's whole

body is lying straight and the head is in the sniffing position.

f) Use your right index finger or thumb to gently open the baby's

mouth.

g u r e 5.9. Hold the

laryngoscope in your left hand.

129

Fi g u r e 5.1 O. Positioning the baby for intubation

lnsert the laryngoscope and identify key landmarks.

8 Insert the laryngoscope blade in the midline and gently slide it over

the tongue through the oropharynx until the tip lies in the space

between the base of the tongue and the epiglottis. This space is

called the vallecula (Figure 5.11). In extremely preterm newborns,

Tongue

Epiglottis

Fi g u r e 5.11. lnsert the laryngoscope blade in the midline (A) and advance until the tip lies in the vallecula (B).

Hold the laryngoscope in the midline (C) to identify landmarks through the open, curved portien of the laryngoscope

blade (D).

130

the vallecula may be very small and you may need to gently place

the laryngoscope tip directly under the epiglottis.

9 Lift the entire laryngoscope in the direction that the handle is

pointing, opening the mouth and moving the tongue out of the

way to expose the glottis. You may need to tilt the tip of the blade

very slightly to lift the epiglottis and see the glottis and vocal cords.

When first learning the procedure, operators tend to bend their wrist,

pulling the top of the handle toward themselves in a "rocking" motion

against the baby's upper gum. This will not produce the desired view

and may injure the baby's lips and gums (Figure 5.12).

CORRECT INCORRECT

Figure 5. 1 2. Correct (left) and incorrect (right) method for lifting the laryngoscope to expose the larynx. Lift the

laryngoscope in the direction that the handle is pointed; do not rotate or "rock" the handle against the baby's upper gum.

Note: This lesson describes placing the tip of the

blade in the vallecula to lift the epiglottis. In sorne

cases, where the vallecula is small or the epiglottis

is large and floppy, it may be necessary to use the

blade tip to gently lift the epiglottis directly.

0 The vocal cords and glottis appear at the

very top of your view as you look down the

laryngoscope. An assistant can help bring the

glottis into view by using their thumb and first

finger to provide gentle pressure on the baby's

thyroid and cricoid cartilage (Figure 5.13).

They should direct the pressure downward and

toward the baby's right ear.

0 Identify the key landmarks (Figure 5.14). If the

tip of the blade is correctly positioned in the

vallecula, you should see the epiglottis hanging

Figure 5. 1 3. Thyroid and cricoid pressure provided

by an assistant may improve visualization of the vocal

cords and glottis. Press downward and toward the baby's

right ear.

131

Fi g u r e 5.1 S. Corrective actions

for poor visualization of landmarks

during laryngoscopy

132

clown from the top and the vocal cords directly below. The vocal

cords appear as thin vertical stripes in the shape of an inverted

letter «y

Laryngoscope -

blade

Esophagus

Epiglottis

Vocalcord

Fi g u r e 5.14. Key landmarks. The baby is lying supine. The

laryngoscope blade is at the top of the photo, holding the tongue

up and out of the way.

If these structures are not immediately visible, adjust the blade until

the structures come into view. You may need to insert or withdraw the

blade slowly to see the vocal cords (Figure 5.15).

Problem

Laryngoscope not

inserted far enough.

-.. "V

....,

,..

Laryngoscope inserted

too far.

Laryngoscope inserted

off to one side.

Landmarks

You see the tongue

surrounding the blade.

'",/,

You see the walls

of the esophagus

surrounding the blade.

You see part of the glottis

off to one side of the blade.

Corrective Action

Advance the blade

farther.

""'-

,&,,·•¼!!)

,__

Withdraw the blade

slowly until the epiglottis

and glottis are seen.

Gently move the blade back

to the midline. Then advance

or retreat according to

landmarks seen.

If the blade is not inserted far enough, you will see the base of the

tongue and posterior pharynx (Figure 5.16). Advance the blade slightly

until the epiglottis comes into view.

If the blade is inserted too far, you will see only the esophagus

(Figure 5.17) and will need to withdraw the blade slightly until the

epiglottis drops down from above.

Fi g

u re S. 1 6. Laryngoscope not

inserted far enough. Tongue and

posterior pharynx obscure view.

Fi g

u re S. 1 7. Laryngoscope

inserted too far. Only the esophagus

is visible.

If the anatomic landmarks are obstructed by

secretions, use a size lOF or 12F catheter to

remove secretions from the mouth and pharynx

(Figure 5.18).

lnsert the endotracheal tube.

O Once you have identified the vocal cords, hold

the laryngoscope steady and maintain your view

of the vocal cords, while an assistant places the

endotracheal tube in your right hand. Insert

Figure 5.18. Suctioning

secretions duri ng laryngoscopy

the tube into the right side of the baby's mouth,

outside the blade, with the concave curve in the

horizontal plane (Figure 5.19). Do not insert the

tube through the laryngoscope's open channel.

This will obstruct your view of the vocal cords.

Fi g ur e 5.19. lnsertion of the endotracheal tube into

the right side of the mouth

Pass the tube along the right side of the baby's

mouth toward the vocal cords. As the tip approaches the vocal cords,

rotate the tube's curvature into the vertical plane so the tip is directed

upward. When the vocal cords open, insert the tube until the vocal

cords are positioned between the marked guide lines on the tube. If

your assistant is providing gentle thyroid and cricoid pressure, they

may feel the tube pass beneath their fingers. Note the centimeter depth

marking on the outside of the tube that aligns with the baby's upper lip.

If the vocal cords are closed, wait for them to open. Do not touch the

closed cords with the tip of the tube and never try to force the tube

133

between closed cords. If the cords do not open within 30 seconds, stop

and resume ventilation with a mask until you are prepared to reattempt

insertion.

Secure the endotracheal tube.

0 Use your right index finger to hold the tube securely against the

baby's hard palate. Carefully remove the laryngoscope without

displacing the tube (Figure 5.20). If a stylet was used, an assistant

should remove it from the endotracheal tube-being sure that

you are holding the tube in place (Figure 5.21). Although it is

important to hold the tube firmly, be careful not to squeeze the

tube so tightly that the stylet cannot be removed.

Fi g u r e 5.20. Stabilize the tube against the

baby's palote or cheek while carefully removing the

la ryngoscope.

Fi g

u r e 5.21. An assistant removes the optional stylet

while the operator holds the tube in place.

Figure 5.22. Attach a C0 2 detector and PPV device

to the endotracheal tube and begin ventilation. Note the

secure hand position used to hold the endotracheal tube

in place.

134

Ventilate through the endotracheal tube.

O An assistant should attach a C0 2 detector and

PPV device to the endotracheal tube (Figure 5.22).

Having the same person hold the endotracheal

tube and the PPV device may help to avoid

accidental extubation. Once the PPV device is

attached, begin ventilation through the tube.

How much time should be allowed

f or an intubation attempt?

The steps of intubation should be

completed within approximately

30 seconds. Effective teamwork is

required to perform this procedure

Start

30 Seconds

quickly. The baby is not being ventilated during the procedure, so

rapid action is essential. If the baby's vital signs worsen during the

procedure (severe bradycardia or decreased oxygen saturation), it

is usually preferable to stop, resume PPV with a mask, and then try

aga1n.

Repeated attempts at intubation are not advised because you will

increase the likelihood of soft-tissue trauma and make subsequent

airway management more difficult. If the initial attempts are

unsuccessful, evaluate other options, including using a video

laryngoscope if available, requesting assistance from another provider

with intubation expertise ( eg, anesthesiologist, emergency department

physician, respiratory care practitioner, neonatal nurse practitioner,

physician's assistant), inserting a laryngeal mask, or continuing

face-mask ventilation.

How do you confirm that the endotracheal tube is in the

trachea?

The primary methods of confirming endotracheal tube insertion

within the trachea are detecting exhaled C0 2 and a rapidly rising

heart rate. As soon as you insert the endotracheal tube, connect a

C0 2 detector (Figure 5.22) and confirm the presence of C0 2 during

exhalation. If the tube is correctly inserted and you are providing

effective ventilation through the tube, you should detect exhaled C0 2

within 8 to 10 positive-pressure breaths.

There are 2 types of C0 2 detectors available. Colorimetric devices

change color in the presence of C0 2 (Figure 5.23). These are the

most commonly used devices in the delivery room. Capnographs are

electronic monitors that display the C0 2 concentration with each

breath.

Can the tube be in the trachea even though (0 2 is NOT

detected?

Yes, there are limitations to the use of C0 2 detectors. If the tube is

inserted in the trachea, but the lungs are not adequately ventilated,

there may not be enough exhaled C0 2 to be detected. This may

occur if the endotracheal tube or trachea are obstructed by

secretions, you are not using enough ventilating pressure, or there

are large bilateral pneumothoraces and the lungs are collapsed. In

addition, babies with a very low heart rate or decreased cardiac

function (low cardiac output) may not carry enough C0 2 to their

lungs to be detected.

Fig ure 5.23. The colorimetric

C02 detector is purple or blue

before detecting exhaled C02 (A).

The detector turns yellow in the

presence of exhaled C02

(B).

13S

136

Can the (0 2 detector change color when the tube is NOT in

the trachea?

Although uncommon, it is possible for a colorimetric C0 2 device to

change color even though the tube is not in the trachea (Table 5-3).

If the detector has already changed color in the package and is yellow

when you remove it, the device is defective and should not be used.

If epinephrine, surfactant, or atropine are administered through the

endotracheal tube and touch the paper inside the C0 2 detector, or if

gastric secretions touch the paper, they may permanently change the

screen yellow and make the detector unusable.

Table 5-3. Colorimetric C02 Detector Problems

False Negative

(Tube IS IN trachea

but NO color change)

• lnadequate ventilating pressure

• Collapsed lungs

• Bilateral pneumothoraces

• Very low heart rote

• Low cardiac output

• Obstructed endotracheal tube

False Positive

(Tube IS NOT in trachea

but color changes)

• Defective device changed color in

package before use

• Epinephrine, surfactant, atropine,

or gastric secretion contamination

What are other indicators that the tube is in the trachea?

Demonstrating exhaled C02 and observing a rapidly increasing heart

rate are the primary methods of confirming endotracheal tube insertion

within the trachea.

If the tube is positioned correctly, you should also observe

• Audible and equal breath sounds near both axillae during PPV

• Symmetrical chest movement with each breath

• Little or no air leak from the mouth during PPV

• Decreased or absent air entry over the stomach

Be cautious when interpreting breath sounds in newborns because

sounds are easily transmitted. When listening to breath sounds, use a

small stethoscope and place it near the axilla. A large stethoscope, or

one placed near the center of the chest, may transmit sounds from the

esophagus or stomach.

What if you suspect that the tube is not in the trachea?

The tube is not likely to be in the trachea if the C0 2 detector <loes

not show the presence of exhaled C0 2 within 8 to 1 O breaths. An

endotracheal tube inserted in the esophagus provides no ventilation

to the baby's lungs, and continuing to use it only delays effective

ventilation. In most cases, you should remove the tube, resume

ventilation with a face mask, ensure that your equipment is properly

prepared, ensure that the baby is optimally positioned, and repeat the

procedure using a clean tube.

Remember that babies with a very low heart rate or decreased cardiac

function may not carry enough C0 2 to their lungs to change the color

on the C0 2 detector. If you believe that the tube is correctly inserted in

the trachea despite the lack of exhaled C0 2, you may choose to stabilize

the tube, reinsert the laryngoscope, and attempt to confirm that the

tube is passing betwee11 the vocal cords. This "second look,, procedure

can be difficult and may delay establishing effective ventilation if the

tube is not correctly inserted. If the tube position is confirmed and

the baby's heart rate <loes not improve with ventilation through the

endotracheal tube, chest compressions are indicated. Once cardiac

output is improved, C0 2 will be detected.

How deeply should the tube be inserted in the trachea?

The goal is to insert the endotracheal tube tip in the middle portion

of the trachea. This generally requires inserting the tube so that the

tip is only 1 to 2 centimeters below the vocal cords. It is important not

to insert the tube too far so that the tip touches the carina or enters a

main bronchus. Two methods may be used for estimating the insertion

depth. Your team should determine which method is preferred in your

practice setting.

The nasal-tragus length (NTL) is a method that has been validated

in both full-term and preterm newborns. The NTL method uses a

calculation based on the distance ( cm) from the baby,s nasal septum

to the ear tragus (Figure 5.24). Use a measuring tape to measure the

NTL. The estimated insertion depth (cm) is NTL + 1 cm. Insert the

endotracheal tube so that the marking on the tube corresponding to

the estimated insertion depth is adjacent to the baby's lip.

137

Figure 5.24. Measuring the NTL. Measure from the middle of the nasal septum (arrow, A) to the ear tragus

(arrow, B) and add 1 cm to the measurement.

138

Studies have shown that gestational age is also an accurate predictor

of the correct insertion depth (Table 5-4) and has the advantage of

being known before birth. This table could be placed near the radiant

warmer or with your intubation supplies.

Table 5-4. lnitial Endotracheol Tube lnsertion Depth ("Tip to Lip") for

Orotracheal lntubation

Endotracheal Tube

Gestation lnsertion Depth al Lips Baby's Weight

23-24 weeks 5.5 cm 0.5-0.6 kg

25-26 weeks 6.0 cm 0.7-0.8 kg

27-29 weeks 6.5 cm 0.9-1 kg

30-32 weeks 7.0 cm 1 . 1-l .4 kg

33-34 weeks 7.5 cm 1.5-l.8kg

35-37 weeks 8.0 cm 1.9-2.4 kg

38-40 weeks 8.5 cm 2.5-3. l kg

41-43 weeks 9.0 cm 3.2-4.2 kg

Adapted from Kempley ST, Moreiras JW, Petrone FL. Endotracheal tube length for neonatal

intubation. Resuscitation. 2008 ;77(3) :369-373.

Remember that both of these methods are estima tes of the correct

endotracheal tube depth. After inserting the tube, use a stethoscope

to listen for breath sounds in both axillae and over the stomach

(Figure 5.25).

• If the tube is correctly positioned, the breath sounds should be equal

on both sides.

• If the tube is in too far, the breath sounds may be decreased on one side.

- Most often, if the tube is inserted too far, it will en ter the right

mainstem bronchus causing breath sounds to be louder on the

right side and quieter on the left side. Slowly withdraw the tube

while listening to the breath sounds on the quieter side.

- When the tube is correctly positioned, the breath sounds should

improve and become equal.

Figure 5.25. Listen for equal breath sounds in both axillae (A). Breath sounds should not be audible over the

stomach (B).

lf you plan to keep the tube in place, how do you secure it?

Severa} methods of securing the tube have been described. Either

water-resistant tape ora device specifically designed to secure an

endotracheal tube may be used.

One method is described as follows:

O After you have correctly positioned the tube, note the centimeter

marking on the side of the tube adjacent to the baby's upper lip

(Figure 5.26).

f) Cut a piece of 3/4- or 1/2-inch tape so that it is long enough to

extend from one side of the baby's mouth, across the upper lip, and

about 2 cm onto the opposite cheek (Figure 5.27).

8 Split the tape along half its length so that it appears like a pair of

pants (Figure 5.27 A).

8 Place the un cut section of tape on the baby's

cheek so that the beginning of the split is close

to the corner of the baby's mouth. Place the

upper «leg,, of tape across the baby's upper lip

(Figure 5.27B).

0 Carefully wrap the lower «leg,, around the tube

(Figures 5.27C and 5.27D). Be sure that the

desired centimeter marking remains next to

the baby's upper lip. It is easy to inadvertently

push the tube in farther than desired during the

taping procedure. Figure 5.26. Note the marking adjacent to the

upper lip.

139

Figure 5.27. Split the tape a long half its length (A).

Place the uncut section on the baby's cheek close to the

corner of the mouth and the upper "leg" of tape above the

baby's lip (B). Wrap the lower "leg" of tape around the

tube (C and D). Leave a small tab of tape folded over at

the end to assist removal (E).

140

O At the end, turn the tape onto itself to leave a small "tab" that you

can hold to unwind the tape when you want to adjust the insertion

depth or remove the tube (Figure 5.27E).

fj Listen with a stethoscope over both sides of the chest to be sure

the tube has not been displaced. Assess color change on the C0 2

detector and rise and fall of the chest with each assisted breath.

0 If the tube will be left in place beyond the initial resuscitation,

obtain a chest x-ray for fi11al placement confirmation

The tip of the tube should appear

in the mid-trachea adjacent to the

first or second thoracic vertebra

(Figure 5.28). The tip should be

above the carina, which is generally

adjacent to the third or fourth

thoracic vertebra. Avoid using the

clavicles as a landmark because their

location varíes depending upon the

baby's position and the angle that the

x-ray is taken. If the tube advanced

too far, it may touch the carina or

enter the right main bronchus and

cause the right upper lobe or left

lung to collapse (Figure 5.29).

Figure 5.28. Correct placement.

The tip of the endotracheal tube

is adjacent to the second thoracic

vertebra.

What can an assistant do to help the operator during the

intubation procedure?

Effective teamwork is required to complete the intubation procedure

quickly and efficiently. A skilled assistant can perform multiple

steps that improve teamwork, shorten the duration of the intubation

procedure, and increase the likelihood of first-attempt success.

O Check that the laryngoscope is working.

f) Check that suction is set at 80 to 100 mm Hg.

E) Prepare the tape or tube-securing device.

8 Attach chest leads and begin cardiac monitoring if not already

done.

0 Ensure that the correct-sized laryngoscope blade and endotracheal

tube are selected based on the newborn's expected gestational age

or weight.

O Communicate with the operator about what method will be used

to estímate the endotracheal tube insertion depth-the NTL or the

estimated insertion depth table.

O Check that the stylet, if used, <loes not protrude beyond the tube's

side or end hole.

O Ensure that the newborn and bed are correctly positioned before

starting the procedure and maintained in the correct position

throughout the procedure.

Figure 5.29. lncorrect

placement. The tip of the

endotracheal tube is inserted

too far. lt is touching the carina,

approaching the right mainstem

bronchus, and the left lung is

collapsed.

141

142

O Hold equipment and pass as directed so that the operator <loes not

need to look away from anatomic landmarks to suction secretions

or grasp the tube in preparation for insertion.

E) Monitor the newborn's heart rate and alert the operator if the

intubation attempt lasts longer than 30 seconds.

4D Provide thyroid and cricoid pressure as directed.

0 After endotracheal tube insertion, carefully remove the stylet and

attach the C0 2 detector.

O, Listen for increasing heart rate and assess C0 2 detector color change.

4D Check the tip-to-lip insertion depth.

G, Listen for breath sounds in both axillae and assess chest movement

with PPV.

Assist with securing the tube.

How do you use an endotracheal tube to suction thick

secretions f rom the trachea?

If a baby's condition has not improved and you have not been able to

achieve chest movement despite all the ventilation corrective steps and

a properly i11serted e11dotracheal tube, there may be thick secretions

obstructing the airway. Thick secretions may be from blood, cellular

debris, vernix, or meconium. You may attempt to clear the airway using

a suction catheter inserted through the endotracheal tube (Table 5-2).

If you cannot quickly clear the airway with the suction catheter, you

may be able to clear the airway by applying suction directly to the

endotracheal tube using a tracheal aspirator. Although this device

is often called a meconium aspirator, it may be used for any thick

secretions that are obstructing the airway.

Once the endotracheal tube has been inserted,

O Connect a tracheal aspirator, attached to a suction source

(80-100 mm Hg suction), directly to the endotracheal tube

connector. Several types of tracheal aspirators are commercially

available. Sorne endotracheal tubes have an integrated suction port.

f) Occlude the suction-control port on the aspirator with your

finger and gradually withdraw the tube over 3 to 5 seconds as you

continue suctioning secretions in the trachea (Figure 5.30).

E) Be prepared to resume face-mask PPV, inserta laryngeal mask, or

re-intubate with a clean tube.

How many times should suctioning be repeated if thick

secretions prevent yo u f rom achieving eff ective ventilation

through an endotracheal tube?

If the airway is obstructed by secretions that have prevented you from

achieving effective ventilation, you must repeat the procedure until

you have cleared the airway sufficiently to intlate the lungs and achieve

effective ventilation.

What problems should you consider if a baby' s condition

worsens after endotracheal intubation?

If a baby's condition suddenly worsens after intubation, the

endotracheal tube may be inadvertently displaced. It may have been

advanced too far into the airway or pulled back into the pharynx and

outside the trachea. The tube may be obstructed by blood, meconium,

or other thick secretions. The baby may have developed a tension

pneumothorax that collapses the lungs and prevents gas exchange.

Additional information about this complication is discussed in Lesson

10 (Special Considerations). Finally, the device used to provide

PPV may have become disconnected from the endotracheal tube or

compressed gas source, or it may have developed a leak.

The mnemonic "DOPE" can be used to help remember these potential

problems (Table 5-5).

Focus on Teamwork

Inserting an endotracheal tube highlights several opportunities for

effective teams to use the Neonatal Resuscitation Program® (NRP

®) Key

Behavioral Skills.

Behavior Example

Figure 5.30. Suctioning thick

secretions that obstruct ventilation

using an endotracheal tube and

tracheal aspirator

Table 5-5. Sudden

Deterioration After lntubation

The DOPE mnemonic

D Displaced endotracheal tube

o Obstructed endotracheal tube

p Pneumothorax

E Equipment failure

Adapted from Kleinman ME,

Chameides L, Schexnayder SM, et al.

Part 14: Pediatric advanced life support:

201 O American Heart Association

Guidelines for Cardiopulmonary

Resuscitation and Emergency

Cardiovascular Care. Circulation.

201 O; 122(18 Supp/):5876-5908.

Call for additional lf unanticipated intubation is required, you will likely need 3 or more health care providers to

help when needed. quickly perform ali of the required tasks without delay.

Communicate When preparing to insertan alternative airway, clearly and calmly request the desired

effectively. supplies.

Maintain professional Confirm the insertion depth with your team members before securing the tube.

behavior.

Delegate workload Determine which team member(s} will perform important tasks such as inserting the endotracheal

optimally. tube, providing thyroid and cricoid pressure, monitoring the baby's heart rote, placing the C0 2

detector, auscultating breath sounds, assisting with securing the tube, and documenting events.

Allocate attention Maintain situation awareness. At ali times, a team member needs to be monitoring the baby's

wisely. condition, the number of insertion attempts, the duration of insertion attempts, and alerting

the operators to any important changes (eg, heart rote, oxygen saturation).

143

Behavior Example

Use available

resources.

144

lf an alternative airway is needed, but initial intubation attempts are unsuccessful, do not

make repeated intubation attempts. Use your other resources, such as another individual

with intubation expertise, a laryngeal mask, or a video laryngoscope.

Allow all team members to use their unique skills during the resuscitation process. For

example, respiratory therapists may hove valuable skills specific to intubation. Using the

respiratory therapist's skills during intubation may allow another provider to focus attention

on preparing equipment for vascular access and medications.

Quality lmprovement Opportunities

Ask yourself the following questions and begin a discussion with your

team if you find a difference between the NRP recommendations and

what is currently done in your own hospital setting. Consider using the

suggested process and outcome measures to guide your data collection,

identify areas for improvement, and monitor if your improvement

efforts are working.

Quality improvement questions

O Who is responsible for checking and preparing intubation supplies

and equipment befo re every birth?

f) Who are the providers that have intubation skills in your delivery

room setting?

E) Is someone with intubation skills immediately accessible if needed?

8 How often do providers practice their intubation skills?

0 Do assistants know how to measure and secure an endotracheal

tube?

Process and outcome measures

O How often are newborns intubated in your delivery room setting?

f) When intubation is required, how often is a skilled provider

present at the time of birth?

E) How often is intubation successful on the first attempt?

8 How often <loes intubation require more than 30 seconds?

0 How often do adverse events occur during intubation?

Frequently Asked Questions

Why should I insert an endotracheal tube before starting chest

compressions? Does that just delay the initiation of chest compressions?

In most situations, this program recommends inserting an

endotracheal tube prior to starting chest compressions to ensure

maximum ventilation efficacy both before and after chest compressions

begin. In many cases, the baby's heart rate will increase during the

30 seconds of ventilation following intubation and compressions will

not be necessary.

Can the provider with intubation skills be on call outside the hospital or in

a distant location?

No. A person with intubation skills should be in the hospital and

available for immediate assistance if needed. If the need for intubation

is anticipated, this person should be present in the delivery room at the

time of birth. It is not sufficient to have someone on call at home or in

a remote area of the hospital.

Should sedative premedication be used before intubation?

When emergency intubation is performed as part of resuscitation,

there is generally insufficient time or vascular access to administer

sedative premedication. This program focuses on resuscitation of the

newly born baby and, therefore, the details of premedication are not

included. Premedication is recommended for non-emergent intubation

in the neonatal intensive care unit (NICU).

Can a video laryngoscope be useful for neonatal intubation?

Yes, a video laryngoscope may be a helpful device for training novice

operators and for intubating a baby with a difficult airway. A video

laryngoscope is a laryngoscope that has an integrated camera that

displays a magnified view of the airway structures on a video screen.

Several different types are available, including devices that are

shaped like a traditional laryngoscope and others that have a more

pronounced curve. When using a video laryngoscope, an instructor

can watch the video screen and see what the trainee is seeing directly

through the laryngoscope. This allows the instructor to give advice and

feedback and confirm that the operator has inserted the tube into the

glottis. Studies have shown that trainees have improved first-attempt

intubation success when guided by an instructor using a video

laryngoscope. Sorne video laryngoscopes have a recording function

that can be used for debriefing after the procedure is completed. For

14S

146

a newborn with a difficult airway, a video laryngoscope may allow

the operator to see the airway structures more easily with less airway

manipulation. Using a video laryngoscope <loes require training and

practice, and the smallest blade 011 sorne video laryngoscopes is too

lar ge f or very premature newborns.

LESSON S REVIEW

1. A newborn has been receiving face-mask ventilation but is

not improving. Despite performing the first 5 ventilation

corrective steps, the heart rate is not rising and there is poor

chest movement. An alternative airway, such as an endotracheal

tube ora laryngeal mask, (should)/(should not) be inserted

immediately.

2. For babies weighing less than 1 kg, the recommended

endotracheal tube size is (2.5 mm)/(3.5 mm).

3. If using a stylet, the tip of the stylet (must)/(must not) extend

beyond the endotracheal tube's side and end holes.

4. The preferred laryngoscope blade size for use in a term newborn

is (No. 1)/(No. O).

5. In the photograph, which arrow is pointing to the epiglottis?

6. You should try to take no longer than (30)/(60) seconds to

complete the endotracheal intubation procedure.

7. If a baby's condition worsens after endotracheal intubation, list 4

possible causes.

l.____ , 2. ____ , 3. _____ , 4. ____ _

8. Which image shows the correct way to lift the tongue out of the

way and expose the larynx?

9. You have inserted an endotracheal tube and are giving

positive-pressure ventilation through it. The C02 detector does

not change color and the baby's heart rate is decreasing. The

tube is most likely inserted in the (esophagus)/(trachea).

10. The 2 most important indicators that the endotracheal tube

has been inserted in the trachea are demonstrating exhaled

____

and observing a rapidly increasing _______ .

11. You have inserted a laryngoscope and are attempting intubation.

You see the view depicted in the following illustration. The

correct action is to (advance the laryngoscope farther)/

(withdraw the laryngoscope).

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148

Answers

1. An alternative airway, such as an endotracheal tube or a

laryngeal mask, should be inserted immediately.

2. For babies weighing less than 1 kg, the recommended

endotracheal tube size is 2.5 mm.

3. The tip of the stylet must not extend beyond the endotracheal

tube's side and end holes.

4. The preferred laryngoscope blade size for use in a term newborn

is No. l.

5. Arrow A is pointing to the epiglottis.

6. You should try to take no longer than 30 seconds to complete

the endotracheal intubation procedure.

7. Possible causes include (1) displaced endotracheal tube,

(2) obstructed endotracheal tube, (3) pneumothorax,

( 4) equipment failure.

8. Image A shows the correct way to lift the tongue out of the way

and expose the larynx.

9. The tube is most likely inserted in the esophagus.

1 O. The 2 most important indicators that the endotracheal tube

has been inserted in the trachea are demonstrating exhaled

C02 (C02 detector changes to yellow) and observing a rapidly

increasing heart rate.

11. The correct action is to advance the laryngoscope farther.

LESSON S: PRACTICE SCENARIOS

Endotracheal lntubation

Learning Objectives

O Identify the newborn that requires endotracheal intubation.

f.) Demonstrate preparation for intubation, including choosing the

correct-sized tube for the newborn's estimated weight.

8 Demonstrate correct technique for inserting an endotracheal tube

(operator).

8 Demonstrate the role of the assistant during intubation.

0 Demonstrate strategies to determine if the endotracheal tube is

in the trachea, including increasing heart rate, color change of

carbon dioxide ( C0 2) detector, bilateral breath sounds, and chest

movement with positive-pressure ventilation (PPV).

O Demonstrate how to use a tracheal aspirator to suction thick

secretions from the trachea.

O List pertinent Neonatal Resuscitation Program (NRP) Key

Behavioral Skills related to successful endotracheal intubation.

These Practice Scenarios are for review / practice and evaluation.

This is the suggested Practice Scenario sequence.

O Review the Knowledge Check Questions with your NRP

instructor.

a. What are the indications for endotracheal intubation during

resuscitation?

b. How do you determine what size endotracheal tube should be

used for various gestational ages and weights?

c. What 2 strategies can be used to determine depth of insertion

of the endotracheal tube?

d. What are the primary indicators that determine correct

insertion of the endotracheal tube? What additional indicators

can be used?

149

150

e. What is the role of the assistant duri11g intubation?

f. What are indications for an obstructed airway and what is the

recommended intervention?

f.) Practice/review these skills with your NRP instructor.

a. Locate and assemble the supplies and equipment needed for

intubation, including the cognitive aids available to help you,

such as the endotracheal tube size chart for babies of various

ages and weights and the chart of initial endotracheal tube

insertion depth, if used.

b. Practice or assist with the steps of intubation, including PPV

delivery and assessing proper insertion of the endotracheal tube

in the trachea.

c. Practice your unit's method for securing the endotracheal tube

in the delivery room.

d. Practice using a suction catheter and/ or tracheal aspirator in

case thick secretions obstruct the airway.

Q Practice the scenario(s) as the individual who intubates the

newborn or as the assistant until you need little or no assistance

or coaching.

O Pass the Lesson 5 Practice Scenario evaluation by leading practice

scenario(s) and performing intubation as the operator or the

assistant.

0 When you can lead the scenario(s) and perform the skills with little

or no instructor coaching, you may proceed to the next lesson's

practice scenario.

Practice Scenarios

Two scenario options are offered. The number of people attending

the birth scenarios and their qualifications are determined by the

instructor and based on hospital policy.

O Term newborn with risk factors requires endotracheal intubation

f.) Newborn of 37 weeks' gestation with risk factors requires

intubation and tracheal aspiration for suspected airway obstruction

Option 1 : Term newborn with risk factors requires endotracheal intubation

"You are called to attend a birth complicated by a Category III fetal heart rate pattern. The laboring mother

is a 28-year-old primigravida at 39 weeks' gestation. Demonstrate how you would prepare for the birth of this

baby. As you work, say your thoughts and actions aloud so I will know what you are thinking and doing."

Critical Performance Steps

Assess perinatal risk.

Assesses perinatal risk (learner asks 4 pre-birth questions and the instructor [

0B provider

] responds)

Gestational age? "39 weeks' gestation."

Clear fluid? "Amniotic fluid is clear."

Additional risk factors? "Mom has a fever."

Umbilical cord management plan? "1 will delay cord clamping. lf the baby is not crying, 1'11 take a moment to

stimulate the baby. lf there's no response, 1'11 clamp and cut the cord."

Assemble team.

Assembles team based on perinatal risk factors.

lf risk factors are present, at least 2 qualified people should be present solely to manage the baby.

The number of team members and qualifications vary depending on risk.

Perform a pre-resuscitation briefing:

ldentifies team leader.

Assesses risk factors, delegates tasks, identifies who will document events, determines supplies and equipment

needed, knows how to call for additional help.

Perform equipment check (includes checking supplies and equipment for intubation).

"The baby has been born."

Rapid evaluation.

Asks 3 rapid evaluation questions:

• Term? "Appears term."

• Muscle tone? "No tone."

• Breathing or crying? "No breathing."

lnitial steps at radiant warmer.

Receives baby at radiant warmer, dries and removes linen, stimulates briefly by rubbing the baby's back,

positions airway, suctions mouth and nose

Assess breathing. lf breathing, assess heart rote.

Is the baby breathing? "No." (Heart rote per auscultation = 40 bpm, if assessed)

lndicates need for PPV

Begin PPV within 60 seconds of birth.

Positions head in sniffing position

Applies mask correctly

Starts PPV in 21 % oxygen (room air) at 20 to 25 cm H20 (positive end-expiratory pressure [PEEP] of 5 cm H20

if using T-piece resuscitator, flow-inflating bag, or self-inflating bag with PEEP valve); rote 40 to 60 breaths/min

Requests pulse oximeter sensor placement on baby's right hand or wrist

151

Critical Performance Steps (cont)

Requests cardiac monitor (optional at this time)

Within 15 seconds of beginning PPV, learner asks assistant to state heart rote and if it is increasing.

Heart rate = 40 bpm and not increasing "Pulse oximeter has no signal."

Asks assistant to assess chest movement

"No chest movement."

Perform ventilation corrective steps (MR. SOPA).

Performs M and R, S and O, and P steps; assesses for increasing heart rote and chest movement after PPV

following each step

Heart rote= 40 bpm and not increasing.

"No chest movement." "Pulse oximeter has no signal."

Places cardiac monitor leads and connect to monitor in anticipation of intubation (if not already done).

Preparation for intubation. (Most of these tasks are included in the pre-birth equipment check.)

Operator (lntubator) Operator's Assistant

Prepares for intubation • Ensures suction set at 80 to l 00 mm Hg

• Requests correct-sized tube • Selects correct-sized tube

• Requests correct-sized laryngoscope blade • Chooses correct laryngoscope blade (size l [term],

• Communicates preference for stylet usage size O [preterm])

• Checks laryngoscope light

• lnserts stylet correctly (stylet optional}

• Obtains C0 2 detector

• Prepares tape or tube-securing device

lntubating the newborn.

Operator (lntubator) Operator's Assistant

• Holds laryngoscope correctly in left hand • Positions newborn's head in sniffing position, body

• Opens baby's mouth with finger and inserts blade to straight, table at correct height for operator

base of tongue • Monitors heart rote and announces if attempt lasts

• Lifts blade correctly (no rocking motion) longer than 30 seconds

• Requests cricoid pressure if needed • Applies cricoid pressure if requested

• ldentifies landmarks, takes corrective action to • Hands endotracheal tube to operator

visualize glottis if needed

• lnserts tube from right side, not down center of

laryngoscope blade

• Aligns vocal cord guide with vocal cords

• Removes laryngoscope then removes stylet while • Removes stylet (if used)

firmly holding tube against baby's palote • Connects C0 2 detector and PPV device to

• Holds tube against baby's palote endotracheal tube

• Hands PPV device to operator

Positive-pressure ventilation and confirming endotracheal tube insertion.

• Administers PPV • Auscultates for increasing heart rote and assesses

• Observes for symmetrical chest movement C0 2 detector color change

• Listens for bilateral breath sounds, notes symmetrical

chest movement with PPV, and reports findings

152

Critical Performance Steps (cont)

lf endotracheal tube is not successfully inserted,

"Color is not changing on the C0 2 detector. The chest is not moving."

Heart rate = 60 bpm and not increasing

• Removes endotracheal tube

• Resumes PPV by face mask

• Repeats intubation attempt or indicates need for laryngeal mask

lf endotracheal tube successfully inserted,

"Color is changing on the C0 2 detector." Heart rate slowly increases to about 70 bpm.

• Operator continues PPV x 30 seconds

• Assistant checks tip-to-lip depth using gestational age/weight table or nasal-tragus length (NTL} measurement.

- lf using NTL, measures distance from the nasal septum to the ear tragus (insertion depth [cm]= NTL + 1 cm)

• Assistant secures endotracheal tube

Vital signs.

Checks heart rote after 30 seconds of PPV through endotracheal tube

"Baby is apneic. Pulse oximeter has a signal now."

Heart rote = 70 bpm and increasing SP02 = 67%

Continues PPV and adjusts oxygen concentration per pulse oximetry

Checks heart rote after 30 seconds of PPV

"Baby is apneic." Heart rote is > 100 bpm and increasing 5Po2 = 72% and increasing slowly

End scenario.

Supports baby with PPV and supplemental oxygen per Target Oxygen Saturation Table.

Monitors heart rote, respiratory effort, oxygen saturation, activity, temperature.

Prepares to move baby to post-resuscitation care setting.

Communicates with perinatal team.

Updates parents and informs them of next steps.

Option 2: Newborn of 37 weeks' gestation with risk factors requires intubation and tracheal aspiration for

suspected airway obstruction

"You are called to attend a birth complicated by a Category III fetal heart rate pattern. The laboring mother

is a 39-year-old primigravida at 37 weeks' gestation. Demonstrate how you would prepare for the birth of this

baby. As you work, say your thoughts and actions aloud so I will know what you are thinking and doing."

Critical Performance Steps

Assess perinatal risk.

Assesses perinatal risk (learner asks 4 pre-birth questions and instructor ["OB provider"] responds)

Gestational age?

Clear fluid?

Additional risk factors?

"37 weeks' gestation."

"Amniotic fluid is clear."

"Category 111 fetal heart rote pattern and maternal chronic hypertension."

Umbilical cord management plan? "I will delay cord clamping. lf the baby is not crying, 1'11 take a moment to

stimulate the baby. lf there's no response, 1'11 clamp and cut the cord."

153

Critical Performance Steps (cont)

Assemble team.

Assembles team based on perinatal risk factors.

lf risk factors are present, at least 2 qualified people should be present solely to manage the baby.

The number of team members and qualifications vary depending on risk.

Perform a pre-resuscitation briefing.

ldentifies team leader.

Assesses risk factors, delegates tasks, identifies who will document events, determines supplies and equipment

needed, knows how to call for additional help.

Perform equipment check (includes checking supplies and equipment to prep for intubation).

"The baby has been born."

Rapid evaluation.

Asks 3 rapid evaluation questions:

• Term? "Appears about 37 weeks' gestation as expected."

• Muscle tone? "No tone."

• Breathing or crying? "No breathing."

lnitial steps at radiant warmer.

Receives baby at radiant warmer, dries and removes linen, stimulates briefly by rubbing the baby's back,

positions airway, suctions mouth and nose

Assess breathing. lf breathing, assess heart rote.

Is the baby breathing? "No." (Heart rate=40 bpm, if assessed)

lndicates need for PPV

Begin PPV within 60 seconds of birth.

Positions head in sniffing position

Applies mask correctly

Starts PPV in 21 % oxygen (room air) at 20 to 25 cm H20 (PEEP of 5 cm H20 if using T-piece resuscitator or

flow-inflating bag, or self-inflating bag with PEEP valve); rote 40 to 60 breaths/ min

Requests pulse oximeter sensor placement on baby's right hand or wrist

Requests cardiac monitor (optional at this time)

Within 15 seconds of beginning PPV, learner asks assistant to state heart rote and if it is increasing

Heart rote = 40 bpm and not increasing "Pulse oximeter has no signal."

Asks assistant to assess chest movement

"No chest movement."

Perform ventilation corrective steps (MR. SOPA).

Performs M and R, S and O, and P steps; assesses for increasing heart rote and chest movement after PPV

following each step

Heart rote = 40 bpm and not increasing.

"No chest movement." "Pulse oximeter has no signal."

Place cardiac monitor leads and connect to monitor in anticipation of intubation (if not already done).

154

Critical Performance Steps (cont)

Preparation for intubation. (Most of these tasks are included in the pre-birth equipment check.)

Operator (lntubator) Operator1

s Assistant

Prepares for intubation • Ensures suction set at 80 to 100 mm Hg

• Requests correct-sized tube • Selects correct-sized tube

• Requests correct-sized laryngoscope blade • Chooses correct laryngoscope blade (size 1 [term],

• Communicates preference for stylet usage size O [preterm ])

• Checks laryngoscope light

• lnserts stylet correctly (stylet optional)

• Obtains C0 2 detector

• Prepares tape or tube-securing device

lntubating the newborn.

Operator Operator's Assistant

• Holds laryngoscope correctly in left hand • Positions newborn's head in sniffing position, body

• Opens baby's mouth with finger and inserts blade to straight, table at correct height for operator

base of tengue

• Lifts blade correctly (no rocking motion)

• Requests cricoid pressure if needed • Applies cricoid pressure if requested

• ldentifies landmarks, takes corrective action to • Hands endotracheal tube to operator

visualize glottis if needed • Monitors heart rote and announces if attempt lasts

• lnserts tube from right side, not down center of longer than 30 seconds

laryngoscope blade

• Aligns vocal cord guide with vocal cords

• Removes laryngoscope then removes stylet while • Removes stylet (if used)

firmly holding tube against baby's palote • Connects C0 2 detector and PPV device to

• Holds tube against baby's palote endotracheal tube

• Hands PPV device to operator

Positive-pressure ventilation and confirming endotracheal tube insertion.

• Administers PPV • Auscultates for increasing heart rote and assesses

• Observes for symmetrical chest movement C0 2 detector color change

• Listens for bilateral breath sounds, notes symmetrical

chest movement with PPV, and reports findings

Heart rote = 40 bpm and not increasing

"Chest is not moving with PPV. No audible breath sounds.

"Color is not changing on the C0 2 detector."

"In this scenario, the endotracheal tube has been correctly inserted, but there is no chest movement with PPV.

What is your next step?"

Suspect airway obstruction and use tracheal aspirator.

• Connects a tracheal aspirator to a suction source (80-100 mm Hg suction) and directly to the endotracheal

tube connector or occludes integrated suction port

• Occludes the tracheal aspirator with a finger or occludes the suction-control port on the endotracheal tube and

gradually withdraws the endotracheal tube over 3 to 5 seconds while continuing to suction secretions in the

trachea

155

Critical Performance Steps (cont)

After tracheal suction, re-intubate baby with a clean endotracheal tube.

(Learner may also resume face-mask PPV or insert a laryngeal mask.)

After re-intubation, if endotracheal tube is not successfully inserted,

"Color is not changing on the C0 2 detector." Heart rote= 40 bpm and not increasing

• Removes endotracheal tube

• Resumes PPV by face mask

• Repeats intubation attempt or indicates need for laryngeal mask

After re-intubation, if endotracheal tube is successfully inserted,

"Color is changing on the C0 2 detector." Heart rate = 60 bpm and increasing

Pulse oximeter displays signal as heart rote increases to more than 60 bpm

• Operator continues PPV x 30 seconds

• Assistant checks tip-to-lip depth using gestational age/weight table or NTL measurement

- lf using NTL, measures distance from the nasal septum to the ear tragus (insertion depth [cm]= NTL + l cm}

• Assistant secures endotracheal tube

Vital signs.

Checks heart rote after completing 30 seconds of PPV

Heart rate = 70 bpm and increasing "Apneic." 5Po2 = 68% and increasing

Continues PPV and adjusts oxygen concentration per pulse oximetry

Checks heart rote after 30 more seconds of PPV

Heart rate is > 100 bpm and increasing "Apneic." SP02 = 72% and increasing

End scenario.

156

Supports baby with PPV and supplemental oxygen per Target Oxygen Saturation Table.

Monitors heart rote, respiratory effort, oxygen saturation, activity, temperature.

Prepares to move baby to post-resuscitation care setting.

Communicates with perinatal team.

Updates parents and informs them of next steps.

Debriefs the resuscitation.

Sample Debriefing Questions

O What went well during this resuscitation?

f) What is the most important issue to discuss during this debriefing?

8 At what point <lid you decide to use a cardiac monitor to assess

the heart rate? How <lid that help you? When is a cardiac monitor

recommended during neonatal resuscitation?

O What will you do differently when faced with intubation in a future

scenario?

0 (Option 2) After inserting an alternative airway, there was still no

chest movement with PPV. How <lid the leader/team members help

each other to manage this emergency? As a leader/team member,

what was the most difficult aspect of this scenario? In an actual

resuscitation, what if a team member had suggested beginning

chest compressions before achieving chest movement with PPV?

O Do you have additional comments or suggestions for your team?

For the team leader?

O Give me an example of how you used at least one of the NRP Key

Behavioral Skills.

NRP Key Behavioral Skills

• Know your environment.

• Use available information.

• Anticipate and plan.

• Clearly identify a team leader.

• Communicate effectively.

• Delegate the workload optimally.

• Allocate attention wisely.

• Use available resources.

• Call for additional help when needed.

• Maintain professional behavior.

157

What you will learn

When to begin chest compressions

How to administer chest compressions

How to coordinate chest compressions with positivepressure ventilation

When to stop chest compressions

Antenatal counseling.

Team briefing.

Equipment check.

... ,

Birth

' J

Term gestation?

Good tone?

Breathing or crying?

Q) 1 ,

, ' e: Warm, dry, stimulate, position ·-

airway, suction if needed.

, -

...

Apnea or gasping?

HR <100 bpm?

Yes

1 J

, ..,

PPV.

Pulse oximeter.

Consider cardiac monitor.

... ,

' ,

- HR <100 bpm?

Yes

' J

, '

Ensure adequate ventilation.

Consider ETT or laryngeal mask.

Cardiac monitor.

... ,

' ,

HR < 60 bpm?

Yes

, '

ETT or laryngeal mask.

Chest compressions.

Coordinate with PPV-100% oxygen.

uve.

... ,

HR <60 bpm?

'-.. Yes

,.._

IV epinephrine every 3-5 minutes.

lf HR remains < 60 bpm,

• Consider hypovolemia.

\ .

• Consider pneumothorax.

160

Yes

- Stay with mother for initial steps,

' routine care, ongoing evaluation.

\ .

Labored breathing or

' persistent cyanosis?

Yes

' ,

r ..,

Position airway, suction if needed.

Pulse oximeter.

Oxygen if needed.

Consider CPAP.

\ .

' , ' ,

Post-resuscitation care.

\ .

Team debriefing.

Target Oxygen Saturation Table

1 min 60%-65

2 min 65%-70%

3 min 70%-75%

4 min 75%-80%

5 min 80%-85%

10 min 85%-95

lnitial oxygen concentration for PPV

- 35 weeks' GA 21% oxygen

< 35 weeks' GA 21%-30

/o oxygen

Key Points

O Chest compressions are indicated when the heart rate remains

less than 60 beats per minute (bpm) despite at least 30 seconds of

positive-pressure ventilation (PPV) that inflates the lungs (chest

movement). In most cases, you should have given ventilation

through a properly inserted endotracheal tube or laryngeal mask.

8 Inaccurate assessment of heart rate can result in un11ecessary

cardiac compressions. If perinatal risk factors suggest the

likelihood of complex resuscitation, consider placing cardiac

monitor leads once PPV starts.

E) If the chest is not moving with PPV, the lungs have not been

inflated and chest compressions are not yet indicated. Continue to

focus on achieving effective ventilation.

8 Once the endotracheal tube or laryngeal mask is secure, move

to the head of the bed to give chest compressions. This provides

space for safe insertion of an umbilical venous catheter and has

mechanical advantages that result in less compressor fatigue.

0 If the heart rate is less than 60 bpm, the pulse oximeter may not

have a reliable signal. When chest compressions begin, ventilate

using 100% oxygen until the heart rate is at least 60 bpm and the

pulse oximeter has a reliable signal.

9 To administer chest compressions, place your thumbs on the

sternum, in the center, just below an imaginary line connecting

the baby's nipples. Encircle the torso with both hands. Support

the back with your fingers. Your fingers do not need to touch each

other.

O Use enough downward pressure to depress the sternum

approximately one-third of the anterior-posterior (AP) diameter of

the chest.

0 The compression rate is 90 compressions per minute and the

breathing rate is 30 breaths per minute.

a. This is a slower ventilation rate than used during assisted

ventilation without compressions.

b. To achieve the correct rate, use the rhythm: "One-and-Twoand-Three-and-Breathe-and .... "

f) After 60 seconds of chest compressions and ventilation, briefly

stop compressions and check the heart rate. A cardiac monitor

is the preferred method for assessing heart rate during chest

161

162

compressions. You may also assess the baby's heart rate by listening

with a stethoscope. If necessary, you may briefly stop ventilation to

auscultate the heart rate.

If the heart rate is 60 bpm or greater, discontinue compressions and

resume PPV at 40 to 60 breaths per minute. When a reliable pulse

oximeter signal is achieved, adjust the oxygen concentration to

meet the target oxygen saturation guidelines.

4D If the baby's heart rate remains less than 60 bpm despite

60 seconds of effective ventilation and high-quality, coordinated

chest compressions, epinephrine administration is indicated and

emergency vascular access is needed.

Case: Late preterm newborn that does not respond to

eff ective ventilation

Your team is called to attend an emergency cesarean birth for a woman

at 36 weeks' gestation because of fetal distress. The amniotic fluid

is clear. You complete a pre-resuscitation briefing, assign roles and

responsibilities, and prepare your supplies and equipment. After birth,

the obstetrician dries and stimulates the baby to breathe, but the baby

remains limp and apneic. The umbilical cord is clamped and cut, and

the baby is moved to a radiant warmer. You position the baby's head

and neck, suction the mouth and nose, and provide brief additional

stimulation, but the baby remains apneic. You begin positive-pressure

ventilation (PPV) with 21 % oxygen, while other team members assess

the baby's heart rate with a stethoscope, place a pulse oximeter sensor

on the right hand, and document the events as they occur. The pulse

oximeter <loes not have a reliable signal and cardiac monitor leads are

placed on the baby's chest. The heart rate is 40 beats per minute (bpm),

not increasing, and the baby's chest is not moving with PPV. You

proceed through the ventilation corrective steps, including increasing

the ventilation pressure, but the chest still <loes not move with

ventilation and the baby's heart rate <loes not increase.

A team member inserts and secures an endotracheal tube, and

ventilation resumes. The carbon dioxide ( C0 2) detector <loes

not change color; however, there is good chest movement with

PPV through the tube, and breath sounds are equal in the axillae.

Anticipating a prolonged resuscitation, a team member applies a

servo-controlled temperature sensor to the baby's skin to monitor

and control the baby's body temperature. Ventilation through the

endotracheal tube is continued for 30 seconds, but the heart rate

remains 40 bpm. Your team increases the oxygen concentration (F102)

to 100%, begins chest compressions coordinated with PPV, and calls

for additional help. During compressions and coordinated ventilation,

the C0 2 detector changes color to yellow, and, within 60 seconds, the

heart rate increases to greater than 60 bpm. You stop compressions

and continue PPV as the heart rate continues to increase. Your team

members frequently reevaluate the baby's condition and share their

assessments with each other. The pulse oximeter shows a reliable

signal and the F102 is adjusted to meet the oxygen saturation target.

As the baby's tone improves, you observe intermittent spontaneous

respiratory effort and the baby's heart rate increases to 160 bpm. The

parents are updated and the baby is moved to the special care nursery

for post-resuscitation care. Shortly afterward, your team members

conduct a debriefing to review their preparation, teamwork, and

communication.

What are chest compressions?

Babies who do not respond to ventilation that

inflates their lungs are likely to have very low blood

oxygen levels, significant acidosis, and insufficient

blood flow in their coronary arteries. As a result,

cardiac muscle function is severely depressed.

Improving coronary artery blood flow is crucial for

restoring the heart's function.

The heart lies in the chest between the lower

third of the sternum and the spine. Rhythmically

depressing the sternum compresses the heart

against the spine, pushes blood forward, and

increases the blood pressure in the aorta. When

pressure on the sternum is released, the heart refills

with blood and blood flows into the coronary

arteries (Figure 6.1). By compressing the chest and

ventilating the lungs, you help to restore the flow

of oxygenated blood to the heart muscle and the

lungs.

When do you begin chest compressions?

• Chest compressions are indicated if the baby's

heart rate remains less than 60 bpm after at least

30 seconds of PPV that inflates the lungs, as

evidenced by chest movement with ventilation.

•.....------,....._

• In most cases, you should have given at least

30 seconds of ventilation through a properly

inserted endotracheal tube or laryngeal mask.

Figure 6. 1. Compression (top) and release (bottom)

phases of chest compressions

163

Apnea or gasping?

HR <100 bpm?

Yes

, PPV.

Pulse oximeter.

Consider cardiac monitor.

...

' J

HR <100 bpm?

Yes

' ,

Ensure adequate ventilation.

Consider ETT or laryngeal mask.

Cardiac monitor.

...

' ,

HR <60 bpm?

Yes

' J

ETT or laryngeal mask.

Chest compressions.

Coordinate with PPV-100% oxygen.

uve.

...

• If compressions are started, call for help if needed as additional

personnel may be required to prepare for vascular access and

epinephrine administration.

If the lungs have been adequately ventilated, it is rare for a newborn

to require chest compressions. Only approximately 1 to 2 per 1,000

newborns are expected to require chest compressions. Do not begin

chest compressions unless you have achieved chest movement with

your ventilation attempts. If the chest is not moving, you are most

likely not providing effective ventilation. Focus your attention on the

ventilation corrective steps, ensuring that you have an unobstructed

airway, before starting compressions. This program recommends

ventilating through an endotracheal tube or laryngeal mask for

30 seconds before starting chest compressions.

Sometimes a newborn receives unnecessary chest compressions

because the heart rate is inaccurately assessed. If perinatal risk factors

suggest the likelihood of a complex resuscitation, consider placing

cardiac monitor leads once PPV starts. The cardiac monitor can then

be used to assess the heart rate and support critical decision-making,

such as beginning chest compressions and administering medication.

Where do you stand to administer chest compressions?

When chest compressions are started, you may be standing at the

side of the warmer. One of your team members, standing at the head

of the bed, will be providing coordinated ventilations through an

endotracheal tube.

)

If chest compressions are required, there

is a high probability that you will also

need to insert an emergency umbilical

venous catheter for intravascular access.

It is difficult to insert an umbilical venous

catheter if the person administering

compressions is standing at the side of

Figure 6.2. Compressor standing at the head of the bed

the warmer with their arms encircling the

baby's chest. Once intubation is completed

and the tube is secure, the compressor

should move to the head of the bed while

the person operating the PPV device

moves to the side (Figure 6.2). In addition

to providing space for umbilical venous

catheter insertion, this position has

mecl1anical advantages that result in less

fatigue for the compressor.

164

Nipple

llne

Xiphoid

......__.

-- Sternum

Compression

area

Figure 6.3. Landmarks for chest compressions

Figure 6.4. Chest compressions using 2 thumbs from

the head of the bed. Thumbs are placed over the lower

third of the sternum, hands encircling the chest.

Where do you position your hands during chest compressions?

During chest compressions, apply pressure to the lower third of the

sternum. Place your thumbs on the center of the sternum, either

side-by-side or one on top of the other, just below an imaginary line

connecting the baby's nipples (Figure 6.3). Do not place your thumbs

on the ribs or on the xiphoid. The xiphoid is the small, pointed

projection at the bottom of the sternum where the lower ribs meet at

the midline.

Encircle the baby's chest with your hands. Place your fingers under the

baby's back to provide support (Figure 6.4). Your fingers do not need to

touch.

How deeply do you compress the chest?

Using your thumbs, press the sternum downward to compress the

heart between the sternum and the spine. Do not squeeze the chest

with your encircling hands. With your thumbs correctly positioned,

use enough pressure to depress the sternum approximately one-third

of the anterior-posterior (AP) diameter of the chest (Figure 6.5), and

then release the pressure to allow the heart to refill. One compression

consists of the downward stroke plus the release. The actual distance

compressed will depend on the size of the baby.

Your thumbs should remain in contact with the chest during both

compression and release. Allow the chest to fully expand by lifting

your thumbs sufficiently during the release phase to permit the chest

165

166

···············

Figure 6.5. Compression depth is approximately one-third of the

anterior-posterior diameter of the chest.

One-third

to expand; however, do not lift your thumbs completely off the chest

between compressions.

What is the compression rate?

The compression rate is 90 compressions per minute. To achieve this

rate, you will give 3 rapid compressions and 1 ventilation during each

2-second cycle.

How are compressions coordinated with positive-pressure

ventilation?

During neonatal cardiopulmonary resuscitation, chest compressions

are always accompanied by coordinated PPV. Give 3 rapid

compressions followed by 1 ventilation.

Coordinated Compressions and Ventilations

3 compressions + 1 ventilation every 2 seconds

To assist coordination, the person doing compressions should count

the rhythm out loud. Speak loudly enough for the person ventilating

to hear the rhythm, but not so loud that the rest of the team members

cannot hear each other as they share information. The goal is to

give 90 compressions per minute and 30 ventilations per minute

(90 + 30 = 120 events per minute). This is a rapid rhythm. Achieving

good coordination requires practice.

Learn the rhythm by counting out loud: "One-and-Two-and-Threeand-Breathe-and; One-and-Two-and-Three-and-Breathe-and; Oneand-Two-and-Three-and-Breathe-and. 11

• Compress the chest with each counted number ("One, Two, Three").

• Release the chest between each number ("-and-").

• Pause compressions and give a positive-pressure breath when the

compressor calls out "breathe-and. 11

Inhalation occurs during the "breathe-and" portion of the rhythm,

and exhalation occurs during the downward stroke of the next

compression. Note that during chest compressions, the ventilation rate

is slower than you used when giving only assisted ventilation. This

slower rate is used to provide an adequate number of compressions and

avoid simultaneous compressions and ventilation.

3: 1 Compression:Ventilation Rhythm

One-and-Two-and-Three-and-Breathe-and;

One-and-Two-and-Three-and-Breathe-and ...

What oxygen concentration should be used with

positive-pressure ventilation during chest compressions?

• When chest compressions are started, increase the Fio 2 to 100%.

• Once the heart rate is greater than 60 bpm and a reliable pulse

oximeter signal is achieved, adjust the F102 to meet the target oxygen

saturation guidelines.

The ideal F102 to use during chest compressions is an area of active

research, and this recommendation is based on expert opinion. Oxygen

is essential for organ function. During chest compressions, blood

flow to vital organs may be decreased, and using a higher oxygen F102

concentration may improve oxygen uptake and delivery. In addition,

circulation may be so poor that the pulse oximeter will not give a reliable

signal, and targeting an oxygen saturation may not be possible. However,

once heart function has recovered, continuing to use 100% oxygen may

increase the risk of tissue damage from excessive oxygen exposure.

When should you check the baby' s heart rate after starting

compressions?

Wait 60 seconds after starting coordinated chest compressions and

ventilation before briefly pausing compressions to reassess the heart rate.

167

168

Studies have shown that it may take a minute or more for the heart rate

to increase after chest compressions are started. When compressions

are stopped, coronary artery perfusion is decreased and requires time

to recover once compressions are resumed. It is, therefore, important

to avoid unnecessary interruptions in chest compressions because each

time you stop compressions, you may delay the heart's recovery.

How should you assess the baby' s heart rate response

during compressions?

Briefly pause compressions to assess the baby's heart rate. If necessary,

briefly pause PPV. A cardiac monitor is the preferred method for

assessing heart rate during chest compressions. You may assess the

baby's heart rate by listening with a stethoscope or using a pulse

oximeter. There are limitations to each of these methods.

• During resuscitation, auscultation can be difficult, prolonging the

interruption in compressions, and potentially giving inaccurate

results.

• If the baby's perfusion is very poor, a pulse oximeter may not

reliably detect the baby's pulse.

• A cardiac monitor displays the heart's electrical activity and may

shorten the interruption in compressions, but electrical activity

may be present without the heart pumping blood. This unusual

finding is called pulseless electrical activity (PEA), and is suspected

when the cardiac monitor shows electrical activity but the baby

continues to deteriorate without palpable pulsations in the umbilical

cord, audible heart sounds on auscultation, or a signal on the

pulse oximeter. In the newborn, PEA is treated the same as absent

electrical activity (heart rate = O or asystole).

When do you stop chest compressions?

Stop chest compressions when the heart rate is 60 bpm or greater.

Once compressions are stopped, return to giving PPV at the faster

rate of 40 to 60 breaths per minute. When a reliable pulse oximeter

signal is achieved, adjust the F102 to meet the target oxygen saturation

guidelines.

What do yo u do if the heart rate is not improving af ter

60 seconds of compressions?

While continuing to administer chest compressions and coordinated

ventilation, your team needs to quickly assess the quality of your

ventilation and compressions. In most circumstances, endotracheal

intubation or laryngeal mask insertion should have been performed.

If not, one of these procedures should be performed now.

Quickly ask each of the 5 questions in Table 6-1 out loud and confirm

your assessment as a team. You can use the mnemonic ''CARDIO" to

remember the 5 questions.

Table 6-1. Questions to Ask When Heart Rate Is Not lmproving With

Compressions and Ventilation (Mnemonic CARDIO)

l. Chest movement: Is the chest moving with each breath?

2. Airway: Is the airway secured with an endotracheal tube or laryngeal

mask?

3. Rote: Are 3 compressions coordinated with l ventilation being delivered

every 2 seconds?

4. Depth: Is the depth of compressions one-third of the AP diameter of the

chest?

5. lnspired Oxygen: Is l 00% oxygen being administered through the PPV

device?

If the baby's heart rate remains less than 60 bpm despite 60 seconds of

effective ventilation and high-quality, coordinated chest compressions,

epinephrine administration is indicated and emergency vascular access

is needed.

Focus on Teamwork

Providing chest compressions highlights several opportunities for

effective teams to use the Neonatal Resuscitation Program® (NRP

®) Key

Behavioral Skills.

Behavior Example

Anticípate and

plan.

Ensure that you hove enough personnel present at the time of delivery based on the risk factors

you identified. lf there is evidence of severe fetal distress, be prepared for the possibility of a

complex resuscitation, including chest compressions.

Call for additional

help when

needed.

Delegate workload

optimally.

lf chest compressions are required, there is a high likelihood of also needing vascular access

and epinephrine. Plan for this possibility during your team briefing.

lf compressions are started, a team member should immediately prepare the equipment

necessary for emergency vascular access (umbilical venous catheter or intraosseous needle)

and epinephrine.

lf a complex resuscitation is anticipated, prepare to apply a servo-controlled temperature sensor

to the baby's skin to monitor and control the baby's body temperature.

lf chest compressions are required, you may need 4 or more health care providers. Performing

ali of the tasks quickly, including PPV, auscultation, placing a pulse oximeter, intubating the

airway, administering compressions, monitoring the quality of compressions and ventilations,

monitoring the baby's response, preparing emergency vascular access, documenting events as

they occur, and supporting the baby's family, requires multiple team members.

169

Behavior Example

Clearly identify a

team leader.

Allocate attention

wisely.

Use available

resources.

Communicate

effectively.

Maintain

professional

behavior.

170

The team leader needs to maintain situation awareness, paying attention to the entire situation,

and not becoming distracted by any single activity or procedure. This means that leadership

may need to shift to another person if the team leader is performing a procedure that

occupies their attention.

lt is important for someone to monitor the quality of ventilation and compressions while also

monitoring the baby's heart rote.

lf the compressor becomes fatigued, hove another team member take over compressions.

A respiratory therapist can administer PPV, enabling a nurse or physician to prepare for

emergency vascular access and medication administration.

During compressions, the compressor and ventilator need to coordinate their activity and

maintain correct technique. They cannot perform other roles or hove conversations while

. . compress1ons are 1n progress.

lf a correction is required, make a clear, calm, and directed statement.

Speak clearly, directly, and loudly enough for team members to hear you, but avoid extraneous

conversation or unnecessarily loud communication that may be distracting.

Share information with the individual documenting events so they can be accurately noted.

Quality lmprovement Opportunities

Ask yourself the following questions and begin a discussion with your

team if you find a difference between the NRP recommendations and

what is currently done in your own hospital setting. Consider using the

suggested process and outcome measures to guide your data collection,

identify areas for improvement, and monitor if your improvement

efforts are working.

Quality improvement questions

O Who are the providers that have chest compression skills in your

delivery room setting?

8 Is someone with chest compression skills immediately accessible if

needed?

Q How often do providers practice their chest compression and

coordinated ventilation skills?

O Is a cardiac monitor accessible in your delivery room setting for

use when a baby requires intubation and chest compressions?

Process and outcome measures

O How often do newborns receive chest compressions in your

delivery room setting?

8 When compressions are required, how often is a skilled provider

present at the time of birth?

E) How often <loes a baby have an endotracheal tube or laryngeal

mask inserted before chest compressions are started?

O How often is the Fro2 increased to 100% when compressions begin?

Frequently Asked Questions

What are the potential complications of chest compressions?

Chest compressions can cause trauma to the baby. Two vital organs

lie within the rib cage-the heart and lungs. As you perform chest

compressions, you must apply enough pressure to compress the heart

between the sternum and spine without damaging underlying organs.

The liver lies in the abdominal cavity partially under the ribs. Pressure

applied directly over the xiphoid could cause laceration of the liver.

Chest compressions should be administered with the force directed

straight down on the middle of the sternum. Do not become distracted

and allow your thumbs to push on the ribs connected to the sternum.

By following the procedure outlined in this lesson, the risk of injuries

can be minimized.

Why does the Neonatal Resuscitation Program Algorithm follow A-8-C

(Airway-Breathing-Compressions) when other programs follow C-A-8

(Compressions-Airway-Breathing)?

The NRP focuses on establishing effective ventilation, rather than

starting chest compressions because the vast majority of newborns who

require resuscitation have a healthy heart. The underlying problem is

respiratory failure with impaired gas exchange; therefore, ventilation of

the baby's lungs is the single most important and effective step during

neonatal resuscitation. Very few babies will require chest compressions

once effective ventilation has been established. Other programs focus

on chest compressions because adults are more likely to have a primary

cardiac problem causing cardiorespiratory collapse. Teaching a single

approach for children and adults simplifies the educational process.

Why does the Neonatal Resuscitation Program use a 3: 1 compression-toventilation ratio instead of the 15:2 ratio used in other programs?

Neonatal animal studies have shown that the 3:1 ratio shortens the

time to return of spontaneous circulation. Alternative ratios, as well

as asynchronous (uncoordinated) ventilations after intubation, are

routinely used outside the newborn period but have not been shown

to improve recovery in newborns. Additional chest compression

techniques and ratios are currently being studied, but there is

insufficient evidence to recommend them at this time.

171

172

In the case at the beginning of the lesson, the C02 detector did not change

color even though the endotracheal tube was correc y inserted. Why?

If a baby has a very low heart rate or very poor cardiac function, there

may not be enough C0 2 carried to the lungs to change the detector's

color. In this case, you will need to use other indicators ( chest

movement and breath sounds) to determine if the endotracheal tube

is correctly inserted. If the C0 2 detector begins to change color during

compressions, this may be an indication of improving cardiac function.

LESSON 6 REVIEW

1. A newborn is apneic at birth. The baby <loes not improve with

the initial steps, and positive-pressure ventilation is started.

After 30 seconds, the heart rate has increased from 40 beats per

minute (bpm) to 80 bpm. Chest compressions (should)/(should

not) be started. Positive-pressure ventilation (should)/(should

not) continue.

2. A newborn is apneic at birth. The baby <loes not improve with

the initial steps or positive-pressure ventilation. An endotracheal

tube is inserted properly, the chest moves with ventilation,

bilateral breath sounds are present, and ventilation has continued

for another 30 seconds. The heart rate remains 40 beats per

minute. Chest compressions (should)/(should not) be started.

Positive-pressure ventilation (should)/(should not) continue.

3. Mark the area on this baby where you would apply chest

compress1ons.

A. Top of sternum

B. Just below nipples

C. Over xiphoid

4. The correct depth of chest compressions is approximately

a. One-fourth of the anterior-posterior diameter of the chest

b. One-third of the anterior-posterior diameter of the chest

c. One-half of the anterior-posterior diameter of the chest

d. Two inches

5. The ratio of chest compressions to ventilation is (3 compressions

to 1 ventilation)/(1 compression to 3 ventilations).

6. What phrase is used to achieve the correct rhythm for

coordinating chest compressions and ventilation? ____ _

----------------·

7. You should briefly stop compressions to check the baby's

heart rate response after (30 seconds)/(60 seconds) of chest

compressions with coordinated ventilations.

8. Chest compressions can be discontinued when the heart rate is

greater than (100 beats per minute)/(60 beats per minute).

Answers

l. Chest compressions should not be started. Positive-pressure

ventilation should continue.

2. Chest compressions should be started. Positive-pressure

ventilation should continue.

3. Compression area (B) just below the nipples.

4. The correct depth of chest compressions is approximately

one-third of the anterior-posterior diameter of the chest.

5. The ratio of chest compressions to ventilation is 3 compressions

to 1 ventilation.

6. ((One-and-Two-and-Three-and-Breathe-and .... "

7. You should briefly stop compressions to check the baby's heart

rate response after 60 seconds of chest compressions with

coordinated ventilations.

8. Discontinue chest compressions when the heart rate is greater

than 60 beats per minute.

173

174

LESSON 6: PRACTICE SCENARIO

Chest Compressions

Learning Ob¡ectives

O Identify the newborn that requires chest compressions.

f) Interpret the meaning of a carbon dioxide ( C0 2) detector that <loes

not change color even though there are other clinical signs that

indicate lung inflation with positive-pressure ventilation (PPV).

E) Demonstrate the correct technique for performing chest

compress1ons.

O Identify the sign that indicates chest compressions should be

discontinued.

0 Demonstrate behavioral skills to ensure clear communication and

teamwork during this critica! component of newborn resuscitation.

This Practice Scenario is for review/practice and evaluation.

This is the suggested Practice Scenario sequence.

O Review the Knowledge Check Questions with your Neonatal

Resuscitation Program (NRP) instructor.

a. What are the indications for beginning chest compressions?

b. What oxygen concentration is used when chest compressions

are required?

c. How long are chest compressions administered before checking

a heart rate?

d. When can chest compressions be discontinued?

f) Practice/review these skills with your NRP instructor.

a. Move to the head of the baby to perform compressions when

intubation is complete and the tube is secure. The person

providing PPV moves to the side.

b. Position your hands in correct positio.n on the baby's chest.

c. Provide compressions at the correct rate and depth.

d. Count the chest compression rhythm out loud and coordinate

chest compressions with ventilation.

e. Apply a servo-controlled temperature sensor and adjust the

radiant warmer.

E) Practice this scenario with your NRP instructor and your team

until you need little or no assistance or coaching.

O Pass the Lesson 6 Practice Scenario evaluation by leading a

practice scenario and performing chest compressions and other

skills relevant to your role and responsibilities. If a technical skill

included in a scenario is not within your scope of responsibility,

delegate the skill to a qualified team member and perform the role

of assistant if appropriate.

0 When you can lead the scenario(s) and perform the skills with little

or no instructor coaching, proceed to the next lesson's practice

scenar10.

Practice Scenario

"You are called to attend an emergency cesarean birth due to fetal bradycardia. How would yo u prepare f or

the resuscitation of the baby? As you work, say your thoughts and actions aloud so I will know what you are

thinking and doing."

Critical Performance Steps

Assess perinatal risk.

Assesses perinatal risk (learner asks 4 pre-birth questions and instructor ["OB provider"] responds)

Gestation? "Term."

Fluid clear? "Fluid is clear."

Additional risk factors? "Fetal bradycardia for the last 3 minutes."

Umbilical cord management plan? "We'II assess the baby at birth. lf the baby's not vigorous, 1'11 give brief

stimulation, and if there's no improvement, 1'11 clamp the cord and bring the baby to the radiant warmer."

Assemble team.

Assembles team based on perinatal risk factors.

lf risk factors are present, at least 2 qualified people should be present solely to manage the baby.

The number of team members and qualifications vary depending on risk.

Perform a pre-resuscitation briefing.

ldentifies team leader.

Assesses risk factors, delegates tasks, identifies who will document events as they occur, determines supplies and

equipment needed, identifies how to cal! for additional help.

Perform equipment check. (Learners may prep for intubation, umbilical venous catheter insertion, and medication.)

"The baby has been born."

Rapid evaluation.

• Term? "Appears term."

• Tone? "No tone."

• Breathing or crying? "No breathing."

lnitial steps.

Receives baby at radiant warmer, dries, stimulates, positions airway, suctions mouth and nose

175

Critical Performance Steps (cont)

Assess breathing. lf breathing, assesses heart rate.

Checks breathing

"Baby is apneic." (Heart rote = 40 bpm, if assessed)

Begin PPV within 60 seconds of birth.

Begins PPV in 21 % oxygen (room air). Within 15 seconds of beginning PPV, learner asks assistant to check heart

rote and assess if heart rote is rising.

Heart rote = 40 bpm, not increasing "Pulse oximeter has no signal."

Applies cardiac monitor (optional at this time).

Assess chest movement.

• lf chest movement observed, continues PPV x 15 seconds (for total of 30 seconds PPV).

• lf no chest movement observed, proceeds through corrective steps (MR. SOPA) until chest movement is

achieved (instructor may determine how many steps are required); then administers PPV x 30 seconds. Heart

rote will remain less than 60 bpm.

• lf no chest movement is achieved after M and R, S and O, and P steps, learner indicates need for alternative

airway and proceeds directly to intubation or laryngeal mask insertion.

Check heart rote after 30 seconds of PPV that moves the chest.

Checks heart rote.

Heart rate = 40 bpm and not increasing

lndicates need for alternative airway.

Places cardiac monitor leads and connects to monitor in anticipation of alternative airway (if not already done)

lnsert alternative airway (endotracheal tube or laryngeal mask).

• In tu bates (size 1 blade and size 3 .5 endotracheal tube) or inserts laryngeal mask (size 1)

• Checks for rising heart rote, C0 2 detector color change, bilateral breath sounds, and chest movement with PPV

• For endotracheal intubation: Checks tip-to-lip insertion depth using nasal-tragus length or insertion depth chart

• Asks assistant to secure endotracheal tube or laryngeal mask

lf PPV device not successfully inserted:

"Color is not changing on the C0 2 detector, chest is not moving, and heart rote is not increasing."

• Removes device

• Resumes PPV by face mask

• Repeats insertion attempt

lf device successfully inserted:

Note: Color might not change on the C0 2 detector due to low heart rate.

Heart rote = 40 bpm and not increasing

"Chest is moving with PPV, pulse oximeter has no signal."

• Continues PPV x 30 seconds

Check heart rote after 30 seconds of PPV with alternative airway.

Checks heart rote after 30 seconds of PPV that moves the chest

Heart rote = 40 bpm and not increasing "Pulse oximeter has no signal."

Begin chest compressions.

Calls for additional help if necessary.

Asks assistant to increase oxygen to l 00%.

Asks assistant to place servo-controlled temperature sensor on baby and adjust the radiant warmer to maintain

baby's temperature 36.5º C to 37.5º

C .

May ask team member to prepare for umbilical venous catheter insertion and epinephrine administration.

176

Critical Performance Steps (cont)

Compressor moves to head-of-bed position, ventilator to side of bed

Places thumbs on sternum (lower third, below imaginary line connecting nipples); fingers under back, supporting

spine (fingers do not need to touch)

Compresses sternum one-third of the anterior-posterior diameter of chest, straight up and down

• Compressor counts cadence "One-and-two-and-three-and-breathe-and"

• Positive-pressure ventilation administered during compression pause ("breathe-and")

• One cycle of 3 compressions and 1 breath every 2 seconds

Check heart rote after l minute.

Pauses compressions, continues PPV, and checks heart rote after 60 seconds of compressions and ventilations

Heart rote = 70 bpm and rising

"Pulse oximeter has o signal. No spontaneous respirations."

Discontinue compressions-Continue PPV.

• Discontinues chest compressions

• Continues PPV with higher ventilation rote (40-60 breaths/min)

• Adjusts oxygen concentration per target oxygen saturation

Heart rote is > l 00 bpm and increasing SP02=78% "No spontaneous respirations."

Check vital signs.

Continues PPV and adjusts oxygen concentration per oximetry

Heart rote is > l 00 bpm SP02=90%

"Muscle tone improving. Sorne spontaneous respirations."

End scenario.

Supports baby with PPV and supplemental oxygen per Target Oxygen Saturation Table.

Monitors heart rote, respiratory effort, oxygen saturation, activity, temperature.

Prepares to move baby to post-resuscitation care setting.

Communicates with perinatal team.

Updates parents and informs them of next steps.

Debriefs the resuscitation.

Sample Debriefing Questions

O What went well during this resuscitation?

8 What is the most important issue to discuss during this debriefing?

Q What will you do differently when faced with chest compressions

in a future scenario?

8 Do you have additional comments or suggestions for your team?

For the leader?

0 Give me an example of how you used at least one of the NRP Key

Behavioral Skills.

177

178

If significant errors were made, consider asking the learners

O What happened? What should have happened? What could you

have done to make the right things happen?

O What NRP Key Behavioral Skills might have been helpful in this

situation?

NRP Key Behavioral Skills

• Know your environment.

• Use available information.

• Anticípate and plan.

• Clearly identify a team leader.

• Communicate effectively.

• Delegate the workload optimally.

• Allocate attention wisely.

• Use available resources.

• Call for additional help when needed.

• Maintain professional behavior.

What you will learn

■ When to give epinephrine during resuscitation

■ How to administer epinephrine

■ When to give a volume expander during resuscitation

■ How to administer a volume expander

■ What to do if the baby is not improving after giving

intravenous epinephrine and volume expander

■ How to insertan emergency umbilical venous catheter

■ How to insertan intraosseous needle

f •

r Antenatal counseling.

Team briefing.

Equipment check.

... ,

Birth

' ,

Term gestation? Yes

Stay with mother for initial steps, Good tone? ' routine care, ongoing evaluation. Breathing or crying?

... ,,

Q) ' ,

r '

e: Warm, dry, stimulate, position ·-

airway, suction if needed . ..- '" ,,

' .,

Apnea or gasping? No Laborad breathing or -

HR <100 bpm? . persistent cyanosis?

Yes

' , ' (

r .., ,

PPV. Position airway, suction if needed.

Pulse oximeter. Pulse oximeter.

Consider cardiac monitor. Oxygen if needed.

... , Consider CPAP.

... ,,

' ,

- HR < 100 bpm? No

Yes

' , ' , ' ,

r r

Ensure adequate ventilation. Post-resuscitation care.

Consider ETT or laryngeal mask.

...

Team debriefing.

,, Cardiac monitor.

... ,

' ,

HR <60 bpm?

Target Oxygen Saturation Table

Yes

1 min 60%-65

' .,

, ..,

ETT or laryngeal mask.

2 min 65%-70%

Chest compressions. 3 min 70%-75%

Coordinate with PPV-100% oxygen.

uve. 4 min 75%-80% ... ,

• ,

5 min 80%-85%

HR <60 bpm?

10 min 85%-95

'-- Yes

,...

lnitial oxygen concentration for PPV r IV epinephrine every 3-5 minutes.

lf HR remains < 60 bpm, - 35 weeks' GA 21% oxygen

• Consider hypovolemia.

• Consider pneumothorax. < 35 weeks' GA 21%-30

/o oxygen

'" ,,

180

Key Points

O Epinephrine is indicated if the baby's heart rate remains less than

60 beats per minute (bpm) after:

a. At least 30 seconds of positive-pressure ventilation (PPV) that

inflates the lungs as evidenced by chest movement and

b. Another 60 seconds of chest compressions coordinated with

PPV using 100% oxygen.

c. In most cases, ventilation should have been provided through a

properly inserted endotracheal tube or laryngeal mask.

8 Epinephrine is not indicated before you have established

ventilation that effectively inflates the lungs, as evidenced by chest

movement.

E) Epinephrine recommendations

a. Concentration: 0.1 mg/mL = 1 mg/10 mL

b. Route: Intravenous (preferred) or intraosseous

i. The central venous circulation may be rapidly accessed

using either an umbilical venous catheter or an intraosseous

needle. Por babies requiring vascular access at the time of

delivery, the umbilical vein is recommended.

ii. One endotracheal <lose may be considered while vascular

access is being established.

c. Preparation:

i. Intravenous or Intraosseous: 1-mL syringe (labeled

Epinephrine-IV)

ii. Endotracheal: 3- to 5-mL syringe (labeled Epinephrine-ET

ONLY)

d. Dose:

i. Intravenous or intraosseous = 0.02 mg/kg ( equal to

0.2 mL/kg)

a. May repeat every 3 to 5 minutes

b. Range = 0.01 to 0.03 mg/kg (equal to 0.1 to 0.3 mL/kg)

c. Rate: Rapidly-as quickly as possible

d. Flush: Follow intravenous or intraosseous <lose with a

3-mL saline flush

181

182

ii. Endotracheal = 0.1 mg/kg (equal to 1 mL/kg)

a. Range = O.OS to 0.1 mg/kg (0.5 to 1 mL/kg)

b. If no response, recommend intravenous or intraosseous

for subsequent doses

O Administration of a volume expander is indicated if the baby is

not responding to the steps of resuscitation and there are signs of

shock or a history of acute blood loss.

0 Volume expansion recommendations

a. Solution: Normal saline (NS) or type O Rh-negative blood

b. Route: Intravenous or intraosseous

c. Preparation: 30- to 60-mL syringe (labeled NS or O- blood)

d. Dose: 1 O mL/kg

e. Rate: Over 5 to 1 O minutes

O If there is a confirmed absence of heart rate after ali appropriate

steps of resuscitation have been performed, cessation of

resuscitation efforts should be discussed with the team and family.

A reasonable time frame for considering cessation of resuscitation

eff orts is around 20 minutes after birth; however, the decision to

continue or discontinue should be individualized based on patient

and contextual factors.

Case: Resuscitation with positive-pressure ventilation, chest

compressions, and medications

Your team is called to attend the birth of a woman at 36 weeks'

gestation who arrived complaining of decreased fetal movement and

vaginal bleeding. Fetal bradycardia is noted on the monitor. Your

resuscitation team quickly assembles in the delivery room, completes a

pre-resuscitation team briefing, and prepares supplies and equipment.

An endotracheal tube, umbilical venous catheter, epinephrine, and

volume replacement are prepared because an extensive resuscitation

is anticipated. An emergency cesarean birth is performed and the

obstetrician reports bloody amniotic fluid. The umbilical cord is

immediately clamped and cut, and a limp, pale baby is handed to

the resuscitation team. A team member begins documenting the

resuscitation events as they occur.

You perform the initial steps under a radiant warmer; however, the

baby remains limp without spontaneous respirations. You begin

positive-pressure ventilation (PPV) with 21 % oxygen, a pulse oximeter

sensor is placed on the baby's right hand, and cardiac monitor leads are

placed on the chest. The baby's heart rate is 40 beats per minute (bpm)

by cardiac monitor and auscultation, but the pulse oximeter does not

display a reliable signal. Despite PPV that moves the baby's chest, the

heart rate does not improve. The baby is successfully intubated and

PPV through the endotracheal tube is continued for 30 seconds, but

the heart rate remains 40 bpm. Chest compressions are performed

with coordinated PPV using 100% oxygen. A team member confirms

the quality of compressions and ventilation, but, after 60 seconds, the

baby's heart rate has slowed to 30 bpm.

One team member quickly inserts an umbilical venous catheter

and another administers epinephrine and a saline flush through the

catheter. Ventilation and compressions are continued, and, 1 minute

later, the baby's heart rate has increased to greater than 60 bpm. Chest

compressions are stopped. As the heart rate continues to increase, the

pulse oximeter begins to detect a reliable signal and shows oxygen

saturation 70% and rising. Assisted ventilation continues and the oxygen

concentration is adjusted to maintain the baby's oxygen saturation within

the target range. By 1 O minutes after birth, the baby makes an initial

gasp. The baby is transferred to the nursery for post-resuscitation care.

Shortly afterward, your team members conduct a debriefing to discuss

their preparation, teamwork, and communication.

A very small number of newborns will require emergency

medication.

Most newborns requiring resuscitation will improve without

emergency medications. Before administering medications, you

should ensure the accuracy of your heart rate assessment and check

the effectiveness of ventilation and compressions. In most cases, you

should have inserted an endotracheal tube or a laryngeal mask to

improve the efficacy of ventilation.

Despite inflating the lungs and augmenting cardiac output with chest

compressions, a very small number of newborns (approximately

1 per 1,000 newborns) will still have a heart rate less than 60 bpm.

This occurs when blood flow into the coronary arteries is severely

decreased, resulting in such low oxygen delivery to the newborn's heart

that it cannot contract effectively. These newborns should receive

epinephrine to improve coronary artery perfusion and oxygen delivery

(Figure 7.1). Newborns with shock from acute blood loss (eg, bleeding

vasa previa, fetal trauma, cord disruption, severe cord compression)

may also require emergency volume expansion

HA< 100 bpm?

Yes

' i

Ensure adequate ventilation.

Consider ETT or laryngeal mask.

Cardiac monitor.

' -

' i

HA< 60 bpm?

Yes ' ,

r " ETT or laryngeal mask.

Chest compressions.

Coordinate with PPV-100% oxygen.

uve.

' - ,

HA< 60 bpm?

'-.. Yes

IV epinephrine every 3-5 minutes.

lf HR remains < 60 bpm,

• Consider hypovolemia.

• Consider pneumothorax.

184

Figure 7. 1. Few newborns require emergency medication to regain cardiac

function.

What is epinephrine and what does it do?

Epinephrine is a cardiac and vascular stimulant. It causes constriction

of blood vessels outside of the heart, which increases blood flow

into the coronary arteries. Blood flowing into the coronary arteries

carries the oxygen required to restore cardiac function. In addition,

epinephrine increases the rate and strength of cardiac contractions.

When is epinephrine indicated and how should it be

administered?

lndication

Epinephrine is indicated if the baby's heart rate remains less than 60

bp m after

• At least 30 seconds of PPV that inflates the lungs as evidenced by

chest movement, and

• Another 60 seconds of chest compressions coordinated with PPV

using 100% oxygen.

In most cases, ventilation should have been provided through a

properly inserted endotracheal tube or laryngeal mask. Epinephrine is

not indicated before you have established ventilation that effectively

inflates the lungs.

Concentration

Caution: Epinephrine is available in 2 concentrations.

The only concentration that should be used for neonatal resuscitation

is labeled either 0.1 mg/mL or 1 mg/10 mL. It is usually supplied in a

10-mL glass vial that is packaged in a box with an injection device.

Do not use the higher concentration epinephrine that may be stocked

with emergency supplies for pediatric and adult resuscitation. This is

often supplied in a small glass vial with a breakable top that <loes not

have an injection device.

Route

Intravenous (preferred) or intraosseous: Epinephrine needs to

rapidly reach the central venous circulation. Medications reach the

central venous circulation quickly when administered into either

an umbilical venous catheter or an intraosseous needle. For babies

requiring vascular access at the time of delivery, the umbilical vein

is recommended. When umbilical venous access is not feasible or

successful, the intraosseous route is a reasonable alternative.

Attempting insertion of a peripheral intravenous catheter is not

recommended for emergency medication administration in the setting

of cardiovascular collapse. It is likely to be unsuccessful, result in

epinephrine extravasation into the tissue, and delay the administration

of potentially lifesaving therapy.

Endotracheal {less effective): Sorne clinicians may choose to give a <lose

of epinephrine into the endotracheal tube while vascular access is

established. Although it may be faster to give endotracheal epinephrine

than intravenous epinephrine, studies suggest that absorption is

unreliable and the endotracheal route is less effective. For this reason,

the intravenous and intraosseous routes are recommended.

Preparation

Use a sterile connector or stopcock to transfer epinephrine from the

glass vial injector to a syringe (Figure 7.2).

Intravenous/Intraosseous: Prepare intravenous or intraosseous

epinephrine in a labeled 1-mL syringe. Clearly label the syringe:

ccEpinephrine-lV.''

Endotracheal: Prepare endotracheal epinephrine in a 3- to 5-mL

syringe. Clearly label the syringe: ccEpinephrine-ET ONLY." Be

certain not to use this larger syringe for intravenous or intraosseous

administration.

185

186

Figure 7 .2. Use a connector or stopcock to transfer epinephrine.

Dose

Intravenous or intraosseous: The suggested initial intravenous or

intraosseous dose is 0.02 mg/kg (equal to 0.2 mL/kg). You will need to

estímate the baby's weight after birth.

• The recommended dose range for intravenous or intraosseous

administration is 0.01 to 0.03 mg/kg (equal to 0.1 to 0.3 mL/kg).

Endotracheal: If you decide to give an endotracheal dose while vascular

access is being established, the suggested endotracheal dose is 0.1 mg/

kg (equal to 1 mL/kg). The recommended dose range is 0.05 to 0.1 mg/

kg (equal to 0.5 to 1 mL/kg). This higher dose is only recommended

for endotracheal administration. DO NOT give the higher dose via

the intravenous or intraosseous route.

Administration

IV /JO Rate: Rapidly-give epinephrine as quickly as possible.

IV /IO Flush: Follow IV or 10 doses with a 3-mL flush of normal saline.

Endotracheal: When giving endotracheal epinephrine, be sure to give

the drug directly into the tube, being careful not to leave it deposited

in the tube connector. Because you will be giving a large fluid volume

of epinephrine into the endotracheal tube, you should follow the drug

with several positive-pressure breaths to distribute the drug into the

lungs. No flush is recommended.

Closed-loop communication

Use closed-loop communication when giving a medication order. State

individual digits for numbers. Say the leading zero and the decimal

point, but do not say trailing digits. Avoid using abbreviations during

medication orders.

Por example:

• The me di cal provider (Liz) and person administering medications

(Taylor) first agree on an estimated weight.

- Liz: "Taylor, I estímate the baby's weight is three kilograms:'

Taylor: "Weight is three kilograms:'

• The medical provider then gives the medication name,

concentration, <lose, and route. The order is repeated back by the

person administering the medication.

- Liz: "Taylor, give epinephrine, one milligram in ten milliliters

concentration, zero-point-zero-two milligrams per kilogram,

rapidly through the umbilical venous catheter, then give three

milliliters of saline flush:'

- Taylor: "I have epinephrine, one n1illigram in ten milliliters (show

box). I'm giving zero-point-zero-two milligrams per kilogram,

which is equal to zero-point-two milliliters per kilogram.

The baby weighs three kilograms, so I will give zero-point-six

milliliters (show syringe). I'm giving it rapidly through the

umbilical venous catheter. Then I will flush \.\rith three milliliters

of saline ( show syringe) :'

• Once completed.

- Taylor: "Liz, epinephrine has been given and the flush is completed:'

What should you expect to happen after giving epinephrine?

Assess the baby's heart rate 1 minute after epinephrine administration.

As you continue PPV with 100% oxyge11 and chest compressions, the

heart rate should increase to 60 bpm or higher within approximately

1 minute of intravenous or intraosseous epinephrine administration.

If the heart rate is less than 60 bpm after the first <lose of intravenous

or intraosseous epinephrine, continue coordinated ventilation

and compressions. You can repeat the epinephrine <lose every 3 to

5 minutes. If you started with the suggested initial <lose of 0.02 mg/kg

or lower, you should consider increasing subsequent doses. Do not

exceed the maximum recommended <lose. If there is not a satisfactory

response after intravenous or intraosseous epinephrine, consider other

problems such as hypovolemia and tension pneumothorax.

The response may take longer, or may not occur, if you give

endotracheal epinephrine. If the first <lose is given by the endotracheal

route and there is not a satisfactory response, a repeat <lose should be

given as soon as an umbilical venous catheter or intraosseous needle is

inserted. Do not delay. If the heart rate is less than 60 bpm, you do not

187

188

need to wait for 3 minutes after an endotracheal <lose to give the first

intravenous or intraosseous <lose. Once an umbilical venous catheter or

intraosseous needle has been inserted, ali subsequent doses should be

given by the intravenous or intraosseous route.

In addition, check to be certain that

• A cardiac monitor is being used for the most accurate assessment of

heart rate.

• The lungs are being adequately ventilated as indicated by chest

movement. Insertion of an endotracheal tube or a laryngeal

mask should be strongly considered if not already done. If PPV is

provided through an endotracheal tube or a laryngeal mask, there

should be equal breath sounds.

• The endotracheal tube is not displaced, bent, or obstructed by

secretions.

• Chest compressions are being given at the correct depth (one-third

of the anterior-posterior [AP] diameter of the chest) and correct rate

(90/min).

• Interruptions in chest compressions are minimized because each

interruption decreases coronary artery perfusion.

Epinephrine Summary

Concentration

O. 1 mg/ ml epinephrine = 1 mg/ 1 O ml

Route

lntravenous (preferred} or lntraosseous

Option: Endotracheal only while intravenous or intraosseous access is being

established

Preparation

lntravenous or lntraosseous: 1-ml syringe labeled "Epinephrine-lV"

• Prepare a 3-ml saline flush

Endotracheal: 3- to 5-ml syringe labeled "Epinephrine-ET only"

Dose

lntravenous or lntraosseous = 0.02 mg/kg (equal to 0.2 ml/kg).

• Range=0.01 to 0.03 mg/kg (equal to 0.1 to 0.3 mL/kg)

Endotracheal = O. 1 mg/kg (equal to 1 ml/kg)

• Range = O. 05 to O. l mg/kg (equal to 0.5 to l mL/kg)

Administration

lntravenous or lntraosseous

• Rapidly-as quickly as possible.

• Flush with 3 ml normal saline.

• Repeat every 3 to 5 minutes if heart rote remains less than 60 bpm.

Endotracheal: Administer PPV breaths to distribute into lungs. No flush.

When should you consider administering a volume expander?

If there has been an acute fetal-maternal hemorrhage, bleeding vasa

previa, extensive vaginal bleeding, a placenta! laceration, fetal trauma,

an umbilical cord prolapse, a tight nuchal cord, or blood loss from the

umbilical cord, the baby may be in hyp ovolemic shock. The baby may

have a persistently low heart rate that <loes not respond to effective

ventilation, chest compressions, and epinephrine.

Babies with hyp ovolemic shock may appear pale, have delayed capillary

refill, and/ or have weak pulses. In sorne cases, there will be signs of

shock with no obvious evidence of blood loss.

• Administration of a volume expander is indicated if the baby is

not responding to the steps of resuscitation and there are signs of

shock or a history of acute blood loss.

• Volume expanders should not be given routinely during resuscitation

in the absence of shock or a history of acute blood loss. Giving a large

volume load to a heart that is already injured may actually worsen

cardiac output and further compromise the newborn.

What volume expanders should be considered and how

should they be administered?

Crystalloid fluid

The recommended crystalloid solution for acutely treating

hypovolemia is normal saline (0.9% NaCl).

Lactated Ringer solution is an acceptable alternative but is not as

commonly available. It co11tains sodium, potassium, calcium, and

lactate. Because it contains calcium, it cannot be infused in the same

intravenous line as packed red blood cells.

Packed red blood cells

Packed red blood cells should be considered for volume replacement

when severe fetal anemia is suspected. If fetal anemia was diagnosed

before birth, the donor unit can be cross-matched to the mother to

ensure compatibility with any maternal antibodies transferred to the

baby. If cross-matched blood is not immediately available, use emergency,

non-cross-matched, type O Rh-negative packed red blood cells.

Dose

The initial <lose of the selected volume expander is 1 O mL/kg. If

the baby <loes not improve after the first <lose, you may need to

189

190

give an additional 10 mL/kg. In un usual cases of large blood loss,

administration of additional volume may be considered.

Route

Options for emergency access to the vascular system during

hypovolemic shock include an umbilical venous catheter or an

intraosseous needle. Attempting insertion of a peripheral intravenous

catheter is not recommended for emergency volume administration in

the setting of cardiovascular collapse.

Preparation

Fill a large syringe (30-60 mL) with the selected volume expander.

If using crystalloid fluid, label the syringe to clearly identify its

contents.

Administration

In most cases, acute hypovolemia resulting in a need for resuscitation

should be corrected quickly. No clinical trials have established a

preferred infusion rate, but, in most cases, a steady infusion over 5 to

1 O minutes is reasonable.

In preterm newborns less than 32 weeks' gestation, volume boluses

given during the first day of life, volume bol uses given rapidly, and

volume bol uses greater than 1 O mL/kg have been associated with an

increased risk of intracranial hemorrhage.

Volume Expander Summary

Solution

Normal Saline (0.9% NaCI)

Suspected severe anemia: Type O Rh-negative packed red blood ce/Is

Route

lntravenous or lntraosseous

Preparation

30- to 60-ml syringe (labeled NS or O- blood)

Dose

l O ml/kg

, Aclministration

Over 5 to 1 O minutes

(Use caution with preterm newborns less than 32 weeks' gestation.)

What do you do if the baby is not improving after giving

intravenous epinephrine and volume expander?

While continuing to administer chest compressions and ventilation,

your team needs to quickly reassess the quality of ventilation and

compressions. Intravenous epinephrine may be repeated every 3 to

5 minutes.

If you have not inserted an alternative airway, this procedure should be

performed now. In addition, a STAT chest x-ray may provide valuable

information. If necessary, call for additional expertise.

Quickly ask each of the questions in Table 7-1 and confirm your

assessment as a team.

Table 7 • 1 • Questions to Ask When Heart Rote Is Not lmproving With

Compressions, Ventilation, Epinephrine, and Volume Expansion

1. Is the chest moving with each breath?

2. Is the airway secured with an endotracheal tube ora laryngeal mask?

3. Are 3 compressions coordinated with 1 ventilation being delivered every

2 seconds?

4. Is the depth of compressions one-third of the AP diameter of the chest?

5. Is 100% oxygen being administered through the PPV device?

6. Was the correct dose of epinephrine given intravenously?

7. Is the umbilical venous catheter or intraosseous needle in place or has it

been dislodged?

8. Is a pneumothorax present?

You have followed the Neonatal Resuscitation Program®

(NRP®

) Algorithm, but the newly born baby still has no

detectable heart rafe (Apgar O). For how long should you

continue?

Newly born babies with no detectable heart rate after 10 to 20

minutes of resuscitation frequently do not survive, and those who

survive frequently have serious neurologic disabilities, but survival

without neurodevelopmental impairment is possible. A small number

of newborns who experienced return of circulation and survived

without severe disabilities despite an absent heart rate for 20 or more

minutes after birth have been reported. The decision to discontinue

resuscitative efforts must balance the possibility of stopping too

early, when return of circulation and long-term survival may still be

achievable, and continuing too long, when return of circulation is not

191

Liver

Umbilical

ve1n

.-. - -

... , ...... _ '=' '-"""""

C,,,)

Fi g u re 7 .3. The umbilical vein

travels through the liver to join the

central venous circulation.

192

possible and continued interventions offer no benefit or the baby may

survive but with a significant burden of neurologic injury.

When making the decision to discontinue resuscitation, variables to be

considered may include

• Uncertainty about the duration of asystole

• Whether ali appropriate interventions have been performed

• The baby's gestational age

• The presence of serious congenital anomalies

• The specific circumstances prior to birth such as the presumed

etiology and timing of the perinatal events leading to

cardiorespiratory arrest

• The family's stated preferences and values

• The availability of post-resuscitative resources such as neonatal

intensive care and therapeutic hypothermia

Given these considerations, it is unlikely that a single time interval

after birth or a uniform duration of cardiopulmonary resuscitation will

be appropriate for all newborns.

• If there is a confirmed absence of heart rate after all appropriate

steps of resuscitation have been performed, cessation of

resuscitation efforts should be discussed with the team and family.

• A reasonable time frame for considering cessation of resuscitation

efforts is around 20 minutes after birth; however, the decision to

continue or discontinue should be individualized based on patient

and contextual factors.

There are other situations, such as prolonged bradycardia without

improvement, where, after complete a11d adequate resuscitation efforts,

discontinuation of resuscitation may be appropriate. However, there

is not enough information on outcomes in these situations to make

specific recommendations. Decisions on how to proceed in these

circumstances must be made on a case-by-case basis. If possible,

emergency consultation with a colleague or individual with additional

expertise may be helpful.

How do you establish rapid intravascular access during

resuscitation?

The umbilical vein

The umbilical vein is a rapidly accessible, direct intravenous route

in the newborn (Figure 7.3). If the use of epinephrine can be

anticipated because the baby is not responding to PPV, a member of

the resuscitation team should prepare to insert an umbilical venous

catheter while others continue to provide PPV and chest compressions.

Emergency umbilical venous catheter insertion

O Put on gloves and quickly prepare an area for your equipment

(Figure 7.4). Although you should attempt to use sterile technique,

you must balance the need to rapidly secure emergency venous

access with the risk of possibly introducing infection. If central

venous access will be needed after stabilization, the emergency

umbilical venous catheter will be removed and a new catheter will

be inserted using full sterile technique.

f) Fill a 3.SF or SF single lumen umbilical catheter with normal saline

using a syringe (3-10 mL) connected to a stopcock. Once filled,

close the stopcock to the catheter to prevent fluid loss and air entry

(Figure 7.4). Be certain that you know which direction is «off,, on

the stopcock used in your practice setting.

· I •

·' • I Y: ••

f¡lo

Fi g u r e 7 .4. Umbilical catheter (inside the plastic sleeve) prepared for

emergency insertion

E) Quickly clean the umbilical cord with an antiseptic solution. Place

a loose tie at the base of the umbilical cord (Figure 7.5) around

Wharton's jelly or the skin margin. This tie can be tightened

if there is excessive bleeding after you cut the cord. If the tie is

placed around the skin, be sure that it <loes not compromise skin

perfusion.

193

Figure 7.5. Tie placed around Wharton's jelly (A) or the skin margin (B). (Figure 7.5B used with permission of Mayo

Foundation for Medica! Education and Research.)

O Briefly stop chest compressions and caution the team that a scalpel

is entering the field. Cut the cord with a scalpel below the umbilical

clamp and about 1 to 2 cm above the skin line (Figure 7.6).

Attempt to cut straight across the cord rather than at an angle.

Figure 7.6. Cut the umbilical cord 1 to 2 cm above the skin line. (Figure 7.6B used with permission of Mayo

Foundation for Medica! Education and Research.)

194

0 The umbilical vein will be seen as a larger, thin-walled structure,

often near the 12-o'clock position. The 2 umbilical arteries are

smaller, have thicker walls, and frequently lie close together

(Figure 7.7). The arteries coil within the cord and their position

will vary depending on where you cut the cord.

O Insert the catheter into the umbilical vein (Figures 7.8 and 7.9).

a. Continue inserting the catheter 2 to 4 cm until you get free flow

of blood when the stopcock between the baby and the syringe is

opened and gently aspirated.

b. Por emergency use, the tip of the catheter should be located

only a short distance into the vein-only to the point at which

blood can be aspirated. If the catheter is inserted farther, there

is risk of infusing medications directly into the liver, which may

cause hepatic injury (Figure 7.10).

c. Continue to hold the catheter securely in place with 1 hand

until it is either secured or removed.

g ure 7.7. The umbilical cord

ready for catheter insertion. The

umbilical vein is shown by the yellow

arrow. The 2 umbilical arteries are

shown by the white arrows.

Fi g

u re 7 .8. Saline-filled catheter inserted into the

umbilical vein. Note the black centimeter markings on the

catheter.

Fi g ur e 7.9. Advance the catheter until blood can be

aspirated and the catheter can be easily flushed.

lncorrect

Fi g

u re 7 .1 O. Correct (A and B) and incorrect (C) umbilical venous catheter insertion

195

O Attach the syringe containing either epinephrine or volume

expander to the available stopcock port, turn the stopcock so

that it is open between the syringe and the catheter, ensure that

there are no air bubbles in the syringe or catheter, administer

the appropriate <lose, and flush the catheter (Figure 7.11). Avoid

dislodging the catheter by asking an assistant to infuse the

medication while the operator holds the catheter in place.

0 After medications have been administered, either remove the

catheter or secure it for temporary intravenous access as the baby

is transported to the nursery. If you decide to leave the catheter

in place during stabilization or transport, it should be secured. A

clear adhesive dressing can be used to temporarily secure the line

to the newborn's abdomen (Figure 7.12). Suturing and "goal post"

tape are effective methods for securing the catheter for prolonged

use, but they take time and may not be the best choice during

resuscitation.

Clear

,_,..adhesive

# dressing

Figure 7. 11. Open the stopcock toward the baby and

i nfuse the med ication.

Figure 7 .12. Temporarily secure the umbilical catheter

with a clear adhesive dressing.

196

f) If the umbilical venous catheter is not removed, the insertion site

should remain uncovered and visible to monitor for bleeding.

G) If you remove the catheter, do it slowly and be prepared to control

bleeding by tightening the cord tie, squeezing the umbilical stump,

or applying pressure above the umbilicus.

The intraosseous needle

Although an umbilical venous catheter is typically the preferred

method of obtaining emergency vascular access in the delivery

room, an intraosseous needle is a reasonable alternative if umbilical

venous access is unsuccessful or not feasible. Intraosseous needles

are frequently used for emergency access in prehospital settings

and emergency departments. An intraosseous needle (Figure 7.13)

is inserted through the skin into the flat portion of a large bone

and advanced into the bone marrow cavity (Figure 7.14). When

medications and fluids are infused, they quickly reach the central

venous circulation and have the same hemodynamic eff ect as

intravenous administration. Ali medications and fluids that can be

infused into an umbilical venous catheter can be infused into an

intraosseous needle. Small case series have shown that intraosseous

needles are feasible to insert in term and preterm newborns, have

similar efficacy to intravenous routes, and can be inserted quickly.

However, there is a risk of severe complications, including infections,

bone fractures, and limb ischemia. The rate of successful insertion in

very premature newborns is unknown.

g u re 7. 1 3. Examples of

intraosseous needles. Sorne needles

are inserted with a dril! (left) and

others are inserted manually (right).

Severa! different types of intraosseous needles

Trabeculae Compact bone

are commercially available. Sorne are intended to

be manually inserted using a twisting motion to

penetrate the skin and bone. Other needles are

inserted using a battery-operated drill. Consult the

manufacturer,s literature to identify the correct-sized

needle for your patient. The intraosseous needle will

have a stylet that is used during insertion and must be

removed before infusion.

lntraosseous needle insertion

O Identify the insertion site. For term newborns, the

preferred site is the flat surface of the lower leg,

approximately 2 cm below and 1 to 2 cm medial

to the tibial tuberosity ( the bony bulge below the

kneecap) (Figure 7.15).

Fi g u re 7 .1 5. Needle insertion site along the flat

anteromedial surface of the tibia

,....--Osteon

\' 1

:::::::I\ 1

, r@n #>,:', - -

y-., ,. ";.\.

Fi g u r e 7 .14. lntraosseous needle in the bone

marrow cavity. lnfused medications and fluids reach

the central venous circulation quickly. (Adapted from

Al I rig hts reserved.)

197

198

f) Clean the insertion site with antiseptic solution (Figure 7.16).

Figure 7. 1 6. Ouickly clean the insertion site.

E) Hold the intraosseous needle perpendicular to the skin and

advance the needle through the skin to the surface of the bone

(periosteum) (Figure 7.17).

Figure 7.17. lnsertion using an intraosseous drill

8 Direct the needle perpendicular to the bone and advance the

needle through the bone cortex into the marrow space. If

advancing the needle by hand, use strong downward pressure with

a twisting motion. If advancing the needle with an electric drill,

press the trigger while holding downward pressure as described

in the manufacturer's instructions. When the needle enters the

marrow space, a distinct change in resistance (

pop") is noticeable.

0 Follow the manufacturer's instructions for removing the stylet and

securing the needle (Figure 7 .18).

Fi g u re 7. 1 8. Remove the

intraosseous needle stylet.

O Connect an infusion set (prefilled with normal saline) to the

needle's hub, open the stopcock toward the needle, flush the needle

with 3 to 5 mL of norn1al saline to open the bone marrow space,

and administer the medication and saline flush (Figure 7.19) .

•

Figure 7 .19. Connect an infusion set to the intraosseous needle,

open the stopcock toward the needle, flush the needle (A), and infuse the

medication or fluid (B).

O Monitor the insertion site for evidence of swelling or fluid

extravasation.

199

Focus on Teamwork

The administration of epinephrine and a volume expander during

resuscitation highlights severa! opportunities for effective teams to use

the NRP Key Behavioral Skills.

Behavior Example

Anticípate and plan.

Use available information.

Know your environment.

Call for additional help when

needed.

Allocate attention wisely.

Clearly identify a team leader.

Use available resources.

Communicate effectively.

Maintain professional behavior.

200

lf perinatal risk factors suggest that the fetus may hove experienced acute

blood loss or hove severe cardiorespiratory compromise (eg, prolonged fetal

bradycardia), prepare an umbilical venous catheter or an intraosseous needle,

epinephrine, and fluid for volume expansion before the birth.

Emergency insertion of an umbilical venous catheter or intraosseous needle and

blood administration are infrequently used skills, and teams must practice them

frequently to be certain that they can be performed correctly and efficiently

during an emergency.

lf a baby requires chest compressions, it is likely that epinephrine also will be

required. Once compressions are started, a team member should prepare

epinephrine and an umbilical venous catheter oran intraosseous needle so that

intravascular epinephrine can be administered without delay.

Your team needs to know where emergency type O Rh-negative blood is stored,

how it will be obtained when needed, and what additional equipment will be

needed to prepare and infuse it without delay.

Your team needs to know where the emergency vascular access equipment is

stored.

lf epinephrine or volume expansion is required, you will need additional help. lt

will likely take more than 4 team members to continue effective ventilation and

compressions, quickly insert and secure emergency vascular access, prepare and

administer epinephrine or fluid, monitor the passage of time, monitor the quality

of compressions and ventilations, document events as they occur, and provide

support for the baby's family.

lf the team leader becomes involved in umbilical catheter insertion, their attention

is focused primarily on that task and they may not be able to pay full attention

to the baby's condition, the passage of time, or the adequacy of ventilation and

. compress1ons.

Any team member who has mastered the NRP Algorithm and has strong leadership

skills can become the team leader. Clearly announce the change in leadership

when it occurs.

lf you hove difficulty inserting an emergency umbilical venous catheter, use an

intraosseous needle.

Use efficient, directed, closed-loop communication when epinephrine or volume

expanders are requested.

When you give an instruction, direct the request to a specific individual, call the

team member by name, make eye contact, and speak clearly.

After giving an instruction, ask the receiver to report back as soon as the task is

completed.

After receiving an instruction, repeat the instruction back to the sender.

During a complex resuscitation, it is easy for the quality of communication to

deteriorate. lt is critically important for the leader to establish and maintain calm

and professional behavior.

Quality lmprovement Opportunities

Ask yourself the following questions and begin a discussion with your

team if you find a difference between the NRP recommendations and

what is currently done in your own hospital setting. Consider using the

suggested process and outcome measures to guide your data collection,

identify areas for improvement, and monitor if your improvement

efforts are working.

Quality improvement questions

O Who are the providers that can insert an umbilical venous catheter

and intraosseous needle in your delivery room setting?

f) Is someone with these skills immediately accessible if needed?

8 Is a kit with ali necessary supplies for emergency vascular access

immediately accessible if needed?

0 Do providers know where to obtain an intraosseous needle?

0 Does your emergency medication cart/box only include the dilute

(O.l mg/mL) solution of epinephrine for newborn resuscitation, or

<loes it also have the concentrated (1 mg/mL) solution?

O How often do NRP providers practice how to calculate and prepare

a <lose of epinephrine for neonatal resuscitation?

O Do you have a weight-based emergency medication chart/table

near each radiant warmer?

0 Do NRP providers know how to access emergency type O

Rh-negative blood in your delivery room setting? Do they know

the procedure for blood administration?

Process and outcome measures

O How often do newborns receive epinephrine in your delivery room

setting?

f) How often do newborns receive volume expanders in your delivery

room setting?

8 When emergency medications are required, how often is a skilled

provider present at the time of birth?

201

202

O How often is the first <lose of epinephrine given by the

intravascular route?

0 What percentage of resuscitation team members have

demonstrated that they can properly calculate and prepare

emergency epinephrine in a simulation setting each year?

Frequently Asked Questions

Why has the suggested dose of epinephrine been changed to a single

dose instead of using the full range?

The new suggested <lose for epinephrine is based on a desire to simplify

the dosing for educational efficiency. This single <lose may be easier for

NRP providers to remember in an emergency, may improve teamwork

by allowing the team member preparing epinephrine to anticipate the

requested <lose, and may allow easier preparation across a wide range

of newborn weights. Although sorne studies suggest that the lower end

of the dosing range may be less effective, the current suggested <lose is

not based on evidence of superior efficacy and <loes not represent an

endorsement of any particular <lose within the recommended dosing

range. The ideal epinephrine <lose for persistent, severe neonatal

bradycardia and asystole remains an important knowledge gap and

additional research is needed.

Why has the flush volume after intravascular epinephrine administration

been increased from 1 ml to 3 ml?

Evidence from an animal study has suggested that a 1-mL flush volume

may leave a significant amount of epinephrine in the umbilical vein or

liver instead of carrying it to the heart. Pending additional studies to

identify the ideal flush volume in newly born humans, this program

recommends a 3-mL flush volume for babies of all gestational ages

after intravascular epinephrine administration.

When ordering emergency epinephrine, is it safer to express the dose as

a mass (mg/kg) or a volume (ml/kg)?

Because this question has not been fully resolved, this program

describes the <lose using both mass (mg/kg) and volume (mL/kg)

expressions. Each method has risks and benefits. If the <lose is

expressed using the mass method, the team member preparing the

<lose will need to convert milligrams to milliliters, and there is a risk of

making a decimal point error. If the <lose is expressed using the volume

method, the provider preparing the <lose <loes not have to convert

between units, but there is a risk of giving a 1 O-times overdose if the

provider accidently uses the concentrated (1 mg/mL) epinephrine

solution. This medication error is preventable by ensuring that the

dilute (0.1 mg/mL) solution of epinephrine is the ONLY concentration

included in neonatal emergency supplies.

Whichever dosing method is used, the providers should use

closed-loop communication, repeat back the intended <lose, include

the desired units and the baby's estimated weight when ordering and

preparing the <lose, confirm the concentration of the epinephrine

solution used by showing the box to another team member, and

compare the prepared <lose with a weight-based chart or table to

ensure accuracy.

Why is the intravenous route for epinephrine administration preferred over

the endotracheal route? lsn't the endotracheal route easier and faster?

Epinephrine given into the endotracheal tube may be absorbed by the

lungs and enter blood that drains directly into the heart. Although it

may be faster to give epinephrine to an intubated baby through the

endotracheal tube, the process of absorption by the lungs makes the

response time slower and more unpredictable than if epinephrine

is given directly into the blood. Data from both animal models and

clinical studies suggest that the standard intravenous <lose is ineffective

if given via the endotracheal tube. There is sorne evidence in animal

models that giving a higher <lose can compensate for the delayed

absorption from the lungs; however, no studies have confirmed

the efficacy or safety of this practice in newborns. If the need for

medications is anticipated, advance preparation of an umbilical venous

catheter, before delivery, allows rapid administration of intravenous

epinephrine without delay.

After intraosseous needle insertion, is it necessary to aspirate the syringe

before infusing fluid?

No. In the newborn, aspiration of the intraosseous needle is not a

reliable indicator of correct needle insertion and is not necessary. If the

needle is correctly inserted, it should feel firmly secured in the bone

and not "wiggle:' When fluid is infused, the soft tissue surrounding the

bone should not swell.

203

204

Previous editions of the Textbook of Neonatal Resuscitation suggested

that it may be reasonable to stop resuscitative efforts if the heart rote

was undetectable after 1 O minutes of resuscitation. Why does this edition

suggest that the time interval to consider stopping resuscitative efforts

should be around 20 minutes?

Since the last recommendation was published, additional studies have

been completed. Although the scientific evidence is weak because

of incomplete reporting, a recent systematic review completed by

the International Liaison Committee on Resuscitation (ILCOR)

found that stopping resuscitative effort at 1 O minutes may preclude

survival of sorne newborns who would have survived without

significant disabilities. Improvements in neonatal intensive care and

the availability of neuroprotective interventions, such as therapeutic

hy p othermia, may be improving the long-term outcome for these

newborns. Extending the time frame to consider discontinuing

resuscitative efforts may allow the resuscitation team more time to

complete ali appropriate interventions, achieve the correct balance

between continuing too long and stopping too soon, make an

individualized decision, and include the family in decision-making and

care for their newborn.

LESSON 7 REVIEW

l. Ventilation that moves the chest has been performed through an

endotracheal tube for 30 seconds, followed by coordinated chest

compressions and 100% oxygen for an additional 60 seconds.

Epinephrine is indicated if the baby's heart rate remains less

than (60 beats per minute)/(80 beats per minute).

2. The preferred route for epinephrine is (intravenous)/

( endotracheal).

3. Your team is resuscitating a baby born at term. The baby's

heart rate is 40 beats per minute after 30 seconds of ventilation

through an endotracheal tube and an additional 60 seconds of

coordinated chest compressions and ventilation using 100%

oxygen. You determine that epinephrine is indicated. Your

team should ( quickly attempt to insert a peripheral intravenous

catheter in the baby's right hand)/(insert an umbilical venous

catheter).

4. The recommended concentration of epinephrine for newborns

is (0.1 mg/mL)/(1 mg/mL).

5. The suggested initial intravenous <lose of epinephrine is

(0.02 mg/kg)/(0.1 mg/kg).

6. Intravenous epinephrine should be administered (slowly)/(as

quickly as possible), followed by a (3-mL)/(l-n1L) normal saline

flush.

7. If the baby's heart rate remains less than 60 beats per minute,

you can repeat the <lose of epinephrine every (3 to 5 minutes)/(8

to 10 minutes).

8. If an emergency volume expander is indicated, the initial <lose is

(1 mL/kg)/(10 mL/kg).

Answers

1. Epinephrine is indicated if the baby's heart rate remains less

than 60 beats per minute.

2. The preferred route for epinephrine is intravenous.

3. Your team should insert an umbilical venous catheter or an

intraosseous needle. During cardiopulmonary collapse, a

peripheral intravenous catheter is unlikely to be successful and

attempts at insertion may delay appropriate therapy.

4. The recommended concentration of epinephrine for newborns

is 0.1 mg/mL.

5. The suggested initial intravenous <lose of epinephrine is

0.02 mg/kg.

6. Intravenous epinephrine should be administered as quickly as

possible, followed by a 3-mL normal saline flush.

7. If the baby's heart rate remains less than 60 beats per minute,

you can repeat the <lose of epinephrine every 3 to 5 minutes.

8. The initial <lose is 1 O mL/kg.

205

206

LESSON 7: PRACTICE SCENARIO

Medications

Comprehensive Skills Test Scenario for Neonatal Resuscitation Program

(NRP) Advanced Providers

Learning Objectives

O Identify when the newborn requires epinephrine and a volume

expander during resuscitation.

8 Demonstrate preparation and administration of epinephrine and

volume expander.

8 Demonstrate preparation and insertion/assistance with insertion of

an emergency umbilical venous catheter.

9 Demonstrate how to secure an emergency umbilical venous

catheter.

0 Practice NRP Key Behavioral Skills to ensure effective

communication and teamwork during this critica! component of

neonatal resuscitation.

This Practice Scenario is for review / practice and evaluation. This scenario

may also be used as the Comprehensive Skills Test ("test out") option for

NRP Advanced providers during a Provider Course.

This is the suggested Practice Scenario sequence.

O Review the Knowledge Check Questions with your NRP

instructor.

a. What are the indications for epinephrine during neonatal

resuscitation?

b. What epinephrine concentration is used during neonatal

resuscitation?

c. What is the preferred route of administration? What is the

alternative route while vascular access is being established?

d. What is the correct <lose range for each route? Where is the

pre-calculated drug dosage chart our hospital uses during a

neonatal code?

e. How quickly should you expect to see a rising heart rate after

giving intravenous epinephrine? How often can you repeat

epinephrine?

f. If the heart rate does not respond to intravenous epinephrine,

what clinical conditions might be considered?

g. What are signs of shock in a newborn, indicating the need for

volume expander?

h. What volume expanders are used? What is the <lose of the

selected volume expander?

i. What is the route of the volume expander and how fast is it

administered?

f) Practice/review these skills with your NRP instructor.

a. Draw up epinephrine for administration via endotracheal

tube and emergency umbilical venous catheter using a 3-way

stopcock and/ or connector.

b. Prepare the emergency umbilical venous catheter for use.

c. Perform the procedure or assist with insertion of the emergency

umbilical venous catheter.

d. Apply a clear adhesive dressing to secure the emergency

umbilical venous catheter during resuscitation.

e. Practice giving and/ or confirming an order for intravenous

epinephrine using closed-loop communication.

f. Draw up normal saline for volume administration.

E) Practice the scenario with your NRP instructor and team until you

need little or no assistance or coaching.

8 Pass the Lesson 7 Practice Scenario evaluation by leading practice

scenario(s) and performing the skills relevant to your role and

responsibilities. If a technical skill included in a scenario is not

within your scope of responsibility, delegate the skill to a qualified

team member and perform the role of assistant if appropriate.

0 When you can lead the scenario(s) and perform the skills with little

or no instructor coaching, learners may proceed to the Simulation

and De briefing component of the Provider Course.

207

Practice Scenario

"You are called to attend an emergency cesarean birth due to umbilical cord prolapse with fetal bradycardia.

How would you prepare for the resuscitation of the baby? As you work, say your thoughts and actions aloud

so I will know what you are thinking and doing."

Critical Performance Steps

Assess perinatal risk.

Assesses perinatal risk (learner asks the 4 pre-birth questions and instructor ["OB provider"] responds)

Gestation? "Term."

Fluid clear? "Fluid is clear."

Additional risk factors? "Cord prolapse and fetal bradycardia for the last 3 minutes."

Umbilical cord management plan? "We'II assess the baby at birth. lf the baby's not vigorous, 1'11 give brief

stimulation, and if there's no improvement, 1'11 clamp the cord and bring the baby to the radiant warmer."

Assemble team.

Assembles team based on perinatal risk factors.

lf risk factors are present, at least 2 qualified people should be present solely to manage the baby.

The number of team members and qualifications vary depending on risk.

Perform a pre-resuscitation briefing.

ldentifies team leader.

Assesses risk factors, delegates tasks, identifies who will document events as they occur, determines supplies and

equipment needed, identifies how to call for additional help.

Perform equipment check.

"The baby has been born."

Rapid evaluation.

• Term? "Appears term."

• Tone? "No tone."

• Breathing or crying? "No breathing."

lnitial steps.

Receives baby at radiant warmer, dries, stimulates, positions airway, suctions mouth and nose

Assess breathing. lf breathing, assess heart rote.

Checks breathing

"The baby is apneic." (Heart rote = 50 bpm, if assessed)

Begin PPV within 60 seconds of birth.

Begins PPV in 21 % oxygen (room air). Within 15 seconds of beginning PPV, learner asks the assistant to assess

the heart rote and state if heart rote is rising.

Heart rote = 40 bpm, not increasing

Assess chest movement.

• lf chest movement observed, continues PPV x 15 seconds (for total of 30 seconds)

• lf no chest movement observed, proceeds through corrective steps (MR. SOPA) until chest movement; then

administers PPV x 30 seconds

• lf no chest movement with corrective steps M and R, S and O, and P, learner indicates need for alternative

airway and proceeds directly to intubation or faryngeaf mask insertion

208

Critical Performance Steps (cont)

Check heort rote after 30 seconds of PPV that moves the chest.

Checks heart rate

Heort rote= 30 bpm, not increasing

lndicates need for alternative airway

Places cardiac monitor leads and connect to monitor in anticipation of alternative airway (if not already done).

lnsert alternative airway (endotracheal tube [preferred] or laryngeal mask).

NOTE: Administration of epinephrine into a laryngeal mask is not recommended.

• lntubates (size 1 blade and size 3.5 endotracheal tube) or inserts laryngeal mask (size 1)

• Checks for C0 2 detector color change, rising heart rote; also checks for bilateral breath sounds and chest

movement with PPV

• For endotracheal tube: checks tip-to-lip insertion depth using nasal-tragus length (NTL) or insertion depth chart

• Asks assistant to secure endotracheal tube or laryngeal mask

lf device not successfully inserted,

"Color is not changing on the C0 2 detector and the chest is not moving."

Heort rote = 30 bpm and not increasing

• Removes device

• Resumes PPV by face mask

• Repeats insertion attempt

lf device successfully inserted,

Note: Color might not change on the C0 2 detector dueto low heart rote.

Heort rote = 30 bpm, not increosing

"The baby's chest is moving, breath sounds are equal, pulse oximeter has no signal."

• Operator continues PPV x 30 seconds

• Assistant checks tip-to-lip depth using gestational age/weight table or NTL measurement

- lf using NTL, measures distance from the nasal septum to the ear tragus (insertion depth [cm]= NTL + 1 cm)

• Assistant secures endotracheal tube

Check heart rote after 30 seconds of PPV with alternative airway.

Checks heart rate by observing cardiac monitor (may also auscultate heart rote) after 30 seconds of PPV that

moves the chest with an alternative airway

Heort rote= 30 bpm and not increasing "Pulse oximeter has no signal."

Begin chest compressions.

• Calls for additional help

• Asks assistant to increase oxygen to 1 00%

• Asks assistant to place servo-controlled temperature sensor on baby, if not already done, and adjust to

maintain baby's temperature 36.5º

C to 37.5º

• Administers compressions from head of bed with coordinated ventilation (thumbs on lower one-third of sternum,

compressions one-third of the anterior-posterior [AP] diameter of the chest, 3 compressions: 1 ventilation every 2

seconds)

209

Critical Performance Steps (cont)

Check heart rate after 60 seconds.

Pauses compressions, continues PPV, and checks heart rote after 60 seconds of compressions and ventilations.

Heart rate = 30 bpm and not increasing

lndicates need for emergency vascular access.

Medication administration vio endotracheal tube (optional, while umbilical venous catheter is being established}.

Requests epinephrine vio endotracheal tube Concentration: 0.1 mg/ml= l mg/10 ml

Suggested endotracheal tube dese: 0.1 mg/kg (l ml/kg)

• Requests estimated weight: "The baby's estimated weight is 3 kg."

• Orders epinephrine for endotracheal tube for a baby weighing 3 kg:

0.3 mg epinephrine vio the endotracheal tube (equal to 3 ml in syringe)

• Uses closed-loop communication with confirmation of medication, dese, and route

• Assistant checks medication label, opens medication, attaches stopcock or syringe connector and 5-ml syringe

• Assistant prepares correct volume, labels syringe with medication name and intended route

Administers endotracheal epinephrine (can be performed by assistant or operator)

• Gives the epinephrine directly into the endotracheal tube, does not leave it deposited in the tube connector.

• Follows the drug with several positive-pressure breaths to distribute the drug into the lungs.

• Announces "ET epinephrine given."

Requests heart rote check after 60 seconds. Pauses compressions briefly and observes cardiac monitor; may also

auscultate heart rote.

Heart rote = 30 bpm and not increasing

Continues PPV and compressions.

Prepare emergency umbilical venous catheter (may be performed by assistant or operator).

• Obtains syringe with normal saline flush

• Attaches 3-way stopcock to umbilical venous catheter

• Flushes catheter and stopcock with normal saline

• Closes stopcock to catheter

lnsert emergency umbilical venous catheter.

• Cleans lower segment of umbilical cord with antiseptic solution

• Ties umbilical tape loosely at base of cord

• Cuts cord about l to 2 cm above base (may request compressions pause)

• lnserts catheter into vein, opens stopcock and gently aspirates syringe, advances catheter approximately 2 to

4 cm until blood return is detected

• Flushes catheter and closes stopcock toward catheter

• Ensures catheter is being held in place; may secure with clear adhesive dressing

Administer medication via umbilical venous catheter.

Requests epinephrine vio umbilical venous catheter Concentration: 0.1 mg/ml = l mg/l O ml

Suggested intravenous dese: 0.02 mg/kg (0.2 ml/kg) every 3 to 5 minutes.

• Requests estimated weight if not already known: "The baby's estimated weight is 3 kg."

• Orders epinephrine for umbilical venous catheter for a baby weighing 3 kg:

.06 mg epinephrine vio the umbilical venous catheter (equal to 0.6 ml in syringe)

• Uses closed-loop communication with confirmation of medication, dese, and route

• Assistant checks medication label, opens medication, attaches stopcock or syringe connector and l -ml syringe

• Assistant prepares correct volume, labels syringe with medication name and intended route

210

Critical Performance Steps (cont)

Administer medication vio umbilical venous catheter (cont).

Administers epinephrine vio the umbilical venous catheter (can be performed by assistant or operator)

• Ensures that catheter is being held in place; attaches syringe to stopcock, opens stopcock to catheter and

syringe, administers epinephrine rapidly without air bubbles.

• Flushes umbilical venous catheter with 3 ml of normal saline.

• Announces "IV epinephrine given."

Check heort rote ofter 60 seconds.

• Continues PPV and compressions

• Pauses compressions and checks heart rote 60 seconds after intravenous epinephrine

Heort rote= 50 bpm "Pulse oximeter has no signol. The baby is pole."

• Continues PPV and compressions

Administer volume exponder.

Requests 30 ml (1 O ml/kg) of normal saline per umbilical venous catheter over 5 to 1 O minutes using

closed-loop communication

• Draws up correct vol u me or uses prefilled syringes. Numbers more than one syringe (# 1, #2, #3).

• Ensures that catheter is being held in place; attaches syringe to stopcock, opens stopcock to catheter and

syringe, administers volume in slow infusion over 5 to 1 O minutes without air bubbles (or use an infusion

pump).

Check heort rote every 60 seconds.

• Continues PPV and compressions.

• Monitors heart rote vio cardiac monitor while volume administered. May also auscultate heart rote.

• Pauses compressions, continues PPV while heart rote is assessed.

NOTE: The instructor may compress time and announce, "The 30-mL infusion of normal saline has been given."

Heort rote = 80 bpm and increasing SP02 = 68%

"Color is changing on C0 2 detector. Pulse oximeter has a reliable signal."

Discontinue compressions-Continue PPV.

• Discontinues chest compressions

• Continues PPV with higher ventilation rote (40-60 breaths/min)

Heort rote is > 100 bpm SP02 = 80% "There ore no spontaneous respirations."

Check vital signs.

Continues PPV and adjusts oxygen concentration per pulse oximetry

Heort rote is > 100 bpm SP02 = 90%

"The baby has fair muscle tone and some spontaneous respirations."

End scenario.

Supports baby with PPV and supplemental oxygen per Target Oxygen Saturation Table.

Monitors heart rote, respiratory effort, oxygen saturation, activity, and temperature.

Prepares to move baby to post-resuscitation care setting.

Communicates with perinatal team.

Updates parents and informs them of next steps.

Debriefs the resuscitation.

211

212

Sample Debriefing Questions

O What went well during this resuscitation?

f) What will you do differently when faced with this complex

resuscitation in a future scenario?

8 Do you have additional comments or suggestions for your team?

For the leader?

O Why <lid this baby receive volume expander?

0 Give me an example of how you used at least one of the NRP Key

Behavioral Skills.

NRP Key Behavioral Skills

• Know your environment.

• Use available information.

• Anticípate and plan.

• Clearly identify a team leader.

• Communicate effectively.

• Delegate the workload optimally.

• Allocate attention wisely.

• Use available resources.

• Call for additional help when needed.

• Maintain professional behavior.

Resuscitation an ta i ization

o Ba ies Born Preterm

What you will learn

■ Why babies born preterm are at higher risk of medical

complications

■ The additional resources needed to prepare for a preterm

birth

■ Additional strategies to maintain the preterm baby's body

temperature

■ How to assist ventilation when a preterm baby has

difficulty breathing

■ Additional considerations for oxygen management in a

preterm baby

■ Ways to decrease the chances of lung and brain injury in

preterm babies

■ Special precautions to take after the initial stabilization

period

■ How to present information to parents before the birth of

an extremely premature baby

(Used with permission of Mayo Foundation for Medical Education and Research.)

RESUSCITATION AND STABILIZATION OF BABIES BORN PRETERM

214

Key Points

O Preterm newborns are at increased risk for requiring resuscitation

and assistance with transition after birth.

f) Preterm newborns are at increased risk of complications because of

rapid heat loss, immature organ systems, small blood volume, and

vulnerability to hypoglycemia.

8 Additional resources (including skilled personnel, a polyethylene

plastic bag or wrap, a hat, thermal mattress, temperature sensor

and cover for a servo-controlled radiant warmer, preterm-sized

masks and endotracheal tubes, a positive-pressure device that can

provide positive-end expiratory pressure [PEEP] and continuous

positive airway pressure [CPAP], and surfactant) should be

available.

8 The temperature in the room where resuscitation takes place

should be 23ºC to 25º C (74º F-77º F).

0 If the baby is less than approximately 32 weeks' gestation, a

polyethylene plastic bag or wrap and a thermal mattress should be

prepare d.

O If positive-pressure ventilation (PPV) is required, use the lowest

inflation pressure necessary to achieve and maintain an adequate

heart rate response. lt is preferable to use a device that can provide

PEEP.

O Consider using CPAP immediately after birth if the baby is

breathing spontaneously with a heart rate of at least 100 beats

per minute (bpm) but has labored respirations or low oxygen

saturation.

0 To decrease the risk of neurologic injury, handle the baby gently,

avoid positioning the baby's legs higher than the head, avoid high

PPV or CPAP pressures, use a pulse oximeter and blood gases

to adjust ventilation and oxygen concentration, and avoid rapid

intravenous fluid infusions.

The following 2 cases describe the birth and resuscitation of preterm

babies. As you read the cases, imagine yourself as part of the team from

the anticipation of the delivery through the resuscitation, stabilization,

and transfer to an intensive care nursery.

Case 1: Stabilization of a baby born very preterm

A woman is in premature labor at 29 weeks' gestation with ruptured

membranes and clear amniotic fluid. A vaginal birth is anticipated.

The resuscitation team leader meets with the obstetrician and parents

to discuss the care plan. Anticipating the possibility of a complex

resuscitation, your resuscitation team is assembled and reviews each

team member's role. Using a written checklist, your team ensures

that ali supplies and equipment needed to resuscitate and stabilize

a preterm baby are ready for use. One team member attaches a

preterm-sized mask to the T-piece resuscitator. The peak inflation

pressure (PIP) is adjusted to 20 cm H20 and positive end-expiratory

pressure (PEEP) is set to 5 cm H20 . Next, a laryngoscope with a

size O blade and both a 3.0-mm and 2.5-mm endotracheal tube are

prepared. The oxygen blender is adjusted to deliver 21 % oxygen.

Additional team members increase the delivery room temperature,

turn on the radiant warmer, obtain polyethylene plastic wrap, activate

a thermal mattress, and cover the mattress with a cotton blanket. The

obstetrician prepares a warm blanket.

At the time of birth, the baby has flexed extremities but <loes not cry.

The obstetrician holds the baby on the warm blanket, provides gentle

tactile stimulation, and gently suctions secretions from the mouth and

nose. After 15 seconds, the baby begins to take spontaneous breaths.

By 30 seconds, the baby has sustained respirations and is actively

moving. An assistant clamps and cuts the umbilical cord 60 seconds

after birth and the baby is handed to your resuscitation team. The

baby is carried to the radiant warmer, placed on the blanket-covered

thermal mattress, and wrapped in the plastic sheet. A servo-controlled

temperature sensor is applied to the baby's skin to monitor and

control the baby's body temperature, and a hat is placed on the baby's

head. The baby is breathing and has a heart rate greater than 100 beats

per minute (bpm), but breathing is labored and breath sounds are

decreased. A team member attaches a pulse oximeter sensor to the

baby's right hand and cardiac monitor leads to the chest. Continuous

positive airway pressure (CPAP) with 21 % oxygen is administered

using the face mask and T-piece resuscitator. The baby's breath sounds

and work of breathing improve, but the oxygen saturation (SPo2) is

below the target range. The oxygen concentration (F10 2) is gradually

increased to 30% and the SPo2 begins to rise. Nasal CPAP prongs are

placed. Your team continues to adjust the oxygen blender based on

pulse oximetry and, by 15 minutes of age, the F102 has been decreased

to 21 %.

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RESUSCITATION AND STABILIZATION OF BABIES BORN PRETERM

216

The parents are updated by the team leader, they have an opportunity

to see and touch their baby, and the baby is moved to the intensive care

nursery in a pre-warmed transport incubator. Shortly afterward, team

members co11duct a debriefing to review their preparation, teamwork,

and communication.

Case 2: Resuscitation and stabilization of a baby born

extremely preterm

A woman is in preterm labor at 24 weeks' gestation with ruptured

membranes and clear amniotic fluid. Your resuscitation team leader

meets with the obstetrician and parents to discuss current outcome

data and the procedures that may be required to resuscitate and

stabilize an extremely premature newborn. After the discussion,

they develop a care plan based on the parents' assessment of their

baby's best interest. The parents and health care providers agree to

provide intensive medica} care, including endotracheal intubation,

chest compressions, and emergency medication, if necessary. Despite

tocolysis, labor progresses anda vaginal birth is anticipated. Your

resuscitation team is assembled f or a pre-resuscitation team briefing

to review each member's roles and responsibilities. Using a written

checklist, the team prepares the necessary supplies and equipment.

At the time of birth, the baby is flaccid and does not cry. The

obstetrician holds the baby on the warm blanket, provides gentle

tactile stimulation, and gently suctions secretions from the mouth and

nose, but the baby's tone remains poor and the baby is not breathing.

The umbilical cord is clamped and cut and the baby is handed to your

resuscitation team. The baby is carried to the radiant warmer, placed

on the blanket-covered thermal mattress, and wrapped in the plastic

sheet. A servo-controlled temperature sensor is applied to the baby's

skin to monitor and control the baby's body temperature, and a hat is

placed on the baby's head. The baby remains limp without respiratory

effort. You administer positive-pressure ventilation (PPV) using the

T-piece resuscitator and 30% oxygen. A team member attaches a

pulse oximeter sensor to the right wrist and cardiac monitor leads

to the chest. The baby's heart rate is 60 bpm and the chest is not

moving with PPV. The ventilation corrective steps are performed,

including incrementally increasing the inflation pressure from

20 cm H20 to 30 cm H20 , but the heart rate still <loes not improve.

A 2.5-mm endotracheal tube is inserted and placement is confirmed

with a carbon dioxide (C02

) detector. Positive-pressure ventilation

is continued with the T-piece resuscitator, breath sounds are equal

bilaterally, and the heart rate promptly increases. The nasal-tragus

length (NTL) is 4.5 cm and the endotracheal tube is secured with the

5.5-cm mark adjacent to the baby's lip. The F102 is gradually adjusted

to meet the oxygen saturation target, and the T-piece PIP is adjusted

to maintain gentle chest movement with each breath. A short time

later, surfactant is administered through the endotracheal tube. By

20 minutes, the F102 has been decreased to 25%.

The parents are updated by the team leader, they have an opportunity

to see and touch their baby, and the baby is moved to the intensive care

nursery in a pre-warmed transport incubator with blended oxygen

and continuous monitoring. Shortly afterward, your team members

conduct a debriefing to review their preparation, teamwork, and

communication.

Preterm Birth

In the previous lessons, you learned a systematic approach to neonatal

resuscitation. When birth occurs before term gestation (less than

37 weeks' gestation), additional challenges make the transition

to extrauterine life more difficult. The likelihood that a preterm

newborn will need help making this transition is related to gestational

age. Babies born at lower gestational ages are more likely to require

additional interventions. Because preterm newborns are also more

vulnerable to injury from resuscitation procedures, it is important to

find the correct balance between initiating resuscitation without delay

and avoiding unnecessarily invasive procedures. Your management

during these first minutes may decrease the risk of both short- and

long-term complications. This lesson focuses on the additional

problems associated with preterm birth and the actions you can take to

prevent or manage them.

Why do preterm babies have a higher risk of complications?

Sorne complications result from the underlying problem that caused

the preterm birth while others reflect the baby's anatomic and

physiologic immaturity.

• Thin skin, decreased subcutaneous fat, large surface area relative to

body mass, and limited metabolic response to cold lead to rapid heat

loss.

• Weak chest muscles, poorly compliant (stiff) lungs, and flexible ribs

decrease the efficiency of spontaneous breathing efforts.

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RESUSCITATION AND STABILIZATION OF BABIES BORN PRETERM

218

• Immature lungs that lack surfactant are more difficult to ventilate

and are at greater risk of injury from PPV.

• Immature tissues are more easily damaged by oxygen.

• Infection of the amniotic fluid and placenta ( chorioamnionitis)

may initiate preterm labor, and the baby's immature immune

system increases the risk of developing severe infections such as

pneumonia, sepsis, and meningitis.

• A smaller blood volume in creases the risk of hyp ovolemia from

blood loss.

• Immature blood vessels in the brain cannot adjust to rapid

changes in blood flow, which may cause bleeding or damage from

insufficient blood supply.

• Limited metabolic reserves and immature compensatory

mechanisms increase the risk of hyp oglycemia after birth.

What additional resources do yo u need f or resuscitating a

preterm newborn?

The chance that a preterm baby will require resuscitation is

significantly higher than for a baby born at full term. This is true even

for late-preterm babies born at 34 through 36 weeks' gestation.

• If the baby is anticipated to be less than 32 weeks' gestation, prepare

a polyethylene bag or wrap and a thermal mattress as described in

the next section.

• A servo-controlled radiant warmer with a temperature sensor helps

to maintain the baby's temperature within the normal range.

• An oxygen blender and a pulse oximeter with an appropriate-sized

sensor should be available for all preterm births.

• A cardiac monitor with 3 chest leads or limb leads provides a rapid

and reliable method of continuously displaying the baby's heart rate

if the pulse oximeter has difficulty acquiring a signal.

• A resuscitation device capable of providing PEEP and CPAP, such as

a T-piece resuscitator or flow-inflating bag, is preferred.

• A preterm-sized resuscitation mask, size O laryngoscope blade (size

00 optional), and appropriate-sized endotracheal tubes (3.0 mm and

2.5 mm) should be prepared.

• Consider having surfactant available if the baby is expected to be

less than 30 weeks' gestation.

• A pre-warmed transport incubator with blended oxygen anda pulse

oximeter is important for maintaining the baby's temperature and

oxygenation within the target range if the baby will be moved after

the initial stabilization.

How do you keep the preterm newborn warm?

Preterm newborns have a high risk of developing hypothermia (body

temperature below 36.Sº

C ) and complications from cold stress. While

drying with warm towels, skin-to-skin contact, and early breastfeeding

may be sufficient to maintain normal temperature for term newborns

and sorne vigorous late-preterm newborns, additional measures

are required for more premature newborns and those requiring

assistance after birth. When a preterm birth is expected, anticípate that

temperature regulation will be challenging and prepare for it.

• Set the temperature in the room where the baby will be resuscitated

and receive initial careto approximately 23°C to 25° C (74° F to 77

ºF).

• Preheat the radiant warmer well before the time of birth.

• After delivery, quickly place a hat on the baby's head.

• Use a pre-warmed transport incubator if the baby will be moved

after initial care is completed.

• Maintain the baby's axillary temperature between 36.SºC and 37.S

ºC .

Additional steps for thermoregulation of babies less than 32 weeks'

gestation*

• Use a thermal mattress as an additional heat source.

Portable thermal mattresses release heat when a chemical gel inside

the mattress is activated to form crystals.

- The thermal mattress should be stored and activated at room

temperature (19ºC to 28ºC or 66ºF to 82ºF). If the mattress is

stored or activated at a warmer temperature, it

may exceed the target surface temperature.

- Following the manufacturer's recommendations,

squeeze the pad to actívate the gel approximately

5 minutes before the baby is born. Once activated,

it will reach the target surface temperature within

5 minutes and maintain that temperature for

1 hour after activation.

- Once the thermal mattress is activated, place it

on the radiant warmer and cover it with a blanket

(Figure 8.1) so the mattress is not directly

exposed to radiant heat and the heated surface is

not in direct contact with the baby's skin.

*Note: Depending on the baby's birth weight and

environmental conditions, sorne babies up to 35 weeks'

gestation may benefit from the use of a tl1ermal mattress

and plastic bag/wrap.

Figure 8. 1. Thermal mattress placed under a

blanket on the resuscitation table

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RESUSCITATION AND STABILIZATION OF BABIES BORN PRETERM

- -

• Wrap the baby in a polyethylene plastic bag or wrap.

- Drying the body is not necessary. Instead of drying the body with

towels, very premature newborns should be wrapped up to their

neck in polyethylene plastic immediately after birth.

- You may use a food-grade reclosable 1-gallon plastic bag, a large

plastic surgical bag, food wrap, a commercially available plastic

poncho, or sheets of commercially available polyethylene plastic

(Figure 8.2).

- If using a reclosable bag, you may cut the bottom open, slide the

baby into the bag through the cut side, and close the bag below

the baby's feet.

- If using a plastic sheet or food wrap, you may either wrap the

baby in a single sheet or use 2 sheets and place the baby between

the sheets.

- It is important to keep the newborn fully covered during

resuscitation and stabilization. If the newborn requires insertion

of an umbilical catheter, cut a small hole in the plastic and pull

the umbilical cord through the hole rather than uncovering the

newborn.

• Monitor the baby's temperature frequently because overheating has

been described while using a combination of warming methods.

- Consider placing a temperature sensor and sensor cover on the

newborn and using the warmer's servo-control mode to adjust the

radiant heat.

Fi g u r e 8.2. Polyethylene plastic bag {A) and wrap (B) for reducing heat loss. (Figure 8.2B used with permission of

Mayo Foundation for Medica! Education and Research.)

220

How do you assist ventilation?

Preterm babies have immature lungs that may be difficult to ventilate

and are more susceptible to injury from PPV. Use the same criteria

for initiating PPV with a preterm baby that you have learned for a

term baby ( apnea, or gasping, or heart rate less than 100 bpm within

60 seconds of birth despite the initial steps).

The following are special considerations for assisting ventilation of

preterm babies:

• If the baby is breathing spontaneously, consider using CPAP

rather than intubating.

If the baby is breathing spontaneously and has a heart rate of at least

100 bpm, but has labored respirations or oxygen saturation below

the target range, administration of CPAP may be helpful. Using

early CPAP, you may be able to avoid the need for intubation and

mechanical ventilation. CPAP alone is NOT appropriate therapy for a

baby who is not breathing or whose heart rate is less than 100 bpm.

• If PPV is required, use the lowest inflation pressure necessary to

achieve and maintain a heart rate greater than 100 bpm.

The baby's heart rate response is the best indicator of effective

ventilation. An initial inflation pressure of 20 to 25 cm H20 is

adequate for most preterm newborns. The volume of air required to

ventilate a preterm baby's lungs is very small and may not result in

perceptible chest movement.

Use the lowest inflation pressure necessary to maintain a heart rate

of at least 100 bpm and gradually improve oxygen saturation. The

maximum inflation pressure used for a baby born at term may be

too high for preterm newborn. Use your judgment when increasing

ventilation pressure; however, it is reasonable to limit face-mask

ventilation to a maximum inflation pressure of 30 cm H20 . If

face-mask ventilation at this pressure <loes not result in clinical

improvement, providing ventilation through an endotracheal tube

may improve the efficacy of PPV and allow you to decrease the

ventilating pressure.

Airway obstruction and face-mask leak are common problems

during face-mask ventilation with preterm newborns, and very

small changes in the head and neck position may lead to significant

changes in ventilation. A C0 2 detector placed between the mask and

PPV device may provide a visual cue to help identify when you have

achieved the correct mask and neck position. The C0 2 detector will

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RESUSCITATION AND STABILIZATION OF BABIES BORN PRETERM

222

change color when ventilation successfully exchanges gas within the

baby's lungs and C0 2 is exhaled through the mask.

• If PPV is required, it is preferable to use a device that can provide

PEEP.

Using PEEP (5 cm H20 ) helps the baby's lungs to remain inflated

between positive-pressure breaths. This is particularly important

if you are using an endotracheal tube for ventilation. Both the

T-piece resuscitator and flow-inflating bag can provide PEEP during

ventilation through either a face mask or an endotracheal tube. If

a PEEP valve is attached, a self-inflating bag may provide PEEP

during endotracheal tube ventilation. It is difficult to maintain PEEP

during face-mask ventilation with most self-inflating bags.

• Consider administering surfactant if the baby requires intubation

for respiratory distress or is extremely preterm.

After initial stabilization, preterm babies who need intubation and

mechanical ventilation because of respiratory distress syndrome

should be given surfactant.

Studies completed prior to the common use of antenatal steroids and

early CPAP concluded that babies born at less than approximately

30 weeks' gestation would benefit from intubation and prophylactic

surfactant treatment before they developed respiratory distress.

Subsequent studies indicate that CPAP used immediately after birth

should be considered as an alternative to routine intubation and

prophylactic surfactant administration. Many preterm babies can

be treated with early CPAP and avoid the risks of intubation and

mechanical ventilation.

Surfactant can be selectively administered to babies who fail a trial

of CPAP. In sorne cases, you may be able to administer surfactant

through a thin tube while the baby remains on CPAP (Less Invasive

Surfactant Administration [LISA] or Minimally Invasive Surfactant

Treatment [MIST]) or remove the endotracheal tube immediately

after surfactant administration and return to CPAP for ongoing

respiratory support (INtubate-SURfactant-Extubate [INSURE]).

Sorne experts still recommend prophylactic surfactant for extremely

premature newborns (less than 26 weeks' gestation) because the

likelihood of CPAP failure in this subgroup is relatively high.

Criteria for CPAP failure and the administration of surfactant

should be developed in coordination with local experts.

If the resuscitation team does not have expertise in surfactant

administration, it may be preferable to wait for the arrival of more

experienced providers.

How much oxygen should you use?

You have learned in previous lessons that injury during transition

may result from inadequate blood flow and oxygen delivery and

that restoring these factors are important goals during resuscitation.

However, research indicates that administering excessive oxygen after

perfusion has been restored can result in additional injury. Preterm

babies may be at higher risk for this reperfusion injury because

fetal tissues normally develop in a low-oxygen environment and the

mechanisms that protect the body from oxygen-associated injury have

not yet fully developed. Nevertheless, many preterm newborns will

require supplemental oxygen to achieve the gradual increase in oxygen

saturation that occurs after a healthy term birth.

When stabilizing a preterm baby, it is important to balance the desire

to rapidly correct low oxygen saturation against avoiding exposure to

excessive levels of oxygen. The current recommendation is to initiate

resuscitation of preterm newborns (less than 35 weeks' gestational age)

with 21 % to 30% oxygen and use a pulse oximeter and oxygen blender

to maintain oxygen saturation within the same target range described

for full-term newborns (Table 8-1).

What can you do to decrease the chances of neurologic in¡ury

in preterm newborns?

Before approximately 32 weeks' gestation, a preterm newborn has a

fragile network of capillaries in their brain that are prone to rupture

and bleeding. Obstruction of venous drainage from the head or rapid

changes in blood C0 2 levels, blood pressure, or blood volume may

increase the risk of rupturing these capillaries. Bleeding in the brain may

cause tissue damage and lead to lifelong disability. Inadequate blood flow

and oxygen delivery may cause damage to other areas of the brain even

in the absence of hemorrhage, while excessive oxygen administration

may cause damage to the developing retina, leading to vision loss.

An organized care plan that is practiced during simulation can help

you to cluster interventions and complete them efficiently while

minimizing disturbances to the preterm newborn.

Consider the following precautions when resuscitating a preterm

newborn:

• Handle the baby gently.

While this may seem obvious, this aspect of care may be forgotten

when members of the resuscitation team are trying to perform many

Table 8-1. Target Pre-Ductal

Ox y

gen Saturation

Target Oxygen

Saturation Table

l min 60%-65%

2 min 65%-70%

3 min 70%-75%

4 min 75%-80%

5 min 80%-85%

l O min 85%-95%

lnitial Oxygen

Concentration for PPV

> 35 weeks'

<35 weeks'

21 % oxygen

21%-30%

oxygen

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RESUSCITATION AND STABILIZATION OF BABIES BORN PRETERM

224

steps quickly. If possible, avoid multiple intubation attempts, frequent

tracheal suctioning, and other painful, noisy, or irritating stimuli.

• Do not position the baby's legs higher than the head

(Trendelenburg position).

Placing the legs higher than the head may increase cerebral venous

pressure and the risk of bleeding. lt may be helpful to place the baby

in a midline, supine ( on the back) position with the head slightly

elevated to avoid obstruction of venous drainage.

• Avoid using high pressure during PPV or CPAP.

Excessive pressure can create a pneumothorax or interfere with

venous return from the head. Both of these complications have been

associated with an increased risk of brain hemorrhage.

• Use a pulse oximeter and blood gases to monitor and adjust

ventilation and oxygen concentration.

Continuously monitor SPo2 until you are confident that the baby

can maintain normal oxygenation while breathing room air. If the

baby requires continued assistance with ventilation, a blood gas

should be obtained to guide therapy. Rapid changes in C0 2

levels

can increase the risk of bleeding. If your hospital <loes not have the

resources to manage preterm babies who require ongoing assisted

ventilation, arrange transfer to an appropriate facility.

• Do not rapidly infuse intravenous fluids.

If volume expansion is needed, infuse the fluid slowly over at least

5 to 1 O minutes. Hyp ertonic intravenot1s solutions, such as sodium

bicarbonate, should be avoided or given very slowly.

What special precautions should be taken af ter the initial

stabilization period?

During the last trimester of pregnancy, the fetus undergoes physiologic

changes in preparation for extrauterine survival. If a baby is born

prematurely, many of these adaptations have not occurred. Consider

the following:

• Monitor the baby's temperature.

Continue to carefully monitor the baby's temperature after the initial

resuscitation and stabilization period. A servo-controlled warmer or

incubator that uses a skin sensor to adjust the heat output based on

the baby's skin temperature may be helpful. Very premature babies

should remain wrapped in polyethylene plastic until they have been

moved to a warmed and humidified incubator. Even moderate and

late preterm newborns remain at risk for hyp

othermia and should

be carefully monitored.

• Monitor blood glucose.

Babies born very prematurely have lower amounts of stored glucose

than babies born at term. If resuscitation is required, it is more

likely that these stores will be depleted quickly and the baby may

become hyp oglycemic. Promptly secure intravenous access, initiate

a dextrose infusion, and monitor the baby's blood glucose.

• Monitor the baby for apnea and bradycardia.

Respiratory control is often unstable in preterm babies. Significant

apnea and bradycardia during the stabilization period may be

the first clinical sign of an abnormality in body temperature,

oxygenation, C0 2, electrolytes, blood glucose, or blood acid levels.

Focus on Teamwork

The resuscitation and stabilization of babies born preterm highlights

severa! opportunities for effective teams to use the Neonatal

Resuscitation Program® (NRP®) Key Behavioral Skills.

Behavior Example

Anticipate and plan.

Delegate workload optimally.

Multiple procedures may be performed in a brief period of time. Work with a

multidisciplinary team to develop and practice a systematic approach to the first

hours of care by predefining roles and responsibilities.

Use available information.

Clearly identify a team leader.

Know your environment.

Allocate attention wisely.

Communicate effectively.

Maintain professional behavior.

Complete a pre-resuscitation team briefing to review the prenatal and intrapartum

history, identify a team leader, review roles and responsibilities of each team

member, and plan the approach to respiratory support.

Know where polyethylene plastic bags/wraps and thermal mattresses are stored.

Know how to use the temperature sensor on your radiant warmer. Know how to

set up a device to administer CPAP.

lf the team leader becomes involved in endotracheal intubation, their attention is

focused primarily on that task and they may not be able to pay full attention to

the baby's condition or the passage of time. A different team leader who can

maintain situation awareness may need to be identified.

Share your assessments aloud so that all members of the team are aware of the

baby's condition and response to treatment.

The importance of effective communication continues after the resuscitation is

completed. A post-resuscitation team debriefing is an important opportunity to

review the team's performance, identify oreas for improvement, practice effective

communication skills, and improve teamwork.

lf the baby will be transferred to another hospital after birth, develop a plan for

efficiently communicating the maternal and newborn history.

Designate a team member to communicate progress updates and plans with parents.

Quality lmprovement Opportunities

Ask yourself the following questions and begin a discussion with your

team if you find a difference between the NRP recommendations and

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RESUSCITATION AND STABILIZATION OF BABIES BORN PRETERM

226

what is currently done in your own hospital setting. Consider using the

suggested process and outcome measures to guide your data collection,

identify areas for improvement, and monitor if your improvement

efforts are working.

Quality improvement questions

O Where are polyethylene plastic bags/wraps stored in your delivery

setting?

f) Can you increase the room temperature in your delivery setting?

8 Do you have a protocol or checklist to organize the first hour of

post-resuscitation care for a baby born very preterm?

8 Has your team simulated the resuscitation and stabilization of a

very preterm newborn to assess your preparedness?

Process and outcome measures

O How often are preterm newborns hypothermic ( temperature

< 36.Sº C) at 1 hour of age?

f) How often are preterm newborns hyp oglycemic at 1 hour of age?

8 How often do parents receive an update on their baby's condition

and have the opportunity to see and touch their baby within the

first 30 to 60 minutes?

8 How often <loes your team complete a debriefing after the

resuscitation and stabilization of a preterm newborn?

0 How soon after giving birth are mothers instructed how to express

or pump breast milk?

Frequently Asked Questions

Should delayed umbilical cord clamping be considered for preterm

newborns?

Early cord clamping ( < 30 seconds after birth) may interfere with

healthy transition from fetal to neonatal circulation, as it leaves fetal

blood in the placenta rather than filling the newborn's circulating

blood volume. Preterm newborns who have delayed umbilical cord

clamping are less likely to receive medications for hyp otension or

receive a blood transfusion. Delayed umbilical cord clamping for

preterm newborns may increase the probability of survival, but this

evidence is less certain.

Before birth, establish the plan for the timing of umbilical cord

clamping with the obstetric providers. For most vigorous preterm

newborns, the current evidence suggests that it is reasonable to delay

clamping the umbilical cord for at least 30 to 60 seconds after birth. By

carefully coordinating with the obstetric providers, the initial steps of

newborn care, including clearing the airway if necessary and providing

gentle stimulation, can be performed with the umbilical cord intact.

If the mother is hemodynamically unstable or the placenta! circulation

is not intact, such as after a placenta! abruption, bleeding placenta

previa, bleeding vasa previa, or cord avulsion, the cord should be

clamped immediately after birth.

There is not enough evidence to make a definitive recommendation

whether umbilical cord clamping should be delayed in preterm

newborns who are not vigorous after birth. If the placenta! circulation

is intact, it may be reasonable to briefly delay umbilical cord clamping

while the obstetric provider clears the airway and gently stimulates

the baby to breathe. If the baby <loes not begin to breathe during this

time, additional treatment is required. The umbilical cord should

be clamped and the baby should be brought to the radiant warmer.

Research studies are investigating whether it is feasible and beneficia!

to initiate resuscitation adjacent to the mother with the umbilical cord

intact.

For newborns less than 28 weeks' gestation, umbilical cord milking is

not recommended because it has been associated with an increased

risk of intraventricular hemorrhage.

How do you counsel parents before the birth of an extremely preterm

baby?

Meeting with parents before the birth of an extremely preterm baby

is important for both the parents and the neonatal care providers.

Prenatal discussions are an opportunity to provide parents with

important information, discuss goals of care, and establish a trusting

relationship that will support shared decision-making for their baby.

These discussions can be difficult because of the challenges inherent

in communicating a large amount of complex information during a

stressful time. You should be prepared with accurate information about

available treatment options and the anticipated short- and long-term

outcomes for the specific situation. You should be familiar with both

national and local outcome data and understand the limitations of

each. If necessary, consult with specialists at your regional referral

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228

center to obtain up-to-date information. Ideally, both the obstetric

provider and the neonatal provider should be present to talk with the

parents. The obstetric and neonatal perspectives may be different.

These differences should be discussed before meeting with the parents

so that the information presented is consistent.

If possible, meet with both parents ( or the mother and her chosen

support person) at the same time and allow enough time for them to

consider the content of your discussion and ask questions. Try to meet

with the parents before the mother has received medications that might

make it difficult for her to understand or remember your conversation

and befo re the final stages of labor. If you are called when the woman

is in active labor, there may not be time for an extended discussion,

but it is still helpful to introduce yourself and briefly describe potential

issues and your preliminary treatment plan. Use clear language

without medical abbreviations or jargon. Be cautious about describing

outcomes in terms of risk ratios, proportions, or percentages because

parents may have limited understanding of mathematical concepts.

In addition, quoting these data may give the impression that your

estimates are more precise than they actually are. It is important

to present a balanced and objective picture of the range of possible

outcomes while avoiding excessively negative or unrealistically

positive descriptions. Use an appropriately trained medical interpreter,

not a friend or family member, if the family is not proficient in the

language spoken by the health care team or includes someone with a

hearing disability. Visual aids and written materials, including pictures

and graphs, can supplement your discussion and help the parents

remember the topics that you discussed. Offer to give the parents time

alone to discuss what you have told them. Sorne parents may want to

consult with other family members or clergy. If time allows, offer to

make a return visit to confirm both their understanding of what may

occur and your understanding of their wishes.

After you meet with the parents, document a summary of your

conversation in the mother's chart. Review what you discussed with

the obstetric care providers and the other members of your delivery

room resuscitation team. If it was decided that resuscitation would

not be initiated, ensure that all members of your team, including

on-call personnel and the obstetric care providers, are informed and in

agreement with this decision. If disagreements occur, discuss them in

advance and consult additional professionals, including legal and ethics

consultants, if necessary.

LESSON 8 REVIEW

l. You have turned on the radiant warn1er in anticipation of the

birth of a baby at 27 weeks' gestation. List 4 additional steps that

will help maintain this baby's temperature.

a.----------------

b. ----------------

c.----------------

d.----------------

2. A baby is born at 26 weeks' gestation. The initial steps of care,

including gentle stimulation, have been completed and the

baby is nearly 1 minute old. The baby is not breathing and the

heart rate is 80 beats per minute. You should (start continuous

positive airway pressure [CPAP] with a face mask)/(start

positive-pressure ventilation).

3. A baby is delivered at 30 weeks' gestation. At 5 minutes of age,

the baby is breathing, has a heart rate of 140 beats per minute,

and is receiving CPAP with 30% oxygen. A pulse oximeter on

the right hand is reading 95% and is increasing. You should

(decrease the oxygen concentration)/(begin positive-pressure

ventilation).

4. A (self-inflating bag)/(T-piece resuscitator) can provide CPAP

for a spontaneously breathing baby.

5. You are preparing for the birth of a baby of 34 weeks' gestation.

You set the positive-pressure ventilation device so that the peak

inflation pressure is (20 to 25 cm H20 )/(25 to 30 cm H20 ) and

positive end-expiratory pressure (PEEP) is (5 cm H20 )/(10 cm

H20 ).

6. Initiate resuscitation of the preterm baby ( < 35 weeks'

gestational age) with (21 % to 30% oxygen)/(60% to 100%

oxygen).

7. You may decrease the risk of neurologic injury in a premature

newborn during and after resuscitation by ( tilting the bed so the

baby's legs are higher than the head)/(adjusting the bed so that

the baby's legs are even with or lower than the head).

8. Compared with term newborns, preterm newborns have a

(higher)/(lower) risk of developing hy p oglycemia shortly after

resuscitation.

229

RESUSCITATION AND STABILIZATION OF BABIES BORN PRETERM

230

Answers

l. You can increase the room temperature to 23

ºC to 25

°C (74

°F to

77ºF), prepare a thermal mattress, prepare a polyethylene plastic

bag or wrap, and pre-warm a transport incubator if the baby will

be moved after birth.

2. You should start positive-pressure ventilation.

3. You should decrease the oxygen concentration.

4. A T-piece resuscitator can provide CPAP for a spontaneously

breathing baby. A self-inflating bag cannot be used to provide

CPAP.

5. Set the peak inflation pressure to 20 to 25 cm H20 and positive

end-expiratory pressure (PEEP) to 5 cm H20 .

6. Initiate resuscitation of the preterm baby with 21 % to 30%

oxygen.

7. You may decrease the risk of neurologic injury in a premature

newborn during and after resuscitation by adjusting the bed so

that the baby's legs are even with or lower than the head.

8. Preterm newborns have a higher risk of developing

hypoglycemia shortly after resuscitation.

Post-resuscitation (are

What you will learn

What to do after neonatal resuscitation

Medica! conditions that may occur following neonatal

resuscitation

Management considerations following neonatal

resuscitation

The role of therapeutic hypothermia in post-resuscitation

care

232

Key Points

O A baby who required resuscitation must have close monitoring

and frequent assessment of respiratory effort, oxygenation, blood

pressure, blood glucose, electrolytes, urine output, neurologic

status, and temperature during the immediate neonatal period.

f.) Be careful to avoid overheating the baby during or after

resuscitation.

E) If indicated, therapeutic hypothermia must be initiated promptly;

therefore, every birth unit should have a system for identifying

potential candidates and contacting appropriate resources.

Case: An early term pregnancy with fe tal distress

A baby was born at 3 7 weeks' gestation by emergency cesarean section

beca use of maternal fever with signs of fetal distress during labor.

After birth, the baby was limp and apneic, and did not respond to

the initial steps of newborn care. Positive-pressure ventilation (PPV)

was started and continued for 3 minutes until effective spontaneous

respiratory effort was established. During the next several minutes, the

baby developed labored breathing and required supplemental oxygen

to maintain oxygen saturation within the target range. The team leader

updated the parents, explained the baby's condition, and described the

post-resuscitation care plan.

The newborn arrives in the nursery where vital signs, including

temperature, oxygen saturation, and blood pressure are recorded. The

baby continues to require supplemental oxygen with labored breathing,

anda chest x-ray is requested. A team member obtains a blood sample

for glucose, bacteria! culture, and blood gas testing. An intravenous

catheter is inserted and the baby receives fluids and parenteral

antibiotics. The health care providers discuss their plan for close

monitoring and frequent assessment. The baby's father arrives at the

bedside where he touches and comforts his baby. The medica! provider

gives the father an interval update and explains the treatment plan.

Shortly afterward, the team members conduct a debriefing to review

their preparation, teamwork, and communication.

Postnatal (are

The physiologic transition to extrauterine life continues for several

hours after birth. Babies who required resuscitation may have problems

making this transition even after their vital signs appear to return to

normal. Medical complications after resuscitation may involve multiple

organ systems. Many of these complications can be anticipated and

promptly addressed by appropriate monitoring.

This program refers to 2 broad categories of postnatal care. The

intensity of monitoring and the interventions required for individual

babies will vary within these categories.

• Routine care

Nearly 90% of newborns are vigorous term babies with no risk factors

and they should remain with their mothers to promote bonding,

initiate breastfeeding, and receive routine newborn care (Figure 9.1).

Similarly, a baby with certain prenatal or intrapartum risk factors, who

responded well to the initial steps of newborn care, may only need

close observation and <loes not need to be separated from the mother.

Ongoing observation of breathing, thermoregulation, feeding, and

activity are important to determine if additional interventions are

required. The frequency of these evaluations will be determined by the

specific perinatal risk factors and the baby's condition.

- ••

••

Lí.•

•

• • ••

• ..

Figure 9. 1. Routine care. (Used with permission of Mayo Foundation for

Medical Education and Research.)

• Post-resuscitation care

Babies who required supplemental oxygen, PPV, or co11tinuous positive

airway pressure ( CPAP) after delivery will need closer assessment.

They may develop problems associated with abnormal transition and

should be evaluated frequently during the immediate newborn period.

In addition to routine newborn care, they often require ongoing

respiratory support, such as supplemental oxygen, nasal CPAP, or

mechanical ventilation. Many will require admission to a nursery

233

234

environment where continuous cardiorespiratory monitoring is

available and vital signs can be measured frequently (Figure 9.2). Sorne

will require transfer to a neonatal intensive care unit. If a newborn

requires post-resuscitation care in a location outside of the mother's

room, the parents should be encouraged to see and touch their baby as

soon as it is feasible. The period of time needed for close observation

is dependent on the newborn's condition, progress toward normal

transition, and the presence of identifiable risk factors.

Figure 9.2. Post-resuscitation care in a setting where continuous

cardiorespiratory monitoring is available and vital signs can be measured

frequently

What medical conditions may occur in babies who required

resuscitation?

Abnormalities in multiple organ systems may occur following

neonatal resuscitation. Anticipated clinical signs, laboratory findings,

and management considerations are summarized in Table 9-1.

Individual circumstances will determine which of these management

considerations are appropriate.

Temperature instability

After resuscitation, babies may become too cold (hypothermic) or

too warm (hyperthermic). Premature newborns are at high risk of

hypothermia and this has been associated with increased mortality.

Special techniques for maintaining body temperature in preterm

newborns are addressed in Lesson 8. Babies may become hyp erthermic

if their mother has a fever or chorioamnionitis, if the baby has an

Table 9-1 • Clinical Signs, Laboratory Findings, and Management Considerations

Clinical Signs and Laboratory

Organ System Findings

Constitutional Hypothermia

Management Considerations

Del ay bath i ng.

Respiratory Tachypnea, grunting, retractions,

nasal flaring, low oxygen saturation,

pneumothorax

Maintain adequate oxygenation and ventilation.

Monitor for signs of pulmonary hypertension.

Avoid unnecessary suctioning.

Cluster care to allow periods of rest.

Consider antibiotics.

Consider x-ray and blood gas.

Consider surfactant therapy.

Consider delayed initiation of feedings with use

of intravenous fluids.

Cardiovascular

EndocrineMetabolic

Gastrointestinal

Renal

Neurologic

Hematologic

Hypotension, tachycardia, metabolic

acidosis, poor perfusion

Metabolic acidosis, hypoglycemia (low

glucose}, hypocalcemia (low calcium},

hyponatremia (low sodium}, hyperkalemia

(high potassium)

Feeding intolerance, vomiting, abdominal

distention, abnormal liver function tests,

gastrointestinal bleeding

Decreased urine output, edema, electrolyte

abnormalities

Apnea, seizures, irritability, poor tone,

altered neurologic examination, poor

feeding coordination

Anemia, thrombocytopenia, delayed clotting,

pallor, bruising, petechiae

Monitor blood pressure and heart rate.

Consider volume replacement or inotrope

administration if baby is hypotensive.

Monitor blood glucose.

Monitor serum electrolytes as indicated.

Consider intravenous fluids.

Replace electrolytes as indicated.

Consider abdominal x-ray.

Consider delayed initiation of feedings.

Consider use of intravenous fluids.

Consider parenteral nutrition.

Monitor urine output.

Monitor serum electrolytes as indicated.

Monitor weight.

Restrict fluids if baby has decreased urine

output and vascular volume is adequate.

Monitor for apnea.

Support ventilation as needed.

Monitor glucose and electrolytes.

Avoid hyperthermia.

Consider anticonvulsant therapy.

Consider therapeutic hypothermia.

Consider delayed initiation of feedings.

Consider using intravenous fluids.

Monitor hematocrit, platelets, jaundice,

bilirubin, and coagulation studies as

indicated.

infection, or if the radiant warmer is not used properly. Hyperthermia

has been associated with worsened outcomes and should be avoided.

Pneumonia and other respiratory problems

The need for resuscitation may be an early sign that a newborn has

pneumonia, a perinatal infection, or an aspiration event. Neonatal

pneumonia (Figure 9.3B) may present with tachypnea and other

signs of respiratory distress such as grunting, nasal flaring, and

235

Fi g u re 9.3. Neonatal chest x-rays: (A) normal, (B) pneumonia

retracting. It can be difficult to differentiate between respiratory

distress syndrome, retained fetal lung fluid, and neonatal pneumonia

by chest x-ray. If a baby who required resuscitation continues to show

signs of respiratory distress or requires supplemental oxygen, consider

evaluating the baby for pneumonia and perinatal infection. Obtain

appropriate laboratory tests and begin parenteral antibiotics.

If acute respiratory deterioration occurs during or after resuscitation,

consider the possibility that the baby has a pneumothorax (Figure 9.4).

Lesson 10 includes details about managing a pneumothorax. If the

baby is intubated and develops acute respiratory deterioration, ensure

that the endotracheal tube has not become dislodged or obstructed by

Figure 9.4. Right pneumothorax secretions.

236

Pulmonary hypertension

As described in Lesson 1, blood vessels in the fetal lungs are tightly

constricted. After birth, the pulmonary vessels relax and blood flows

into the lungs where hemoglobin can be saturated with oxygen for

delivery to the tissues and organs.

The pulmonary blood vessels may remain constricted after birth. This

condition is called persistent pulmonary hy p

ertension of the newborn

(PPHN) and is most often seen in babies greater than or equal to

34 weeks' gestational age. PPHN usually is managed with supplemental

oxygen and, in sorne cases, mechanical ventilation. Severe PPHN

may require special therapies such as high-frequency mechanical

ventilation, inhaled nitric oxide, and extracorporeal membrane

oxygenation (ECMO).

After resuscitation, the baby's pulmonary vascular tone can be labile

and may increase in response to sudden decreases in oxygen saturation

or unintentional hy p othermia; therefore, avoid unnecessary suction,

excessive stimulation, and immediate bathing. While avoiding sudden

decreases in saturation may be beneficia!, intentionally maintaining

very high blood levels of oxygen is not likely to be helpful and may

cause additional complications. A pulse oximeter should be used to

guide ox:ygen therapy. In the setting of suspected PPHN, an arterial

blood gas provides additional useful information that cannot be

determined from pulse oximetry alone.

Hypotension

Hyp otension during the post-resuscitation phase may occur for

multiple reasons. Low oxygen levels around the time of birth can

decrease both cardiac function and blood vessel tone. If the baby had

significant blood loss, the circulating blood volume may be low and

contribute to hyp otension. Babies with sepsis may have normal or high

cardiac output, but they may become hyp otensive because of dilation

of peripheral blood vessels.

Babies who require significant resuscitation should have their blood

pressure monitored until it is stable within an acceptable range. If there is

evidence of hyp ovolemia, volume expansion with a crystalloid solution,

or blood transfusion, may be indicated. Routine volume expansion

without evidence of hyp ovolemia is not recommended. Sorne babies may

require a medication such as dopamine, dobutamine, or epinephrine to

improve cardiac output and increase systemic blood flow.

Hypoglycemia

Glucose consumption is increased when metabolism occurs without

adequate oxygen (anaerobic metabolism). Hyp oglycemia may occur

because glucose stores are depleted rapidly during perinatal stress. A

transiently high glucose level may occur in sorne stressed newborns

before the blood glucose level begins to fall. Glucose is an essential

fuel for brain function in newborns and prolonged hyp oglycemia may

contribute to brain injury after resuscitation.

Babies who require resuscitation need to have their blood glucose level

checked soon after resuscitation and then at regular intervals until it

remains stable and within normal limits. Intravenous dextrose may be

necessary to maintain normal blood glucose levels until oral feedings

are established.

Feeding problems

The newborn's gastrointestinal tract is very sensitive to decreased

oxygen and blood flow. Feeding intolerance, poor motility,

inflammation, bleeding, and perforation of the intestinal wall can

occur after resuscitation. In addition, sucking patterns and oral feeding

coordination may be affected for severa! days because of neurologic

237

238

dysfunction. Alternative methods for providing nutrition may be

required during this interval.

Ideally, f eedings should be initiated with breast milk. If the baby

is born very preterm or is unable to start breastfeeding, work with

the mother's health care providers to develop a plan that supports

expressing and storing breast milk as soon as possible after birth.

Renal failure

Hyp otension, hypoxia, and acidosis can decrease blood flow to the

kidneys and cause either temporary or permanent renal failure. Acute

tubular necrosis (ATN) is usually a temporary form of renal failure

that may occur after resuscitation. It can cause fluid retention and

significant electrolyte abnormalities. Babies initially may have low

urine output and require fluid restriction for severa! days. During the

recovery phase, they may develop very high urine output and require

additional fluid.

Babies who require significant resuscitation should have their urine

output, body weight, and serum electrolyte levels checked frequently.

Adjust fluid and electrolyte intake based on the baby's urine output,

body weight changes, and laboratory results.

Metabolic acidosis

Metabolic acidosis is a common finding after resuscitation because

acids are produced when tissues receive insufficient oxygen and blood

flow. Severe acidosis may interfere with heart function and worsen

pulmonary hypertension. In most cases, the acidosis will gradually

resolve as the baby's respiratory and circulatory systems recover. The

most important intervention is to identify and correct the underlying

cause of the metabolic acidosis.

Seizures or apnea

Newborns with hyp otension, hypoxemia, and acidosis may develop

signs of brain injury. This injury is called hyp oxic-ischemic

encephalopathy (HIE). Initially, the baby may have decreased muscle

tone, lethargy, poor respiratory effort, or apnea. Seizures may appear

after severa! hours. Babies who have required extensive resuscitation

should be carefully examined for signs of HIE. A standardized

neurologic assessment is a useful tool. Consultation with a specialist

should be considered.

Lethargy, apnea, and seizures may be signs of other conditions such

as exposure to maternal narcotics or anesthetics, infection, electrolyte

disturbances, or metabolic abnormalities.

When should therapeutic hypothermia ( cooling) be considered?

Studies have demonstrated that therapeutic hypothermia ( cooling)

after resuscitation reduces the risk of death and improves neurologic

outcomes in late preterm and term babies with moderate to severe HIE.

If your hospital <loes not have a neonatal hyp othermia program,

contact the closest referral center that provides this therapy as soon as

you suspect that a baby may be a candidate. Work with your referral

center to develop an organized plan to identify candidates for therapy

and quickly arrange for transport. Delay in the recognition or referral

of a baby that qualifies for cooling could mean that treatment cannot

be initiated beca use the baby is outside of the therapeutic window.

If the decision is made to transport the baby to another center,

follow instructions from the referral center to avoid unintentional

hyperthermia while awaiting transport.

Focus on Teamwork

Post-resuscitation care highlights severa! opportunities for effective

teams to use the Neonatal Resuscitation Program® (NRP®) Key

Behavioral Skills.

Behavior Example

Anticipate and Plan where post-resuscitation care will take place at your institution.

plan. Discuss what type of post-resuscitation care will be provided in the mother's room and when care

should be transferred to a transitional orea or intensive care nursery.

Know your

envi ron ment.

Delegate

workload

optimally.

Communicate

effectively.

Plan who will be responsible for ongoing monitoring and who to contact if the baby's condition

changes.

Develop a plan to rapidly recognize babies who may qualify for therapeutic hypothermia and

who to contact if this therapy may be indicated.

Practice how to initiate therapeutic hypothermia or the process for promptly transferring the baby

to a referral center with the required expertise.

Know what equipment is available in your institution to obtain a blood gas, electrolytes, and

serum glucose level.

Know how to use the temperature sensor on your radiant warmer.

Many procedures need to be performed during the first hour after a successful resuscitation. Plan

who will perform each task to avoid unnecessary delays.

Bring the care team together for a post-resuscitation debriefing to reinforce good teamwork

habits and identify areas for improvement. ldentifying small changes may result in significant

improvements in your team's performance and patient safety.

239

240

Quality lmprovement Opportunities

Ask yourself the following questions and begin a discussion with your

team if you find a difference between the NRP recommendations and

what is currently done in your own hospital setting. Consider using the

suggested process and outcome measures to guide your data collection,

identify areas for improvement, and monitor if your improvement

efforts are working.

Quality improvement questions

O If a baby has received oxygen, PPV, or CPAP during the initial

stabilization, who will be responsible for post-resuscitation care

and continued assessments?

f.) What resources are available to care for a baby who requires

advanced neonatal care?

E) What challenges <loes your team face when transporting a newborn

from the delivery location to an environment where continuous

cardiorespiratory monitoring is available and vital signs can be

measured frequently?

O Have neonatal care providers been trained to identify babies that

may be candidates for therapeutic hyp othermia?

0 Do you know who to contact if you believe a baby is a candidate for

therapeutic hyp othermia?

O Do you have a process to support the mother's breastfeeding plan

when the newborn requires ongoing monitoring?

Process and outcome measures

O How often is a resuscitation record completed that documents ali

interventions performed during resuscitation and stabilization?

f.) How often <loes the resuscitation team complete a

post-resuscitation debriefing?

E) How often are babies hyp oglycemic after resuscitation?

O How often are babies transferred from the delivery location to an

advanced care nursery/unit?

0 How often <loes the receiving medical center conduct a

collaborative review with the referring medical center of babies

transported to its facility?

Frequently Asked Questions

Can post-resuscitation care and monitoring be performed in the mother

room?

The location of post-resuscitation care is less important than ensuring

that appropriate monitoring occurs, medical conditions that require

intervention are promptly recognized, and the necessary treatment

is initiated. In n1any institutions, this will require transfer to a

transitional nursery or intensive care setting.

Should sodium bicarbonate routinely be given to babies with metabolic

acidosis?

No. Infusing a chemical buffer, like sodium bicarbonate, may appear

to be a helpful intervention; however, there is currently no evidence

to support this routine practice. Sodium bicarbonate infusion has

several potential side effects. When sodium bicarbonate mixes with

acid, carbon dioxide ( C0 2) is formed. If the baby's lungs cannot

rapidly exhale the additional C0 2, the acidosis will worsen. Although

the blood measurement of acid (pH) may appear to improve,

sodium bicarbonate n1ay interfere with other acid buffering systems

and actually worsen the acidosis inside of cells. In addition, rapid

administration of sodium bicarbonate may increase the risk of

intraventricular hemorrhage in preterm newborns.

LESSON 9 REVIEW

l. A baby born at 36 weeks' gestation received positive-pressure

ventilation and oxygen supplementation in the delivery

room. This baby (does)/(does not) need frequent evaluation

of respiratory effort and oxygenation during the immediate

neonatal period.

2. If a newborn requires admission to a neonatal intensive care

unit, the parent(s) (should)/(should not) be encouraged to see

and touch their baby.

241

242

3. A full-term newborn had significant birth depression and

required a complex resuscitation. The baby has continued

respiratory failure with carbon dioxide retention and metabolic

acidosis. Sodium bicarbonate (should)/(should not) be infused

immediately after resuscitation.

4. Among babies who required complex resuscitation and

have signs of neurologic injury, aggressive warming and

hyperthermia (improves)/(worsens) the outcome and should be

( encouraged) / ( avoided).

Answers

1. This baby <loes need frequent evaluation of respiratory effort

and oxygenation during the immediate neonatal period.

2. The parent(s) should be encouraged to see and touch their baby.

3. Sodium bicarbonate should not be infused immediately after

resuscitation.

4. Aggressive warming and hyperthermia worsens the outcome

and should be avoided.

What you will learn

■ When to suspect a pneumothorax or a pleural effusion

■ How to manage a life-threatening pneumothorax or

pleural effusion

■ How to manage a newborn with an airway obstruction

■ How to manage congenital lung abnormalities that may

complicate resuscitation

■ How to manage the newborn with complications from

maternal opiate or anesthetic exposure

■ How to manage a newborn with myelomeningocele

■ How to manage a newborn with an abdominal wall defect

r ..,

Antenatal counseling.

Team briefing.

Equipment check.

... ,

Birth

' ,

Term gestation? Yes

r ..,

Stay with mother for initial steps, Good tone? ' routine care, ongoing evaluation. Breathing or crying?

... ,,

' ,

·-

T""

Warm, dry, stimulate, position

'" airway, suction if needed.

' .,

Apnea or gasping? No Labored breathing or -

HR < 100 bpm? , persistent cyanosis?

Yes

' , ' (

r .., r

PPV. Position airway, suction if needed.

Pulse oximeter. Pulse oximeter.

Consider cardiac monitor. Oxygen if needed.

... , Consider CPAP.

... ,,

' ,

- HR < 100 bpm? No

Yes

' , ' , ' ,

r r

Ensure adequate ventilation. Post-resuscitation care.

Consider ETT or laryngeal mask.

...

Team debriefing.

,, Cardiac monitor.

... ,

' ,

HR < 60 bpm?

Target Oxygen Saturation Table

Yes

1 min 60%-65

' .,

r ..,

ETT or laryngeal mask.

2 min 65%-70%

Chest compressions. 3 min 70%-75%

Coordinate with PPV-100% oxygen.

uve. 4 min 75%-80% ... ,

' ,

5 min 80%-85%

HR < 60 bpm?

10 min 85%-95

'-- Yes

lnitial oxygen concentration for PPV r IV epinephrine every 3-5 minutes.

lf HR remains < 60 bpm, - 35 weeks' GA 21% oxygen

• Consider hypovolemia.

• Consider pneumothorax. < 35 weeks' GA 21%-30

/o oxygen

'" ,,

244

Key Points

O Suspect a pneumothorax if a baby fails to improve despite

resuscitative measures or suddenly develops severe respiratory

distress. In an emergency, a pneumothorax may be detected by

decreased breath sounds and increased transillumination on the

affected side.

f) Suspect a pleural effusion if a newborn has respiratory distress and

generalized edema (hydrops fetalis).

Q A pneumothorax or pleural effusion that causes cardiorespiratory

compromise is treated by aspirating the air or fluid with a

needle-catheter-stopcock assembly attached to a syringe and

inserted into the chest.

8 If thick secretions obstruct the airway despite a correctly

positioned endotracheal tube, attempt to remove the secretions

using a suction catheter (SF-8F) inserted through the endotracheal

tube. If the obstruction persists, directly suction the trachea with

a tracheal aspirator attached to the endotracheal tube. In most

circumstances, establish an open airway and ventilation that

inflates the lungs before proceeding to chest compressions.

0 Respiratory distress associated with the Robin sequence can

be improved by placing the baby prone and inserting a small

endotracheal tube (2.5 mm) into the nose so the tip is in the

pharynx. If this <loes not result in adequate air movement, a

laryngeal mask may provide a lifesaving airway. Endotracheal

intubation is frequently difficult in this situation.

O Respiratory distress associated with bilateral choanal atresia can be

improved by inserting a modified feeding nipple or pacifier, with

the end cut off, into the baby's mouth or an endotracheal tube into

the mouth with the tip in the posterior pharynx.

O If a congenital diaphragmatic hernia is suspected, avoid

positive-pressure ventilation with a face mask. Quickly intubate

the trachea in the delivery room and insert an orogastric tube with

continuous or intermittent suction to decompress the stomach and

intestines.

O If a mother received opiates in labor and her baby is not breathing,

provide airway support and assisted ventilation until the baby has

adequate spontaneous respiratory effort.

245

246

O Avoid placing newborns with myelomeningocele (spina bifida)

on their back. Position the newborn lying on their side, on their

stomach, or on a "doughnut,, made from towels or latex-free foam.

Place the lower body and abdomen of a newborn with gastroschisis

or omphalocele in a sterile, clear plastic bowel bag and secure the

bag across the baby,s chest. Position the baby on the right side to

optimize bowel perfusion.

This lesson reviews less common circumstances that you may

encounter during neonatal resuscitation. Because these scenarios

do not occur frequently, it is important to be able to recognize them

and be prepared to respond quickly and efficiently. As you read the

following case, imagine yourself as part of the resuscitation team.

Case: A newborn with tension pneumothorax

A woman is admitted in labor at 40 weeks' gestation with clear fluid

and a Category 111 fetal heart rate pattern. An emergency cesarean

birth is planned. Your resuscitation team assembles in the operating

room, completes a pre-resuscitation team briefing, and prepares

equipment and supplies for a complex resuscitation. After birth, the

umbilical cord is clamped and cut and a limp, apneic baby is handed

to the team. One team member begins documenting the resuscitation

events as they occur.

The initial steps are performed, but the baby remains limp without

spontaneous respirations. You begin positive-pressure ventilation

(PPV) with a face mask, but the heart rate <loes not improve. You

perform the ventilation corrective steps and achieve chest movement

after increasing the ventilating pressure; however, the baby's heart

rate remains 40 beats per minute (bpm). Team members place a

pulse oximeter sensor on the baby's right hand and cardiac monitor

leads on the baby's chest. An endotracheal tube is rapidly inserted

for continued PPV, but there is no improvement in heart rate. Your

team increases the oxygen concentration (F102

) to 100% and begins

chest compressions while an umbilical venous catheter is prepared

and inserted. The baby's heart rate <loes not improve after 60 seconds

of coordinated compressions and ventilation. A <lose of intravenous

epinephrine is given through the umbilical catheter, followed by a

normal saline flush, but the baby's condition still <loes not improve.

The team reevaluates the insertion of the endotracheal tube and the

efficacy of ventilation and compressions while considering special

circumstances that may complicate resuscitation. Listening to the

chest, you recognize that breath sounds are absent on the right side.

Your team suspects a life-threatening tension pneumothorax. Rapid

transillumination of the chest confirms the suspicion and a team

member quickly prepares a catheter-over-needle aspiration device.

Chest compressions are stopped while a catheter is inserted and air is

aspirated from the chest. U pon decon1pression of the pneumothorax,

the baby's heart rate rapidly improves. The team continues PPV and

the F102 is adjusted based on pulse oximetry. A small amount of air

continues to flow through the catheter aspiration system and the

baby is transferred to the nursery for a chest x-ray and additional

treatment. Shortly afterward, you update the parents and conduct

a debriefing to review your team's preparation, teamwork, and

communication.

How do yo u identif y a newborn with an air or a

fluid collection around the lung?

Abnormal air or fluid collections that prevent the newborn's

lung from fully expanding within the chest can lead to

severe respiratory distress and persistent bradycardia.

Pneumothorax

It is not uncommon for small air leaks to develop as the

newborn's lung fills with air. When air collects in the pleural

space surrounding the lung, it is called a pneumothorax

(Figure 10.1). Although a pneumothorax may occur

spontaneously, the risk is increased by PPV, particularly

in preterm babies, babies with meconium aspiration, and

babies with other lung abnormalities.

A small pneumothorax may be asymptomatic or cause only

Fi g u re 1 0.1. Pneumothorax causing collapse

of the right lung

mild respiratory distress. If the pneumothorax becomes larger, the

pressure from the trapped air can cause the lung to collapse. If the

pneumothorax becomes large enough, it can interfere with blood

flow within the chest causing severe respiratory distress, oxygen

desaturation, and bradycardia. This is called a tension pneumothorax.

It is a life-threatening emergency and requires urgent treatment to

evacuate the air.

You should consider the possibility of a pneumothorax if a baby fails to

improve despite resuscitative measures or if a baby suddenly develops

severe respiratory distress. Breath sounds may be diminished on

the side of the pneumothorax, but breath sounds can be misleading

because they are easily transmitted across the baby's chest and can

sound normal even in the presence of a pneumothorax. On the other

hand, decreased breath sounds on the left side may be caused by an

endotracheal tube inserted into the right main bronchus (Table 10-1).

247

Table 1 0-1 • Causes of

Diminished Breath Sounds

• lnadequate ventilation

technique

• PPV device leak or equipment

failure

• Malpositioned endotracheal

tube

• Pneumothorax

• Pleural effusion

• Tracheal obstruction

• Congenital diaphragmatic

hernia

• Pulmonary hypoplasia or

agenes1s

• Enlarged heart

Transillumination of the chest is a rapid screening test that may be

helpful. In a darkened room, hold a high-intensity fiber-optic light

against the chest wall and compare the transmission of light on

each side of the chest (Figure 10.2). During transillumination, light

on the side with a pneumothorax will appear to spread further and

glow brighter than the opposite side. In a life-threatening situation, a

positive transillumination test can help to direct immediate treatment.

Be careful when interpreting the results of transillumination in very

premature babies because their thin skin may cause the chest to appear

bright even in the absence of a pneumothorax. If a transilluminator is

not immediately available and the baby is in severe distress, you may

proceed with emergency treatment based on your clinical suspicion. If

the baby is stable, the definitive diagnosis of a pneumothorax is made

with a chest x-ray.

A small pneumothorax usually will

resolve spontaneously and often

<loes not require treatment. The baby

should be monitored for worsening

distress. If the baby is maintaining

normal oxygen saturation,

supplemental oxygen is not indicated

and <loes not result in faster

resolution of the pneumothorax. If

a pneumothorax causes significant

respiratory distress, bradycardia, or

hypotension, it should be relieved

urgently by inserting a catheter into

the pleural space and evacuating

Fi g u re 1 0.2. Positive transillumination of a left-sided pneumothorax.

The light spreads and glows across a wide orea.

the air. If the baby has ongoing

respiratory distress, insertion of

a thoracostomy tube attached to

continuous suction may be required.

Fi g u re 1 0.3. large bilateral pleural

effusions

248

Pleural effusion

Fluid that collects in the pleural space is called a pleural

effusion (Figure 10.3). Similar to a pneumothorax, a large

pleural effusion can prevent the lung from expanding. The

fluid may be caused by edema, infection, or leakage from the

baby's lymphatic system. Frequently, large pleural effusions

are diagnosed before birth by ultrasound. There may be a

history of severe fetal anemia, twin-to-twin transfusion, cardiac

arrhythmia, congenital heart disease, congenital infection,

or a genetic syndrome. You should suspect a pleural effusion

if a newborn has respiratory distress and generalized body

edema (hydrops fetalis). Excess fluid may also be present in the baby's

abdomen (ascites) and around the baby's heart (pericardial effusion).

Because the fluid collection interferes with lung expansion, breath

sounds may be decreased on the affected side. The definitive diagnosis

of a pleural effusion is made with a chest x-ray or ultrasound.

A small pleural effusion may not require treatment. If respiratory distress

is significant and <loes not resolve with intubation and PPV, you may

need to inserta catheter into the pleural space to drain the fluid. If a large

pleural effusion is identified before birth, the obstetrician may remove

fluid before delivery. In addition, emergency drainage may be required

after birth. If time allows, a baby with a large pleural effusion identified by

antenatal testing should be born in a facility where emergency

airway management and fluid drainage by an experienced

team is immediately available in the delivery room.

How do you evacuate a pneumothorax or pleural

effusion?

The air or fluid is aspirated by inserting a catheter into the

pleural space on the affected side. This procedure is called

thoracentesis. Ideally, thoracentesis should be performed

using sterile technique with appropriate anesthetic for pain

management; however, modifications may be required

during emergency aspiration of a tension pneumothorax.

O Take a brief "time-out" and confirm the side that you

plan to aspirate.

f) Aspiration site and positioning.

a. For a pneumothorax, the aspiration site is either the

fourth intercostal space at the anterior axillary line

or the second intercostal space at the mid-clavicular

line (Figure 10.4). Using a small blanket roll,

position the baby on their back ( su pin e) with the

affected side directed slightly upward to allow the air

to rise to the upper (superior) portion of the chest.

....

•

b. For a pleural effusion, the aspiration site is the

fifth or sixth intercostal space along the posterior

axillary line. Place the baby on their back ( supine)

to allow the fluid to collect in the lower (posterior)

portion of the chest (Figure 10.5).

8 Prepare the insertion site with topical antiseptic and

sterile towels.

Figure 1 0.4. Locations for percutaneous

aspiration of a pneumothorax. Fourth intercostal

space at the anterior axillary line (A), second

intercostal space at the mid-clavicular line (B).

Cardiac monitor leads and skin temperature

sensor not shown.

249

250

Fi g u r e 10.5. Location for aspiration of a pleural effusion

9 Insertan 18- or 20-gauge percutaneous catheter-over-needle device*

perpendicular to the chest wall and just over the top of the rib. The

needle is inserted over the top of the rib, rather than below the rib, to

avoid puncturing the blood vessels located under each rib.

a. Por a pneumothorax, direct the catheter slightly upward toward

the front of the chest (Figure 10.6).

b. For a pleural effusion, direct the catheter slightly downward

toward the back.

0 Once the pleural space is entered, the needle is removed and a large

syringe (20-60 mL) connected to a 3-way stopcock is attached to

the catheter (Figure 10.7).

a. When the stopcock is opened between the syringe and the

catheter, the air or fluid can be evacuated.

b. When the syringe is full, the stopcock may be closed to the

chest while the syringe is emptied.

c. After the syringe is emptied, the stopcock can be reopened to

the chest and more fluid or air may be aspirated until the baby's

condition has improved.

d. To avoid accidental reinjection of air or fluid into the chest

cavity, care must be taken when manipulating the stopcock.

e. When evacuating a pleural effusion, maintain a sample of the

fluid for diagnostic evaluation.

O An x-ray should be obtained to document the presence or absence

of residual pneumothorax or effusion.

*Note: If an appropriate catheter-over-needle device is not available,

a small "butterfly" needle may be used. In this case, the syringe and

stopcock will be connected to the tubing attached to the needle.

Figure 1 0.6. Aspiration of a pneumothorax. The

needle is inserted over the rib and directed slightly

upward toward the front of the chest. Note: The

aspiration site is not covered with sterile towels for

photographic purposes; however, modified sterile

technique is acceptable for emergency aspiration.

Figure 10.7. Syringe and stopcock assembly used to

aspirate pneumothorax. The stopcock is opened between

the catheter and syringe during aspiration. The stopcock

is closed if the syringe becomes full and must be emptied.

The sorne assembly is used to drain a pleural effusion.

How do you manage a newborn with an airway obstruction?

Airway obstruction is a life-threatening emergency. The newborn's

airway may be obstructed by thick secretions or a congenital anomaly

that leads to an anatomic obstruction.

Thick secretions

Thick secretions, such as meconium, blood, mucus, or vernix, may

cause complete tracheal obstruction. If you are attempting PPV, but

the baby is not improving and the chest is not moving, perform each of

the ventilation corrective steps (MR. SOPA) until you have successfully

inflated the lungs.

If you have correctly inserted an endotracheal tube for ventilation, but

still can11ot achieve chest movement, the trachea 1nay be obstructed by

thick secretions. As described in Lesson 5, you may attempt to remove

secretions from the trachea using a suction catheter (5F-8F) inserted

through the endotracheal tube.

If the secretions are thick enough to completely obstruct the airway,

you may not be able to clear them using a thin suction catheter. In this

case, directly suction the trachea with a tracheal aspirator attached

toan endotracheal tube (Figure 10.8). Set the suction pressure to

80 to 100 mg Hg, connect suction tubing to the aspirator, and attach

the aspirator directly to the endotracheal tube connector. Sorne

endotracheal tubes have an integrated aspiration device designed for

suctioning the trachea. Occlude the aspirator's suction -control port

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