Skills workshop:                                                      Neonatal                                            ...
32    NEWBORN CAREfor peripheral cyanosis (blue or grey). Most        1-e Determining the response to stimulationinfants h...
SK ILLS WORKSHOP : NEONATAL RESUSCITATION     33GIVING MASK                                              1-h Bag and mask ...
34    NEWBORN CARE                                                Bag     Valve                       Mask                ...
SK ILLS WORKSHOP : NEONATAL RESUSCITATION       35                                                                Wire int...
36    NEWBORN CARE                                                           Unscrew base to replace batteries            ...
SK ILLS WORKSHOP : NEONATAL RESUSCITATION      37   procedure the tip of the blade must always       6. Now use the laryng...
38     NEWBORN CAREFigure 1-H: The laryngoscope is lifted upwards to see the vocal cords. Note that the tip of the blade i...
SK ILLS WORKSHOP : NEONATAL RESUSCITATION        39                      Cords                      Figure 1-I: View of th...
40       NEWBORN CARE          the tube is in the trachea and not the      1-m Giving chest compressions          oesophag...
SK ILLS WORKSHOP : NEONATAL RESUSCITATION      41Pressing on the sternum compresses the heart              compressions sh...
Newborn Care: Skills workshop Neonatal resuscitation
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Newborn Care: Skills workshop Neonatal resuscitation


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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents

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Newborn Care: Skills workshop Neonatal resuscitation

  1. 1. Skills workshop: Neonatal resuscitation is counted for 30 seconds and then multiplied Objectives by 2, or counted for 6 seconds and multiplied by 10. A wall clock with a second hand is needed in all delivery rooms. When you have completed this skills The normal heart rate is 140 beats per minute workshop you should be able to: with a range of 120 to 160. If the heart rate • Perform an Apgar score. is 100 or more, a score of 2 is given. A score • Mask ventilate an infant. of 1 is given if the heart rate is less than 100, • Intubate an infant. while a score of 0 is given if no heart beat can • Give chest compressions. be detected. 1-b Assessing the respiratory effort Observe the infant’s respiratory movements. IfASSESSING THE the infant breathes well or cries, a score of 2 isAPGAR SCORE given. If there is poor or irregular breathing, or occasional gasping only, a score of 1 isThe Apgar score determines the infant’s given. A score of 0 is given if the infant doesclinical condition after birth. It consists of not make any attempt to breathe. If infants arescoring the infant’s heart rate, breathing, being ventilated, stop the ventilation for a fewcolour, tone and response to stimulation. seconds to assess any spontaneous respiration.1-a Counting the heart rate 1-c Determining the presence or absence of cyanosisThe heart rate can be counted by listeningto the heart with a stethoscope, or by feeling The infant’s tongue must be examined tothe pulsations of the umbilical arteries at determine the presence or absence of centralthe base of the umbilical cord. The femoral, cyanosis (blue). Normally the tongue is pink.brachial and carotid arteries are difficult to feel Do not look at the infant’s lips or mucousimmediately after birth. Usually the heart rate membranes of the mouth as their colour is not reliable. Also look at the infant’s hands and feet
  2. 2. 32 NEWBORN CAREfor peripheral cyanosis (blue or grey). Most 1-e Determining the response to stimulationinfants have peripheral cyanosis for the first The infant can be stimulated by simply dryingfew minutes after birth. This is normal. with a towel. There is no need to repeatedly flickIf the tongue, hands and feet are pink the the feet to assess a response to stimulation. If theinfant is given a score of 2. If the tongue is infant responds well with a cry and movementpink but the hands and feet are cyanosed, a of the limbs, a score of 2 is given. However, if thescore of 1 is given. A score of 0 is given if the response is poor, a score of 1 is given. A score oftongue, hands and feet are all cyanosed. 0 is given if there is no response to stimulation.1-d Assessing muscle tone 1-f The final Apgar scoreThe normal infant has good muscle tone at The individual scores of the 5 criteria are nowdelivery. When lying face up, the arms and added up to give the Apgar score. The bestfeet are moved actively in the air or are held in way to learn how to perform an Apgara flexed position against the body. If the tone score accurately is to score infants with anand movement appear normal, a score of 2 is experienced colleague. With practice thegiven. If there is some movement of the limbs Apgar score can be accurately performedbut the tone appears decreased, then a score in less than a minute. Do not guess theof 1 is given. With decreased tone the limbs Apgar score as this is usually higher than theare usually not flexed but lie in an extended correctly assessed score. Always record theposition away from the body and resting on Apgar score in the infant’s notes.the towel. If the infant is completely limp and The individual scores and total Apgar scoredoes not move at all, a score of 0 is given. are recorded at 1 minute on a special formHealthy, normal preterm infants often have which should be attached to the infant’s notes.poor tone and are given a score of only 1. The score is repeated at 5 minutes if active resuscitation is required. 1 minute 5 minutesHeart rate per minute None 0 None 0 Less than 100 1 Less than 100 1 More than 100 2 More than 100 2Respiratory effort Absent 0 Absent 0 Weak/irregular 1 Weak/irregular 1 Good/cries 2 Good/cries 2Colour Centrally cyanosed 0 Centrally cyanosed 0 Peripherally cyanosed 1 Peripherally cyanosed 1 Peripherally pink 2 Peripherally pink 2Muscle tone Limp 0 Limp 0 Some flexion 1 Some flexion 1 Active/well flexed 2 Active/well flexed 2Response to stimulation None 0 None 0 Some response 1 Some response 1 Good response 2 Good response 2Total /10 /10Figure 1-A: The Apgar scoring sheet.
  3. 3. SK ILLS WORKSHOP : NEONATAL RESUSCITATION 33GIVING MASK 1-h Bag and mask ventilationVENTILATION A self-inflating neonatal ventilation bag and mask is an essential piece of equipment. If possible a soft face mask with a cushioned rim1-g Position of the infant should be used. The neonatal Laerdal, Cardiff or Ambu bags with moulded face masksThe infant must lie supine (back down) on a are recommended. A Samson resuscitatorfirm, flat horizontal surface. A resuscitation should only be used if a bag and mask are notunit, table or bed can be used. Ideally, the available. A ventilation bag and mask can alsoworking surface should be at the height of the be used with an endotracheal tube.examiner’s waist. The infant’s neck should beslightly extended (in the ‘sniffing position’). Do The bag and mask can be dismantled andnot overextend the neck as this may obstruct cleaned with soap and water. Shake and thenthe airway. If possible, a folded nappy or sheet allow to dry before reassembling. The maskshould be placed under the infant’s shoulders can best be cleaned with an alcohol keep the head in the correct position. However, if possible, the bag and mask should be gas sterilised after use. If additional oxygenIf you pretend that you are offered a flower to is needed, make sure that the oxygen source issmell, you would hold the flower in front of switched on at 5 litres per minute to ensure anyour nose, push your head slightly forward adequate flow. Humidification is not necessary.and slightly extend your neck. This is the A reservoir is needed if high percentages ofposition that you want the infant’s head and oxygen need to be given. A bag and mask canneck to be in as it keeps the upper airways be used with room air (and makes the vocal cords easier to seewith a laryngoscope). Remember that you can only provide supplementary oxygen via a bag and mask ifSee Figure 1-B. the bag is regularly squeezed. Correct IncorrectFigure 1-B: Position of head during mask ventilation.
  4. 4. 34 NEWBORN CARE Bag Valve Mask ReservoirFigure 1-C: A bag and mask for resuscitation. NOTE A Neopuff infant resuscitator can be used to provide positive pressure ventilation. The Most infants can be well ventilated with a bag percentage oxygen, rate and inflation pressure and mask can be controlled.1-i Position of the mask TRACHEAL INTUBATIONThe mask must be firmly placed over theinfant’s nose and face (from the tip of thechin to the top of the nose but do not cover 1-j Equipment needed for intubationthe eyes). Hold the mask tightly against the 1. A firm, level surface on which to place theinfant’s face so that there are no air leaks. The infantmask should be held in place with the left hand 2. A good light so that you can see the infantwhile the bag is compressed at about 40 times 3. A source of heat, such as an overheadper minute with the right hand. If the little heater or a warm room, so that the infantand ring fingers of the left hand are placed does not get coldunder the angle of the infant’s jaw, the jaw 4. A source of oxygen, a flow meter andcan be gently pulled upwards to help keep the plastic tubing. An air/oxygen blenderairway open and the tongue from falling back. is useful to control the concentrationAn inserted oral airway is not needed if mask of oxygen provided, if mechanical air isventilation is only needed for a few minutes. available. Usually a flow of 5 litres is used.When giving bag and mask ventilation, always 5. Endotracheal tubes: 2.5, 3.0 and 3.5 mmwatch for chest movement. Squeeze the bag (internal diameter). Straight tubes are saferhard enough to move the chest with each and therefore should be used rather thaninspiration. Good, bilateral air entry over the shouldered tubes. A 2.5 mm tube is bestsides of the chest (in the axilla) should be for infants below 200 g; a 3.0 mm tube forheard if ventilation is adequate. Most infants infants 1000 to 2000 g; and a 3.5 mm tubecan be well ventilated with bag and mask if the for infants larger than 2000 g. Sometimesairway is open and clear. tubes are cut to 15 cm before use. Make sure that the connector has been inserted into the top of the endotracheal tube.
  5. 5. SK ILLS WORKSHOP : NEONATAL RESUSCITATION 35 Wire introducer Connector Blunt end to introducer piece 12 11 10 4 9 Transparent endotracheal tube 5 8 6 7 with measurement markingsFigure 1-D: An endotracheal tube with an introducer in place.6. A ventilation bag and face mask (e.g. endotracheal tube while a F6 catheter will Laerdal or Ambu bag). A reservoir enables pass down a 3.0 mm tube. 100% oxygen to be given if needed. 13. A small stethoscope7. Introducers for the endotracheal tubes. 14. A saturation monitor is very useful but not Before intubating an infant, the introducer essential. should be placed into the endotracheal The equipment must be checked daily to make tube. Make sure that the end of the certain that everything is present and in good introducer does not stick out beyond the working order. tip of the endotracheal tube. It is important to bend a wire introducer at the top of the tube so that it does not slip out beyond 1-k Look for the vocal cords with the the tip of the tube. With the introducer in laryngoscope place, bend the tip of the endotracheal tube 1. Pull the laryngoscope blade into a slightly upward. 90 degree position so that the light is8. A laryngoscope handle with small straight switched on. Make sure that the bulb is blades, size 0 (for small infants) and size 1 tightly screwed in. (for big infants). The blades must be 2. Hold the laryngoscope in your left hand cleaned or sterilised after use. (even if you are right handed).9. Spare batteries 3. With the infant lying supine (back down),10. Spare bulbs and the infant’s head towards you in the11. Suction apparatus and tubing. The suction correct position for mask ventilation, place pressure most not exceed 200 cm water the blade into the infant’s mouth. Always (20 kPa or 200 mbar). keep the base of the blade to the left of12. Suction catheters, sizes F5 and F6. A size the mouth with the tip of the blade in the F5 catheter will pass down a 2.5 mm midline of the tongue. Throughout the
  6. 6. 36 NEWBORN CARE Unscrew base to replace batteries Handle Blade BulbFigure 1-E: A laryngoscope with a small, straight blade. Laryngoscope Tongue Laryngoscope blade and bulb UvulaFigure 1-F: The blade of the laryngoscope on the tongue.
  7. 7. SK ILLS WORKSHOP : NEONATAL RESUSCITATION 37 procedure the tip of the blade must always 6. Now use the laryngoscope to lift the remain in the midline. See Figure 1-F. epiglottis out of the way so that the4. Slowly move the tip of the blade along vocal cords and glottis can be seen. It is the back of the tongue until you can see important to lift the laryngoscope upwards the infant’s epiglottis. The epiglottis is and not to pull the handle back towards about 1 cm long and is in the midline. It you, as this may damage the infant’s upper hangs down from the wall of the pharynx gum. Slight downward pressure on the to cover the opening of the larynx (the infant’s throat with the little finger of your glottis). If your view is obstructed by left hand may make the vocal cords and mucus, suction the pharynx with a catheter glottis easier to see. This is called cricoid held in your right hand. pressure. See Figure 1-H.5. Place the tip of the laryngoscope blade in 7. The larynx (vocal cords and glottis) is a the hollow just before the epiglottis (i.e. triangular structure and, therefore, is easy the vallecula). The epiglottis must always to recognise. The two sides of the triangle remain in view. One of the commonest are formed by the vocal cords. The vocal mistakes is to push the blade in too far, cords tend to move apart when the infant beyond the epiglottis. It is important to breathes out. If the cords are in spasm initially look for the epiglottis rather than against one another, they can be separated the vocal cords. See Figure 1-G. by gently squeezing the infant’s chest. The Laryngoscope EpiglottisFigure 1-G: A view of the epiglottis.
  8. 8. 38 NEWBORN CAREFigure 1-H: The laryngoscope is lifted upwards to see the vocal cords. Note that the tip of the blade is in thehollow just before the epiglottis. most important step in intubation is to hold the endotracheal tube tightly against get a good view of the vocal cords. The the infant’s hard palate. Note the length of opening between the vocal cords is the the endotracheal tube at the infant’s lip. glottis. This is where the endotracheal 2. Remove the introducer with your right tube must be inserted. See Figure 1-I. hand while the endotracheal tube is held in position with your left hand. Make sure1-l Introducing the endotracheal tube that the endotracheal tube does not slip out of the larynx. See Figure 1-J.1. Take the endotracheal tube, with the 3. Attach the connector at the end of the introducer in place, in your right hand endotracheal tube to the ventilation bag and and insert it towards the larynx from the ventilate the infant at about 40 breaths per right side of the mouth. This will allow minute using your right hand. Usually the you to keep the vocal cords in view all face mask is removed before the ventilation the time. Push the first 1 to 2 cm of the bag is attached to the connector of the endotracheal tube between the vocal cords endotracheal tube. and into the glottis (to the black ‘vocal 4. Listen to both sides of the chest and watch cord line’). Always make sure that you can the chest movement: see the vocal cords clearly, otherwise you • The chest should move well with each will push the tube into the oesaphagus. inspiration and air should be heard to Make sure that you do not push the tube enter both sides equally when the chest in too far. Once the tube is correctly in is examined with a stethoscope. Misting place, the laryngoscope can be removed. of the inside of the endotracheal tube Your left hand can now be used to hold the during expiration is a helpful sign that endotracheal tube in place. It is helpful to
  9. 9. SK ILLS WORKSHOP : NEONATAL RESUSCITATION 39 Cords Figure 1-I: View of the larynx. Laryngoscope Wire introducer Endotracheal tube Figure 1-J: Introducing the endotracheal tube.
  10. 10. 40 NEWBORN CARE the tube is in the trachea and not the 1-m Giving chest compressions oesophagus. An assistant ventilates the infant while you • If the air entry is good on the right give chest compressions. The person giving side but poor on the left side of the chest compressions stands at the feet of the chest, then the endotracheal tube has infant while the person ventilating the infant been pushed in too far and has entered stands at the head. With the infant supine the right bronchus. Slowly pull the (back down) and the head facing away from endotracheal tube back until good air you, place both of your hands under the entry is heard over the right chest. infant’s chest. Both thumbs are now placed on • If the endotracheal tube has been placed the lower half of the infant’s sternum about into the oesophagus by mistake, then 1 cm below the level of the nipples and 1 cm the air entry will be poor on both sides above the tip of the sternum. It is best to place of the chest and the chest movement one thumb over the other in a small infant as will also be poor. In addition, the the sternum is very narrow. This will prevent stomach will become distended with air you pushing on the infant’s ribs. Push down and air entry will be well heard over the with both thumbs but do not squeeze the abdomen. The tube must be removed chest. This will depress the sternum about one and be replaced correctly. third of the chest diameter (by about 2 cm). • If the infant cannot be intubated Keep your hands and thumbs in contact with within 20 seconds of attempting, the chest wall both when you are pushing remove the laryngoscope and mask down and while the chest is allowed to expand ventilate for a minute to allow the again. Push down on the sternum at about infant to recover. Then try again. If a 90 times per minute. Continue with the second attempt also fails, give mask cardiac massage until the infant’s heart rate ventilation and call for help. increases to above 60 beats per minute. • Once the infant has started to breathe well, the heart rate is above 100 beats per minute and the tongue is pink, the endotracheal tube can be pulled out. • The laryngoscope and blade must be cleaned after use.A plastic intubation head model or freshstillborn infant can be used to learn themethod of laryngeal intubation. The correct‘tip to lip’ distance of an endotracheal tubewith oral intubation is approximately theinfant’s weight plus 6 cm (e.g. 2.3 + 6 = 8.3 cmfor a 2.3 kg infant).CHEST COMPRESSIONSIf the heart rate remains below 60 beats perminute after adequate ventilation has beenachieved for 30 seconds, the infant shouldbe given regular chest compressions (cardiacmassage) to improve the circulation to the Figure 1-K: The position of the hands when givingheart, brain and other organs. chest compressions.
  11. 11. SK ILLS WORKSHOP : NEONATAL RESUSCITATION 41Pressing on the sternum compresses the heart compressions should be given each minute.between the sternum and the spine. This This means 3 compressions to each ventilation.squeezes blood out of the heart and into the However, it is important to avoid giving acirculation. When the sternum returns to the breath and a chest compression at the samenormal position, the heart fills again with time, especially with bag and mask ventilation.blood. Therefore it is important that the chest Therefore chest compressions and breathsbe allowed time to expand fully after each must be co-ordinated. This is best achievedcompression. Repeated compression of the if the person giving the chest compressionsheart causes the blood to circulate throughout counts out aloud ‘one-and-two-and-three-the body. and-breath-and-one-and-two-and- …’. At NOTE The main aim of chest compressions is to each number count (one-and-two-and-three) perfuse the coronary arteries. This takes place the chest is compressed and then allowed to when the compression on the chest is released relax. At the count of ‘breath’ the chest is not (i.e. during diastole). Therefore, do not give chest compressed but the infant is given a breath. compressions too fast. Note that the ventilation rate is reduced to 30 breaths per minute in order to allow1-n Co-ordinating ventilation with chest time for chest compressions. Once chestcompressions compressions are stopped the ventilation rateWhen ventilation and chest compressions should be increased again to 40 breaths perare both being given, 30 breaths and 90 chest minute.