Neonatal resuscitation program 7th ed

1. Neonatal Resuscitation Program
7th Edition

2. • Transition from fetal to neonatal respiration
• Respiratory failure
• Basics of NRP/ flow diagram
• Preparation for resuscitation
• Oxygen/PPV/Chest compressions/ Medications
• Special scenarios- MSAF, Preterm
• 2017 NRP changes

3. • Most newborns make the cardio respiratory transition to
extra uterine life without intervention.
• Many will require assistance to begin breathing
• A small number will require extensive intervention.
• After birth, approximately 4% to 10% of term and late
preterm newborns will receive positive pressure ventilation.
• Only 1 to 3 per 1,000 will receive chest compressions or
emergency medications.

4. Transition From Fetal to Neonatal Respiration

5. Respiratory failure
INSUFFICIENT SUPPLY OF O2;
REMOVAL OF CO2
ACIDOSIS; CO2 INCREASES
• Fetal monitoring - a decrease in
activity, loss of heart rate variability,
and heart rate decelerations.
A series of gasps followed by
apnea and bradycardia.

6. • Early phase of respiratory failure - tactile stimulation may be
sufficient to initiate spontaneous breathing and recovery.
• Later phase of respiratory failure- stimulation will not be
sufficient and the newborn will require assisted ventilation for
recovery.
• Severely affected newborns may require chest compressions
and Epinephrine.

7. Why do newborns require a different approach to
resuscitation than adults?
A. Newborns – require resuscitation because of heart
disease.
B. Newborn resuscitation is usually the result of
respiratory failure.
The focus of neonatal resuscitation is effective
ventilation of the baby’s lungs.

8. Neonatal Resuscitation Program
• Initial Assessment
• Airway (A)
• Breathing (B): PPV, oxygen, CPAP
• Circulation (C)
If severe bradycardia persists despite assisted ventilation;
supported by performing chest compressions coordinated
with PPV.
• Drug (D)
If severe bradycardia persists despite assisted ventilation
and coordinated compressions, the Drug epinephrine is
administered as PPV and chest compressions continue.

9. NRP
FLOW
DIAGRAM

10. Focus on team work
Team work : Poor teamwork and communication were
the most common root causes for potentially
preventable infant deaths in the delivery room.
Effective communication-
closed loop communication
Accurate documentation
Post resuscitation team debriefing
Pre-resuscitation team briefing
• Assess perinatal risk factors.
• Identify a team leader.
• Delegate tasks.
• Identify who will document events as
they occur.
• Determine what supplies and
equipment will be needed.
• Identify how to call for additional
help.

11. Members of an effective resuscitation team
• share information?
• work quietly and independently?

12. Preparing for resuscitation
• Questions you ask before birth
• Personnel needed for delivery
• Supplies and equipment should be available

13. What questions should you ask before every birth?
• 4 pre-birth questions:
❶ What is the expected gestational age?
❷ Is the amniotic fluid clear?
❸ How many babies are expected?
❹ Are there any additional risk factors?

14. What personnel should be present at delivery?
• Every birth should be attended by atleast 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.
• If risk factors are present, at least 2 qualified people
should be present solely to manage the baby.
• A qualified team with full resuscitation skills should be
identified and immediately available for every
resuscitation.

15. NRP Quick equipment Checklist

16. Initial Steps of Newborn Care

18. Vigorous
term newborn
If answer to all the three
questions is ‘yes’

20. Radiant warmer
Leave the baby uncovered
Apply a servo-controlled temperature sensor
Avoid both hypothermia and overheating.
Baby’s temperature maintained between
36.5°C and 37.5°C.
Position head and neck to open airway
Supine
Sniffing
Avoid hyperextension or flexion
Shoulder roll
If needed, clear secretions from the airway.
•Baby is not breathing, is gasping
•Secretions are obstructing the airway
•Difficulty clearing their secretions
•Meconium-stained fluid
•If you anticipate starting PPV
Mouth before nose
Not to suction vigorously or deeply
Bulb syringe/ suction catheter(80-100 mm Hg)
Warm towel
Not necessary for less
than 32 weeks
•Brief additional
tactile stimulation
• Gently rub the
newborn’s back,
trunk, or
extremities.

21. Which image shows the correct way to position a
newborn’s head to open the airway (A, B, or C)?

22. • 3 rapid evaluation questions that determine
which newborns should be brought to the
radiant warmer for the initial steps?

23. How do you assess the newborn’s response to
the initial steps?
• Respirations
• Heart rate
Auscultation- counting the number of beats in 6
seconds and multiplying by 10.
Pulse oximetry or electronic cardiac (ECG)
monitor leads
If cannot determine the heart rate by physical
examination

24. Pulse oximeter
Proper placement of the pulse oximeter sensor is important.
• The sensor and source positioned opposite
• It may be helpful to cover the sensor to shield it from light in
the room.
• Place the pulse oximeter sensor on the right hand or wrist.
Target preductal sats after birth

25. Baby is breathing and the heart rate is at least 100
but the baby appears persistently cyanotic/ has
labored breathing?

26. Supplemental oxygen
When the oximeter reading remains below the target range for the baby’s age.

27. Supplemental oxygen
1. Compressed air and oxygen
2. Blender
3. Flowmeter
• Adjust the flowmeter to 10 L/min.
• Start with the blender set to 30% oxygen.
• Adjust the oxygen concentration as needed to
achieve the oxygen saturation target.

28. CPAP
If the baby has labored breathing or persistently low oxygen saturation

29. True/ False
• Free flow oxygen can be given by?
A. Oxygen tubing
B. Mask attached to flow inflating bag
C. Mask attached to self inflating bag
D. T- piece resuscitator

30. True/ False
• Indications of CPAP?
A. Labored breathing
B. Persistent cyanosis/ saturations below target
despite supplemental oxygen
C. Baby is apneic / gasping

31. Positive Pressure Ventilation

32. PPV
Start PPV
• Baby is not breathing (apnea) OR has gasping
• Baby appears to be breathing, but the heart
rate is below 100 bpm.
• Oxygen saturation below the target despite
supplemental oxygen or CPAP
When indicated, PPV should be started within
1 minute of birth.

33. Devices used to deliver PPV
• Three types of devices are commonly used for
ventilation.
1. Self inflating bag
2. Flow inflating bag
3. T- piece resuscitator

34. There are 8 basic parts
➊ Gas outlet
❺ Gas inlet
❷ PEEP valve (optional)
❻ Gas tubing
❸ Manometer
❼ Oxygen reservoir
❹ Pressure-release valve
❽ Valve assembly

35. Valve assembly

36. Flow inflating bag

37. T- piece resuscitator

38. Adjusting PIP

39. Masks…

40. One hand technique

41. Two hand technique with jaw thrust

42. What concentration of oxygen should be used to
start positive-pressure ventilation?
• Greater than or equal to 35 weeks’ gestation
set the blender to 21% oxygen.
• Less than 35 weeks’ gestation, set the
blender to 21% to 30% oxygen.
• Set the flowmeter to 10 L/minute

43. Rate for PPV
Rate of 40 to 60 breaths per minute.
Count out loud
Rhythm-“Breathe, Two, Three; Breathe, Two, Three;
Breathe....(squeeze) Two... ...Three... ...(release... ... ... ... ....)

44. Pressures
• Start with a PIP of 20 to 25 cm H2O.
• Full-term babies may require 30-40 cm H2O
• When PEEP is used, the suggested initial
setting is 5 cm H2O.
• Caution in preterm- visual assessment of
chest movement may be less reliable
• It is possible to achieve successful ventilation
without apparent chest movement.

45. Position of baby’s head and neck
Place the right size mask/ tight seal
Oxygen concentration
Adequate pressures/ rate
Position yourself at baby’s head end

46. Evaluate the baby’s response to PPV
• The most important indicator of successful
PPV is a rising heart rate.
• With a stethoscope, pulse oximeter, or an
electronic cardiac (ECG) monitor.

49. Ventilation Corrective steps
MRSOPA

50. Alternative airways

51. When should an alternative airway be
considered?
• If PPV with a face mask does not result in clinical
improvement.
• If PPV lasts for more than a few minutes
• If chest compressions are necessary
• Special circumstances- An endotracheal tube provides the
most reliable airway access
(1) suspected diaphragmatic hernia
(2) for surfactant administration,
(3) for direct tracheal suction if the airway is obstructed by thick
secretions.

52. Laryngoscope blades:
No. 1 (term newborn)
No. 0 (preterm newborn)
No. 00 (optional for very preterm ).
Straight blades (Miller)
Endotracheal tube
Uniform diameter throughout
the length of the tube.

53. Depth of insertion
Nasotragal length :
The estimated insertion depth (cm) is
NTL +1 cm.
Gestational age

54. • How much time should be
allowed for an intubation attempt?
• How do you confirm that the endotracheal
tube is in the trachea?
Detecting exhaled CO2
Rapidly rising heart

55. • ET in trachea, but no color change??
A. Inadequate ventilating pressure
B. Collapsed lungs
C. Bilateral pneumothoraces
D. Low heart rate
E. Low cardiac output

56. How do you hold the laryngoscope?
• In left hand by right handed/ right hand by left
handed
• In left hand by both right- and left-handed users

57. LMA
“can’t ventilate and can’t intubate”
• congenital anomalies involving the
mouth, lip,tongue, palate or neck
• small mandible or large tongue,
Limitations:
•Suctioning of secretions
•Intratracheal medications
•High ventilation pressures
•Very small neonates

58. Chest compressions

59. Chest compressions
Indication
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.

60. Where?
Thumbs should be placed either side-by-side or one on top of the other
in the center of the sternum.
From the head of the bed From the side of the bed

61. Depth of compression
Approximately one-third of the anterior-posterior (AP) diameter
of the chest then release the pressure to allow the heart to refill.
Thumbs should remain in contact with the chest during both
compression and release
90 compressions : 30 breaths per minute
“One-and-Two-and-Three and-Breathe-and;
One-and-Two-and-Three-and-Breathe-and……”
• 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”.

62. • When chest compressions are started, increase
the oxygen concentration to 100%.
• When should you check the baby’s HR?
Wait 60 seconds after starting coordinated chest
compressions and ventilation.
• How should you assess the baby’s heart rate
response during compressions?
• ECG monitor- preferred method
• Auscultation, pulse oximeter

63. When do you stop chest compressions?
• When the heart rate is 60 bpm or higher.
• Return to giving PPV at the faster rate of 40 to
60 breaths per minute.
If the heart rate is less than 60 bpm, check the
quality of ventilation and compressions.

64. Medications

65. Epinephrine
Indication
If heart rate remains below 60 bpm after
•At least 30 seconds of PPV that inflates the lungs
and
• Another 60 seconds of chest compressions coordinated with
PPV using 100% oxygen.

67. Response to Epinephrine
• Assess the heart rate 1 minute after epinephrine
administration.
• If the heart rate is less than 60 bpm after the first dose of
intravenous or dose, can repeat the dose every 3 to 5
minutes.
• If started at the lower end of the dosage range, consider
increasing subsequent doses.
• Do not exceed the maximum recommended dose.

68. Volume expanders

69. If there is a confirmed absence of heart rate after 10 minutes of resuscitation,
it is reasonable to stop resuscitative efforts;
however, the decision to continue or discontinue should be individualized.

71. Does the presence of meconium-stained amniotic fluid change
the approach to the initial steps?
Meconium-stained fluid and a vigorous newborn
• With good respiratory effort and muscle tone, the baby may stay
with the mother to receive the initial steps of newborn care.
• Use a bulb syringe to gently clear meconium-stained secretions
from the mouth and nose.
Meconium-stained fluid and a non-vigorous newborn
• Has depressed respirations or poor muscle tone, bring the baby to
the radiant warmer and perform the initial steps of newborn care .
• Use a bulb syringe to clear secretions from the mouth and nose.
• Not breathing or the heart rate is less than 100 bpm after the initial
steps , proceed with PPV.
• Routine intubation for tracheal suction is not suggested.

72. Resuscitation and Stabilization of
Babies Born Preterm
Thin skin, large surface area
Immature lungs that lack surfactant
Immature tissues are more easily
damaged by oxygen.
Immature blood vessels in the brain
Polythylene plastic bag/wrap
CPAP, lowest inflation pressures,
PEEP, surfactant
Blended oxygen- 21-30%
Gentle handling, avoid head low,
excess PIP/PEEP, rapid changes in
CO2, rapid boluses

73. For babies born at less than 32weeks’
•Place a thermal mattress under the blanket
on the radiant warmer.
•Wrap the baby in a polyethylene plastic bag
or wrap.
•Food-grade reclosable 1-gallon plastic bag,
large plastic surgical bag, food wrap, or sheets
of commercially available polyethylene plastic

74. 2017 NRP MAJOR CHANGES
Cord clamping
• Evidence suggests that cord clamping should be delayed for
atleast 30-60 seconds for most vigorous term and preterm.
• Insufficient evidence for recommendation for neonates who
require resuscitation or who have known risk factors for
decreased placental circulation( Class IIa, LOE-CLD)

75. 2017 NRP MAJOR CHANGES
OXYGEN USE
• > 35 weeks – begin with 21% oxygen
• < 35 weeks- with 21-30% oxygen
• Continued recommendation of use of 100% oxygen when
chest compressions are provided.
PPV
• Once initiated- adjust flowmeter to 10 L/min
• When PPV begins, the assistant listens for increasing HR for
the first 15 seconds of PPV
• If PPV needed for preterm , preferable to use a device that
can provide PEEP

76. 2017 changes
MSAF
Assessment of HR
• 3 lead ECG for rapid/ accurate measurement may be
beneficial; but doesn’t replace the need for pulse oximetry to
evaluate oxygenation
• Initial HR assessment to be performed by auscultation
( umbilical palpation unreliable)

77. 2017 Changes
Chest compressions:
Two thumb technique preferred
Intubation & LMA
• Intubation strongly recommended prior to beginning chest
compressions
• If intubation not successful or feasible- LMA may be used.
Medications
• One ET dose of Epinephrine may be considered while vascular
access is being established
• Unsatisfactory response via ETT, a repeat dose should be
given as soon as emergency UVC is obtained.

78. 2017 NRP MAJOR CHANGES
Thermoregulation
• The goal is an axillary temperature between 36.5- 37.5 C
• If anticipated gestational age is less than 32 weeks- additional
thermoregulation interventions- plastic bag, thermal
mattress, hat are recommended.