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![Initial Steps of Resuscitation
66
Learning Objectives
Identify the newborn who requires initial steps of resuscitation.
Demonstrate correct technique for performing initial steps,
including decision making for a baby born with meconium-stained
amniotic fluid.
Demonstrate correct placement of oximeter probe and
interpretation of pulse oximetry.
“You are called to attend a cesarean birth due to breech presentation.
How would you prepare for the birth of this baby? As you work, say
your thoughts and actions aloud so your assistant and I will know
what you are thinking and doing.”
Instructor should check boxes as the learner responds correctly.
Participant Name:
Obtains relevant perinatal
history
Gestational age? Fluid clear? How many babies? Other
risk factors?
Performs equipment check
If obstetric provider indicates
that meconium is present in
amniotic fluid, prepares for
intubation and meconium
aspiration
Warmer on and towels to dry, Clear airway (bulb
syringe, wall suction set at 80-100 mm Hg, meconium
aspirator), Auscultate (stethoscope), Oxygenate (checks
oxygen, blender, pulse oximeter and probe), Ventilate
(checks positive-pressure ventilation [PPV] device),
Intubate (laryngoscope and blades, endotracheal tubes,
stylets, end-tidal CO2 detector), Medicate (code cart
accessible), Thermoregulate
Option 1: Meconium-stained amniotic fluid, vigorous newborn.
“The baby has been born.”
Sample Vital
Signs Performance Steps Details
Appears term
Respiratory rate
(RR)-crying
Tone-flexed
Completes initial assessment
when baby is born.
Learner asks 3 questions:
• Term?
• Breathing or crying?
• Good tone?
Initial assessment determines whether or not baby will
receive initial steps of resuscitation at the radiant warmer.
Allows baby to stay with his
mother for routine care:
Warm, clear airway if
necessary, dry, stimulate if
necessary, continue
evaluation
“Vigorous” meconium-stained baby is defined by
• Strong respiratory efforts
• Good muscle tone
• Heart rate (HR) 100 beats per minute (bpm)
Assume that a crying baby with good tone has
HR 100 bpm.](https://image.slidesharecdn.com/02pc-140928202202-phpapp02/85/NRP-Lesson-2-2-320.jpg)
Uploaded byNikki Damen
NRP: Lesson 2
This document provides guidance on performing initial steps of newborn resuscitation. It includes: 1) A performance checklist that guides assessment and intervention based on factors like breathing, heart rate, and tone. 2) Target oxygen saturation levels by age to guide use of supplemental oxygen. 3) Sample scenarios walking through assessing an infant at birth and performing appropriate initial steps or resuscitation based on conditions. The document is intended to help learners practice newborn resuscitation skills.
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NRP: Lesson 2
- 1. L E SS O N 2 65 Lesson 2: Initial Steps Performance Checklist Term gestation? Breathing or crying? Good tone? No Warm, clear airway if necessary, dry, stimulate Yes—stay with mother HR below 100 bpm, gasping, or apnea? Routine Care • Provide warmth • Clear airway if necessary • Dry • Ongoing evaluation Labored breathing or persistent cyanosis? No No PPV, Yes SPO2 monitoring Yes Clear airway SPO2 monitoring Consider CPAP Post-resuscitation care Targeted Pre-ductal SPO2 After Birth 1 min 2 min 3 min 4 min 5 min 10 min 60-65% 65-70% 70-75% 75-80% 80-85% 85-95% HR below 100 bpm? Yes Take ventilation corrective steps HR below 60 bpm? Yes Consider intubation Chest compressions Coordinate with PPV HR below 60 bpm? Yes IV epinephrine No Birth 30 sec 60 sec No The Performance Checklist Is a Learning Tool The learner uses the checklist as a reference during independent practice or as a guide for discussion and practice with a Neonatal Resuscitation Program™ (NRP™) instructor. When the learner and instructor agree that the learner can perform the skills correctly and smoothly without coaching and within the context of a scenario, the learner may move on to the next lesson’s Performance Checklist. Knowledge Check • How do you determine if a newborn requires resuscitation? • How do you manage the baby who is born with meconium-stained amniotic fluid? • How does pulse oximetry work and what is its function? NRP
- 2. Initial Steps ofResuscitation 66 Learning Objectives Identify the newborn who requires initial steps of resuscitation. Demonstrate correct technique for performing initial steps, including decision making for a baby born with meconium-stained amniotic fluid. Demonstrate correct placement of oximeter probe and interpretation of pulse oximetry. “You are called to attend a cesarean birth due to breech presentation. How would you prepare for the birth of this baby? As you work, say your thoughts and actions aloud so your assistant and I will know what you are thinking and doing.” Instructor should check boxes as the learner responds correctly. Participant Name: Obtains relevant perinatal history Gestational age? Fluid clear? How many babies? Other risk factors? Performs equipment check If obstetric provider indicates that meconium is present in amniotic fluid, prepares for intubation and meconium aspiration Warmer on and towels to dry, Clear airway (bulb syringe, wall suction set at 80-100 mm Hg, meconium aspirator), Auscultate (stethoscope), Oxygenate (checks oxygen, blender, pulse oximeter and probe), Ventilate (checks positive-pressure ventilation [PPV] device), Intubate (laryngoscope and blades, endotracheal tubes, stylets, end-tidal CO2 detector), Medicate (code cart accessible), Thermoregulate Option 1: Meconium-stained amniotic fluid, vigorous newborn. “The baby has been born.” Sample Vital Signs Performance Steps Details Appears term Respiratory rate (RR)-crying Tone-flexed Completes initial assessment when baby is born. Learner asks 3 questions: • Term? • Breathing or crying? • Good tone? Initial assessment determines whether or not baby will receive initial steps of resuscitation at the radiant warmer. Allows baby to stay with his mother for routine care: Warm, clear airway if necessary, dry, stimulate if necessary, continue evaluation “Vigorous” meconium-stained baby is defined by • Strong respiratory efforts • Good muscle tone • Heart rate (HR) 100 beats per minute (bpm) Assume that a crying baby with good tone has HR 100 bpm.
- 3. L E SS O N 2 67 Option 2: Meconium-stained amniotic fluid; non-vigorous newborn “The baby has been born.” Sample Vital Signs Performance Steps Details Appears term Not breathing Limp Completes initial assessment when baby is born. Learner asks 3 questions: • Term? • Breathing or crying? • Good tone? This baby requires initial steps, even without the additional risk factor of meconium-stained amniotic fluid. RR-apneic HR-70 bpm Tone-limp Receives at radiant warmer. Does not dry or stimulate to breathe. Assesses breathing, heart rate, tone. Indicates tracheal suctioning would be required. This is a “non-vigorous” meconium-stained baby. Intubation and tracheal suctioning procedure discussed in Lesson 5. Baby has been intubated and suctioned. Continue with any option below and begin with “Receives baby at radiant warmer.” Option 3: Clear fluid, newborn requires initial steps “The baby has been born.” Term-yes RR-weak Tone-limp Completes initial assessment when baby is born Learner asks 3 questions: • Term? • Breathing or crying? • Good tone? Instructor may tailor scenario to meet learner needs; any or all of the assessment questions may prompt initiation of initial steps. Receives baby at radiant warmer • Positions airway • Suctions mouth and nose • Dries with towel or blanket • Removes wet linen • Stimulates by flicking soles or rubbing back Learner should move quickly through these steps. RR-cry HR-120 bpm Tone–fair Color-cyanotic Assesses breathing and heart rate If learner believes baby is cyanotic and requires supplemental oxygen, learner should administer free-flow oxygen and immediately connect pulse oximeter to confirm the perception of cyanosis. “The baby is now 3 minutes old and appears cyanotic” Breathing HR-140 bpm Appears cyanotic Begins supplemental oxygen Places oximeter probe on right hand or wrist, then connects oximeter Confirms reliable signal by ensuring audio/pulsing light correlates with baby’s actual heart rate Free-flow oxygen may be given by oxygen mask, flow-inflating bag and mask, T-piece resuscitator, or oxygen tubing. It may not be given through the mask of a self-inflating bag.
- 4. Initial Steps ofResuscitation SPO2-65% Continues free-flow oxygen 68 and weans per oximetry target range for age Target range for 3 minutes of age 70%-75%. SPO2-72% Does not begin supplemental oxygen and continues to monitor baby’s transition Option 4: Clear fluid, newborn requires initial steps. “The baby has been born.” Sample Vital Signs Performance Steps Details Appears term Weak cry Limp Completes initial assessment when baby is born Learner asks 3 questions: • Term? • Breathing or crying? • Good tone? Receives baby at radiant warmer • Positions airway • Suctions mouth and nose • Dries with towel or blanket • Removes wet linen • Stimulates by flicking soles or rubbing back Learner should move through these steps quickly; handle baby gently, do not use bulb syringe aggressively, do not waste time continuing to stimulate baby if unresponsive. RR-labored HR-110 bpm Tone-fair Color-cyanotic Assesses breathing, heart rate Visual perception of cyanosis is unreliable. If newborn seems persistently cyanotic, start supplemental oxygen and confirm cyanosis with pulse oximetry. Begins free-flow oxygen Attaches oximeter probe to right hand or wrist; then attaches to oximeter Considers continuous positive airway pressure (CPAP) Free-flow oxygen may be given by oxygen mask, flow-inflating bag and mask, T-piece resuscitator, or oxygen tubing. It may not be given through the mask of a self-inflating bag. CPAP is possible with flow-inflating bag or T-piece resuscitator. RR-40 breaths per minute HR-120 bpm SPO2-74% Evaluates oximetry reading in relation to age. Refers to table of pre-ductal oxygen saturation targets on Neonatal Resuscitation Program flow diagram. RR-40 breaths per minute and unlabored HR-140 bpm SPO2-97% or SPO2-65% At 3 minutes of age: Weans supplemental oxygen Indicates need for PPV Increases free-flow oxygen concentration and/or indicates need for trial of PPV.
- 5. L E SS O N 2 69 Instructor asks the learner Reflective Questions to enable self-assessment, such as: How did you know if the newborn required A. Initial steps at the radiant warmer? B. Intubation and suction of meconium from the trachea? C. Routine care and could stay with his mother? D. Supplemental oxygen? Tell us about how you used pulse oximetry to guide your actions. At what point would you need to call for more help? What went well during this resuscitation? Would you do anything differently when faced with this scenario (indicate which scenario) again? Neonatal Resuscitation Program Key Behavioral Skills Know your environment. Allocate attention wisely. Anticipate and plan. Use all available information. Assume the leadership role. Use all available resources. Communicate effectively. Call for help when needed. Delegate workload optimally. Maintain professional behavior.