The document provides guidelines for care in the labour room and newborn resuscitation. It discusses:
1) Checking equipment and supplies needed for resuscitation, including items for warmth, ventilation, oxygenation and medications.
2) Steps of newborn care like drying, assessing breathing and tone, providing warmth and positioning.
3) Indications for positive pressure ventilation, chest compressions and medications like epinephrine during resuscitation.
4) Post-resuscitation care including monitoring babies who required support and providing ongoing respiratory support if needed.
Neonatal resuscitation also known as newborn resuscitation is an emergency procedure focused on supporting the approximately 10% of newborn children who do not readily begin breathing, putting them at risk of irreversible organ injury and death.
This is only providing the theoretical aspects of neonatal resuscitation and will be helpful for the student nurses to understand what exactly the neonatal resuscitation and compare it with practical scenario.
Neonatal resuscitation also known as newborn resuscitation is an emergency procedure focused on supporting the approximately 10% of newborn children who do not readily begin breathing, putting them at risk of irreversible organ injury and death.
This is only providing the theoretical aspects of neonatal resuscitation and will be helpful for the student nurses to understand what exactly the neonatal resuscitation and compare it with practical scenario.
step by step description of resuscitation in newborn for clinical year 2 medical students easier to understand and help revise for exam and osce examinations
Presentation on NRP (Neonatal Resuscitation Program)Moninder Kaur
NRP is neonatal resuscitation program. Approximately 10% of newborns require some assistance to begin breathing at birth. Less than 1% require extensive resuscitative measures. Although the majority of newly born infants do not require intervention to make the transition from intrauterine to extra-uterine life, because of the large total number of births, a sizable number will require some degree of resuscitation.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
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Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
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VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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1. Care in Labour Room &
Resuscitation
Dr. Ashik Majumder
PGT-II, Pediatrics
2. Care at Birth
Most newborns make the
cardiorespiratory transition to extrauterine
life without any intervention
After birth, approximately 4-10% of term
and late preterm will receive PPV, while
only 1-3 per 1,000 will receive chest
compression or emergency medications.
3. Check list for Resuscitation
Preparedness
For Warmth •Preheat Warmer
•Prewarmed towel and blanket
Thermoregulation •Plastic bag or plastic wrap, heated
mattress and cap for small babies
Positioning •Shoulder rolls (2cm thickness)
Clearing airway •10-12F Suction catheter (80-
100mmHg)
•Bulb Syringe
•Meconium Aspirator
4. Ventilation •PPV device
•Masks (size 00,0,1)
•8F feeding tube with large syringe
Oxygenation •Oxygen tubing
•Pulse oxymeter
•Target oxygen saturation table
Intubation •Laryngoscope with blades (size 00,0,1)
•ET tubes (size 2.5,3.0,3.5)
•Stylet (Optional)
Medication •1:10000 epinephrine
•NS
•Supplies for emergency umbilical
catheter and administering medications
5. Standard precautions and
asepsis at birth
Sterile Gloves, masks and gowns
The protective eye wear or face shield
Maintaining 5 cleans:
◦ Clean Hands
◦ Clean surface
◦ Clean cut
◦ Clean thread
◦ Clean cord
6. Preventing Hypothermia
Temp. of delivery room: 25-28⁰C
Free from draft of air
Baby should be received in prewarmed
sterile linen
Baby should be dried thoroughly
including head and face areas
Any wet linen should not be allowed to
remain in contact
7. Skin to skin contact (STS)
Any infant born vaginally and requiring
only routine steps should be placed on
mother’s abdomen or chest immediately
after birth for initial 1 hour.
This will maintain normal temperature,
promote early breast feeding and decrease
pain and bleeding of the mother
Mother-baby dyad Should not be left
alone and observed for breathing, color
and temperature
8. Delayed cord clamping
At least 60 seconds
Infants who require resuscitation beyond
the initial steps, cord should be clamped
and divided shortly after birth
The cord should be clamped at 2-3 cm
away from abdomen
The stump should be away from genitals
to avoid contamination
9. Care of eye
The baby should be dried and cleaned at birth
Should be gentle and should only wipe out the
blood and meconium
Not be vigorous enough to remove vernix
caseosa
Cleaning of baby
• Both eyes should be cleaned with separate
swabs.
• Sterile water or NS can be used
10. Routine stomach wash
Should not be done
Patency of esophagus should be checked
at birth in following circumstances
• Presence of polyhydraminos
• Antenatally suspected esophageal atresia
or diaphragmatic hernia
• Excessive frothing
• Presence of vertebral or anorectal
anomalies (VACTERL association)
11. Identity Band
Each infant must have an identity band
containing name of the mother, hospital
registration number, gender and birth weight
of the infant
• Should be recorded at 1 minute and 5 minutes
of birth.
Apgar Score
12. Weight
The baby should be weighed after stabilization
and the temp. is documented to be normal
Initiation of breastfeeding
• At earliest as possible within one hour of birth
13. Vitamin K administration
To all babies (0.5 mg for less than 1000 gm
and 1 mg for babies more than 1000 gm)
IM injection on anterolateral aspect of the
thigh
First examination
• The baby should be thoroughly examined and
findings should be recorded in neonatal record
sheet.
16. Preparing for Resuscitation
Ask the following 4 pre-birth questions:
◦ What is the expected gestational age?
◦ Is the amniotic fluid clear?
◦ How many babies are expected?
◦ Are there any additional risk factors?
Every delivery should be attended by at
least 1 skilled person whose only
responsibility is the management of the
newborn
17. If risk factors are present, 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
Perform a pre-resuscitation team briefing
All appropriate supplies and equipment
should have been checked and ready for
immediate use
18. A rapid evaluation for every newborn
Term?
Tone?
Breathing or crying?
19. Initial steps of newborn care
◦ Provide warmth
◦ Position the head and neck
◦ Clear secretion if needed
◦ Dry
◦ Stimulate
21. Breaths should be given at a rate of 40 to 60
breaths per minute
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”
Start with a PIP of
20 to 25 cm H2O
22. Indications for Pulse Oximetry
When resuscitation is anticipated
To confirm your perception of persistent
central cyanosis
When supplemental oxygen is
administered
When positive-pressure ventilation is
required
24. Oxygen Supplementation
For the initial resuscitation of
newborns greater than or equal to 35
weeks’ gestation, set the blender to 21%
oxygen
For the initial resuscitation of
newborns less than 35 weeks’ gestation,
set the blender to 21% to 30% oxygen
Set the flow meter to 10 L/minute
28. 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, such as
◦ stabilization of a newborn with a suspected
diaphragmatic hernia
◦ for surfactant administration
◦ for direct tracheal suction if the airway is
obstructed by thick secretions.
31. How deeply should the tube be
inserted within the trachea?
1 to 2 centimeters below the vocal cords
Two methods may be used for estimating
the insertion depth
◦ The estimated insertion depth (cm) is NTL+1
cm
34. When should you consider using a
laryngeal mask?
When you “can’t ventilate and can’t intubate”
Newborns with congenital anomalies involving
the mouth, lip, tongue, palate or neck, where
achieving a good seal with a face mask is
difficult and visualizing the larynx with a
laryngoscope is difficult or unfeasible
Newborns with a small mandible or large
tongue, where face-mask ventilation and
intubation are unsuccessful. Common examples
include the Robin sequence and Trisomy 21
When PPV provided with a face mask is
ineffective and attempts at intubation are not
feasible or are unsuccessful
36. Indications for Chest Compressions
Chest compressions are indicated when
the 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
37. 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
Use enough downward pressure to depress
the sternum approximately one-third of the
anterior-posterior (AP) diameter of the chest
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
“One-and-Two-and-Three and-Breathe-and”
38. When chest compressions are started,
increase the oxygen concentration to
100%
Wait 60 seconds after starting coordinated
chest compressions and ventilation before
pausing briefly to reassess the heart rate
Stop chest compressions when the heart
rate is 60 bpm or higher
Once compressions are stopped, return to
giving PPV at the faster rate of 40 to 60
breaths per minute
39. Medications
Epinephrine is indicated if
the baby’s heart rate
remains below 60 bpm
after
At least 30 seconds of
PPV that inflates the
lungs (moves the
chest),and
Another 60 seconds of
chest compressions
coordinated with PPV
using 100% oxygen
40. Dose
Intravenous or intraosseous: 0.1 to 0.3
mL/kg (equal to 0.01 to 0.03 mg/kg)
Endotracheal: 0.5 to 1 mL/kg (equal to
0.05 to 0.1 mg/kg)
Only the 1:10,000 preparation (0.1
mg/mL) should be used for neonatal
resuscitation
41. Administration
Rapidly—as quickly as possible
Intravenous or Intraosseous: Flush with
0.5 to 1 mL normal saline
Endotracheal: PPV breaths to distribute
into lungs
Repeat every 3 to 5 minutes if heart rate
remains less than 60 bpm.
42. Volume Expander
Normal saline (0.9% NaCl)
O-negative packed red blood cells
Route: Intravenous or Intraosseous
Dose: 10 mL/kg
Administration: Over 5 to 10 minutes
43. Post-natal Care
The physiologic transition to extrauterine
life continues for several hours after birth
Medical complications after resuscitation
may involve multiple organ systems
These complications can be anticipated &
promptly addressed by appropriate
monitoring
44. Routine Care
Nearly 90% of newborns are vigorous term
babies with no risk factors and babies with
prenatal or intrapartum risk factors, who
responded well to the initial steps of
newborn care, may only need close
observation for
◦ Breathing
◦ Thermoregulation
◦ Feeding and
◦ Activity
Frequency of baby’s monitoring depends on
condition of the baby
45. Post-resuscitation Care
Babies who required supplemental oxygen
or PPV after delivery will need closer
assessment
They often require ongoing respiratory
support
◦ Supplemental oxygen
◦ Nasal CPAP
◦ Mechanical ventilation
46. Different conditions following
resuscitation
Organ System Clinical Signs and Laboratory Findings
Neurologic Apnea, seizures, irritability, poor tone,
altered neurologic examination, poor
feeding coordination
Respiratory Tachypnea, grunting, retractions, nasal
flaring, low oxygen saturation,
pneumothorax
Cardiovascular Hypotension, tachycardia, metabolic
acidosis
Renal Decreased urine output, edema,
electrolyte abnormalities
48. Withholding Resuscitation
Preterm infants at less than 25 weeks of
gestation
It is reasonable to consider variables such
as perceived accuracy of gestational age
assignment, the presence or absence of
chorioamnionitis, and the level of care
available for location of delivery
49. Discontinuing Resuscitative Efforts
In infants with an Apgar score of 0 after 10
minutes of resuscitation, if the heart rate remains
undetectable, it may be reasonable to stop assisted
ventilation; however, the decision to continue or
discontinue resuscitative efforts must be
individualized
Variables to be considered may include whether
the resuscitation was considered optimal;
availability of advanced neonatal care, such as
therapeutic hypothermia; specific circumstances
before delivery (eg, known timing of the insult);
and wishes expressed by the family
50. References
Cloherty and Stark’s Manual of Neonatal
care, 8th edition
Care of the Newborn by Meharban Singh,
Revised 8th edition
Textbook of Neonatal Resuscitation, 7th
edition