This document provides an overview of neonatal resuscitation, covering topics such as factors that increase resuscitation risk, initial resuscitation steps, positive pressure ventilation methods, endotracheal intubation, and post-resuscitation care. Approximately 10% of newborns require some life support, rising to 80% for infants under 1500 grams. Proper preparation, warming, positioning, stimulation and evaluation of respirations and heart rate are the initial steps of resuscitation if needed. Positive pressure ventilation, endotracheal intubation or medications may be required if the infant remains in distress. Ongoing observation and intensive care is provided as needed after resuscitation.

1. Neonatal Resuscitation 4.0 CEU’S

2. Introduction Approximately 10 % of all newborns require some type of life support in the delivery room or nursery. In those less than 1500 grams the need rises to about 80%. 1% of all infants will require major resuscitative measures.

3. Transition The First Breath Clamping of the Umbilical Cord Pressure Changes Closure of the Ductus/Foramen ovale

6. Factors Associated with Increased Risk for Resuscitation Antepartum 1. Maternal Age > 35 2. Diabetes 3. SGA 4. Pre or Post Term 5. PROM 6. Drugs

7. Intrapartum 1. Breech Presentation 2. Infection 3. Prolonged Labor 4. Prolapsed Cord 5. Meconium–Stained Fluids 6. Operative Delivery 7. Fetal HR Abnormalities

8. Preparation for Delivery Anticipation Adequate Planning and Preparation Prompt Initiation of Resuscitation Steps

9. Initial Steps of Resuscitation 1. Provide Warmth/Prevent Heat Loss 2. Position/Clear the Airway 3. Dry/Stimulate – Initiate Breathing 4. Evaluation

10. Meconium-Stained Infants * Vigorous strong respirations, good muscle tone, HR>100 * Not Vigorous

12. Thermoregulation 1. Always preheat the radiant warmer ** Preterm babies are especially vulnerable to cold stress. 2. Warm blankets to be used prior to birth. *** baby cannot benefit from radiant heat if covered with blankets, or team members block the heat with their head or upper body.

14. Opening/Clearing the Airway Place infant of his back or side. Place in a “sniffing” position Suction mouth, then nose.

15. Dry/Stimulate Drying and removal of wet linen may be enough to initiate breathing. Tactile Stimulation (if necessary)

18. Evaluation Respiratory Effort Heart Rate Color

19. Providing Free Flow Oxygen Give the baby free-flow oxygen if… the newborn is breathing, Heart rate is above 100, but the baby is cyanotic.

20. ** When after tactile stimulation and administration of free flow O2 baby remains… Apneic Gasping Heart Rate < 100 PPV is indicated

21. **Ventilation of the lungs is the most important and effective action of NRP

22. Positive Pressure Ventilation Bag and Mask 1. Self Inflating Bag 2. Flow Inflating/Anesthesia Bag 3. T-piece Resuscitator

23. Self Inflating Bag Fills spontaneously after squeezed and remains inflated at all times. Can deliver PPV without a compressed air source Requires an oxygen reservoir to deliver 90-100% oxygen Cannot be used to deliver free-flow O2 through the mask. ***Pop-off valve should always be used to avoid delvivery of too much pressure.

25. Flow-Inflating Bag Also known as an anesthesia bag Fills only when oxygen from a compressed source flows through it. Depends on a compressed gas source. Uses a flow-control valve to regulate pressure (pressure manometer is required to avoid excess pressures) Looks like a deflated balloon when not in use Can be used to administer free-flow O2

27. T-Piece Resuscitator Requires a gas source Must have a tight face-mask seal to inflate the lungs Pressures are set manually with adjustable controls Operator sets maximum circuit pressure, PiP, and peep PiP must be adjusted to achieve correct chest movement Can be used to delivery free-flow O2 **Postive Pressure is provided by occluding and releaseing the hole in the peep cap.

31. Bag and Mask Performance * Face Masks 1. size/shape 2. seal/correct position * Rate * Pressures * NG/OGT placement

32. Supplemental Oxygen Term Preterm Heart Rate <100

33. Chest Compressions Indicated when Heart Rate is less than 60 despite 30 seconds PPV. Two acceptable techniques a. two finger b. thumb Correct positioning Rate/Depth/Coordination Complications

35. Endotracheal Intubation Indications 1. Suctioning the trachea 2. When Bag & Mask is ineffective 3. Facilitate coordination with CC 4. Administer Epinephrine

36. Endotracheal Intubation Equipment 1. Laryngoscope 2. Endotracheal Tubes 3. Stylette 4. Suction 5. Ambu bag 6. Oxygen

37. Endotracheal Intubation Steps of Intubation 1. Position the Head 2. Inserting Laryngoscope 3. Landmarks 4. Suction/insertion of tube

39. Endotracheal Intubation * Correct Placement 1. Vital Signs 2. Breath Sounds 3. Vapor 4. Chest Movement 5. CO2 detectors 6. Lip to Tip 7. CXR * Securing the Tube

40. Endotracheal Intubation Complications 1. Hypoxia 2. Bradycardia/Apnea 3. Pneumothorax 4. Contusions/Lacerations 5. Perforations 6. Infections

41. Laryngeal Mask What is it? How does it work? Indications for it? Limitations Complications

42. Medications Naloxone Epinephrine Volume Expanders Sodium Bicarbonate

43. Premature Infants Additional Risks Additional Equipment Use of Oxygen Brain Injury Thermoregulation

44. Post Resuscitation Care Routine Care Observational Care Post-resuscitative Care

45. Routine care

46. Observational Care

47. Intensive Care

48. Ethics/Compassionate Care at the End of Life Ethical Principals 1. Autonomy 2. Benefits 3. Nonmalefience 4. Justice * Parents Role * Law

49. Support at Death Be clear and honest What “not” to say Provide humane and compassionate care Follow-up Care of the Staff