Chapter 1 Flashcards
Four Initial Questions?
(Perinatal Risk Assessment)
- gestational age?
- clear amniotic fluid?
- additional risk factors
- umbilical cord management
Rapid Evaluation Questions
- term
- tone
- breathing/crying
MR. SOPA
M- ask readjustment
R - reposition head/ariway
S - suction airway (mouth/nose)
O - open mouth
P - Pressure increase for PPV
A - lternative airway (LMA/ETT)
What does clamping of the umbilical cord cause?
– Clamping the umbilical cord increases the baby’s systemic blood
pressure, decreasing the tendency for blood to bypass the baby’s
lungs. p.7
How long can it take for a healthy newborn to reach a POX of 90%
t may take up to 10 minutes for a healthy term newborn to
achieve an oxygen saturation greater than 90% p.7
Clinical findings of an abnormal extrauterine transition?
- Irregular breathing, absent breathing (apnea), or rapid breathing
(tachypnea) - Slow heart rate (bradycardia) or rapid heart rate (tachycardia)
- Decreased muscle tone
- Pale skin (pallor) or blue skin (cyanosis)
- Low oxygen saturation
- Low blood pressure p.7
If the child is born and the “term, tone, and crying” are good, where does treatment continue?
With the mother
If the child is born and the “term, tone, and crying” are NOT good, where does treatment continue?
The warmer
If after 60 sec. if the babies HR is less than 100 bpm and they have apnea of gasping, what is one intervention and two assessements in order of application?
- PPV
- POX
- Consider HR monitor p.8
If after 60 sec. the NB has a HR > 100 bpm, BUT has labored breathing or persistent cyanosis? (4)
Position airway, suction if needed.
Pulse oximeter.
Oxygen if needed.
Consider CPAP. p.8
If the NB has a HR < 60 bpm what are you initial interventions? (4)
ETT or laryngeal mask.
Chest compressions.
Coordinate with PPV-100% oxygen.
UVC.
The HR is < 60 bpm and the patient has an ETT or LMA and is receiving PPV with 100% FiO2 and compressions. What is the next intervention and 2 considerations as possible causes?
- Epi 0.02 IV Q 3-5 min
- consider pneumothorax
- consider hypovolemia
Target Oxygen Saturation table
Target Oxygen Saturation Table
Initial oxygen concentration for PPV
1 min 60%-65%
2 min 65%-70%
3 min 70%-75%
4 min 75%-80%
5 min 80%-85%
10 min 85%-95%
˜ 35 weeks’ GA 21 % oxygen
< 35 weeks’ GA 21 %-30% oxygen
Preferred FiO2 setting for term and preterm?
~ 35 weeks 21%
< 35 weeks 21-30 % p. 8
Compare and contrast heating methods based on gestational age?
- < 32 weeks - plastic wrap
- > 32 weeks warmer p. 25
At what range should wall suction be set up in mmHg?
At 80-100 mmHg
At what flow rate should your O2 be set at in liters per minute?
at a flow rate of 10L/min p.25
What size OG tube is needed?
- 8F orogastric tube
What size LMA is needed?
Size 1 with a 5cc syringe
Laryngoscope size
Size 0 and 1 ( a 00 may also be needed)
ETT sizes?
2, 2.5, 3
Epi concentration
1mg/10ml
Describe the categories of fetal heart rate tracings ?
Category I: This is a normal tracing and is predictive of normal fetal
acid-base status at the time of the observation, and routine follow-up is
indicated.
Category II: This is considered an indeterminate tracing. There is
currently inadequate evidence to classify these tracings as either
normal or abnormal. Further evaluation, continued surveillance, and
reevaluation are indicated.
Category III: This is an abnormal tracing and is predictive of abnormal
fetal acid-base status at the time of the observation. A Category III
tracing requires prompt evaluation and intervention.
T- piece PIP for term baby?
T-piece resuscitator at peak inflation pressure (PIP)= 20 to 25 cm H2O for term baby
T- piece PIP and PEEP for a preterm
PIP= 20 cm H2O for
preterm baby; positive end-expiratory pressure (PEEP)= 5 cm H2O
If the LMA has a port what size OGT tube should be used?
5f or 6f OGT
If the GA is < 32 weeks, what temp would the warmer be set for?
Temperature in resuscitation location (23°C to 25°C [74°F-77°F] if < 32 weeks’ gestation)
For most vigorous term and preterm newborns, clamping the
umbilical cord should be delayed for how long?
at least 30 to 60 seconds
The 5 initial steps include the following post birth ?
provide warmth, dry,
stimulate, position the head and neck to open the airway, clear
secretions from the airway if needed.
How do you determine the time of birth?
Mark the time of birth by starting a timer when the last fetal part
emerges from the mother’s body
Describe the benefits of delayed cord clamping in preterms? (3)
In preterm newborns, potential benefits of delayed cord clamping
compared with immediate cord clamping include,
1. decreasing the chance of needing medications to support blood pressure after birth,
2. requiring fewer blood transfusions during hospitalization, and
3. possibly improved survival.
In term and late preterm newborns, delayed cord clamping may cause what benefits and risks?
In term and late preterm newborns, delayed cord clamping may
1. improve early hematologic measurements and,
2. although uncertain, there may be benefits for neurodevelopmental outcomes. However,
3. there may also be an increased chance of needing phototherapy for
hyperbilirubinemia.
When should the cord be clamped immediately? (4)
If the placental circulation is not intact, such as after a placental
abruption, bleeding placenta previa, bleeding vasa previa, or cord
avulsion, the cord should be clamped immediately after birth
During resuscitation and stabilization, the baby’s body temperature
should be maintained between what temps ?
36.5°C and 37.5°C.
What is the order for suctioning?
Mouth then nose
How long should you assess the newborns response to the INITIAL STEPS?
Assess the newborn’s respirations to determine if the baby is
responding to the initial steps. This should take no more than an
additional 30 seconds
How would you ascertain the baby’s heart rate?
Auscultation along the left side of the chest is the most
accurate physical examination method of determining a newborn’s
heart rate (Figure 3.10). Although pulsations may be felt at the
umbilical cord base, palpation is less accurate and may underestimate
the true heart rate. Count for 6 sec. and multiply x10.
Why is the right hand preferred for POX readings?
In most babies, the artery supplying the baby’s right arm branches from
the aorta before the patent ductus arteriosus enters the aorta. Blood
in the right arm is often called “pre-ductal” and has a similar oxygen
saturation as the blood perfusing the heart and brain. The origin of
blood flow to the left arm is less predictable. The arteries supplying
both legs branch from the aorta after the patent ductus arteriosus and
are called “post-ductal
What are the criteria for PPV? (3)
After completing the initial steps, positive-pressure ventilation
(PPV) is indicated if the baby is not breathing, OR if the baby
is gasping, OR if the baby’s heart rate is less than 100 beats per
minute (bpm).
Describe the FiO2 concentrations of supplemental oxygen for newborns that are greater than and less than 35 weeks gestation?
During PPV, the initial oxygen concentration (Fio2) for newborns
greater than or equal to 35 weeks’ gestation is 21%. The initial Fio2
for preterm newborns less than 35 weeks’ gestation is 21% to 30%.
What is the ventilation rate and pressure for PPV.
The ventilation rate is 40 to 60 breaths per minute and the initial
ventilation pressure is 20 to 25 cm H2O
What parameter indicates successful PPV?
The most important indicator of successful PPV is a rising heart rate.
How long after you initiate PPV should you determine if corrective steps are needed? What parameters would you look for (2)?
If the heart rate is not increasing within the first 15 seconds of
PPV and you do not observe chest movement, start the ventilation
corrective steps
What are the PPV corrective steps?
The ventilation corrective steps (MR. SOPA) are:
a. Mask adjustment.
b. Reposition the head and neck.
c. Suction the mouth and nose.
d. Open the mouth.
e. Pressure increase.
f. Alternative airway.
If the heart rate remains less than 60 bpm despite at least
30 seconds of face-mask PPV that inflates the lungs (chest
movement) what should you do? (6)
- reassess your ventilation technique,
- consider performing the ventilation corrective steps,
- adjust the Fio2 as indicated by pulse oximetry,
- insert an alternative airway (endotracheal tube or laryngeal mask), and provide 30 seconds of PPV through the alternative airway.
After these steps, if the heart
rate remains less than 60 bpm, - increase the Fio2 to 100% and begin
- chest compressions.
How long after starting PPV should you be able to evaluate improvement?
Within 15 seconds of starting PPV, the baby’s heart rate should be
increasing.
* Within 30 seconds of starting PPV, the baby’s heart rate should be
greater than 100 bpm
If the baby’s heart rate is not increasing after the first 15 seconds of PPV, what should you do?
ask your assistant if the chest is moving.
* If the chest is moving, continue PPV while you monitor your
ventilation technique. You will check the baby’s response again after
30 seconds of PPV.
* If the chest is NOT moving, you may not be ventilating the baby’s
lungs. Perform the ventilation corrective steps described below until
you achieve chest movement with PPV
What are the criteria for CPAP? (4)
If the baby is breathing spontaneously and has a heart rate of at least
100 bpm, but has labored or grunting respirations or low oxygen
saturation, CPAP may be considered
When should you consider a gastric tube?
”. If a newborn requires CPAP or PPV for longer than
several minutes, consider placing an orogastric tube and leaving it
uncapped to act as a vent for the stomach” p.91
In what time frame should the INITIAL STEPS of newborn care be delivered in ?
30 seconds to WDSOS
warm
dry
stimulate
open airway
suction p.40
How long should it take to assess the NBs respirations to determine of they are responding to the initial steps?
Assess the newborn’s respirations to determine if the baby is
responding to the initial steps. This should take no more than an
additional 30 seconds.
p.44
When should you use free flow oxygen?
Use supplemental free-flow oxygen when the pulse
oximeter reading remains below the target range
for the baby’s age p.48
At what FiO2 should supplemental O2 be started at?
If supplemental oxygen is necessary, it is reasonable
to start with 30% p.48
If you do not have an oxygen blender, how would you adjust the FiO2 administered?
The closer the tubing or mask is to the face, the higher
the concentration of oxygen breathed by the baby. Guided by pulse
oximetry, adjust the Fio2 by moving the tubing or mask closer to or
farther from the baby’s face. p.50
What are some indications for CPAP?
If the baby has labored breathing, or the oxygen saturation cannot
be maintained within the target range despite 100% oxygen, you may
consider a trial of continuous positive airway pressure (CPAP) or PPV. The baby must be breathing with a HR > 100 bpm p.51
What is one risk of using CPAP?
a pneumothorax p.51
What equipment can be used to administer CPAP?
If desired, a trial of CPAP in the delivery room can be given by using
a flow-inflating bag or a T-piece resuscitator attached to a mask
that is held tightly to the baby’s face (Figure 3.18). CPAP cannot
be given using a self-inflating bag. p.51
If during the antenatal assessment (Four questions), it is determined that the amniotic fluid is meconium stained, how many people should attend the birth?
Two p.51
If there is meconium and the baby is vigorous, where should treatment continue?
with the mother p.52
If there is meconium and the baby is NOT vigorous, where should treatment continue?
at the warmer p. 52
When is PPV indicated?
After completing the initial steps, positive-pressure ventilation
(PPV) is indicated if the baby is not breathing, OR if the baby
is gasping, OR if the baby’s heart rate is less than 100 beats per
minute (bpm).
p.61
How long should you provide PPV before the HR is expected to improve? If it does not, what is your next step?
If the heart rate is not increasing within the first 15 seconds of
PPV and you do not observe chest movement, start the ventilation
corrective steps (MR.SOPA). p.67
What are the ventilation corrective steps acronym?
MR.SOPA
If the heart rate remains less than 60 bpm despite at least
30 seconds of face-mask PPV that inflates the lungs (chest
movement) what is your next step(s)?
If the heart rate remains less than 60 bpm despite at least
30 seconds of face-mask PPV that inflates the lungs (chest
movement), reassess your ventilation technique, consider
performing the ventilation corrective steps, adjust the Fio2
as indicated by pulse oximetry, insert an alternative airway
(endotracheal tube or laryngeal mask), and provide 30 seconds of
PPV through the alternative airway. After these steps, if the heart
rate remains less than 60 bpm, increase the Fio2 to 100% and begin
chest compressions. p.67
What are the indications for positive-pressure ventilation?
After completing the initial steps, PPV is indicated if the baby is not
breathing (apneic), OR if the baby is gasping, OR if the baby’s heart rate
is less than 100 bpm (Figure 4.11). When indicated, PPV should be
started within 1 minute of birth. p.75
Other than a HR < 100 bpm and ineffective breathing, what is another indication for PPV?
In addition, a trial of PPV may be considered if the baby is breathing
and the heart rate is greater than or equal to 100 bpm, but the baby’s
oxygen saturation cannot be maintained within the target range despite
free-flow oxygen or CPAP. p.76
What rhythm would you apply PPV?
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.” p.80
When administering PPV, what times frames should you be looking at and what parameters should be accomplished?
Within 15 seconds of starting PPV, the baby’s heart rate should be
increasing.
* Within 30 seconds of starting PPV, the baby’s heart rate should be
greater than 100 bpm. p.82
When administering PPV and the heart rate is not increasing, what should you assess?
If the chest is rising. p.87
When administering PPV and the HR is not improving and the chest IS rising, what should you do next?
If the chest is moving, continue PPV while you monitor your
ventilation technique. You will check the baby’s response again after
30 seconds of PPV. p.82
When administering PPV and the HR is not improving and the chest is NOT rising, what should you do next?
If the chest is NOT moving, you may not be ventilating the baby’s
lungs. Perform the ventilation corrective steps described below until
you achieve chest movement with PPV. p.82
How many breaths should you give after each ventilation corrective step to see if the correction worked?
Five breaths p. 82
When administering PPV and the HR is consistently > 100 bpm, what should you do?
Adjust the Fio2 as needed based on pulse oximetry.
– When the heart rate is consistently greater than 100 bpm,
gradually reduce the rate of PPV, observe for effective spontaneous
respirations, and gently stimulate the baby to breathe.
– Positive-pressure ventilation may be discontinued when the baby
has a heart rate continuously greater than 100 bpm and sustained
spontaneous breathing. p.85
When administering PPV and he HR is between 60 - 100 bpm, what should you do?
Quickly reassess your ventilation technique. Is the chest moving?
Are you ventilating at a rate of 40 to 60 breaths/minute? Do
you hear breath sounds? If necessary, perform the ventilation
corrective steps.
– Adjust the Fio2 to meet the target saturation.
– If not already done, consider placing cardiac monitor leads for
continuous monitoring.
– If not already done, consider inserting a laryngeal mask or
endotracheal tube.
– If available, call for additional expertise to help problem solve this
situation. p.85
When administering PPV and the HR remains less than 60 bpm what should you do? (6-8)
Quickly reassess your ventilation technique. Is the chest moving?
Are you ventilating at a rate of 40 to 60 breaths/minute? Do you
hear breath sounds? If necessary, perform ventilation corrective
steps.
– If the pulse oximeter has a reliable signal, adjust the Fio2 to meet
the target saturation.
– If not already done, place cardiac monitor leads and begin
continuous monitoring.
– If not already done, insert a laryngeal mask or endotracheal tube.
– If available, call for additional expertise to help problem solve this
situation.
– If the baby’s heart rate remains less than 60 bpm after at least
30 seconds of PPV that moves the chest, preferably through an
alternative airway, increase the Fio2 to 100% and begin chest
compressions as described in Lesson 6
How would you determine if an LMA has been properly placed? (5)
If the laryngeal mask is correctly inserted and you are providing
ventilation that inflates the lungs, you should detect exhaled CO2
within 8 to 10 positive-pressure breaths. You should see chest wall
movement and hear equal breath sounds when you listen with a
stethoscope. You should not hear a large leak of air coming from
the baby’s mouth or see a growing bulge in the baby’s neck. p. 88
What do you do if the baby is breathing spontaneously and has
a heart rate of at least 100 bpm, but has labored breathing or
low oxygen saturation despite free-flow oxygen?
If the baby is breathing spontaneously and has a heart rate of at least
100 bpm, but has labored or grunting respirations or low oxygen
saturation, CPAP may be considered. CPAP is NOT appropriate if the
baby is apneic or gasping or if the baby’s heart rate is less than 100 bpm. p.85
How much pressure should be used for CPAP?
5-6 mmHg but no more than 8 mmHg p. 90
Pros and Cons of a self-inflating BVM?
Pro -
easier set up
does not need compressed gas
Cons
because it self inflates, you may not be aware of air leaks
it is difficult to control inflation time
cannot be used for CPAP or free flow O2 p. 94
T-Piece device pros and cons?
Pros-
less squeeze fatigue
CPAP, PEEP, free flow
inspiration time control
much more precise pressure
CONS-
requires flow
increased set up time p. 95
Limitations of an LMA?
cant reliably deliver meds
may not work with high pressure due to seal break
questionable use with compressions
hard to use with preemies due to size p. 96
