Neonatal Resuscitation

Question 1

Do most infants require resuscitation?

Answer 1

No

Question 2

Can the need for resuscitation usually be anticipated?

Answer 2

Yes e.g preterm delivery

And preparations can be made before delivery

Question 3

A newborn who does not establish normal respiration directly will need to be transferred to a…

Answer 3

Resuscitation table

There should be an overhead radiant heater and infant should be dried and partially covered to keep warm

Question 4

Is suction of the nose and mouth usually necessary?

Answer 4

No - vigorous suction at back of throat may provoke bradycardia from vagal stimulation, so should be avoided

Question 5

What should be done if breathing in first minute is irregular or shallow but HR is normal (>100) ?

Answer 5

Breathing encouraged with airway opening manoeuvres

Question 6

Is a blue baby at birth normal?

Answer 6

Yes

Question 7

Is a white baby at birth normal?

Answer 7

No - indicates vasoconstriction and approximately 20 minutes of hypoxia

Question 8

Describe the overall steps of resuscitation

Answer 8

Dry baby, put hat on and cover with towel
Start the clock
Assess - tone, breathing, HR
If gasping or not breathing:
Open the airway
Give 5 inflation breaths (long and slow)
Re-assess (HR should increase, look for chest movement during inflation)
If chest not moving:
Recheck head position, consider 2 person jaw support and other airway manoeuvres, put airway in via laryngoscope
Repeat inflation breaths
Reassess
If no increase in heart rate look for chest movement
When chest is moving:
If heart rate not detectable/slow (less than 60bpm) ventilate for 30 seconds and start chest compressions coordinated with ventilation breaths (ratio 3:1)
Reassess HR every 30 seconds
If HR is not detectable or very slow (<60) consider venous access and drugs

Question 9

What kind of monitoring should be done during resuscitation?

Answer 9

ECG

Pulse oximetry

Question 10

Hypothermia increases morbidity and mortality and every 1 degree below this on neonatal admission increases mortality by…

Answer 10

28%

Question 11

How is the airway opened?

Answer 11

Placing infants head in a neutral position

Question 12

What should be done in the airway step?

Answer 12

Neutral position to open airway
Place support under shoulders if necessary
Provide chin lift or jaw thrust if necessary
Suction any blood or secretions if blocking airway

Question 13

What should the mask cover?

Answer 13

Mouth, nose and chin

Question 14

What are the 3 Ps?

Answer 14

Referring to mask ventilation

Position, pressure, pull up

Question 15

Where should the pulse oximeter be placed?

Answer 15

On the right hand - pre ductal

Question 16

When is intubation and mechanical ventilation indicated?

Answer 16

If mask ventilation ineffective
Tracheal suction needed to clear an obstructed airway
Congenital upper airway abnormality
To give surfactant to extremely preterm infants

Question 17

When should chest compressions be given?

Answer 17

If HR < 60bpm in spite of effective lung inflation

Question 18

What is the ratio of compression to lung inflation?

Answer 18

3:1

Question 19

During chest compressions, when should the HR be rechecked?

Answer 19

Every 30 seconds

Question 20

When should chest compressions be stopped?

Answer 20

When HR >60bpm

Question 21

Where should chest compressions be done on the baby?

Answer 21

Apply pressure to lower third of sternum, just below imaginary line joining the nipples
Depress to reduce anterior-posterior diameter by 1/3 (1-1.5cm)

Question 22

What techniques are there for chest compressions?

Answer 22

Thumb technique with hands encircling the chest. In larger infants thumbs can be placed side by side
Two finger technique - less effective but easier if alone

Question 23

When should drugs be considered?

Answer 23

If HR<60 in spite of adequate ventilation and chest compression
They are rarely needed

Question 24

How should drugs be given ideally?

Answer 24

Centrally via an an umbilical venous catheter or if not possible via an intraosseous needle

Question 25

What may be needed if hypovolaemia?

Answer 25

0.9%NaCl or blood transfusion with group O rhesus neg blood

Question 26

What drugs can be used in neonatal resuscitation?

Answer 26

Adrenaline 1:10,000 if HR <60 in spite of adequate ventilation and cardiac compression
Sodium bicarbonate for severe lactic acidosis
Dextrose 10% if hypoglycaemia
Volume expander e.g sodium chloride blood 10ml/kg if blood loss

Question 27

If after tracheal intubation, the HR does not increase and good chest movement is not achieved, what should be considered?

Answer 27

DOPE
Displaced tube - often oesophagus or right main bronchus
Obstructed tube - especially meconium
Patient - tracheal obstruction, lung disorders (lung immaturity, RDS, pneumothorax, diaphragmatic hernia, lung hypoplasia, pleural effusion), shock from blood loss, perinatal asphyxia or trauma, upper airway obstruction
Equipment failure

Question 28

If there is no breathing or cardiac output after how long of effective resuscitation, should consideration be given to stopping resuscitation?

Answer 28

After 10 minutes of effective resuscitation

Question 29

If prolonged resuscitation is required, the infant should be…

Answer 29

Transferred to the neonatal unit for assessment and monitoring

Question 30

During resuscitation, pre term infants are particularly liable to what?

Answer 30

Hypothermia

Question 31

What should be done to infants less than 30w gestation to keep them warm?

Answer 31

Placed into a plastic bag (with exception of face) or wrapped in clear plastic sheeting without drying to allow the plastic to cling to the skin

Question 32

What than plastic wrap/bag, what else is used to warm the baby?

Answer 32

Resuscitation table radiant heat source

Thermal mattress

Question 33

What can excessive tissue oxygenation cause?

Answer 33

Tissue damage to the brain, lungs and eyes from oxygen free radicals

Question 34

Air is used for initial resuscitation in term infants, what should be used in pre term infants?

Answer 34

Low concentration 21-30%
An air/oxygen mixer should be used and any additional oxygen given should be titrated against oxygen saturation - avoiding pre ductal saturation of 95%

Question 35

What may preterm infants require non invasive respiratory support in the form of…

Answer 35

CPAP to avoid the need for intubation

Question 36

Very preterm infants may develop respiratory distress syndrome and … may be indicated

Answer 36

Early tracheal administration of artificial surfactant indicated

Question 37

Describe what happens when the fetus is subject to hypoxia in utero /during passage through birth canal

Answer 37

Faster breathing movement occurs
This eventually stops as medulla ceases to function due to lack of oxygen
The fetus enters a period of absent respiratory effort = primary apnoea
HR has remained unchanged up to this point, but soon decreases to half of normal as myocardium reverts to anaerobic metabolism
Circulation to non vital organs reduced
Release of lactic acidosis adds to the respiratory acidosis from CO2 accumulation
If hypoxic insult continues, shuddering agonal gasps initiated by spinal reflexes - approx 12 per minute
If these gasps fail to aerate the lungs, they stop and fetus enters secondary/terminal apnoea - no further spontaneous breathing
As terminal apnoea progresses and acidosis worsens, cardiac function is impaired and eventually fails
The process takes up to 20 minutes

Question 38

What is the most urgent requirement for any severely hypoxic infant at birth?

Answer 38

That the lungs are aerated effectively (the infant can maintain effective circulation even for a while after the onset of terminal apnoea)