Obstetrics (Neonatal resuscitation) Flashcards
What is the key to newborn resuscitation?
- effective ventilation
- the majority of newborns requiring resuscitation are apnoea and bradycardia due to ineffective ventilation
- priorities establishing and maintaining effective ventilation at each stage of resuscitation
What is the best indicator of effective ventilation?
- improvement of HR >100bpm
How quickly should ventilation be initiated for the management of the non-vigorous newborn?
60 seconds
At what rate should ventilations be delivered? and how do you know if they are effective?
- 40-60 per minute
- enough pressure to see the chest rise
When should you apply PEEP and how much?
- where appropriate equipment is available, apply PEEP (5cmH2O) whenever positive pressure ventilation is being provided
What should you do if the neonates HR remains between 60-100 bpm after 30 seconds of effective ventilation on room air?
- ensure adequate mask seal and airway position
- increase ventilation pressure
- where HR remains <100, 100% FiO2 oxygen (5L/min) should be administered
What do you do in regard to O2 if HR >100 and target sats are being met?
Wean O2 to avoid hyperoxaemia
What do you do if the HR <60 despite 30 seconds of effective ventilation?
- commence CPR with 100% oxygen
What are the indications for withholding resuscitation?
- <23 weeks gestation - as there is no possibility of successful resuscitation. Where there is any doubt as to the gestation of the newborn, paramedics should attempt resuscitation and consult with PIPER
- While resuscitative efforts may not be required it is a legal requirement in Victoria that any infant born >20 weeks gestation of >400g at birth OR showing signs of life regardless of gestation, be registered by a hospital, medical facility or midwife.
- There is no requirement that miscarriages <20 weeks gestation be reported to the coroner or police unless the loss of pregnancy has occurred due to violence or injury
How do you manage a neonates airway position?
The head and neck should be placed in a neutral position. Avoid flection and excessive head extension. This will likely require placing a folded towel or blanket underneath the shoulders
When is suctioning required in neonatal resus?
- only when the airway is obstrcuted
How do you suction a neonate?
- the mouth should be suctioned first, followed by the nose.
- the newborn is a nasal breathing and may gasp and inhale pharyngeal fluid if the nose is cleared first
- suction should be gentle, brief (5-6 seconds) and no deeper than the oropharynx (measured from the tragus to the corner of the mouth) to avoid laryngospasm and bradycardia
- a size 10 or 12 catheter with approx <100mmHg or ¼ the adult pressure of suction should be applied
- only apply suction as the catheter is being withdrawn;
When do you suction an intubated neonate?
if the newborn is intubated - only consider tracheal suction is a lower airway obstruction (meconium or blood) is suspected)
Can you use an OPA in a neonate?
- OPAs are not recommended as they may cause airway obstruction and vaguely mediated bradycardia
- a size 0 may be useful where airway abnormalities or the tongue impedes effective ventilation
How do you measure a neonates HR?
- by auscultation in the vigorous newborn (preferred method in preterm newborns <28 weeks)
- in the non-vigorous newborn ECG electrodes can be placed to guide resuscitation (be mindful electrodes can damage their skin)
Do you shock a newborn?
- shockable newborns are extremely rare in newborns. Should these rhythms be observed, apply multifunction electrode pads and defibrillate in manual mode using 4J/kg at 2 min intervals
Where do you attach the pulse oximetry on a new born?
- Attach it to the right hand or right wrist (pre-ductal)
How do you administer CPR to the newborn?
- 3:1 compression to ventilation
- achieve 90 compressions and 30 ventilations per minute with a 0.5 second pause for ventilation (120 events per minute)
- Compression depth should be approximately ⅓ depth of the chest
- the two thumb technique is preferred
- the two finger technique may be performed if access to the tibia for IO is required
What is the focus for a single rescuer?
- the focus should be provided on effective positive pressure ventilation until back up arrives
Recite the newborn resuscitation CPG
What are normal values for a newborn baby?
What is a APGAR score and how is it scored?
What is the purpose of an APGAR score?
- to guide resuscitation
When should the APGAR score be conducted?
- At 1 minute and 5 minutes post birth
- Repeat at 5 min intervals until APGAR score >7
What is a satisfactory APGAR score?
7-10
What is an APGAR score that identifies respiratory depression and that the patient may require ventilation?
4-6
What is the APGAR score that suggests requirement of ongoing resuscitation?
- 0-3
What do you do if the baby is apnoeic or gasping or has no muscle tone?
- stimulate by drying (no more than 30 seconds)
- maintain warmth
- place supine with head/neck in neutral position
- suction only if airway obstruction is suspected
How long do you stimulate a newborn baby before attempting resuscitation?
No more than 30 seconds
What do you do if the babies HR is <100 and/or apnoeic or gasping
- IPPV 40-60 per minute on room air
- pulse oximetry (right hand or right wrist)
- ECG monitoring if not already attached
- reassess after 30 seconds
What do you do if the babies HR is <60
- commence CPR
- 3:1 ratio with oxygen 5L/min
- Consult with PIPER
- MICA
What do you do if the babies HR is 60-100
- IPPV at 40-60 breaths per minute
- ensure adequate mask seal, airway position and increase ventilation pressure targeting chest rise
- If no increase in HR
- IPPV with O2 5L/min
What do you do if the babies HR is >100 but SpO2 <90 and their breathing is laboured?
- IPPV @ 40-60 per minute
- titrate O2 1-5L/min to meet target saturations
What do you do if the babies HR is > 100 but SpO2 <90 and they’re breathing normally
- maintain warmth and treat as per newborn aby
- Titrate oxygen to 1-2 L/min via nasal cannula to meet target saturations
- discontinue oxygen when SpO2 >90
