Launceston General Hospital Clinical Guideline SDMS ID P2010/0380-001 WACSClinProc4.1/10 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Newborn Resuscitation Newborn Resuscitation WACSClinProc4.1/08 Resuscitation of the newborn at birth Midwives and medical officers, QVMU Newborn, neonatal, resuscitation Meconium Stained Liquor WACSClinProc2.4
Purpose: Transition from fetal to extrauterine life presents unique physiological challenges for the newly born infant. Therefore resuscitation presents a different set of challenges from resuscitation of the adult or even the older infant or child. Although most newborns achieve this transition from fetal to extrauterine life without difficulty, a minority (<10%) require some degree of active resuscitation at birth. Effective ventilation is the key to successful neonatal resuscitation. Strategies: While the need for resuscitation of the newly born infant can often be predicted the need may also arise suddenly. It is essential that all staff possess the knowledge and skills to initiate appropriate neonatal resuscitative techniques. Personnel: All staff who attend births should be trained in basic neonatal resuscitation skills, which included intermittent positive pressure ventilation and cardiac compressions. For low risk newborns midwives will provide initial newborn assessment and resuscitation. If risk factors are identified during pregnancy or labour the obstetric consultant / registrar is responsible for informing the paediatric consultant and/or registrar and a management plan should be formulated and documented in the medical record. Equipment: The need for resuscitation cannot always be anticipated therefore a complete set of equipment should always be available. All staff must be familiar with the location of neonatal resuscitation equipment in the clinical area. Communication: Detailed maternal and fetal information needs to be communicated to the paediatric team. The minimum information required is gestational age, number of babies, reason this is a high risk delivery, presence of meconium in liquor, assessment of fetal condition and/or fetal monitoring in labour, any known congenital abnormalities, maternal group B streptococcal status and maternal medication. A staff member familiar with the maternal and infant history should assume the role of team leader and coordinate the resuscitation.
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Environment: Newborns are at risk of hypothermia so prevention of heat loss is important. Hypothermia can increase oxygen consumption and impede effective resuscitation. The baby requiring resuscitation should be wrapped in a warmed towel or OT drape and carried immediately to the overhead heater. The face and head should be dried and tactile stimulation applied while drying the remainder of the body. This frequently strongly stimulates respiratory movements making further resuscitation much easier, or unnecessary. The wet towel should then be discarded and replaced for a dry warm towel (already on the resuscitation surface.) Hyperthermia may be injurious to a baby, so overheating the baby during and after resuscitation must also be avoided. Procedure: A rapid evaluation of the newly born infant to assess the need for resuscitation: • Breathing, tone, colour, gestation, response to stimulation (slapping, foot flicking, shaking, spanking or holding the newborn upside down are inappropriate and should not be used) and visual inspection for meconium on the skin If normal: routine clinical care If abnormal: • Airway Position the newborn with the head in a neutral or slightly extended position. If secretions are obstructing the airway they can be cleared with suctioning. Using a large bore suction catheter (10 to 12FG) it should be limited to 5 seconds and inserted no more than 5 cm from the lips in a term infant. Evaluate: if breathing effectively, assess heart rate, consider supplemental oxygen if central cyanosis persists. • Breathing Early effective ventilation is the key to successful neonatal resuscitation. Positive pressure ventilation with air (21% oxygen) should be started if the newborn remains apnoeic after tactile stimulation or if breathing is inadequate. If effective ventilation is unable to be achieved using the Neopuff or Laerdel bag and mask, tracheal intubation (by an appropriately trained medical officer) is indicated. Oxygen concentration should be increased to 100% if: o The heart rate does not increase above 100 bpm after 60 seconds of effective ventilation OR chest compressions are initiated o SpO2 ≤ 70% at 5 minutes o SpO2 < 90% at 10 minutes Once the oximeter SpO 2 is >90% the FiO2 is reduced in stages by 10% every 30 seconds. • Circulation After thirty seconds of effective ventilation the heart rate should be assessed. If the heart rate is greater than 60bpm continue effective ventilation. If the heart rate is less than 60bpm after thirty seconds of effective ventilation commence cardiac compressions:1 breath:3 compressions at a rate to achieve 120 (30 breaths and 90 compressions) events in 60 seconds. • Drugs Umbilical vein catheter is the most rapidly accessible route for medication administration and may be used for adrenaline and volume expanders. Adrenaline may also be given via the endotracheal tube.
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Adrenaline If the heart rate does not increase above 60 bpm after 30 seconds of effective ventilation and cardiac compression Adrenaline should be administered. The recommended intravenous dose is 0.1 to 0.3ml/kg of 1:10 000 solution by quick push. The endotracheal dose is 0.3 to 1ml/kg of 1:10 000. Volume Expanding Fluids Intravascular fluids should be considered when there is suspected blood loss and/or the newborn appears to be in shock (pale, poor perfusion, weak pulse) and has not responded adequately to other resuscitative measures. Isotonic crystalloid (normal saline) should be used. The initial dose is 10ml/kg given by quick IV push. This dose may be repeated after observation of the response. Naloxone Naloxone should not be used as part of the initial resuscitation of newborns with respiratory depression in the delivery room. Before naloxone is given, the newborn’s heart rate and colour should be restored by appropriate ventilation. Naloxone should not be administered to newborns whose mothers are suspected of recent illicit drug use. The current dose is 0.1mg/kg given IV or IM. As the half life of naloxone is much shorter than that of the opioid given to the mothers, any newborn who receives naloxone should have a paediatric review before transfer to the postnatal ward. Oxygen Saturation Monitoring • SaO2 is indicated for newborns o ≤ 35 weeks gestation o who require IPPV for > 30 seconds o who are receiving free flow facial oxygen • Establishing effective ventilation is the priority, when additional personnel arrive SaO2 monitoring can be applied • SaO2 probe should be attached to the newborns right hand or wrist to measure pre ductal SaO2. There is significant difference between pre and post ductal readings from birth to 15 minutes (Mariani, 2007) which is most likely due to shunting through patent ductus arteriosus. Pre-ductal (right arm) may be 7% - 10% higher therefore more reflective of oxygenation • Expected SaO2 values in a healthy infant (Saugstad 2006): o In utero SaO2 < 60% o Median SaO2 @ 1 minute – 63% o Median SaO2 @ 3 minutes – 76% o Median SaO2 @ 5 minutes – 90% o SaO2 lower at 5 minutes in infant born by C/S without labour or by vacuum o SaO2 are significantly lower in pre term infants Care of the Newborn after Resuscitation Admission to 4N for observation is required when there has been: • active resuscitation involving CPR • ongoing respiratory distress or oxygen requirement • poor muscle tone 10 minutes after birth • any newborn who has responded slowly to significant resuscitation. Newborns with rapid recovery following resuscitation should be placed skin to skin to receive ongoing care as soon as appropriate. These newborns should have a paediatric review and management plan documented prior to transfer to the postnatal ward or admission to 4N if required.
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The parents should be kept informed as much as possible during and after the resuscitation. A senior member of staff should provide information and the opportunity to debrief after the resuscitation. Early contact between parents and their baby is important. Staff should facilitate parental visits to 4N at the earliest opportunity. Documentation The resuscitation interventions and responses should be documented on the Neonatal Resuscitation Record (3S). Electronic Incident Monitoring (EIMS) should be completed if the apgar < 6 at 5 minutes, there has been a delay or difficulty with resuscitation or when active resuscitation requiring CPR or prolonged IPPV has been performed. Staff Education All midwives will receive annual neonatal resuscitation education as a component of the WACS Professional Development Program. Following the completion of the education session midwives are required to undertake their annual neonatal resuscitation assessment. Resident medical officers (RMO) will receive neonatal resuscitation education at commencement of their rotation to WACS. O & G registrars will receive annual neonatal resuscitation education. Consultant O & G will attend internal or external neonatal resuscitation training on an annual basis. Paediatric registrars and Consultants, O & G registrars and Consultants, (Level II / III) Midwives should be able to lead newborn resuscitation. Resources • Australian Resuscitation Council Neonatal Guidelines February 2006 • Neonatal Resuscitation Textbooks (6 edn) with DVD Rom are available in Wards 4B, 4O and 4N.
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Attachment 1 Attachment 2
Neonatal Resuscitation Flowchart References
Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years, April 2013 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Women’s & Children’s Services Sue McBeath Co-Director (Nursing & Midwifery) Women’s & Children’s Services
Stakeholders: Developed by:
Dr A Dennis Co-Director (Medical) Women’s & Children’s Services Date: __19th October 2010
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ATTACHMENT 1 - NEONATAL RESUSCITATION FLOWCHART
(a) Endotracheal intubation may be considered at several stages
Source: American Heart Association, American Academy of Pediatrics, Pediatrics 2006; 117: e1029-e1038
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ATTACHMENT 2 REFERENCES American Academy of Paediatrics 2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) of Pediatric and Neonatal Patients: Neonatal Resuscitation Guidelines Online: http://pediatrics.org/cgi/content/full/117/5/e1029 Australian Resuscitation Council 2006 Neonatal Guidelines Online: http://www.resus.org.au/ Herschel, M, Khoshnood, B & Lass, N 2000 Role of naloxone in newborn resuscitation, Pediatrics, vol. 106, no. 4, pp, 831-834. Online: http://www.pediatrics.org/cgi/content/full/106/4/831 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendation for Pediatric and Neonatal Patients: Neonatal Resuscitation Online: http://www.pediatrics.org/cgi/content/full/117/5/e978 Mariani, G, Dik, P, Ezquer, A, Aguirre, A, Esteban, M, Perez, C, Jonusas, S & Fustinana, C 2007 Preductal and postductal O2 saturation in healthy term neonates after birth, Journal of Paediatrics, April, pp. 418-421. McGuire, W & Fowlie, P Naloxone for narcotic-exposed newborn infants Cochrane Database of Systematic Reviews 2002, Issue 4, Art. No.: CD003483. DOI 10.1002/1461858.CD003483 Online: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003483/frame.html New South Wales Department of Health Policy Directive PD2008_027 Maternity – Clinical Care and Resuscitation of the Newborn Infant Online: http://www.health.nsw.gov.au/policies/pd/2008/PD2008_027.html Royal Hobart Hospital Clinical Practice Guidelines & Protocols 2008 Neonatal Resuscitation Protocol Neo-1-0010 Online: http://intra.dhhs.tas.gov.au/dhhs-online/page.php?id=23225 Saugstad, O 2006 Oxygen saturations immediately after birth, Journal of Paediatrics, vol. 148, No. 5, pp. 569-570.