2014 NRP Neonatal Resuscitation Program Study Guide 2011, 6th Edition Neonatal Resuscitation American Academy of Pediatrics and the American Heart Association
There are 9 lessons in the 2011 6th edition of the Online Neonatal Resuscitation Program.
Lesson 1 – Overview and Principles of Neonatal Resuscitation
Lesson 2 – Initial Steps in Resuscitation
Lesson 3 – Use of the Resuscitation Devices with PPV
Lesson 4 – Chest Compressions
Lesson 5 – Endotracheal Intubation
Lesson 6 – Medications
Lesson 7 – Special Considerations
Lesson 8 – Resuscitation of Babies Born Preterm
Lesson 9 – Ethics and Care of the End of Life
The NRP Provider Course consists of the above 9 lessons; however, you will need to only need to complete those lessons required by your facility or level of expertise. Children’s Hospital Employees are required to complete all 9 lessons. Other facilities only require that you take the mandatory lessons to obtain your provider card.
The mandatory lessons are: Lessons 1, 2, 3, 4 and 9. Do not do lessons 5, 6, 7 or 8 unless your facility requires them, or you would like to voluntarily take them to gain more knowledge. From my experience, I suggest you take them all, especially if you are a travel nurse and or work in more than one hospital.
Successful completion of the Neonatal Resuscitation Program course includes an online written examination that is required before you can attend the classroom portion of the NRP course. After completing the lessons, you must also complete the course evaluation before you can print your completion certificate.
Make sure you read all the instructions before taking the online NRP exam.
There are a few very important things you need to know such as If you fail a test twice, all your progress is erased, and you must pay an additional $25 to retake the exam.
You must also do all the lessons in order. If you start with lesson 9, your exam will close, it will be counted as “failed remaining lessons” and all progress will be erased.
Which lessons do I need to complete ?
Make sure you check with the facility you will be working at. Below are just some suggestions:
If you are a MD, NNP, NRN, or an RN working in NICU or Labor/Delivery or Maternity –You should complete Lessons 1,2,3,4,5,6,7,8 & 9
If you are a Respiratory Therapist –You should complete Lessons 1,2,3,4,5,7 & 9
If you are a Lactation Consultant, or LPN, Scrub Tech or CNA, working in NICU, Labor/Delivery, Pediatrics, or Maternity –You should complete Lessons 1,2,3,4, & 9
The best answer is to ask your supervisor which lessons you need. They may require that you do all 9 lessons.
If you take only the mandatory lessons, and then decide you want to take the additional Lessons 5, 6, 7, & 8 you will need to pay an additional $25 to retake the entire exam and all your progress will be lost. You can’t lose if you just do them all. It will take you longer, but it will be well worth the additional time and effort, and the knowledge you have gained. You’ll know for sure that your provider card will be accepted by anyone you will be working for and you won’t have to go back and repeat anything for 2 years.
IMPORTANT ! You must attend the classroom portion of their NRP Hands-On course within 30 days of completing the online examination.
To successfully complete the Neonatal Resuscitation Program course, participants must successfully pass online exam and demonstrate mastery of resuscitation skills within their scope of practice with simulated resuscitation scenarios.
If it has been more than 30 days since you took the online exam, (and you have not yet done the hands on skills portion) your online exam is no longer valid and must be repeated.
These guidelines are set by the American Academy Of Pediatrics and there are no exceptions.
NEONATAL RESUSCITATION PROVIDER
• Upon completion of the NRP Neonatal Resuscitation Program the participant will be able to: •
* Verbalize the risk factors that can help predict which babies will require resuscitation
* Verbalize and demonstrate the need to resuscitate
* Verbalize and demonstrate the use of the flow-inflating bag, self-inflating bag, and the T-piece resuscitator.
* Verbalize and demonstrate effective chest compressions
* Verbalize and demonstrate intubation or assisting intubation if applicable for your job
* Verbalize the medications used in neonatal resuscitation with the indications, route and dose for each
* Verbalize the special considerations and subsequent management of infants beyond the immediate newborn period or outside the hospital delivery room.
* Verbalize the risk factor of infants born premature and the strategies to consider in their care
* Verbalize the ethical principles associated with end of life situations.
Lesson I – Overview and Principles of Neonatal Resuscitation
Approximately 10% of all newborns require some assistance to begin breathing at birth and about 1% will need extensive resuscitative measures. Careful examination of risk factors may not identify all babies at risk for resuscitation.
When resuscitation is anticipated additional personnel should be present in the delivery room at the time of the delivery. One skilled person is required of all deliveries and 2 skilled persons for high risk deliveries.
When twins are expected 4 skilled persons are required.
Keep in mind that all newborns require initial assessment to determine whether resuscitation is required.
Chest compressions and medications are rarely needed when resuscitation is required.
There are 3 questions you should ask yourself to help you decide the need of resuscitation:
* Is the baby term
* Is the baby breathing and crying
* Does the baby have good muscle tone
The most important resuscitative action is effective ventilation of the newborns lungs.
Air that fills the alveoli contains 21% oxygen, and causes the pulmonary arterioles to relax so that oxygen can be absorbed from the alveoli and distributed to all organs.
At every delivery, you should anticipate the need for advanced resuscitation and be prepared and present at the hospital. For this reason, every birth should be attended by at least 1 person skilled in neonatal resuscitation whose only responsibility is the management of the newborn.
When a newborn first becomes deprived of oxygen, an initial period of rapid breathing is followed by primary apnea. Primary apnea can be resolved by tactile stimulation. If oxygen deprivation continues, secondary apnea ensues. The heart rate continues to fall, and the blood pressure falls. Secondary apnea cannot be reversed with stimulation.
Therefore, the deciding factor to determine primary versus secondary apnea is the response to tactile stimulation. The infant in secondary apnea will require positive pressure ventilation to initiate spontaneous breathing. Restoration of adequate ventilation usually will result in rapid improvement in heart rate.
Normal transition occurs with relaxation of blood vessels in the lungs leading to decrease in resistance to blood flow
Premature babies present unique challenges. They are:
* Fragile brain capillaries that bleed easily.
* Lungs deficient in surfactant making ventilation more difficult.
* Poor temperature control and they get cold easily.
* Higher risk of infection. Resuscitation should proceed rapidly.
The initial steps of resuscitation are:
Provide warmth Position the head and clear the airway Dry and stimulate the baby to breath Evaluate respirations
The three signs of effective resuscitation are:
Heart rate Respirations Assessment of oxygenation (O2 Sat based on age in minutes) Baby can take up to ten minutes to reach an oxygen saturation of 90-95%.
If the baby is apneic or has a heart rate less than 100 bpm
Begin the initial steps Warm, dry and stimulate for 30 seconds
If the heart rate remains below 100
Start PPV with room air (40% O2 if a preemie) and continue for 30 seconds Apply an oximeter probe on the baby’s right hand for pre-ductile saturation.
If the heart rate remains below 100
Perform the steps of MR SOPA for an additional 30 seconds
Resuscitation should not be delayed until the 1 minute Apgar score is obtained.
All anticipated or needed equipment should be opened and ready for use.
Lesson I Neonatal Resuscitation Program Review Questions:
1. About ___________% of newborns will require some assistance to begin regular breathing. (10% / 50%)
2. About ____________% of newborns will require extensive resuscitation to survive. (1%/ 10% )
3. Careful identification of risk factors during pregnancy and labor can identify all babies who will require resuscitation. (True/False)
4. Chest compressions and medications are _____________needed when resuscitating newborns. (always / rarely)
5. Before the birth, the alveoli in a baby’s lungs are ________and filled with_____________ (inflated / collapsed) (air / fluid)
6. The air that fills the baby’s lungs during normal transition contains______% of oxygen. (21% / 40%)
7. The air in the baby’s lungs causes the pulmonary arterioles to ___________so that the oxygen can be absorbed from alveoli and distributed to all organs. (relax / constrict)
8. If baby does not begin breathing in response to stimulation, you should assume she is in ___________apnea and you should provide___________ (primary / secondary) (Tactile Stimulation / PPV)
9. If the baby enters the stage of secondary apnea, her heart rate will_________and her BP will___________(rise / fall) (rise / fall)
10. Restoration of adequate ventilation usually will result in a _____________improvement of heart rate. (slow / rapid)
11. Resuscitation _________ be delayed until the 1-minute Apgar score is available. (should / should not)
12. Premature babies have unique challenges during resuscitation because of __________(fragile brain capillaries that my bleed) __________(lungs deficient in surfactant) __________(poor temperature control) __________(higher likelihood of infection) __________(all of the above)
13. Apnea or heart rate below_________(100/ 60 ) Provide__________(room air / oxygen) and apply oximeter probe to _______ (Right Hand/ Left Wrist ). Heart rate then drops to__________(100 / 60) take____________(Ventillation / Stimulation) corrective measures – MR SOPA) If heart rate continues below_______(60) start chest compressions and insert an __________(IV or UVC) and give________ (atropine / epinephrine)
14. Every delivery should be attended with at least_____ skilled persons.
15. At least_____skilled persons should be present with high risk delivery.
16. Equipment_________be opened if a newborn is anticipated to be depressed. (should / should not)
17. Since the baby required continuous supplemental oxygen, she should receive ____________ (post resuscitation care / normal care without special monitoring)
18. When twins are expected, there should be _______people present the delivery room to form the resuscitation team prepared to resuscitate.
Lesson 2 – Initial Steps in Resuscitation
* If meconium is present and the infant is vigorous (good muscle tone, strong respiratory effort, and heart rate greater than 100 bmp) clear the secretions with bulb syringe from the mouth and nose immediately and continue with resuscitation.
* If meconium is present and the infant is not vigorous, the infant’s trachea needs to be suctioned. When a suction catheter is used to clear the oropharynx of meconium before inserting the endotracheal tube,the appropriate size is 12 F to 14 F catheter. Begin the initial steps of resuscitation by asking yourself: Is the infant term? Is the infant breathing? Does the infant have good muscle tone?
* Open the airway by placing the infant in the sniffing position and if needed suction with a bulb syringe – mouth first and then the nose.
* Provide tactile stimulation by slapping the soles of the feet or gently (not vigorously ) rubbing the back
* If the infant does not immediately respond, proceed to PPV with an FIO2 of 21%, place oximeter probe on the right hand for preductile saturations. The oximeter will provide you with minute by minute saturations. Do not expect the saturation to be greater than 60% initially. It will take at least 10 minutes for healthy newborns to increase their saturations to >90%. At 2 minutes of life, expect the O2 saturations to be only greater than 65%.
Target preductile sats are:
1 min = 60-65% 2 min = 65-70% 3 min = 70-75 % 4 min = 75-80% 5 min = 80-85% 10 min = 85-95%
Refer to these target sats frequently during your exam:
Use a pulse oximeter when: Resuscitation is anticipated. PPV is required for more than a few minutes Central cyanosis is present Supplemental oxygen is administered, you need to confirm your perception of cyanosis.
Check the heart rate by counting the beats in 6 seconds and multiply by 10, if the heart rate is less than 60 bpm, (Perform MR SOPA for 30 seconds before begining chest compressions.
After completing the initial steps of providing warmth, positioning the infant in the sniffing position, clearing the airway and evaluate the infant’s response with the following:
Respirations with good chest movement. Gasping respirations are ineffective and require PPV.
Heart rate should be greater than 100 bmp by counting the heart beats in 6 seconds a multiplying by 10.
Color with pink lips and pink trunk, there should not be central cyanosis which indicates hypoxemia. If central cyanosis exist, free-flow supplemental oxygen or CPAP (continuous positive airway pressure) is required.
Supplemental oxygen can be provided in the following ways:
Holding the oxygen tubing cupped closely over the infants mouth and nose.
Closely hold the mask of a flow-inflating bag or T-piece resuscitator over the infants mouth and nose.
If supplemental oxygen is required for longer than a few minutes the oxygen needs to be heated and humidified. The baby will also need and OGT to decompress the abd.
Lesson II – Review Questions
1. A newborn who is born at term, has no meconium in the amniotic fluid or on the skin, is breathing well, and has good muscle tone___________(does /does not) need resuscitation.
2. A newborn with meconium fluid who is not vigorous__________(will / will not) need to have his trachea suctioned via an endotracheal tube. A newborn with meconium in the amniotic fluid who is vigorous __________(will / will not) need to have his trachea suctioned via an endotracheal tube.
3. When deciding which babies need tracheal suctioning, the term “vigorous” is defined by what 3 characteristics? ______________(HR>100 bpm / HR > 150 bpm) ______________(Strong respiratory effort / spontaneous respirations) ______________(Good muscle tone / Fair muscle tone)
4. When a suction catheter is used to clear the oropharynx of meconium before inserting an endotracheal tube, the appropriate size is __________(10 F / 12F) or ________(14F / 16 F).
5. The position of the head prior to suctioning is the _________(head tilted / sniffing) position.
6. A newborn is covered with meconium, is breathing well, has normal muscle tone, has a heart rate of 120 bpm, and is pink. The correct action is to _______________(suction the mouth and nose with a bulb syringe/ intubate and suction the trachea).
7. In suctioning a baby’s nose and mouth, the rule is to first suction the __________(nose / mouth) and then the______(nose / mouth).
8. The correct way to stimulate a newborn is __________(rub the back gently / slap the buttocks) and ________ (slap the soles of the feet / flick the soles of the feet).
9. If the baby is in secondary apnea, stimulation of the baby________(will / will not) stimulate breathing.
10. A newborn is still not breathing after a few seconds of stimulation. The next step should be to administer ________________(Intubate / PPV).
11. A newborn has poor muscle tone, labored breathing, and cyanosis. Your initial steps are: _________(place the infant on a radiant warmer) _________(remove all wet linens) _________(suction the mouth and nose) _________(consider CPAP or free-flow O2) _________(apply a pulse oximeter probe) _________(dry and stimulate)
12. There are three ways to give free-flow oxygen. ______(Holding the oxygen tubing cupped closely over the infants mouth and nose) ______ (Closely hold the mask of a flow-inflating bag or T-piece resuscitator held over the infant’s mouth and nose.) _______(Holding an oxygen mask firmly over the infant’s face)
13. Oxygen saturation should be expected to be only____ (> 92% / >65%) by 2 minutes of life.
14 If you need to give supplemental oxygen for longer than a few minutes, the oxygen should be____(heated / cooled) and _________(humidified / increased).
15. You have stimulated a newborn and suctioned her mouth. It is now 30 seconds after birth, and he is still apneic and pale. His heart rate is 80 beats per minute. Your next action is to _______________(Intubate / provide PPV).
16. You count a newborns heart rate for 6 seconds and count 6 beats. The heart rate is ______(60 / 100).
17. An oximeter will show both SPO2 and ________ (heart rate / respiratory).
Lesson III – Use of Resuscitation Devices for Positive Pressure Ventilation
As noted in Lesson I, the single most important step in resuscitation is effective ventilation of the lungs. Effective ventilations are defined by the presence of bilateral breath sounds, chest movement and increase in heart rate.
To evaluate effective ventilation, the infant should have a rise and fall of the chest during bag/mask ventilation. The indications for positive pressure ventilations are:
* Heart rate less than 100 bmp even if breathing
* Persistent central cyanosis
* Low SPO2 despite free-flow oxygen
* The most important indicator of successful PPV is a heart rate that is rising.
If PPV is effective the following are the indicators:
* Heart rate rises over 100 bmp
* Improvement of oxygen saturation
* Sustained spontaneous respirations
If there is no audible bilateral breath sounds and you see no rise and fall of the chest intervention is required. To correct inadequate ventilation you may use the pneumonic MR SOPA to determine the interventions that may be helpful:
M = Mask adjustment
R = Reposition the airway
S = Suction the mouth and nose
O = Open the mouth
P = Pressure increase
A = Airway alternative
If the infant does not improve with your resuscitation effort, MR SOPA is always your first priority. Refer to this often for your test.
The AAP recommends resuscitation of newborns may begin with room air PPV; resuscitation of preterm newborns may begin with a somewhat higher oxygen concentration (40%).
Pulse oximetry is used to help adjust the amount of supplemental oxygen to avoid giving too much or too little oxygen concentration.
While someone is doing PPV, the second member should be:
* applying the pulse oximeter probe to the right hand or wrist
* listening for the rise in heart rate
* watching for rising oxygen saturation
To provide a varying degree of FIO2, a blender connected to the ventilation device is required. If an oxygen blender is not available, start PPV with 21% oxygen (room air) while you obtain an air-oxygen source and oximeter.
Use a pulse oximeter with supplemental oxygen and adjust the oxygen concentration to achieve the target values for pre-ductal saturations based on age in minutes:
1 min = 60-65%
2 min = 65-70%
3 min = 70-75 %
4 min = 75-80%
5 min = 80-85%
10 min = 85-95%
Ventilations should be 40-60 breaths per minute. Do not over inflate the lungs which may result in pneumothorax. The initial pressure should be 20 cm H2O.
Providing positive pressure ventilation for greater than a few minutes requires the insertion of an orogastric tube. The orogastric tube needs to inserted the distance from the bridge of nose to the ear and then half way between the umbilicus and the xyphoid process.)
There are three types of resuscitative devices.
Flow-inflating bags Self-inflating bags T-Piece Resuscitators
The flow-inflating bags have the following characteristics:
They fill only when gas from a compressed source flows into it. They are dependent of an oxygen source Must have a tight mask-to-face seal to inflate Have a flow-control valve to regulate the pressure. Looks like a deflated balloon when not in use. Can be used to administer free-flow oxygen and CPAP (continous positive airway pressure)
The flow-inflating bag will not work if:: The bag is not properly sealed over the newborns nose and mouth. There is a hole in the bag The flow-control valve is open too far. The pressure gauge is missing.
The self-inflating bags have the following characteristics:
They will fill spontaneously after they are squeezed Remain inflated at all times Must have a tight mask-to-face to inflate the lungs Can deliver PPV without a compressed gas source but must be connected to a gas source to deliver supplemental oxygen Cannot be used to deliver free flow oxygen or CPAP An oxygen reservoir must be attached to deliver high concentrations of oxygen. Without the reservoir, the bag delivers a maximum of only about 40% oxygen which may be insufficient for resuscitation.
The T-piece resuscitators have the following characteristics:
Allows consistent pressure when ventilating Depends on a compressed gas source Must have a tight seal mask-to-face to inflate the lungs Require selection of a maximum pressure, peakinspiratory pressure (PIP) and positive end expiratory pressure (PEEP) May require adjustment of PEEP during resuscitation to achieve physiologic improvement. Provides PPV when the operator alternately occludes and opens the PEEP cap Can be used to deliver free-flow oxygen or CPAP Safety Feature = Pressure Gauge and Pressure Relief Control Valve
In conclusion: An infant that is apneic – provide PPV - apply an oximeter - listen for rising HR – watch for rising O2 sats.
Lesson III Review Questions
1. Flow-inflating bags __________(will / will not) work without a compressed gas source.
2 A baby is born apneic and cyanotic. You clear her airway and stimulate her. Thirty seconds after birth, she has not improved. The next step is to __________(intubate / begin PPV).
3. The single most important and most effective step in neonatal resuscitation is _______________(intubate / ventilating the lungs).
4. Identify the flow-inflating bag by a ___________(oxygen reservoir / deflated balloon-like appearance). Identify the self-inflating bag by an ___________(oxygen reservoir / deflated balloon like appearance). Identify the T-piece resuscitator by ________(the pressure gauges / shape of a T).
5. Masks of different sizes ______(do / do not) need to be available at every delivery.
6. Self-inflating bags require the attachment of a(n)________ (oxygen reservoir / pressure gauge) to deliver a high concentration of oxygen.
7. A T-piece resuscitator ___________(will / will not) work without a gas source.
8. Neonatal bags are _______(much smaller/ the same size) than/as adult bags.
9. The safety feature of a self-inflating bag is the _______ (Pop-off valve) and the ________(pressure gauge). The safety feature of the flow-inflating bag is the________ (pressure gauge) The safety feature of the T-piece resuscitator is the ______ (pressure relief control valve) and the ____________ (pressure gauge).
10. Free-flow oxygen can be delivered reliably through the mask attached to the__________(flow inflating bag / self inflating bag) and__________ ( flow inflating bag / the T-piece resuscitator).
11. When giving free-flow oxygen with a flow-inflating bag and mask, it is necessary to place the mask ________ (loosely / tightly) on the baby’s face to (allow / prevent) some gas to escape around the edges of the mask.
12 Before an anticipated resuscitation, the ventilation device should be connected to a _________(reservoir bag / blender), which enables you to provide oxygen in any concentration from room air up to 100% oxygen.
13. Resuscitation of the term newborn may begin with _______ (21% / 100%) oxygen. The inspired oxygen concentration used during resuscitation is guided by the use of _________ (pop off valve / oximeter) which measures oxygen saturation.
14. The proper position for PPV is the ____________ (sniffing position / prone).
15. The correct positions to assist in PPV are________or _________ to use a resuscitation device effectively.
16. You must hold the resuscitative device so that you can see newborns _________(chest / head) and _________(abdomen / face).
17. An anatomically shaped mask should be positioned with the _________(pointed / round) end over the newborn’s nose.
18. If you notice that the baby’s chest looks as if he is taking a deep breath, you are __________(overinflating / underinflating) the lungs and it is possible that a pneumothorax may occur.
19. When ventilating a baby, you should provide positive pressure ventilation at a rate of _________(30 / 40 ) to ______ (50 / 60) breaths per minute.
20. Begin positive pressure ventilations with an initial inspiratory pressure of _______(20 / 40) cm H20.
21. MR SOPA stands for:
M _____(Mask adjustment / Call More people to assist) R _____(Reposition the airway / Re suction the Trachea) S______(Suction the mouth and nose / Start Compressions) O______(Open the mouth / Oxygen concentration Increase) P______(Pressure increase / Push IV Drugs) A______(Airway alternative / Atropine)
22. Your assistant assesses effectiveness of positive-pressure by first assessing the ________(heart rate / color) and ________(oximetry) and listening for_________(breath sounds) If these signs are not acceptable, you should look for_____________(chest movement).
23. A properly fitting mask fits over the ________(nose) and the________(mouth) with the __________(pointed end over the nose)
24. You have started positive-pressure ventilation on an apneic newborn. The heart rate is not rising, oxygen saturation is not improving, and your assistant does not hear bilateral breath sounds. List three possibilities of what may be wrong. _________(there may be an inadequate seal / you need to increase the oxygen) ________ (the head may need to be repositioned / the equipment is broken) _________(secretions may need to be suctioned / chest compressions need started)
25. If, after performing the ventilation corrective sequence and making appropriate adjustments, you are unable to obtain a rising heart rate or bilateral breath sound or see chest movement with PPV, you usually will have to insert an ________(OGT / ET tube) or a ___________(LMA / UVC).
26. You have administered PPV with bilateral breath sounds and chest movement for 30 seconds. What do you do if the baby’s heart rate is below 60 bpm? ________(begin chest compression and consider intubation / repeat MR SOPA and consider intubation) . 27. What do you do if the heart rate is more than 60 bmp and less than 100 bpm but steadily improving with effective PPV? ____________(adjust oxygen, gradually, decrease pressure as heart rate improves, insert orogastric tube, continue monitoring OR begin chest compressions, intubate, and give IV Epi).
28. What do you do if the heart rate is more that 60 bpm and less than 100 bmp and not improving with effective PPV? ________________(repeat MR SOPA and consider intubation / start chest compressions and intubate)
29. Assisted ventilation may be discontinued when__________ (heart rate is above 100 bmp / heart rate above 60 bpm) and ___________(the baby is breathing / color has improved).
30. If you must continue with PPV with a mask for more than several minutes, an __________________(orogastric tube / LMA ) should be inserted to act as a vent for the gas in the stomach during the remainder of the resuscitation.
31. The orogastric tube needs to inserted ___________(the distance from the bridge of nose to the ear and then to half way between the umbilicus and the xyphoid process. / the distance from the nose to the tragus of the ear)
Lesson IV – Chest Compressions
The heart lies in the chest between the lower third of the sternum and the spine. Compressing the sternum compresses the heart against the spine and increases the pressure in the chest causing the blood to be circulated to the vital organs. The following are the guidelines for providing chest compressions:
Always provide PPV for 30 seconds and then check the heart rate. Give 30 breaths and 90 compressions per minute .
Chest compressions are indicated when the heart rate remains less than 60 beats per minute despite 30 seconds of effective positive-pressure ventilation to circulate blood to the vital organs.
Once the HR is below 60 bmp the oximeter may not work. You should increase the oxygen concentration to 100% until the oximeter begins displaying a reading. Once the oximeter is reading, then adjust to FIO2 according to the preductile sats based on age in minutes.
1 min = 60-65%
2 min = 65-70%
3 min = 70-75 %
4 min = 75-80%
5 min = 80-85%
10 min = 85-95%
The chest compressions should be well coordinated and with positive pressure ventilations. The person providing the compressions should count out loud “One and Two and Three and Breathe, One and Two and Three and Breathe) Three chest compressions should be given in a row, and then one breath during the pause when the compressor says “Breathe”.
There are two acceptable techniques for providing chest compressions, the 2-finger technique and the two thumb technique. The two thumb technique is preferred.
Chest compressions should be a depth of one third the distance from the anterior to the posterior of the infant’s chest .
Applied to the lower third of the sternum, which lies between the xyphoid and a line drawn between the nipples. (One finger’s width below the nipple line.)
The compressor coordinates the resuscitation by counting out-loud “One-and-Two-and -Three-and Breath-and…………” Allow the chest to completely recoil during the relaxation phase, so that the heart can refill with blood.
Preform the chest compressions with the thumbs or fingers remaining in contact with the chest at all times.
When chest compressions are started, continue for 45-60 seconds before pausing to reassess.
The Guidelines for chest compressions are as follows:
If the heart rate is greater than 60 bpm:
Discontinue chest compressions and continue ventilations at 40-60 ventilation/min
If the heart rate is greater than 100 bpm
Discontinue chest compressions and gradually discontinue ventilation if the infant is breathing spontaneously.
If the heart rate is less than 60 bpm
Consider Intubatation if not already done. Intubation provides a more reliable method of ventilations.Give epinephrine, preferably intravenously with an emergent UVC line.
The thumb technique is preferred because of this technique may be superior in generating peak systolic and coronary artery perfusion pressure. Complications of chest compressions include fractured ribs and injury to the liver.
Lesson IV Review Questions
1. A newborn is apneic and bradycardic. Her airway is cleared and she is stimulated. At 30 seconds,PPV is begun. At 60 seconds her heart rate is 80 bpm. chest compressions ____________(should/ should not) be started. PPV ventilations ___________ (should be / should not) be continued.
2. A newborn is apneic and bradycardic. She remains apneic, despite having her airway cleared, being stimulated, receiving 30 seconds of PPV and ensuring that all ventilation techniques are optimal. Nevertheless, her heart rate is only 40 bpm. Chest compressions ___________(should / should not ) be started. PPV_________(should / should not) be continued.
3. The heart rate is 40 bmp as determined by auscultation, and the oximeter has stopped working. Chest compressions have begun, but the baby is still receiving room air. What should be done about oxygen delivery?___________ (increase oxygen concentration to 100% / continue at slightly higher than room air)
4. During the compression phase of chest compressions, the sternum compresses the heart, which causes blood to be pumped from the heart and into the _______ (veins / arteries). In the release phase, blood enters the heart from the _______( arteries / veins).
5. Chest compressions should be_________________ (applied to the lower third of the sternum, which lies between the xyphoid and a line drawn between the nipples / the upper one third of the breast bone)
6. The preferred method of delivering chest compressions is ____________(the two thumb / two finger) technique.
7. If you anticipate that the baby will need medication by the umbilical route, you should (continue / pause ) chest compressions while the UVC is placed.
8. The correct depth of chest compressions is approximately_____________(one third / one fourth) the anterior to posterior diameter of the chest).
9. The correct method of release of chest compressions is ____________(fingers remaining in contact with the chest / allow the fingers to leave the chest completely between compressions).
10. What phrase is used to time and coordinate chest compressions and ventilations?_________ (One-and-Two-and-Three-and-Breathe / One-and-Two-and-Breathe).
11. The ratio of chest compressions to ventilations is ____(2 / 3) to _______(1 / 4)
12. During PPV without chest compressions the rate of breaths per minute is ____ (30-40 / 40-60) bmp.
13. During PPV and chest compressions, the rate of “events” per minute is _________(90 / 120) “events.”
14. The count of “One-and-Two-and-Three-and-Breath” should take about________( 1 / 2 ) second(s).
15. A baby has required ventilations and chest compressions. After 30 seconds of chest compressions, you stop and count 8 heartbeats in 6 seconds. The baby’s heart now _____( 48 / 80) bpm. You should ____________(stop / continue) chest compressions.
16. A baby has required chest compressions and is being ventilated with bag and mask. The chest is not moving well. You stop and count 4 heartbeats in 6 seconds. The baby’s heart rate is now_______(24 / 40) bpm.
Lesson V – Endotracheal Intubation
Indications for endotracheal tube intubation are as follows:
To suction the trachea in the presence of meconium when the newborn is not vigorous.
To improve efficacy of ventilation if mask ventilation is ineffective
To improve efficacy of ventilation if mask ventilation is required for more than a few minutes.
To facilitate coordination of chest compressions and ventilation and to maximize the efficiency of each ventilation.
To improve ventilation in special conditions, such a extreme prematurity, surfactant administration, ineffective ventilations or suspected diaphragmatic hernia.
Preparation of endotracheal intubation includes the following:
Selection of the laryngoscopy blade
# 1 is used for term infants (>37 weeks but <40 weeks)
# 0 is used for preterm infants (<37 weeks)
# 00 is used for extremely preterm infants
Straight rather than curved blades are preferred
Selection of the size of the endotracheal tube
2.5mm ET - infant weight < 1,000 gram ( < 28 weeks)
3.0mm ET – infant weight 1,000-2,000 grams (between 28-34 weeks)
3.5mm ET - infant weight 2,000-3,000 grams (between 34-38 weeks)
3.5-4.0mm ET - infant weight above 3,000 grams ( above 38 weeks)
Depth selection of the endotracheal tube is done by adding 6 to the weight of the infant in kg.
1 kg + 6 = 7 cm depth
2 kg + 6 = 8 cm depth
3 kg + 6 = 9 cm depth
4 kg + 6 = 10 cm depth
“tip to lip 1-2-3 7-8-9”
For a one kg infant the ET tube is inserted to 7 cm mark on the tube For a two kg infant the ET tube is inserted to 8 cm mark on the tube. For a three kg infant the ET tube is inserted to the 9 cm mark on the tube.
Or you can simply use the guide line on the ETT
The steps in intubation are as follows:
Position and oxygenate the infant for intubation by:
Stabilizing the head in the sniffing position Provide free flow oxygen during intubation Lifting the laryngoscope handle rather than rocking Look for landmarks. The ET tube is inserted into the glottis between the vocal cords. Insert the tube into the right side of the mouth with the curve of the tube lying on the horizontal plane so the tube curves from left to right. Withdraw the laryngoscope blade if the esophagus is visualized. Allow only 30 seconds to complete endotracheal intubation and if unsuccessful in 30 seconds discontinue efforts and oxygenate the infant with positive pressure ventilations.
The following indications confirm endotracheal tube placement in the trachea and not the esophagus:
Improved vital signs ( HR, color/oximeter, and activity) Vapor in the tube when the stylett is withdrawn No epigastric gurgling with bag/mask ventilation Bilateral breath sounds with bag/mask ventilation CO2 detector indicates the presence of CO2 Direct visualization Chest x-ray if the tube will be left in place Only trained personal should attempt endotracheal intubation
The laryngeal mask airway is now considered an acceptable means of intubating an infant. Laryngeal mask airways can be helpful when an infant presents with the following situations:
Congenital anomalies involving the mouth, lip or palate, that make achieving a good seal with bag and mask is difficult.
Anomalies of the mouth, tongue, pharynx, or neck that make it difficult to visualize the larynx with a laryngoscope.
When PPV fails to achieve effective ventilations and ET tube intubation is not possible.
Lesson V Review Questions:
1. A newborn with meconium and depressed respirations ___________(will / will not) require suctioning via an endotracheal tube before other resuscitation measures are started.
2. A newborn receiving ventilations by mask is not improving after 2 minutes using good technique. Despite ventilation corrective steps, the heart rate is not rising and there is poor chest movement. Endotracheal intubation ____________(should / should not) be considered.
3. For babies weighing less than 1,000 grams the inside of the diameter of the endotracheal tube should be_________(2.0 / 2.5)
4. The preferred blade size for use in term newborns is No. ________(0 / 1). The preferred blade size for use in preterm newborns is No.__________(0 / 1) and for extremely newborns is No. ________(00 / 000).
5. When viewing the oral cavity prior to intubation you must be able to visualize the __________ ( glottis / esophagus ) and the vocal cords.
6. Both right – and left-handed people should hold the laryngoscope in the _________(left / right) hand.
7. You should try to take no longer than _______(20 / 30 ) seconds to complete endotracheal intubation.
8. If you have not completed endotracheal intubation within the time limit, you should ____________(not remove the laryngoscope, and try again / remove the laryngoscope, ventilate with PPV and try again)
9. The correct way to lift the laryngoscope to expose the pharyngeal area is_______________(lift in the direction of the handle / rock the handle for better visualization)
10. You have the glottis in view, but the vocal cords are closed. You ___________(should / should not) wait until they are open to insert the tube.
11. What 2 guidelines are helpful for determining the depth that the endotracheal tube be insert into the baby’s trachea? ___________(to level of the vocal cord guide / cm based on baby’s kg)
12. You have inserted an endotracheal tube and are giving PPV through it. When you check with a stethoscope and you hear bilateral breath sounds on both sides of the baby’s chest, with equal intensity on each side and no air entering the stomach. The tube is _________(likely / not likely) correctly placed.
13. X-ray tube place will show the ET tip to be in the trachea midway between the vocal cords and the carina. On the x-ray, the tip should be visible at the level of the_______(clavicles/ aorta), or slightly lower.
14. You have inserted an endotracheal tube and giving PPV through it. When you check with yourstethoscope you hear no breath sounds on either side of the chest and you hear air entering the stomach . The tube is placed the__________ (esophagus / trachea).
15. You have inserted an endotracheal tube and giving PPV through it. When you check with yourstethoscope you hear breath sounds over the right side, but not the left. When you check the tip-to-lip measurement, the first number seen at the lip is higher than expected, You should_________(withdraw / insert) the tube slightly and listen with the stethoscope again.
16. A baby is born at term following abruption of the placenta and is not improving despite PPV bymask. You have tried intubating the trachea but have not been successful Help has not arrived. A reasonable next step would be to insert a ________(LMA/ UVC)
17. An extremely low birth weight baby is born and require sassisted ventilation. Insertion of an LMA would be a reasonable alternative to intubation. (ture / false)
Lesson VI – Medications
The most significant and commonly used drug in neonatal resuscitation is epinephrine to increase heart rate and contractility and improves coronary artery pressure.
Fewer than 1% of infants will require Epinephrine
Epinephrine can be administered with the following routes: IV through an Umbilical Venous Catheter or the ETT (Endotracheal Tube)
The indication for epinephrine are is as follows:
Persistent heart rate less than 60 beats per minute despite 30 seconds of positive pressure ventilations followed by an additional 30 seconds of chest compressions.
The concentration of epinephrine is 1:10,000
The route of epinephrine is preferably UVC but can be given ET while preparing for UVC placement
The dose of epinephrine is as follows:
0.1 to 0.3 ml/kg for the IV route 0.2
0.5 to 1 ml/kg for the ET route
Epinephrine doses can be given every 3-5 minutes
For the test, you will need to calculate doses. The rate of administering epinephrine is rapidly.
The intravascular route is recommended as the best choice.
Allow 60 seconds before rechecking the HR.
Often infants will be born hypovolemic and will not respond to adequate ventilation and cardiac compressions. Babies who are hypovolemic may appear pale and have weak pulses. They may have a persistently low heart rate.
The signs of hypovolemia are as follows:
Pale skin color Weak pulse Persistently low pulse rate No improvement in circulation despite resuscitation effort.
Acceptable solutions for volume expansion are the following:
Normal Saline (0.9% NaCl) Ringer’s Lactate Type O Rh-negative packed red blood cells
The above volume expanders are given at 10 cc/kg of body weight.
The following are examples of doses:
2.5 kg = 25 cc
3.0 kg = 30 cc
3.2 kg = 32 cc
3.8 kg = 38 cc
Volume expanders are given slowly – over 5-10 minutes The route should be UVC (insert the UVC in the large vessel and just far enough to get blood return.)
Lesson VI Review Questions:
1. Fewer than ______(1%) of babies requiring resuscitation will need epinephrine to stimulate their hearts.
2. As soon as you suspect that medications may be needed during a resuscitation, one member of the team should begin to insert a ___________(UVC) to deliver drugs.
3. Effective ventilation and coordinated chest compressions have been preformed for 45-60 seconds, the trachea has been intubated, and the baby’s heart rate is below 60 bmp. You should give________(epinephrine / volume expanders) while continuing chest compressions and ventilations.
4. What is the potential problem with administer epinephrine through the tube? Epinephrine ( is / is not) reliably absorbed in the lungs when given by the ET route.
5. You should follow in intravenous dose with a flush of __________( 30 ml / 3-5 ml ) normal saline to insure that most of the drug is delivered to the baby and not left in the catheter.
6. Epinephrine ___________(increases / decreases) the blood pressure and strength of cardiac contractions and____________ (increases/ decreases) the rate of cardiac contractions.
7. The recommended concentration of epinephrine for newborns is _________(1:10,000 / 1: 1000)
8. The recommended dose of epinephrine if given endotracheally is _________(0.1 / 0.5) ml/kg of a 1, 10,000 solution.
9. Epinephrine should be given __________(as quickly as possible / slowly over 5 -10 minutes)
10. What should you do approximately 1 minute after giving epinephrine?__________(check HR / give a repeat dose via another route).
11. If the heart rate is below 60 beats per minute, you can repeat the epinephrine every ___(1 – 2 min / 3- 5 min)
12. If the baby’s heart rate remains below 60 bpm after you have given epinephrine you should also make sure that ventilation is producing an adequate lung inflation and_______________ (chest compressions/ medications) are done correctly.
13. If the baby appears to be in shock, there is evidence of blood loss, and resuscitation is not resulting in improvement, you should consider giving ____(10 ml/kg) of a ___________(volume expander / glucose)
Lesson VII – Special Considerations
Special situations may occur that can complicate resuscitation. On going problems can also occur after initial resuscitation. They are:
Infant is not improving after endotracheal intubation may be an indications of malposition of the ET tube
Choanal atresia which is a nasal airway that did not form properly. It can be ruled out by placing a nasal airway or suction catheter through the nares
Infants with congenital diaphragmatic hernia have scaphoid abdomens because abdominal organs have herniated up and into the chest. These infants should not be resuscitated with PPV. Immediate intubation is needed and an orogastric tube in place to keep air out of the stomach which may be in the chest cavity.
Unequal breath sounds may be an indication of a pneumothorax and can be detected with transillumination of the chest and treated with needle decompression is required.
The infant placed with the affected side superior prior for needle decompression.
Maternal narcotic administration prior to birth may cause the infant not to breath. You should immediately provide PPV to maintain a heart rate >100 bpm and then consider administration of naloxone (narcan) to the infant. (not the mother!!) Other drugs given to the mother prior to delivery can depress respirations such as magnesium sulfate.
Drugs that may have been given through the epidural route may also cause depressed resipirations
A baby who required resuscitation still has low blood pressure and poor perfusion after having been given a blood transfusion for suspected perinatal blood loss. He may require an infusion of dopamine to improve his cardiac output and vascular tone.
Pulmonary Hypoplasia is poorly developed lungs and high inflation pressures will be required to provide adequate ventilation. Severe pulmonary hypoplasia usually is incompatible with survival.
Babies with Robin Syndrome and airway obstruction may be helped by placing a naso-pharyngeal tube and positioning them on their abdomen or prone. This will help prevent the tongue from occluding the airway. Endotracheal intubation of such babies is difficult.
Pulmonary Hypertension can occur when hypoxemia causes pulmonary constriction.
Hypoglycemia may occur because energy stores are consumed faster in the absence of oxygen blood glucose levels may drop below normal. Blood glucose levels should be at Least 45 at birth
Hypothermia may be injurious to the baby. An infant that has required resuscitation will need close monitoring and management of oxygenation, blood pressure, fluid status, respiratory effort, blood glucose, nutritional issues, and temperature.
If meconium-stained infant has been resuscitated and then develops acute deterioration, a pneumothorax should be suspected. The risk is increased with PPV.
Infants who have been resuscitated may have kidney damage and are likely to need less fluids after resuscitation.
Three causes of seizures following resuscitation are: Hypoxia Encephalopathy due to metabolic disturbances like hypoglycemia Electrolyte abnormality such as hyponatremia or hypocalcemia.
If a 10 day old infant with mechanical ventilation support develops bradycardia and severe desaturation, you should assess and establish adequate ventilation.
Therapeutic hypothermia following perinatal asphyxia should be
Used only for babies >36 weeks’ gestation. Initiated within 6 hours of birth Used only in centers with specialized programs An infant who has been resuscitated and now has brain damage
Lesson VII Review Questions.
1. Choanal atresia can be ruled out by what procedure? _________________(inserting a nasopharyngeal airway / beginning PPV)
2. Babies with Robin Syndrome and airway obstruction may be helped by placing a ___________(naso-pharyngeal tube / an ETT ) and positioning them__________(on their (abdomen/ back).
3. A pneumothorax or a congenital diaphragmatic hernis should be considered if breath sounds are_____(equal / unequal) on 2 sides of the chest.
4. You should suspect a congenital diaphragmatic hernia if the abdomen is ________(scaphoid / protruding).Such babies (should / should not) be resuscitated with PPV.
5. Persistent bradycardia and low Spo2 during neonatal resuscitation most likely are caused by_________(adequate / inadequate) ventilation
6. Babies who do not have spontaneous respirations and whose mothers have been given a narcotic drug should receive PPV and then if spontaneous respirations do not begin, may be given __________(epinephrine / noloxone) to confirm the cause of their respiratory depression.
7. After a resuscitation of a term or new term newborn, vascular resistance in the pulmonary circuit is likely to be __________(low / high). Adequate oxygenation is likely to cause the pulmonary blood flow ______(decrease / increase).
8. If a meconium stained baby has been resuscitated and then develops acute respiratory depression a ____________(pneumothorax / diaphragmatic hernia) should be suspected.
9. A baby who required resuscitation still has low blood pressure and poor perfusion after having been given a blood transfusion for suspected perinatal blood loss. He may require an infusion of__________(dopamine / glucose) to improve his cardiac output and vascular tone.
10. Babies who have been resuscitated may have kidney damage and are likely to need __________(more /less) fluids after resuscitation.
11. Because energy stores are consumed faster in the absence of oxygen, blood ___________(magnesium / glucose) levels may be low following resuscitation
12. A baby with a seizure 10 hours after being resuscitated and with a normal blood glucose and serum electrolyte. What class of drug should be used to treat her seizures?_____________(an anticonvulsant such as Phenobarbital / magnesium)
13. You will likely to have __________(more / less) difficulty controlling body temperature of babies requiring resuscitation beyond the immediate newborn period, since they usually will not be wet.
14. The priority of resuscitating babies beyond the immediate newborn period should be _______________(early intubation / establish effective ventilation)
15. If vacuum suction is not available to clear the airway,2 alternative methods are_______(bulb suction / mouth to mouth) and wiping the airway with a clean cloth.
16. If a 15-day old baby requiring resuscitation had blood loss, vascular access route includes___________(peripheral / UVC ) and IO
17, A baby was delivered at term by emergency C-section for persistent fetal bradycardia lasting 30 minutes. He required chest compression and now is profoundly obtunded, with absent deep tendon reflexes. What procedure may decrease the subsequent severity of hypoxic-ischemic encephalopathy, if instituted before 6 hours following birth?_____________( Dopamine therapy / Theraputic hypothermia.
Lesson VIII Resuscitation of Babies Born Premature
Preterm infants are defined as infants born less than 37 weeks gestational age. When birth occurs before term, there are numerous additional challenges that the fetus must overcome to make this difficult transition.
The likelihood that the preterm baby will need your help becomes greater as the degree of prematurity increases.
The following are factors that place the preterm infant at additional risk for requiring resuscitation.
Loose heat easily. Tissues easily damaged from excess oxygen Weak muscles making adequate ventilation more difficult. Lungs deficient in surfactant Immature immune system and vulnerable to infection. Fragile capillaries in the brain. Small blood volume. Additional personnel as well as additional equipment are needed in resuscitation of a preterm infant.
The following personnel are required for the resuscitation of preterm infants:
Additional personnel including someone with expertise in performing endotracheal intubation and placement of a UVC. Additional means of maintaining body temperature (polyethylene bags and a portable warming pads) Compressed air source An oxygen blender Pulse oximeter.
Premature infants are more vulnerable to hyperoxia and therefore, an oxygen blender and oximeter should be used to achieve an oxygen saturation of 85-95% range during and immediately following resuscitation.
Titrate the infant’s SPO2 to the preductile sats.
1 min = 60-65%
2 min = 65-70%
3 min = 70-75 %
4 min = 75-80%
5 min = 80-85%
10 min = 85-95%
When assisting ventilations for a preterm infant:
Follow the same criteria for initiating PPV as with term infants.
Consider using CPAP if the baby is breathing spontaneously with a heart rate >100 bmp but has labored respirations or a low oxygen saturation.
Remember CPAP can be given with a flow-inflating bag or a T-piece resuscitator. Use PPV if the infant is intubated and use the lowest inflation pressure necessary to achieve an adequate response. Consider giving prophylactic surfactant. Decrease the risk of brain injury by::handilng the infant gently Avoid the Trendelenburg position. The best position is table flat. Avoid high airway pressures when possible. Adjust ventilation gradually based on physical examination, oximeter, and blood gas. Avoid rapid intravenous fluid boluses and hypertonic solutions. IV fluids should be given slowly.
After resuscitation of a preterm infant.
Monitor blood sugar Monitor the infant for apnea, bradycardia, and/or oxygen desaturation. Monitor and control oxygenation and ventilation Consider delaying feeding or initiating feeds cautiously if perinatal compromise was significant. Have a high level of suspicion for infection.
Lesson VIII Review Questions
1. List five factors that increase the likelihood of needing resuscitation with preterm babies. ___________ ( Lose heat easily / gets overheated) ___________ ( Tissues easily damaged from excess oxygen / requires more oxygen) ___________ Weak muscles making it (easier / more difficult) to breath ____________ Lungs ( deficient/ saturated ) in surfactant ___________ ( Immature / stronger ) immune system ___________ ( larger / Fragile) capillaries in the brain ___________ ( Small / Larger for size ) blood volume
2. A baby is about to be born at 30 week gestation. What additional resources should you assemble? ______________(Additional personal / someone in the hospital on another floor) ______________(Additional means to control temp / cool down the room) ______________(Compress gas source / suction turned on at 100 mm Hg) ______________(Oxygen blender / self inflating mask) ______________(Oximeter / laryngoscope)
3. You have turned on the radiant warmer in anticipation of the birth of a 27 week’s gestation. What else might you consider to help you maintain this baby’s temperature? ____(Increase / Decrease) the temperature of the delivery room) ____( Activate a chemical heating pad / use an electric heating pad) ____(Prepare a plastic bag or wrap / keep baby dry and rub vigorously ) ____(Prepare a transport incubator / have someone carry the baby to NICU)
4. A baby is delivered at 30 weeks gestation. She requires PPV for an initial heart rate of 80 bmp despite tactile stimulation. She responds quickly with rising heart rate and spontaneous respirations. At 2 minutes of life she is breathing, has a heart rate of 140 bpm and is receiving and continuous CPAP with a flow-inflating bag and 50% oxygen. You have attached an oximeter and it now reading 85% and is increasing. You should _________________ (decrease / increase) the oxygen concentration.
5. CPAP may be given with a _______________(flow-inflating bag) _______________(T-piece resuscitator) _______________( a self-inflating bag)
6. To decreased the chance of brain hemorrhage, the best position is (table flat / Trendelenburg )
7. Intravenous fluids should be given __________(rapidly / slowly) to preterm infants.
8. List three precautions that should be taken when managing a preterm baby who has required resuscitation? ____________check blood ( glucose / sodium) ____________monitor for apnea and bradycardia / tachycardia) ____________consider (delaying feedings / start feedings immediately) ____________(increased / decreased) suspicion for infection)
Lesson IX Ethical Considerations
The ethical principles of neonatal resuscitation are no different from those of any other child or adult.
Ethical and current national legal principles no do mandate attempted resuscitation in all circumstances.
You may want to talk to the parents about the implication of delivery at early gestational age. “Dating” gestational age is accurate within 3-5 days if applied within the first trimester.
You may want to consult the morbidity and mortality statistics with web-based National Institute of Child Health & Human Development Outcomes.
Withdrawal of critical care interventions and further institution of comfort care are acceptable if there is an agreement by health care professionals and the parents.
The approach to decisions to resuscitate should be guided by the same principles used for adults and older children.
Consider that if further resuscitation effors would be futile, or would merely prolong dying, or would not offer sufficient benefit to justify the burdens imposed, you may want to withhold resuscitation
Parents are considered the decision makers for their own babies. To fulfill this roll responsibly, they must be given relevant and accurate information about the risk and benefits of each treatment option.
When gestation, birth weight, and/or congenital anomalies are associated with almost certain death or unacceptable high morbidity, resuscitation is not indicated although exceptions may be reasonable to comply with parents wishes.
In conditions associated with uncertain prognosis, where there is borderline survival and a high rate of morbidity and where the burden of the child is high. Parents desires regarding initiation of resuscitation should be supported.
When counseling parents about the birth of babies born at the extremes of prematurely advise them that decisions made about neonatal management before birth may need to be modified in the delivery room, depending on the condition of the baby at birth and the postnatal gestational age assessment. (Tell them that you will try to support their decision, but must wait until you examine the infant after birth to determine what you will do.)
Discontinuation of resuscitation efforts should be considered after 10 minutes of absent heart rate.
Factors to take into considerations are as follows:
Presumed etiology of the arrest The gestational age of the infant The presence or absence of complications The potential of therapeutic hypothermia The parents’ previous expressed feeling about acceptable risk and morbidity.
An infant about to be delivered is known to have major congenital malformations. The issues that you should cover with the parents are as follows:
Review the current obstetric plans and expectations. Explain who will be present and their respective roles. Explain the statistics and your assessment of the infant’s chances for survival and possible disability. Determine the parents wishes and expectations. Inform the parents that decisions may need to be modified after you examine the infant. If attempts to resuscitate the infant is unsuccessful you would explain the situation to the parents and ask if they would like to hold the infant.
Appropriate responses to parents that their baby just died after an unsuccessful resuscitation are: “I’m sorry your baby died. She is a beautiful baby.” “I’m sorry, we tried to resuscitate your baby but the resuscitation was unsuccessful and your baby died.”
The four principles of medical ethics that apply to parent as well neonates are the following:
Beneficence, is the act of benefiting others Nonmaleficence, is the act of avoiding harm Autonomy, is the act of respecting individuals right to make choices that affect life Justice refers to the act of treating others truthfully and fairly.
Lesson IX Review Questions
1. Name the four common principles of medical ethics: __________(autonomy / anatomy) __________(beneficence / beneficiary) __________(nonmaleficence / noncompliance) __________(justice / justest)
2. Generally, the parents are considered to be the best “surrogate” decision makers for their own newborn? _______(True / False)
3. The parents of a baby about to be born at 23 weeks’ gestation have requested that, if there is any possible brain damage, they do not want any attempt made to resuscitate their baby. What should your reply be? (Tell them you will try to support their decision, but must wait until you examine the baby after birth to determine what you will do./ Tell the parents you will honor their wishes no matter what)
4. You have been asked to be present of an impending birth of a baby known from prenatal ultrasound and laboratory assessments to have major congenital malformations. List four issues that should be covered when you meet the parents. Check all that apply:
_____Review the current obstetric plans and expectations. _____ Explain who will be present and their respective roles. _____ Explain the statistics and your assessment of the infant’s chances for survival and possible disability. _____ Determine the parents’ wishes and expectations. _____ Inform the parents that decisions may need to be modified after you examine the infant.
5. A mother enters the delivery suite in active labor at 34 weeks’ gestation after having no prenatal care. She proceeds to deliver a live-born baby with major malformations that appear to be consistent with trisome 18 syndrome. An attempt to resuscitate the baby in the adjacent room is unsuccessful. The following action is the most appropriate. _____Explain the situation to the parents and ask them if they would like to hold the baby. _____Explain the situration and tell the parents they are not allowed to hold the baby and the baby.
6. The following two replies are appropriate to say to parents that have newborns that have just died after unsuccessful resuscitation. ___”I’m sorry, we tried to resuscitate your baby, but the resuscitation was unsuccessful and your baby died” ___“I’m sorry your baby died. But it’s for the best.”
Please see the scenarios at the very bottom of this page.I have worked very hard making up these scenarios and mixing pieces of one and combining with others to create new scenarios. Feel free to copy, print, practice these and re-write them to meet your specific educational goals.
Please read the title of each carefully. NPR Scenario 1 has 2 pages and each are individual files.
If you are in the process of obtaining your NRP Certification or are planning to renew, I strongly suggest that you purchase or borrow a baby doll and walk through the steps of these scenarios with actual hands on practice using blankets or towels and performing these steps as best you can with simulated equipment.