NRP 9th edition

Three ways to decrease injury for preterm newborns?

Cluster interventions, use pulse oximeter and blood gases to monitor oxygen concentration, do not rapidly infuse IV fluids.

How should you handle a preterm newborn to decrease injury?

Handle infant gently (While this may seem obvious, this aspect of care may be forgotten when members of the resuscitation team are trying to perform many steps quickly. If possible, avoid multiple intubation attempts, frequent suctioning, and other painful, noisy, or irritating stimuli)

What position should you avoid for the legs of a preterm newborn?

Do not elevate legs higher than head (Trendelenburg)

What type of ventilation should be avoided to decrease injury in preterm newborns?

Avoid high pressure ventilation or CPAP, which can cause a pneumothorax or increased risk for brain hemorrhage

What factors cause rapid heat loss in the preterm newborn?

Thin skin, decreased subcutaneous fat, a large surface area relative to body mass, and a limited metabolic response.

What factors decreases the efficiency of spontaneous breathing efforts in the preterm newborn?

Weak chest muscles, poorly compliant (stiff) lungs, and flexible ribs

What makes preterm newborns at greater risk of injury from ventilation?

Immature lungs that lack surfactant are more difficult to inflate and tend to collapse during exhalation (losing functional residual capacity)

Immature tissues are more easily damaged by what?

oxygen for a preterm newborn

The immature immune system increases the preterm infant's risk of developing

severe infections such as pneumonia, sepsis, and meningitis.

At what gestational age should the newborn infant be placed in a polyethylene plastic bag (or wrap and a thermal mattress should be prepared)

Limited metabolic reserves and immature compensatory mechanisms increase what for the preterm infant?

The risk of hypoglycemia after birth.

What increases the risk of hypovolemia from blood loss for a preterm infant?

A smaller blood volume

You have turned on the radiant warmer in anticipation of the birth of a preterm infant at 27 weeks' gestation. List 4 additional steps that will help maintain this infant's temperature.

-Use a thermal mattress as an additional heat source

-Wrap the newborn infant in a polyethylene plastic bag or wrap

-place a hat on infant's head

-Monitor the newborn infant's temperature frequently because overheating has been described while using a combination of warming methods.

What are the four pre-birth questions?

1. expected gest. age?

2. amniotic fluid clear?

3. Risk factors?

4. Cord management plan?

Every birth should be attended by how many qualified individuals?

1 qualified individual when the risk for resuscitation is low

Who should be identified and immediately available every resuscitation?

A qualified team with full resuscitation skills, including endotracheal intubation, chest compressions, emergency vascular access, and medication administration.

Epinephrine is indicated when the heart rate remains less than 60 beats per minute after which two things are done?

a. At least 30 seconds of ventilation that inflates the lungs as evidenced by chest movement

AND

b. Another 60 seconds of chest compressions coordinated with ventilation using 100% oxygen.

Concentration of epinephrine for NRP

0.1 mg/mL =1 mg/10 mL

Route of epinephrine for NRP

Intravenous (preferred) or intraosseous

PIP

peak inflation pressure is the highest pressure delivered with each breath, should start at 25 cm H2O

PEEP

Positive end expiratory pressure is the pressure maintained in the lungs between breaths 5 cm H2O

Dose of epinephrine

Intravenous or intraosseous = 0.02 mg/kg (equal to 0.2 mL/kg), may repeat q3-5 mins with 3-mL saline flush after

Endotracheal dose of epi

0.1 mg/kg (equal to 1 mL/kg)

Acceptable range: 0.05 to 0.1 mg/kg (0.5 to 1 mL/kg) - if no response recommended using IV or IO

Volume expansion recommendations

Solution: Normal saline (NS) or type O Rh-negative blood

Dose: 10 mL/kg

use a labeled 30- to 60-mL syringe and push over 5-10 minutes

A reasonable time frame for considering cessation of resuscitation efforts is?

20 minutes or individualized on pt context and factors.

How many newborns need chest compressions after inflating the lungs and chest compressions?

approximately 1 per 1,000 newborns

What does epinephrine do?

-it's a cardiac and vascular stimulant.

-constricts the blood vessels outside of the heart, which increases blood flow into the coronary arteries. Blood flow carries the oxygen required to restore cardiac function

-increases the rate and strength of cardiac contractions.

Questions to ask if

1. Is the chest moving with each breath?

2. Is the airway secured with an endotracheal tube or a laryngeal mask?

3. Are 3 compressions coordinated with 1 ventilation being administered every 2 seconds?

4. Is the depth of compressions one-third of the anterior-posterior diameter of the chest?

5. Is 100% oxygen being administered through the ventilation device?

6. Was the correct dose of epinephrine administered intravenously or intraosseously?

7. Is the umbilical vein catheter or intraosseous needle in place or has it been dislodged?

8. Is a pneumothorax or pericardial effusion present?

Antepartum risk factors for greater need for resus

Gestational age less than 36 0/7 weeks

Gestational age greater than or equal to 41 0/7 weeks

Preeclampsia or eclampsia

Maternal hypertension

Multiple gestation

Fetal anemia

Polyhydramnios

Oligohydramnios

Fetal hydrops

Fetal macrosomia

Fetal growth restriction

Significant fetal malformations or anomalies

No prenatal care

Intrapartum risk factors for greater need for resus

Emergency cesarean delivery

Forceps or vacuum-assisted delivery

Breech or other abnormal presentation

Category II or III fetal heart rate pattern

General anesthesia

Maternal magnesium therapy

Placental abruption

Intrapartum bleeding

Chorioamnionitis

Opioids administered within 4 hours of delivery

Shoulder dystocia

Meconium-stained amniotic fluid

Prolapsed umbilical cord

If risk factors are present , how many qualified individuals should be present solely to manage the newborn infant?

2

What size laryngoscope with straight blades for preterm?

0

What size laryngoscope with straight blades for term?

1

Umbilical cord management should not delay appropriate initiation of assisted ventilation for newborn infants who remain ___________________ and ________________ by 60 seconds after birth.

apneic or heart rate

For most newborn infants who do not require immediate resuscitation, clamping the umbilical cord should be deferred for at least how many seconds?

60

initial questions NRP

term? tone? breathing/crying?

initial steps NRP

warmth, drying, position to open airway

If there is ineffective breathing effort or apnea right after birth, what may help to stimulate breathing?

gentle tactile stimulation may stimulate breathing

At 1 minute of life, when would infant need assisted ventilation?

not breathing, gasping, or the heart rate

Pulse oximetry

-O2 is carried by the hgb inside RBC's.

-Hgb carrying O2 absorbs red light differently from hbg that is not carrying O2.

-pulse oximeter uses a light source and sensor to measure the absorption of red light passing through capillaries in the skin and estimates the percentage of hemoglobin that is carrying oxygen.

When to use pulse oximetry

• When resuscitation is anticipated

• To confirm your perception of persistent cyanosis

• If supplemental oxygen is given

• When assisted ventilation is required