NRP 8th Edition, Ch 1-4

According to the NRP algorithm, what are the indicators for PPV? _cyanosis -apnea -tachycardia -gasping -heart rate less than 100 bpm

According to the NRP algorithm, what are the indicators for PPV? _cyanosis -apnea -tachycardia -gasping -heart rate less than 100 bpm

When to d/c PPV?

As HR increases over 100 bpm and baby begins to breathe, slow rate of PPV and gently stimulate the baby. When baby is breathing well enough to sustain HR over 100 bpm, discontinue PPV -Continue to monitor heart rate and O2 sat with pulse ox.

What should be done with baby after completing the initial steps? What should heart rate be?

Assess breathing. If baby is breathing, assess and monitor heart rate. It should be at least 100 bpm.

How many people should be present to manage the baby if risk factors are present.

At least 2.

Where and how should you auscultate the NB heart rate?

Auscultate with stethescope along let side of chest. Estimate the heart rate by counting the number of beats in 6 seconds and add 0. Heart rate should be at least 100, if less. start PPV. Can also connect a pulse ox or a cardiac monitor.

Ventilation rate

# of assisted BPM

What should PPV oxygen be started at?

-21% oxygen for over 35 weeks -21-30% oxygen for less than 35 weeks

You are performing the Mr. SOPA ventilation correction steps on a term baby. You have adjusted the mask and repositioned the head. You have suctioned the mouth and nose and opened the mouth. There is still no chest movement. What is the next step? -Increase PEEP from 5 to 10 -Increase pressure in 5 to 10 increments up to 40 -Increase pressure in 5 to 10 increments up to 50 -Increase pressure in 5 to 10 increments up to 30

-Increase pressure in 5 to 10 increments up to 40

What are the 5 initial steps if baby "fails" rapid evaluation? (Term, Tone, Breathing?)

-Move baby to radiant warmer for initial steps. 1. Place baby uncovered under warmer so radiant heat can reach baby 2. Dry baby (if greater than 32 weeks GA and remove wet linen 3-Gently rub the baby's back, trunk, or extremities if baby is still not breathing. 4. Position baby's head and neck in sniffing position to facilitate breathing. (towel can be placed under shoulders to assist position) 5. suction mouth, then nose, in anticipation of PPV.

What are indications for inserting a laryngeal mask? (SATA) -NB has congenital anomalies involving mouth, lip, tongue, palate or neck -a self inflating bag is not available -you cannot intubate -NB has large tongue -you cannot ventilate -NP has small mandible

-NB has congenital anomalies involving mouth, lip, tongue, palate or neck -you cannot intubate -NB has large tongue -you cannot ventilate -NP has small mandible

What are the four prebirth questions to ask to determine appropriate team and equipment?

-What is the expected gestational age? -Is the amniotic fluid clear -Are there any additional risk factors? -What is our umbilical cord management plan?

How to administer supplemental O2?

-adjust flowmeter to 10L/min -set Oxygen blender to 30% -Administer free-flow O2 -Monitor baby's o2 sat -adjust concentration as needed to maintain O2 sat w/in target range

What should you do prior to cardiac compressions or medications?

-baby should have received 30 seconds of PPV that moves the chest, preferably thru alt airway (use pulse ox)

What to do about cord clamping if baby is not vigorous at birth?

-may be reasonable to delay cord clamping while provider clears airway with bulb syringe and gently stimulates baby to breathe. If baby does not breathe at this point, cord should be clamped and cut and baby brought to radiant warmer.

What are the laryngeal mask supplies? Where should it be located?

-size 1 laryngeal mask -CO2 detector -8F feeding tube and syringe for use as an orogastric tube -5 ml syringe - if needed for mask inflation.

When should you consider using a cardiac monitor? -when an alt airway is required, a cardiac monitor is recommended. -Pulse ox does not work -PPV is required -baby arrives at radiant warmer for initial steps of resuscitation -heart rate is difficult to auscultate -baby is not vigorous

-when an alt airway is required, a cardiac monitor is recommended. -Pulse ox does not work -PPV is required -heart rate is difficult to auscultate -baby is not vigorous

Care for baby if Term, Tone, Breathing is "yes"

1) a)place baby skin-to-skin with mother, dry the baby, b) then cover with warm dry blanket and c) position the head and neck to facilitate breathing. 2) Clear secretions with bulb syringe only if secretions are obstructing baby's breathing or if the baby is having difficulty clearing secretions; 3)-monitor breathing, tone, activity, color, and temperature of baby to determine if additional interventions are needed.

What if you are alone with baby who needs PPV?

1. Start PPV and mobilize additional help. Ask 2 people to help you by a. auscultate heart rate and attach pulse oximeter to right hand or wrist b. document vital signs and interventions about every 30-60 seconds. Include Respiratory effort, heart rate, O2 sat, O2 concentration in use, and chest movement with PPV

According to the NRP Quick Equipment Checklist, how should the flowmeter be set to prepare for ventilation? -5 L/min -10 L/min 15 L/min 18 L/min

10 L/min

What should the flowmeter be set at?

10L/min

What should size of suction catheter and setting?

10f or 12f suction catheter attached to wall suction, set at 80-100 mm Hg

What should oxygen blender be set at?

21% (21-30% if less than 35 weeks GA)

What is required skillset for a resuscitation team?

4 or more qualified providers skilled with ET, chest compressions, emergency vascular access, and medication administration.

How often are breaths given?

40-60 BPM (Waltzing rhythm: "breath - 2 - 3". See gentle rise and fall of breath.

What are oxygen saturation goals at 10 minutes?

85-95%

What if heart rate is increasing after first 15 seconds.

Carry on with ventilations for another 15 seconds, then listen again.

How do you know when a newborn needs supplemental O2?

Compare baby's O2 saturation with target values in the O2 sat table. If reading is below target range, supplemental o2 is appropriate for breathing baby whose heart rate is at least 100 bpm

What is "inspiratory" or "I" time

Durations in second of the inspiratory phase of each breath.

What if severe bradycardia persists (under 60)

ETT or laryngeal mask, chest compressions.

How many people should be present at a birth to manage the baby if there is no risk factors?

Every birth should be attended by at least one qualified individual skilled in the initial steps of newborn care and PPV whose only responsibility is management of the baby.

According to the NRP algorithm, what are the indicators for PPV? -heart rate less than 100 bpm -cyanosis -tachycardia -apnea -gasping

Heart rate less than 100 bpm apnea gasping

PPV terminology: Peak Inspiratory Pressure (PIP)

Highest pressure delivered with each breath

How to administer free-flow o2?

Hold mask or tubing close to (but not on) nose.

When might an OG tube be placed?

If CPAP or PPV has been used longer than several minutes. Leave uncapped to act as a vent for the stomach

How to measure for OG tube?

Measure from bridge of the nose to earlobe; from earlobe to point 1/2way b/n xyphoid process and umbilicus. (during ventilation) Note cm mark at that place. Insert tube, then use syringe to remove some gastric content. Remove syringe.

What skills must be present to comprise a qualified team that must be immediately available for every resuscitation?

Persons skilled in endotracheal intubation, chest compressions, emergency vascular access, and medication administration. (probably requires 4 or more qualified persons)

How to position PPV mask on baby?

Place baby in "sniffing" position;small towel under shoulders may be helpful. Cup chin in mask; bring mask up and over mouth and nose (covering both but not eyes). Circle rim with thumb and index finger. Other fingers are under bony angle of the jaw. Lift the jaw up towards mask. Don't rest hand on baby's eye or compress neck.

PPV terminology: Positive End Expiratory Pressure (PEEP)

Pressure maintained in the lungs between breaths when baby receiving assisted ventilation.

Newborn resuscitation is usually the result of _____________.

Respiratory failure.

You are providing face mask PPV to a newborn who was bradycardic at birth. The heart rate has increased to more than 100 bpm and the baby is beginning to breathe spontaneously. What is your next action? -Slow the rate of PPV and stimulate the baby -D/C PPV immediately -Increase the ventilation rate and pressure -Continue PPV for 3 minutes

Slow the rate of PPV and stimulate the baby

If a baby is apneic, gasping or has a heart rate of less than 100 bpm after the initial steps of resuscitation________ immediately.

Start PPV

What if...baby is breathing, but is bradycardic (heart rate less than 100 bpm)

Start PPV immediately. Also if baby apneic, gasping, or bradycardic.

What are the three rapid evaluation questions that determine if the baby can stay with the mother or should be moved to the radiant warmer?

Term: Does the baby appear to be term? Tone: Does the baby have good muscle tone? Breathing: Is the baby breathing or crying?

What is the single most important and most effective step in neonatal resuscitation?

ventilation of lungs

When should PPV be d/c?

when baby's heart rate is more than 100 bpm and baby has sustained spontaneous respirations

Heart rate still under 60 bpm?

epinephrine q 3-5 minutes. Consider hypovolemia or pneumothorax

How long should cord clamping be delayed in vigorous babies?

30-60 seconds

What is a reasonable Oxygen concentration with which to begin free flow oxygen? -60% -30% -40% -20%

30%

What is a reasonable supplemental oxygen level?

30%; can adjust upward.

How long should cord clamping be delayed in healthy baby?

30-60 seconds

What are the first 2 steps of MR. SOPA ventilation corrective steps that often solve the problem? -Mask adjustment and reposition head -Monitor and reassess the heart rate -suction mouth and reassess heart rate -chest movement and repeat stimulation

-Mask adjustment and reposition head

What are five initial steps of newborn care?

-Provide warmth -dry the baby (if greater than 32 weeks GA) and remove wet linen -Stimulate by gently rubbing baby's back and extremities -Position head and neck to open the airway (sniffing position) -clear secretions from airway if needed.

What is looked at in determining if baby can stay with Mum?

-Term gestation? -Good tone? -breathing or crying? Determine within 1 minute.

What are indications for the use of pulse ox? -all babies should have pulse ox applied. -When delayed cord clamping is in progress -To guide O2 concentration -To assess the need for supplemental oxygen -To confirm your perception of central cyanosis -When PPV is required

-To guide O2 concentration -To assess the need for supplemental oxygen -To confirm your perception of central cyanosis -When PPV is required

When the baby stays with the mother for initial steps after birth, what should be monitored to determine if additional interventions are required? -breathing -blood pressure -temperature -tone and activity -color

-breathing -temperature -tone and activity -color

What if baby is not vigorous at birth (re: cord clamp)

-brief delay in cord clamping while provider clears the airway with the bulb syringe and gently stimulates baby to breath. If baby doesn't breathe after suction and brief stimulation, the cord should be cut and baby brought to radiant warmer.

What if heart rate is not increasing after 15 seconds?

-if chest is moving, continue PPV and check after 15 seconds. -if chest is NOT moving and heart rate is NOT increasing, "MR SOPA" ventilation steps "immediately".

When should you use pulse ox? (4)

-when resuscitation is anticipated (apply after completing initial steps of care) -to confirm perception of central cyanosis persisting several minutes after birth and to assess need for supplement o2 -to guide o2 concentration when oxygen is administered -when PPV is required

What are the five blocks of the NRP algorithm?

1) Rapid evaluation: this evaluation determines if the baby can stay wit the mother for routine care or should be moved to the radiant warmer 2) Airway: The initial steps open the airway and support spontaneous respirations. 3) Breathing: Assist breathing with PPV if baby apneic, gasping, or bradycardic. CPAP or or O2 may be appropriate for labored breathing or low O2 sat. 4) circulation: Perform chest compressions coordinated with PPV if severe bradycardia exists despite assisted ventilation 5) drug: administer epinephrine if severe bradycardia persists despite PPV and coordinated chest compressions.

When performing PPV, you may not proceed to chest compressions or medications until the NB has received at least ______ seconds of PPV that moves the chest, preferably through an ET or laryngeal mask.

30 seconds

After completing the rapid evaluation, the next step is completion of the initial steps of newborn care, which include __________ and __________.

After completing the rapid evaluation, the next step is completion of the initial steps of newborn care, which include opening the airway and supporting spontaneous respiration.

How is a T piece used?

Breath is delivered by alternating b/n covering and releasing the covering on the cap; length of breath is how long finger is covering opening

What must be done prior to every birth?

Checklist that all essential supplies and equipment are at the radiant warmer for neonatal resuscitations.

CPAP (continuous positive airway pressure)

Gas pressure maintained in lungs b/n breath when baby breathing on its own. Keeps lungs slightly inflated so baby doesn't have to work as hard to reinflate lungs with each breath.

What if NB not breathing after moved to radiant warmer and 5 steps completed?

Immediately begin PPV (within first 60 seconds after birth).

What is the single most important and effective step in neonatal resuscitation?

Learning how to provide positive pressure ventilation.

What is a NRP quick equipment checklist?

List of all supplies and equipment for a complete resuscitation that must be readily available and functional for every birth.

What does MR SOPA stand for?

M--mask adjustment R--reposition head and neck Give 5 breaths and assess chest movement. If no chest movement... S--suction mouth and nose O--open mouth Give 5 breaths and assess chest movement, if no chest movement.... P--pressure increase (increments of 5 until 40 max (term) Assess chest movement after several seconds A--airway alternative (laryngeal)

Do you have to visualize the baby's vocal cords to insert a laryngeal mask?

No

Does self inflating bag require oxygen plug-in?

No

Is visual assessment of cyanosis a reliable indicator of O2 saturation?

No - healthy babies may have central cyanosis for several minutes after birth, and may take more than 10 minutes to achieve O2 sat greater than 90%. Use pulse ox to evaluate oxygen saturation.

Starting value suggestions for T piece PPV?

PEEP - 5 21% O2 (use pulse ox). 40-60 BPM. PIP: 20-25 cm H20 (first few for term may be as high as 40) After 15 seconds, do first heart check while ventilation continues and announce BPM.

What would it mean if baby receiving breaths at 25/5

PIP is 25 cm/ and PEEP is 5 cm

What if baby is apneic or gasping or heart rate under 100 bpm after stimulation, et al?

PPV, pulse oximetry, consider cardiac monitor.

What to do if you assess breathing and baby is apneic, gasping, or bradycardic (less than 100 bpm even if breathing)?

Start PPV immediately; to count heartbeat, count for 6 seconds, and add "0" to count.

What if every answer to the rapid evaluation at birth is yes? (Term? Tone? Breathing?)

Then baby can stay with mother; initial steps and care can take place with baby in mother's arms or on chest.

What if any answer to the rapid evaluation is no (Term? Tone? Breathing?)

Then the baby is moved to radiant warmer to perform initial steps.

What if baby fails rapid evaluation?

Warm, dry, stimulate, position airway, suction if needed.

When should you "consider" using a cardiac monitor?

When -PPV is required -baby is not vigorous and heart rate is difficult to auscultate -when pulse ox does not work -you are using alternative airway

What are the time goal of starting PPV in an infant who has heart rate less than 100, is gasping or apneic?

Within 1 minute of birth

How many qualified people should be at the birth if there is meconium stained fluid?

at least two qualified people to only manage the baby, including person with intubation skills, if this is the only risk factor.

What are alternative airways?

laryngeal mask (use size 1 for NB over 1500-2000g) and ET

During initial steps, if the baby is ______ weeks, do not dry the baby.

less than 32 weeks

Where to place the pulse ox?

on right wrist or hand (pre-ductal). Might take few minutes to get good read.

What is the most important indicator of successful PPV?

rising heart rate