NEONATAL RESUSCITATION

INTRODUCTION
Spontaneous breathing after birth is not a problem for most babies. However,
one in twenty babies might require help with breathing at birth. It is not always
possible to know in advance which babies will need this help since half of them (who
require resuscitation) have no identifiable risk factors before birth. Hence resuscitation
must be anticipated at each birth.

KEY TO SUCCESSFUL RESUSCITATION

All health professionals who attend the mother at birth must be skilled at
resuscitation and know how to recognize babies at risk. They must:
 Anticipate
 Be prepared
 Know what to do
 In what order
 Be able to work quickly in coordination
GOALS OF RESUSCITATION
1. Minimizing immediate heat loss.
2. Establishing normal respiration and lung expansion.
3. Increasing arterial pO2
4. Supporting adequate cardiac output.

NEED FOR RESUSCITATION

Assess baby’s risk for requiring resuscitation

Always
Provide warmth
needed by
newborns Position, Clear airway, Dry, stimulate to breathe

Give supplemental oxygen, as necessary

Assist ventilation with positive pressure
Needed less
frequently Intubate the trachea

Provide chest
Compressions
Rarely
needed by Administer
newborns medications

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STEPS OF RESUSCITATION
TABC’s of resuscitation
T- Maintenance of temperature
 Provision of radiant heat source
 Drying the baby
 Removing wet linen.
A- Establishment of an open airway
 Suction the mouth, nose and in some instances the trachea (in meconium
stained liquor)
 If necessary insert the ET tube to ensure open airway.
B- Initiation of breathing
 Tactile stimulation to initiate respirations.
 Positive pressure ventilation, using either bag and mask or bag and ET tube
C- Maintenance of circulation
 Stimulate and maintain the blood circulation by chest compression and/or
medication.
RESUSCITATION ALGORITHM

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  Taking an Apgar score is not a prerequisite for resuscitation.
 The need for resuscitation must be recognized before the end of the first
minute of life which is when the first Apgar score is taken.
INITIAL STEPS
Provide warmth:
Placed under radiant warmer, Leave the baby uncovered under warmer, to
allow full visualization, to permit radiant heat to reach the baby
Position; clear airway as necessary:
 Secretions removed from airway with a towel/ bulb syringe/ suction catheter
 Copious secretions- turn face to side
 Gentle suction- Pressure < 100 mm Hg
 Mouth before Nose (M before N)
 Stimulation of posterior pharynx causes Vagal stimulation and bradycardia-
stop
Dry, stimulate and reposition
 Dry :Use pre-warmed absorbent towels or blankets
 Keep head in ‘sniffing’ position to maintain good airway
 Stimulation :Suction and drying sufficient stimulation
 If inadequate respiration then additional tactile stimulation given briefly by
 Slapping or flicking the soles of the feet
 Gently rubbing the back, trunk or extremities
 Overly vigorous stimulation harmful
 Reposition the baby.
USE OF BAG AND MASK
After 30 seconds of Initial steps if
 Baby is not breathing or is gasping
 Heart rate is less than 100 bpm and /or
 Is cyanotic despite supplemental oxygen.
Different Types of Resuscitation Devices
1. Flow inflating bags: Fills only when oxygen from a compressed source flows in
to it
2. Self inflating bags: Fills spontaneously after it is squeezed, pulling oxygen or
air in to the bag.
3. T-piece resuscitator: Also works when gas from compressed source flows into
it. The gas is directed into the baby by occluding the opening on T-piece.
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General Characteristics
 Size of bag – 240 to 750 ml
 Oxygen capacity -- capable of delivering 90-100% oxygen
 Safety features – capable of avoiding excessive pressures
 Size of mask – appropriate sized mask.

Inserting Orogastric Tube

 Needing PPV longer than several minutes
 Measure the length to be inserted
 Insert the tube through the mouth
 Gently aspirate stomach contents
 Leave the end of the tube open
 Tape the tube to the cheek of the baby
 Equipment Required:8 F feeding tube,20 - syringe
If the Baby Is Not Improving
 Is the chest movement adequate
- Is the face-mask seal tight
- Is the airway blocked: Improper position or Secretions
- Is he equipment working
- Is air in stomach interfering with chest expansion
Is adequate oxygen being used
- Is oxygen tube attached to ventilation device and to oxygen source
- Is gas flowing through the flow meter
- Self-inflating bag, is the oxygen reservoir attached
- If using cylinder (rather than wall oxygen), is there oxygen in the cylinder
NEXT STEP: CHEST COMPRESSION

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  When to begin chest compressions during resuscitation
 How to administer chest compressions
 How to coordinate chest compressions with PPV
 When to stop chest compressions
 Indication: Heart rate less than 60 bpm despite 30 sec of effective positive-
pressure ventilation
 Endotracheal intubation at this time may help to ensure adequate
ventilation and facilitate the coordination of ventilation and chest
compressions
Why perform Chest Compressions
 Myocardium is depressed because of poor oxygen levels - Low cardiac output
 Mechanical pumping of heart required to improve perfusion to the lungs
 Also referred to as External Cardiac Massage
 Rhythmic compressions of sternum that
 Compress the heart against the spine
 Increase the intrathoracic pressure
 Circulate blood to the vital organs.

Compression Release
How many people required:
 Chest compressions and PPV should be simultaneous
 Two people required
Thumb Technique
 Can’t be used effectively if infant is big and hands of operator small
 Less tiresome than two finger technique
 Better control over depth of compression
 Press only sternum
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  Pressure on ribs can cause fractures
Two Finger Technique
 More convenient if baby is large or hands of operator are small
 Better control over depth of compression
 Can’t be used by people with long finger nails

Common Things in Two Techniques

 Position of Baby
- Firm support for the back
- Neck slightly extended
 Compressions
- Same location, depth and rate
Location of Compression
 Heart lies between sternum and spine
 Pressure is applied on lower third of sternum
 Avoid Xyphoid
Position of Thumbs or Fingers
 Essential to
- Locate the position of Xyphoid
- Intermammary Line
 Go along the costal margin identify the Xyphoid and just above this point
 Place your thumbs for fingers immediately above Xyphoid
 Avoid putting direct pressure on Xyphoid
Positioning during Two Finger Technique
 Two fingers (tips of index & middle fingers)
 Position perpendicular to the chest
 Support the back from hand
 Be cautious of putting pressure of whole of your hand on chest

How much pressure needed?

 Approximately 1/3rd of anteroposterior diameter of the chest
 One Compression
- Downward Stroke plus the Release
Dangers associated with Chest Compressions: Trauma
- Liver - Laceration

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 - Ribs - Fracture
Frequency
 Coordinate with IPPR
 One ventilation interposed after every third compression
 Total of 120 events
- 30 breaths
- 90 compressions

C
C C
C C
C B
B
When to Stop Chest Compressions:

 After approx. 30 sec of CC & PPV

- Count Heart Rate
- If > 60 - Stop Chest compressions
 Continue PPV at 40 - 60 bpm Till
- Baby breathing spontaneously
- Heart rate >100 and
- Baby pink
NEXT STEP: ENOTRACHEAL INTUBATION
 If after 30 seconds of effective PPV with supplemental oxygen the baby is not
improving: Evaluate
 Not breathing: Perform ET intubation and continue PPV
 Breathing but HR < 100 continue PPV
 Breathing, HR > 100, central cyanosis + continue PPV
 Heart rate < 60 Initiate Chest compressions
Indication of ET tube insertion
 Prolonged PPV required
 Bag & mask ineffective: Inadequate chest expansion
 If chest compressions required: Intubation may facilitate coordination and
efficiency of ventilation

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  Tracheal suction required : e.g. MSAF
 Diaphragmatic Hernia
 Use of Drugs through ET tube
Prerequisites for Intubation
 Pre oxygenate before intubation PPV with 100% oxygen
 Deliver Free Flow oxygen during intubation
 Not more than 20 sec per attempt : Not more than 3 attempts
 Ventilate with Bag and mask with 100% oxygen in between attempts
Insertion of ET tube
 Insert ET tube holding in the right hand
 Introduce through the right angle of the mouth
 Keep glottis in view
 Insert when vocal cords are apart
 Do not push through vocal cords
 If cords are together wait, if do not open within 20 sec stop and ventilate with
Bag & mask
Signs of ET Tube in Esophagus
 Poor response to intubation (cyanosis, bradycardia etc
 CO2 detector fails to show presence of Expired CO2
 No audible breath sounds
 Air heard entering stomach
 Gastric distension may be seen
 No Mist in tube
 Poor chest movements
NEXT STEP: MEDICATIONS
When to use medications
 Despite Administration of effective chest compressions and effective positive-
pressure ventilation with 100% oxygen:
 Heart Rate is below 60 bpm
HR < 60/min
 Recheck effectiveness of
- Ventilation
- Chest compression
- Endotracheal intubation
Epinephrine hydrochloride
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  Cardiac stimulant
- Increases strength & rate of cardiac contractions
- Causes peripheral vasoconstriction
 It is indicated when HR remains < 60 after 30 sec of effective PPV and another
30 sec of coordinated chest compressions and ventilation
How to prepare and give Epinephrine
 Available concentration 1:1000
 Dilute it 10 times to make it 1:10,000
- 1ml of 1:1000 with 9 ml of water for injection
 Dose: 0.1 – 0.3 ml/kg of 1:10,000
 Preferred Route: Intravenously
- Followed by flush of Normal saline: 0.5 – 1.0 ml
 While IV access is being obtained may give endotracheally
Rate of administration
 Rapidly – As quickly as possible
How to give Epinephrine Endotracheally
 Dose: 0.3 – 1.0 ml/kg of 1:10,000 solution
 Do not give high doses intravenously
 After giving endotracheal dose give several positive-pressure breaths

CARE OF BABY UNDERGOING PHOTOTHERAPY

INTRODUCTION
Phototherapy has been in use since 1958 and has stood the test of time.
Phototherapy was introduced by Cremer in the year 1958. It is now widely used
modality for treatment of neonatal indirect Hyperbilirubinemia as it is effective and
relatively safe. Despite the use of phototherapy for over 40 years now, there are still
many simple issues, which the treating physician should know.
DEFINITION
Phototherapy is a non-invasive, inexpensive and easy method used for
treatment of unconjugated Hyperbilirubinemia and has considerably the need for
exchange transfusion.

Caring for a baby being exposed to light source for prescribed of time.

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INDICATION
 Indicated in babies with indirect Hyperbilirubinemia which is more than
accepted for its maturity, postnatal age and weight, still less than the level at
which an exchange transfusion would be performed.
 It is recommended when serum bilirubin due to any cause approaches 10-12
mg/dl in preterm babies and 12-15 mg/dl in term babies.
 Prophylactic phototherapy is recommended in very low birth weight babies
with perinatal risk.
 In case of hemolysis, start phototherapy at lower level.
 Acidosis, asphyxia, hypoglycemia or sepsis makes the blood brain barrier less
efficient and more susceptible to BIND. So, consider early phototherapy.
 In case of prolonged jaundice (>3 wk), one should always check fractional
bilirubin estimation. Phototherapy is contraindicated in the presence of
conjugated hyperbilirubinemia (≥ 2 mg/dL) because it may result in bronze
baby syndrome.
 Phototherapy should not be undertaken at centers where round the clock
facilities for serum bilirubin estimation and exchange blood transfusion are not
available.
EQUIPMENTS
 Overhead phototherapy light
 Isolette
 Eye shield
 Disposable diapers/ surgical mask (for smaller baby)
 Towel or disposable water proof pad
 Bilirubin leght meter
 Isolette temperature monitor
 Thermometer
 Documentation sheet for Intake and output.
PROCEDURE
STEPS RATIONALE
1) Gather the necessary supplies Promotes efficient time management
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2) Perform hand hygiene.
3) Set up the fluorescent over
lights following manufacturer
recommend- -dation as
close to the infants as possible
in an open bassinet about 44-
45 cm from the infant.
4) Turn the light unit on. Using
the light mater, verify that the
level of irradiance is
appropriate. Approximately
12-15 7 µw/cm2/nm fro low
intensity (single) or 30-35 7
µw/cm2/nm for high intensity
(double).
5) Perform hand hygiene.
6) Undress the infant, leaving a
diaper in place to cover the
genitals. Use a surgical mask
for a diaper if diaper covers
too much skin area of a small
infant.
7) Ensuring that the infant’s eye
lids are closed, carefully cover
the eyes completely with
protective shield. Remove eye
patches every 4 hours.
8) Place the infant in bassinet or
isolette. Ensure that the
position of the lights are
maintained about 45-46 cm.
9) Turn the infant every 2 hours
assessing skin integrity,
and provides an organized approach
to the procedure.
Reduces transmission of micro-
organisms.
Bilirubin absorbs light in the range of
400-500 nm. The distance of the light
source from the infant affects how
well the lights penetrates skin and is
absorbed by bilirubin (this effect is
most significant when special blue
tubes are used).
Intensity of lights may decrease over
time. Lights of intensity may be
ineffective or may require longer
length of exposure to the infants to
achieve the desired therapeutic
effect.
Reduces transmission of micro-
organism.
Undressing the infant increases the
amount of skin surface area exposed.
The diaper protects the gonads
against chromatic radiant damage
from the phototherapy light
exposure.
Eyes are closed to prevent corneal
excoriation eyes are covered by
protective eye shields to protect them
against retinal damage.
For the overhead lights to be safe and
effective, an exact distance from the
lights must be maintained throughout
the treatment.
Ongoing skin surveillance can detect
problems early and prevent
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 hydration, temperature and dehydration or damage to the infant’s
neurologic status. skin integrity.
10) Monitor the infant’s Verifies that the naked infant in an
temperature in an open open bassinet can maintain his or her
bassinet every 30 min for the temperature in a safe range and to
first hour and then every 2 detect alteration promptly.
hours as needed.
11) Remain vigilant in Excretion of bilirubin and exposure to
keeping the diaper area as phototherapy cause the infant’s skin
clear as possible. to be at greater risk for compromise.
12) Provide exclusive Provides the caloric support for
breastfeeding every 2-3 hours. hepatic processing of bilirubin and
Water supplements are not stimulates peristalsis which allows the
recommended. bilirubin rich meconium stool to be
excreted.
13) Insure that bilirubin Evaluation of bilirubin levels provides
blood monitoring is completed data needed to determine when
as ordered by the physician. phototherapy can be discontinued.
14) Discontinue therapy Therapy can be discontinued when
when ordered by the bilirubin levels fall into normal range
physician. for the infant.

CLINICAL GUIDELINES
a) Phototherapy is recommended for term neonate if total bilirubin level rise
above 5 mg/dL in the 1st day of life. TSB greater than 8 mg/dL in the 1 st 24 hours
of life is considered “pathologic” and should be evaluated for hemolytic disease
or other disorder.
b) Phototherapy is generally initiated sooner and at lower levels in premature
neonates and infants with risk factors.
c) Intensity of phototherapy lights is checked daily.
d) Serum bilirubin levels are checked as ordered.
e) Infants receiving phototherapy treatment must be weighed daily.
f) Place an eye pad over eyes and diaper over genitals.
g) Encourage frequent exclusive breastfeeding.
h) Monitor for and ensure urinary frequency 6-8times/day.
i) Monitor temperature every 4 hour.
j) Estimate serum bilirubin frequently every 24 hours.
k) Change tube lights every 6 months (or usage time > 1000 hours) whichever is
earlier.
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l) Monitor irradiance of the phototherapy machine once every week. Use a flux
meter to monitor irradiance.
m) Do not place anything on the phototherapy unit (this blocks air vents).

CAUTION
1) Do not use phototherapy unit under a warmer.
2) Ensure that the eye patches used do not obstruct the nostrils.
3) For babies below 2 kg preferably use phototherapy over incubator.
4) After switching on the unit checks if all tubes/ bulbs are on.

COMPLICATIONS
 Increase in environment and body temperature, irritability and dehydration
due to increased insensible water loss.
 Skin changes like increased pigmentation, erythema, rash, burns.
 Passage of loose green stools because of transient lactose intolerance and
irritant effects of photocatabolites.
 Bronze baby syndrome:- in a baby with direct Hyperbilirubinemia.
 Flea bite rash on trunk and extremities.
 Platelets turn over may increase resulting in low platelet count, but bleeding
does not occur.
 There is theoretical increased risk of developing malignancies of skin later in
life.
 Phototherapy induced hypocalcaemia.
 Retinal damage.
 It has been reported that phototherapy affects function of immune system
via alteration in cytokines production.

CARE OF NEWBORN IN INCUBATOR

DEFINITION - Providing care to prematurely born or sick infant in a device called
incubator which keep them warm.
PURPOSES –
 To maintain a baby core temperature stable at 37 degree Celsius.
 To provide humidified air.
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  To administer oxygen
 To observe the baby without distribution him.
 To conserve the energy of premature canopy.
PARTS OF INCUBATOR
- Deck
- Mattress which is enclosed by a clear plastic canopy
- Microfilter assembly
- Oxygen inlet
- Thermostat
- Caliberated dial
- Arm ports
- Hood : single walled rectangular hood.the hood has a large door to aid in
placing or removing baby from incubator.
- Control panel : heater, blower and electronics.
- Lower unit: air temperature, patient temp.
- Cabinet :
- Humidity percentage
PROCEDURE
S.NO Nursing action Rationale
1 Identify the premature, weak or ill baby promote chance of survival for
who needs to be nursed in an isolette. premature baby who needs
thermoregulation
2 Verity physician orders for management of Facilitates adequacy of required
baby in the incubator unit assembly for care
3 Explain procedure to mother Promotes understanding and
acceptance of parents
4 Prepare the incubator for placing the baby Use of clean disinfection incubator
by cleaning it with soap and water and prevents growth of microorganism
disinfection
5 Switch on the incubator and adjust the
temp. at 36 degree on sevo control mode
6 Prewarm the incubator for 15 min. Prewarming facilitates provision of
required care to baby without
causing stress
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7 Transfer the baby to the prepared isolette Facilitates provision of required
care to baby without causing
stress
8 Undress the baby except for diapers
9 Check temp. of newborn and the incubator Prevents over exposure to heat.
every hour until the temp. of the baby is
stabilized
10 Maintain flow chart to record, temp, heart
rate, respiration and oxygen saturation
11 Change humidifier water every day.
12 Give care for baby by introducing hand
through arm ports
13 Permit mother parents to see and bond Reduces the chances of sensory
with the baby according to hospital policy deprivation
14 Weaning a baby is important and has to be
taken care of. This is done by gradually
decreasing the temp. of incubator and
monitoring the infant body temp.
15 Do not tap incubator Avoids distribution to the baby

ASSISTING IN EXCHANGE TRANSFUSION

Exchange Transfusion is a procedure performed within Newborn Services for the
treatment/correction of anaemia, hyperbilirubinaemia, and to remove antibodies
associated with red blood cell haemolysis. This guideline also covers partial
exchange for treatment of polycythaemia.

DEFINITION – Assisting in withdrawing a baby blood which has high bilirubin

content and replacing with fresh blood through umbilical vein.

AIMS

 To correct anaemia by replacing by replacing the Rh positive sensitized red

cells.
 To remove the circulatory antibodies
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  To eliminate circulatory bilirubin.
INDICATION
 Non obstructive jaundice with serum bilirubin level of 20mg/dl or more in
fullterm and 15mg/dl in preterm infant.
 Kernicterus irrespective of serum bilirubin level.
 Cord Hb 10% or less
 Rise of serum bilirubin of more than 1mg/dl/hour.

ARTICLES

a) Exchange transfusion set containing :-

- Kidney tray – 1
- Bowl -2
- Metal scale – 1
- Suture scissors – 1, fine scissors – 1
- Vein dilator – 1
- Fine toothed forceps 1
- Fine nontoothed foreceps 1
- Curved mosquito forceps 1
- Straight mosquito forceps 1
- Dressing forceps 1
- 20 cc syringe towel – 2
- Cross splint, pads and bandages
b) Inj. Tray with antiseptic
c) Small dressing pack
d) Sterile scalpel blade 3/11
e) Sterile feeding tray with pacifier
f) I.V. stand
g) Inj. Normal saline 500 ml
h) Inj. Heparin
i) 3 way stopcock
j) Heat sourece
k) Suction apparatus with mucus sucker
l) Umbilical vein catheter
m)NG tube no 5,6, 8

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 n) Sterile linen bundlie with 2 sheets and 1 biopsy towel
o) Mask and gloves
p) Cord tie
q) Specimen containers
r) Specimen tubes
s) Adhesive plaster, scissors and extra syringe
t) Emergency drug inj. Adrenalin,inj. Calcium gluconate, inj. Soda bicarbonate,
inj amniophyline
u) Blood giving set
v) Cross splint

CHOICE OF DONOR BLOOD

 The donor blood should be fresh
 The amount needed for an adequate exchange is about 160ml/kg
 The blood should be cross matched against mother blood.
 Make sure that the blood is slowly warmed to infant temp.
 Fresh heparinized blood or blood preserved with acid citrate dextrose is used.
 20 – 30 ml of blood is withdrawn and about 10 -20 ml are replaced each time .

PROCEDURE

S.N NURSING ACTION RATIONALE

O
1. Explain the procedure to the patients. Helps in reassuring the parents

2. Get informed consent from the parent Prevents legalities

3. The procedure is best carried out in an
conditioned room
4. Collect the blood from blood bank and place Prevents hemolytic reaction caused
in tepid water and check the blood type and by mismatched donor blood
group against the neonate blood before
administering
5. Procedure should be carried out in an
incubator maintaining the temp. at 27 – 300C

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6. NPO should be maintained for 4 hour before Minimize the risk of vomiting and
procedure aspiration in to lung
7. Expose and immobilize baby on cross splint Prevents movement during
procedure
8. Open dressing pack and assist in cleaning of Remove microorganisms.
umbilical stump.
9. Assist in cleaning umbilical cord and draping
with sterile linen.
10. Pour 500 ml of IV NS in to a sterile bowl and
add 1ml inj. Heparin in it.
11 Umbilical cord is cut to less than 2.5cm from Helps in location of vein
the skin surface.
12. Attach ligature loosely round the base of
cord. Insert umbilical catheter into vein
13. The catheter should be filled with a flushing Minimizes the risk of air embolism
solution or donor blood before insertion
14. When free flow of blood is obtained ligature
is tightened and the catheter should be deep
enough to reach the inferior venacava
15. Make sure that heat source is available Hypothermia may lead to metabolic
throughout the procedure acidosis
16. Measure CVP after insertion of catheter in to
the umbilical vein.
17. Take sample of pre-exchanged blood as well Helps in estimation of bilirubin and
as after exchange for investigation Hb.
18. Monitor HR, respiration rate, and condition
of baby Hr. during procedure
19. The physician removes 10 ml of umbilical
blood and replaces with 10 ml of fresh
immediately until calculated volume has
been exchanged
20. Apply cord tie at umbilical seal umbilicus Prevents risk heamorrhage and
with tincture benzoin apply small gauze and infection
secure with adhesive

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21 Replace equipment and start phototherapy

22 Document time of starting, duration, Give information to the staff

completion time amount and type of blood members.
exchanged , condition of baby during and
after procedure, drugs given during
procedure and sample sent to lab

COMPLICATION

 Bacterial sepsis
 Thro,bocytopenia
 Portol vein thrombosis
 Dysrhythmia
 Cardiac arrest
 Hypocalcemia
 Hypoglycemia
 Metabolic acidosis

BIBLIOGRAPHY
 Nima bhaskar “ A textbook of Midwifery and Obstetrical Nursing ” published
by Manjunath S Hegde EMMESS medical publisher, edition 3rd 2019, page No.
633- 643.
 John C Hauth “ A textbook of Williams obstetrics ” published by Mc GRAW
HILL, edition 22 page no. 634 -637

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 Sandhya Ghai “ A textbook of Clinical Nursing Procedure” published by Satish
kumar jain CBC publisher, edition 1st , page no. 817-820.
 Meharban Singh “ A textbook of manual of essential Pediatric ” published by
Thieme Medical & Scientific, edition 2nd, page no. 138- 192.
 David Willson “ A textbook of Essential of pediatric Nursing ” published by
ELSEVLER , edition 2nd, page no. 390 – 392.
 John P Cloherty “ A textbook of Manual of neonatal Care” published by
Wolter Kluwar pvt. Ltd. Edition 1st, page no. 59 – 72.
 Barbara K. Timby and Nancy E. Smith “ A textbook of Essentials of Nursing
Care of Adult and Children ” published by Lippincott Williams & Wilkins,
edition 2nd, page no. 15 – 23.
 www.slideshare.net>mohanasundarikrose>advance neonatal
procedure
 www.healthynewbornnetwork.org>hnn-content janvier 2015
 www.slideshare.net/gotolamy/care-for-the-child-uderphototherapy
 www.slideshare.net/SharonAntony8/neonatal-resuscitation-83704051
 www.slideshare.net/Sabburani/care-of-child-with-incubator

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