CONCEPT: NEWBORN SUCTIONING

INTODUCTION:

Suctioning is the aspiration and or removal of secretions from the airway via the nasal
passage and pharynx without a tracheal tube or tracheostomy The principles of suctioning are
the same whether it is via the child’s pharynx or an artificial airway (e.g., tracheal tube or
tracheostomy)

All medical personnel involved in perinatal care are responsible for stabilizing the newborn at
delivery. The initial step in resuscitation both in the delivery room and in the neonatal unit is
ensuring patency of the airway through proper, efficient suctioning.

Suctioning at birth has been the standard of care for newborns for decades. But recent
evidence calls this practice into question, and many hospitals are moving away from it. But this
doesn’t mean that suctioning is obsolete. Newborns in respiratory distress, those with low Apgar
scores, and those struggling with the transition from fetus to newborn may still need bulb
suctioning, or occasionally, suctioning with a machine.

Evidence based clinical guidelines recommend not suctioning a baby’s airways unless they are
Unresponsive, floppy and require resuscitation.

Routes for
Suctioning
Oral To remove secretions from the mouth and performed using a yankeur suction
catheter.

Oropharyngeal Extends from the lips to the pharynx. Can be performed for children who are
breathing spontaneously, but are unable to maintain an open airway.
Oropharyngeal suctioning requires the insertion of a suction catheter through
the mouth to the pharynx.

Nasopharyngeal Extends from the tip of the nose to the pharynx. The suction catheter is
inserted through the nostrils in to the pharynx. Airway adjuncts e.g. (guedal)
can be used if the child is unable to tolerate suction without them or is in an
unconscious state.

FACTS: SUCTIONING NEWBORNS.

1. ROUTINE SUCTIONING IS UNNECESSARY

 The World Health Organization (WHO) now advises against routine bulb suctioning of
neonates in the minutes following birth. If the baby is born through clear amniotic fluid and
begins breathing on their own shortly after birth, do not suction. However, if the baby
struggles with signs of respiratory distress, do not delay suctioning.
 Aspirated meconium can be especially lethal to newborns, and the faster you are able to
suction them, the greater their likelihood of survival.
2. SUCTION ONLY FOR CLEAR INDICATIONS

 Only suction a neonate who shows clear signs that suctioning is appropriate.
Those include:
 An increase in CO2
 Increased oxygen needs
 Bradycardia and apnea
 Audible breathing, gasping, or wheezing
 Visible secretions, or obvious difficulty clearing the airway
 Aspiration

Note: Monitor the baby’s vital signs before and after suctioning, because no procedure is
without risk. Airway trauma, hypoxia, infection, and increased intracranial pressure are
especially dangerous to neonates, so weigh the risks and benefits and know the baby’s health
history before proceeding.

3. MINIMIZE RISK TO NEWBORN

 As with any other patient, hyperoxygenate the neonate before and after suctioning.
Minimize the length of suctioning to 10 seconds or less. If the first pass does not fully clear
the airway, reoxygenate the neonate and try again.

Some other strategies that can reduce risk include:

A. Choosing smaller equipment. Neonates have fragile airways that are easily
damaged.
B. Being mindful of differences in the neonate’s airway. Babies have smaller, more
narrow airways, a larger tongue and epiglottis, and a shorter trachea. Adapt your
technique and your equipment accordingly.
C. Supporting the infant’s head. A newborn cannot support the weight of their own
head, increasing the risk of injury during suctioning if they are not well supported.
D. Reducing the risk of infection. Pathogens that are only mildly annoying to an adult
can be lethal to neonates, especially those with compromised immune systems.
Thoroughly wash hands in hot water. Always wear gloves and a mask, and change
gloves before changing equipment or after touching anything that might be
contaminated

4. DO NOT SEPARATE MOTHER AND INFANT

 Separation is harmful to the health of the baby, and extremely stressful to the mother.
Indeed, skin-to-skin contact may improve infant health outcomes, reduce stress, and help
the neonate better thermoregulate during the transition from fetus to newborn. So keep the
mother and baby together if at all possible.
 When performing bulb suctioning or other procedures during which holding the baby is
possible, allow the mother to continue holding the baby. If it is not possible for her to do so,
return the baby to the mother or another caregiver as soon as any medical procedures are
completed. Perform monitoring and vital signs checks while the mother holds the baby,
unless there are medical indications to do otherwise.

5. CHOOSE THE RIGHT EQUIPMENT

 The right equipment is critical for safe, effective suctioning of neonates. This includes
narrower catheters, as well as machines with reliable, consistent, adjustable suction.
Neonates may need emergency suctioning in unusual locations—such as when a baby is
delivered in the car or at home, or experiences respiratory distress in a hospital waiting
room. Emergency suction machines ensure you can tend to the baby wherever they are,
without delaying care

NOTE:

SUCTIONING AT BIRTH:
 a. Can cause the baby to gasp (inhale deeply which is exactly what you are wanting to
avoid with meconium-stained liquor) Can lower the baby’s heart rate for up to 20
minutes (vagal bradycardia)
b. Does not reduce the risk of Meconium Aspiration syndrome (MAS)
c. Can interfere with the initiation of breastfeeding
d. Can cause tissue trauma
e. Can produce bradycardia
f. Can cause laryngospasm
g. Can cause cardiac dysrhythmias
h. Can cause edema
i. Can cause trauma to mucous membranes
j. Can cause tachycardia
k. Can cause emotional distress
l. Can cause bronchospasm
m. Can cause cardiac arrest

Procedure:

Performing Newborn Suctioning

Instruction: Check under Correctly Done if identified skill is correctly performed; Incorrectly
Done if skill is not performed correctly; and Not Done if the student failed to perform the skill.
Procedure Correctly Incorrectly Not Done
Done Done
2 1 0
1. Identify the patient.
2. Determine the need for suctioning. Verify the suction
order in the patient’s chart, if necessary.
3. Explain what you are going to do and the reason to
the SO, even if the patient does not appear to be alert.
4. Perform hand hygiene.
5. Adjust the bassinet to comfortable working position.
If patient is conscious, place him/her in a semi-Fowler’s
position. If patient is unconscious, place him/her in the
lateral position, facing you. Move the bassinet close to
your work area and raise to waist height.
6. Place a towel or waterproof pas across patient’s
chest.
7. a. Adjust suction to appropriate pressure.

For a wall unit: 60-80 mm Hg

For a portable unit: 6-8 mm Hg

7. b. Put on a disposable, clean glove, and occlude the

end of the connecting tubing to check suction pressure.
Place the connecting tubing in a convenient location.
8. Open sterile suction package using aseptic technique.
The open wrapper or container becomes a sterile field
to hold other supplies. Carefully remove the sterile
container, touching only the outside surface. Set it up
on the work surface and pour a sterile saline into it.
9. Place a small water-soluble lubricant on the sterile
field, taking care to avoid touching the sterile field with
the lubricant package.
10. Increase the patient’s supplemental oxygen per
facility policy or physician order.
11. Put on a face shield or goggles mask. Put on sterile
gloves. The dominant hand will manipulate the catheter
and must remain sterile. The non-dominant hand is
considered clean rather than sterile and will control the
suction valve (Y port) on the catheter.
12. With dominant gloved hand, pick up sterile
catheter. Pick up the connecting tubing with the non-
dominant hand and connect the tubing and suction
catheter.
13. Moisten the catheter by dripping it into the
container of sterile saline. Occlude Y-tube to check
suction.
14. Apply lubricant to the first 2”-3” of the catheter,
using the lubricant that was placed on the sterile field.
15. Remove the oxygen delivery device, if appropriate.
Do not apply suction as the catheter is inserted. Hold
the catheter between your thumb and forefinger.
For Nasopharyngeal suctioning

Gently insert catheter through the naris and along the

floor of the nostril toward trachea. Roll the catheter
between your fingers to help advance it. Advance the
catheter approximately to reach the pharynx.

For Oropharyngeal suctioning

Insert catheter through the mouth, along the side of

the mouth toward trachea. Advance the catheter to
reach the pharynx.

16. Apply suction by intermittently occluding the Y port

on the catheter with the thumb of your non-dominant
hand and gently rotate the catheter as it is being
withdrawn. Do not suction for more than 10-15 seconds
at a time.
17. Replace the oxygen-delivery device using your non
dominant hand.
18. Flush catheter with saline. Assess effectiveness of
suctioning and repeat as needed and according to
patient’s tolerance. Wrap the suction catheter around
your dominant hand between attempts.
19. Allow at least a 30 second to 1minute interval if
additional suctioning is needed. No more than three
suction passes should be made per suctioning episode.
Alternate the nares, unless contraindicated, if repeated
suctioning is required. Do not force catheter through
the nares. Suction the oropharynx after suctioning the
nasopharynx.
20. When suctioning is completed, remove gloves from
dominant hand over the coiled catheter, pulling it off
inside out. Remove glove from the non-dominant hand
and dispose of gloves, catheter, and container with
solution in the appropriate receptacle. Remove face
shield or goggles and mask. Perform hand hygiene.
21. Turn off suction. Remove supplemental oxygen
placed for suctioning, if appropriate. Assist patient to a
comfortable position.
22. Do oral hygiene to the patient after suctioning.
23. Reassess patient’s respiratory status, including
respiratory rate, effort, oxygen saturation, and lung
sounds.
24. Document procedure to patient’s chart.
 CONCEPT: HEIMLICH MANEUVER

INTRODUCTION

Heimlich maneuver, emergency procedure that is used to dislodge foreign bodies from the
throats of choking victims. In the early 1970s, the American surgeon Henry J. Heimlich
observed that food and other objects causing choking were not freed by the recommended
technique of delivering sharp blows to the back. As an alternative, he devised a method of
using air expelled from the victim’s lungs to propel the object up and out of the throat.

The Heimlich maneuver is used only when the victim’s airway is totally obstructed and he is
rendered unable to speak, breathe, or to cough the object out; with only partial blockage of the
throat, the victim can generally work the object free by his own efforts.

While the Heimlich maneuver is used for choking adults and older children, you actually do
not use the Heimlich maneuver on babies — instead, you perform a series of strikes while the
baby is turned face-down.

PURPOSE:
1. Remove a foreign body from obstructing the airway to prevent anoxia and
cardiopulmonary arrest.

ASSESSMENT:
● Identify disorders that put clients at greater risk for airway obstruction:
○ Cerebral vascular accident with hemiparesis
○ Neuromuscular disorders
○ Seizure disorders
○ Tumors of neck or esophagus
○ Decreased level of consciousness
○ Heavy narcotic or sedative use
○ Alcohol intoxication
○ Diminished or absent cough and gag reflex
● Assess client for signs and symptoms of airway obstruction.
Symptoms not needing immediate intervention:
○ Ability to speak
○ Ability to breathe in and out
○ Ability to cough
○ Stable vital signs
○ Note: Stay with the client and allow him or her to cough to clear airway.
● Symptoms needing immediate intervention :
○ Universal distress signal for complete airway obstruction
○ Irregular, slow, shallow breathing
 ○ Apnea
○ High-pitched sounds or no sounds while inhaling
○ Inability to cough forcibly or at all
○ Inability to speak
○ Cyanosis
○ Abnormal pulse (irregular, rapid, or slow)
● Determine which variation of the Heimlich maneuver (chest thrusts, abdominal thrusts)
to use.

EQUIPMENT:
● No equipment is mandatory; suction equipment and emergency cart are useful if in
hospital setting

WHAT TO DO:

1. Determine if the baby can cough. The first thing to do when you see a baby struggling
to breathe is check whether she can cough or make sounds. If she can cough firmly, then let
her cough to try and dislodge the object that is obstructing her breathing. If you are worried
about her breathing and she cannot dislodge the object through coughing you should call for
emergency medical help.

 If your baby can cough forcefully or cry strongly do not attempt the following steps to
dislodge it. Instead, monitor her closely until you know the blockage has been
dislodged. Be ready to act if the symptoms worsen and persist.

Check if the baby is breathing. If the baby cannot cough, cry, or make any sounds or at all,
you should immediately check if he is breathing.

Danger signs for choking:

 baby having only a weak and ineffective cough

 Baby only making soft high-pitched sounds when he breathes in.
 baby is turning blue, losing consciousness, or is waving his arms desperately without
making any sound;
 quickly check his chest to see if it's moving up and down, and listen
for breathing sounds
 If you can see the obstruction in the baby's mouth or throat and it is easily
accessible you can remove it, but do not feel around in the baby's throat. You
risk pushing the obstruction in further.
 You should not try to grab and pull out the obstruction if the baby is conscious.
  If the baby is unconscious, remove any visible objects from the mouth and
begin CPR until the ambulance arrives. Be aware that there may be resistance to
inflation initially until the stuck object is removed.

Call Emergency Services. If a baby is choking you should call emergency services before you
begin to administer first aid.
If possible, ask someone else to make the call, as you start to clear the baby's blocked airway.
If you are alone, shout for help but do not leave the baby and be sure to continue to administer
first aid.
If your baby has been choking, you should always call your doctor afterwards. Do this even if
the obstruction has been removed and she appears to be breathing normally.

DISLODGING AIRWAY OBSTRUCTION

Prepare to give back blows. If your baby is struggling to breathe, or has stopped breathing
you need to act quickly to dislodge the object which is obstructing his airway. The first
technique to use is back blows. Turn the baby face down on your lap for the back blows. Hold
the baby in this secure face-down position and be sure to support the baby's head. The front of
the baby is supposed to be firmly leaning against your arm, and you can use your thigh for
support.

 Ensure that you are not covering the baby's mouth or twisting his neck.
The baby's head should be slightly lower than her chest
Give five firm back blows. Once you have positioned the baby you need to administer five
firm but gentle back blows. Slap the baby's back, between her shoulder blades, with the heel of
your hand five times. After five slaps, stop and check the baby's mouth to see if the blockage
has become dislodged. If there is an obvious blockage which you can see and reach, carefully
take it out. Do not do this if you risk pushing it further in.

If, after administering five back blows, the baby's airway has not been cleared, you will need to
perform five chest thrusts

Prepare to perform chest thrusts. If your baby is coughing and crying, then it's a good
sign, because this means some air is coming through. If the baby is not crying after the
previous step and the object has not been visibly coughed up, then the back blows were
unsuccessful. In this case, it's time to perform chest thrusts. Place the baby facing upwards
across your lap, with the head lower than the body. Use your thigh or lap for support and be
sure to support the head.
 Give five chest thrusts. Once the baby is positioned and supported on your lap you need to
perform five chest thrusts. Place two fingers on the centre of his breastbone, just below the
nipples, or about one finger's breadth below the nipples. Then give five quick thrusts down.

The force you exert should compress the chest between a third and a half of its depth.

 Check if the blockage has been dislodged and if it is easy for you to take it out do so,
but again, do not risk pushing it in further.
 Continue to perform back blows and chest thrusts in this cycle until the blockage has
been removed or until help arrives.
 If the object has not been dislodged after three cycles of back blows and chest thrusts
be sure to call emergency services immediately, if you haven't already.

Monitor your baby after the airway is cleared. Even after the object has been dislodged
you should pay close attention to your baby. It is possible that some of the substance which
caused the blockage may remain and cause problems in the near future. If she has any trouble
swallowing, or has a persistent cough, you should seek medical help immediately. Take your
child to see your doctor or to your local Hospital, or Emergency Room

TIPS:
 Continue performing the airway clearing movements until emergency help arrives. Don't give
up.

 Try to remain calm; being calm is your best chance of succeeding in helping the baby
effectively.

Try to have someone call the emergency help while you are clearing the blocked airway of a
baby. If there is no one around, call the moment you realize that the baby is choking, but do
not leave the baby alone. It may help to stay on speakerphone in this instance, while clearing
the baby's airway so that you can talk and continue acting at the same time

WARNINGS!

Never perform these movements on a baby who is not choking

Don't perform abdominal thrusts (the actual Heimlich Maneuver) on a baby under one year old

PROCEDURE:

For Children Younger than 1 Year of Age (Back Blows and Chest Thrusts)

1. Straddle infant over your arm with head lower than trunk.
2. Support head by holding jaw firmly in your hand.
3. Rest your forearm on your thigh and deliver five back blows with the heel of your hand
between the infant's scapula.
4. Place free hand on infant's back and support neck while turning to supine position.
 5. Place two fingers over sternum in same location as for external chest compression (one
fingerwidth below nipple line).
6. Administer five chest thrusts.
7. Repeat Steps 1 through 6 until airway is not obstructed.

For Children Older than 1 Year of Age

1. Perform Heimlich maneuver with child standing, sitting, or lying as for adult, but more
gently

2. Place thumb side of fist against child's abdomen below xiphoid; press fist into abdomen
with quick, upward thrusts. You may need to kneel behind child or have child stand on a
table.
3. Prevent foreign body airway obstruction in infants and children by teaching parents or
caregivers to:
1. Restrict children from walking, running, or playing with food or foreign objects in
their mouths.
2. Keep small objects (e.g., marbles, beads, beans, thumb tacks) away from
children younger than 3 years of age.
3. Avoid feeding popcorn and peanuts to children younger than 3 years of age, and
cut other foods into small pieces.
4. Instruct parents and caregivers in the management of foreign body airway obstruction

For Conscious child or adult

1. The client will be standing or sitting.

2. Stand behind the client.
3. Wrap your arms around client's waist.
4. Make a fist with one hand. Place thumb side of fist against client's abdomen, above the
navel but below the xiphoid process.
Rationale: Proper positioning is important to avoid injury and to successfully clear the
airway.
5. Grasp fist with other hand.
6. Press fist into abdomen with a quick upward thrust (Fig. 1).
Rationale: A quick upward thrust increases intrathoracic pressure and creates an
artificial cough, which forces air and foreign objects out of the airway.

7. Place your fist just above the person's navel and below the sternum. Repeat distinct
separate thrusts until the client expels the foreign body or becomes unconscious.

For Unconscious client (Heimlich Manuever, Abdominal Thrust)

1. Client will be lying on the ground.

2. Turn client on back and call for help. Activate emergency response system.
Rationale: Prompt access to trained emergency professionals can be life-saving.
3. Finger sweep.
1. Use tongue-jaw lift to open mouth.
Rationale: Tongue-jaw lift draws tongue away from back of throat to relieve
obstruction or visualize foreign body.
2. Insert index finger inside cheek and sweep to base of tongue if an object is
visible. Use a hooking motion, if possible, to dislodge and remove the foreign
body. Note: Avoid finger sweeps in infants and children because you can easily
push the foreign body further into the airway. Remove only if clearly visible and
easy to reach.
3. If there is no effective breathing, attempt to provide 2 rescue breaths. If
unsuccessful, reposition and try to ventilate again.
Rationale: Ventilation, if possible, would reduce hypoxia.
4. Straddle client's thighs or kneel to the side of thighs.
5. Place heel of one hand on epigastric area, midline above the navel but below the xiphoid
process.
 6. Place second hand on top of first hand.
Rationale: Proper positioning is important to avoid injury and successfully clear the
airway.
7. Press heel of hand into abdomen with a quick upward thrust.
Note: Be careful to thrust in the midline to prevent injury to the liver or spleen
Rationale: A quick upward thrust increases intrathoracic pressure and creates an artificial
cough to force air and foreign body out of airway.

8. Abdominal thrusts. Repeat abdominal thrusts 5 times.

9. If airway is still obstructed, attempt to ventilate using mouth-to-mouth respiration and
head tilt/chin lift.
10. Repeat Steps 5 through 8 until successful.

For pregnant women or very obese client (Chest Thrust)

1. Stand behind client.

2. Bring your arms under client's armpits and around chest.
3. Make a fist and place thumb side against middle of sternum.
4. Grasp fist with other hand and deliver a quick backward thrust
5. Performing Heimlich maneuver on pregnant woman. Repeat thrusts until airway is
cleared.
6. Chest thrusts may be performed with client supine and hands positioned with heel over
lower half of sternum (as for cardiac compression). Administer separate downward
thrusts until airway is clear