Newborn Resuscitation - Colchester Hospital University NHS

Women, Children’s and Sexual Health Division
Maternity Services
Guideline: Newborn Resuscitation
1.
Introduction
Passage through the birth canal is a hypoxic experience for the fetus, since significant
respiratory exchange at the placenta is prevented for the 50-75 second duration of the
average contraction. Though most babies tolerate this well, the few that do not may
require help to establish normal breathing at delivery. Neonatal life support (NLS) is
intended to provide this help and comprises the following elements:
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2.
drying and covering the newborn baby to conserve heat;
assessing the need for any intervention;
opening the airway;
aerating the lung;
rescue breathing;
chest compression;
administration of drugs (rarely).
(Neonatal Life Support 2010)
Process
Within Maternity Services all practitioners responsible for resuscitation of the
newborn will follow the modified Resuscitation Council (UK) Neonatal life Support
(NLS) Algorithm 2010 – (Refer to Page 4) Neonatal Life Support Algorithm
2.1
Communication
 Inform the Neonatal Registrar during the Intrapartum period if the woman either
develops or has previously been identified with ‘High Risk factors’ which may
increase the need for Newborn Resuscitation.
 The birthing midwife is responsible for ensuring the appropriately trained staff are
present in the birthing room to assess if Newborn Resuscitation is required
particularly when high risk factors are present.
2.2
Availability of Staff
 All midwives are trained in Newborn resuscitation and they are supported by the
Newborn team who are available to attend Delivery Suite or Lexden Ward in an
emergency throughout 24hours.
 Staff must summon the Help of the Neonatal Team by:
DIALING 2222 - Stating clearly either Neonatal Emergency OR Neonatal Cardiac
Arrest
Followed by the Location that the team is required to attend.
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 1 of 13
2.3
Environment
 The environment should be safe and warm (above 24 centigrade) with adequate
lighting.
2.4
Cord Clamping
 For uncompromised babies, a delay in cord clamping of at least one minute from the
complete delivery of the infant, is now recommended.
There remains insufficient evidence to recommend an appropriate time for clamping
the cord in babies who are severely compromised at birth – with these resuscitative
intervention remains the priority. (NLS 2010)
2.5
Air or Oxygen
 For term infants, air should be used for resuscitation at birth. If, despite effective
ventilation, oxygenation (ideally guided by pulse oximetry) remains unacceptable, use
of a higher concentration of oxygen should be considered – Commence a blend of 5
litres of Oxygen / 5 litres Air
 Preterm babies less than 32 weeks gestation may not reach the same arterial blood
oxygen saturations in air as those achieved by term babies. Therefore blended
oxygen and air should be given judiciously and its use guided by pulse oximetry.
If a blend of oxygen and air is not available use whichever is available
2.6
Pulse Oximetry
 A pulse oximeter is probably the best way of assessing heart rate and oxygenation
during Newborn resuscitation. The pulse oximeter probe should be applied as soon
as possible by an appropriately qualified person.
It will take approximately 90 seconds for the pulse oximeter to provide a reading
once applied.
Refer to Resuscitation Council (UK) Neonatal life Support (NLS) Algorithm 2010 for
Pulse Oximetry values.- Page 4
2.7
Blood Gases
 All babies who require resuscitation should have paired cord blood gas samples
obtained from the double clamped cord See CHUFT Maternity Guideline 4.4
2.8
Preterm Babies
The same standard approach is used for resuscitation with some special considerations: Preterm babies of less than 28 weeks gestation should be completely covered up to
their necks in a food-grade plastic wrap or bag, without drying, immediately after
birth. They should then be nursed under a radiant heater (keep face uncovered and
apply a hat but no blankets). and stabilised. They should remain within the plastic
wrap until their temperature has been checked after admission to the Neonatal Unit
 For these infants delivery room temperatures should be at least 26°C
 Lower inflation pressures of 20-25 cm water may be used to reduce lung damage
initially and only increased to 30cm water if the resuscitation is not demonstrating
success.
 A senior member of the Neonatal team should be called to any birth ≤28 week’s
gestation, where early use of surfactant and skilled intubation, continuous positive
airway pressure (CPAP) and positive end expiratory pressure (PEEP) may be used to
help prevent alveolar collapse.
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 2 of 13
2.9
Meconium
 Attempts to aspirate meconium from the nose and mouth of the unborn baby, while
the head is still on the perineum, are not recommended.
 A crying baby born through meconium has an open airway and does not routinely
require resuscitation.
 If presented with a floppy, apnoeic baby born through meconium it is reasonable to
inspect the oropharynx rapidly to remove potential obstructions.
 If appropriate expertise is available, tracheal intubation and suction may be useful.
 If attempted intubation is prolonged or unsuccessful, start mask ventilation,
particularly if there is persistent bradycardia.
2.10
Drugs
In very few cases inflation of the chest and effective chest compressions will not be
sufficient to produce an effective circulation. Drugs are only required if there is no
significant cardiac output despite effective lung inflation and effective chest compression,
and may be administered by the Neonatal team. These drugs are kept in the clean utility
room in delivery suite and mother and baby room on Lexden ward..
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Sodium bicarbonate (4.2%)
Adrenaline (Epinephrine1:10,000)
Dextrose 10%.
Saline 0.9%
If drugs are to be effective in this situation where there is inadequate circulation they
must be delivered close to the heart, usually via an umbilical venous catheter.
Current guidance suggests adrenaline should be given first but if not immediately
effective it is recommended that sodium bicarbonate is then administered followed if
necessary by a second dose of adrenaline, followed by Dextrose and only Saline if a
volume expander is required. (NLS 2010)
The recommended dosages are: following the SAD algorithm:
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Sodium bicarbonate – 1-2 mmol/per kg = 2 to 4 ml of 4.2% bicarbonate solution.
*Flushed with 2-4mls Normal Saline
If there is no response to an initial dose of epinephrine it is worth repeating the
epinephrine after a dose of bicarbonate
.Adrenaline - 10 microgram/kg = 0.1 ml/kg of 1:10,000 solution).
*Flushed with 2-4mls Normal Saline
If this is not effective Increase dose to
30 microgram/kg = 0.3 ml/kg of 1:10,000 solution)
If the tracheal route is used, it must not interfere with ventilation or delay acquisition of
intravenous access.
The tracheal dose is between 50-100 mcg kg-1
 Dextrose 10% - 250 milligrams/kg (2.5 ml/kg of 10% dextrose).
*Flushed with 2-4mls Normal Saline
 Saline 0.9% – 10ml per kg initially (rarely required for hypovolaemia)
Resuscitation Council (UK) Neonatal life Support (NLS) Algorithm 2010
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 3 of 13
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 4 of 13
3.
Responsibilities of staff in ensuring Equipment is available
The practitioner performing Newborn resuscitation is accountable for ensuring they have
the competence required to safely perform the skill, and that ALL the equipment required
is checked and ready prior to ANY birth (NMC 2004).
All resuscitation equipment in the delivery suite including the theatre and Juno, the
postnatal ward and the coastal midwifery led units are to be checked daily and check lists
completed
See Appendix One /Two/Three for equipment lists and checklist, the completed
checklists are to be returned to the Trust Resuscitation officer see bottom of checklist for
address. A copy should be made of the checklists, this should be sent to Elke Cattermole
Matron for Delivery suite / Lexden Ward and Jenny Collins Matron for Midwifery Led units
as appropriate.
Midwives caring for women in labour in their homes and the birthing centre in Halstead
are responsible for ensuring they have the correct equipment arranged for use, prior to
the birth occurring Appendix Four.
Emergency Department have a paediatric nurse responsible for ensuring equipment is
available.
4.
Record Keeping
The NMC does not encourage the use of a scribe for record keeping purposes as all
professionals are accountable for their own record keeping. However, it is acknowledged
that in times of crisis or extreme emergency the assistance of a scribe may be invaluable
in recording times, professionals present or summonsed and times of arrivals, drugs
administered and vital signs recording.
The NMC clearly states that: ‘if a registrant chooses to scribe on the behalf of
another professional they should be aware that they are professionally
accountable for such an action’. (NMC, 2007)
Record keeping is a statutory responsibility for all health care professionals. The records
should demonstrate the sequence of events with careful documentation of ALL the
significant consultations, assessments, observations, decisions interventions and
outcomes.
Record should include:
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The date and time of writing your entry, making sure that you sign and print your
name following each entry.
Time of birth
Condition at Birth – Heart rate, breathing, colour, muscle tone and retrospective
Apgar Scores
Time help was summoned
Time help arrived
Name and designation of help
Condition of the neonate every 30 seconds including resuscitative measures being
performed including:
o Heart Rate
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 5 of 13
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o Breathing
o Colour
o Tone
Names, Times, Doses, and Responses to Drugs given and all Laboratory results.
5.
Debriefing
In the event of a baby requiring resuscitation the parents should be fully informed of what
is happening during the procedure, and a debriefing afterwards when the time is
appropriate.
Should there be an adverse outcome the women and her partner will require counselling
and support. The responsible midwife and Neonatal staff can provide this along with the
maternity services specialist counsellor who can be contacted via the bleep system.
Debriefing for staff is essential too and should occur as soon as possible with the
participation of all team members.
6.
Staff Training
CHUFT Maternity services provide annual drills and skills training in Newborn
Resuscitation for all maternity staff. See Maternity TNA guideline No 7.12
Attendance will be recorded on the central training database, compliance monitored and
any failure to attend followed up
The Neonatal Life Support (NLS) course can be undertaken as part of Continuing
Professional Development (CPD
7.
Monitoring Compliance
Staff will complete an electronic incident risk reporting form for:
 All neonates who are unexpectedly admitted to the Newborn unit
 All neonates with an Apgar score is less than 6 - 5 minutes after birth.
 Any adverse incident during Newborn resuscitation.
The form will instigate a review of each case and be assessed as part of the risk
management review.
8.
References and Further Reading
Aladangady N, McHugh S, Aitchison TC, Wardrop CA, Holland BM.(2006) Infants' blood
volume in a controlled trial of placental transfusion at preterm delivery. Pediatrics
117:93-8.
Dawson JA, Kamlin CO, Vento M, et al. 2010. Defining the reference range for oxygen
saturation for infants after birth. Pediatrics;125:e1340-7.
McDonald SJ, Middleton P. 2008. Effect of timing of umbilical cord clamping of term
infants on maternal and Newborn outcomes. Cochrane Database Syst Rev
CD004074.
Mariani G, Dik PB, Ezquer A, et al. 2007 Pre-ductal and post-ductal O2 saturation in
healthy term neonates after birth. J Pediatrics;150:418-21
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 6 of 13
Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W. 2006. Delayed cord
clamping in very preterm infants reduces the incidence of intraventricular
hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics
;117:1235-42.
Midwives Rules and Standards. NMC 2004
National Institute for Clinical Excellence (NICE) 2007. Intrapartum Care, care of healthy
women and their babies during childbirth.
NMC 2009 Record Keeping: Guidance for Nurses and Midwives NMC London
Rabe H, Reynolds G, Diaz-Rossello J.2004. Early versus delayed umbilical cord
clamping in preterm infants. Cochrane Database Syst Rev :CD003248.
Resuscitation Council (UK) 2010. Newborn Life Support Provider Manual,3rd ed London
Toth B, Becker A, Seelbach-Gobel B.2002. Oxygen saturation in healthy newborn
infants immediately after birth measured by pulse oximetry. Arch Gynecol Obstet
;266:105-7.
Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, Vivas NI.2004. Oropharyngeal
and nasopharyngeal suctioning of meconium-stained neonates before delivery of
their shoulders: multicentre, randomised controlled trial. Lancet;364:597602
Wyllie J, Perlman JM, Kattwinkel J, et al. 2010. International Consensus on
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with
Treatment Recommendations. Part 11: Newborn Resuscitation. Resuscitation 81:e255e282.
Wyllie J, Richmond S. European Resuscitation Council Guidelines for
Resuscitation 2010. Section 7. Resuscitation of babies at birth. Resuscitation
2010;81.
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 7 of 13
-------------------------------------
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Dymphna Sexton-Bradshaw
Associate Director of Women,
Children's and Sexual health Division
/ Head of Midwifery
Sarah Dalton
Consultant Neonatologist
-----------------------------------Anne Regan
Lead Pharmacist
Version
Author (s)
Date
One
B Lynn
2001
Circulation
Comments
Practice Educator Midwife / NLS
Instructor
Two
S Gosling
2008
Practice Development Midwife
Three
B Lynn
2009
Associate Director of Midwifery &
Governance
Julie Hinchcliffe
S Gosling
Practice Development Midwife
Senior Midwife / Risk Management.
Four
A Ferris
Practice Educator Midwife / NLS
Instructor
B Lynn
Reviewed and
revised
Reviewed and
revised
2011
Practice Educator Midwife / NLS
Instructor /Course Director
Supervisors of Midwives
CHUFT Resuscitation
Officer
Sandra Gosling
Reviewed and
revised
Practice Development Midwife
Julie Hinchcliffe
Senior Midwife / Risk Management
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 8 of 13
Appendix One
Resuscitaire Equipment List for
Delivery Suite/Lexden Ward
Small SIDE SHELF – Right hand side of Resuscitaire
X1
X1
X1 each
X1
X1
Facemask (round) size 0
Facemask (round) size 0/1
Hats - Small Medium Large
Pulse Oximeter
Pulse Oximeter Skin Probe
Basinet – LARGE SURFACE AREA
X1
X2
X1
X1
X1
X1
X1
X1
Sheet to cover Mattress
Towels
Neopuff Manometer (Disposable)
Suction Tubing
Paediatric Yankauer Mini Sucker
Argyle Suction Catheter Size 10ch
Argyle Suction Catheter Size 12ch
Neonatal Stethoscope
TOP TRAY
Lilac Dust Cover
100 mls Normal Saline
500 mls 10% Dextrose
10 ml Ampoules Normal Saline 0.9%
Umbilical Venous Catheter – (Vygon 5fg)
Laryngoscope Size 0 Miller (Short Blade)
Laryngoscope Size 1 Miller (Long Blade)
ET Tubes Sizes 2.0 2.5; 3.0; 3.5; 4.0. (Uncuffed)
ET Tube Stylet/Introducer
Neofit
Oropharyngeal airways: Sizes 000; 00; 0; & 1
Infant feeding Tube Set- Size 6fg (Entral)
10 ml Purple Oral Syringe
Green Needles Size 21G
Orange Needles Size 25 G
1 ml Syringes
2 ml Syringes
5 ml Syringes
10 ml Syringes
Straight Scissors
Chloraprep
1.25cm Transpore
Neoflon
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
X1
X1
X1
X2
X1
X1
X1
X1 each
X1
X1
X 1 each
X1
X2
X4
X4
X2
X2
X2
X2
X1
X4
X1
X2
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 9 of 13
BOTTOM TRAY/BACK OF RESUSCITAIRE
X2
X3
X2
X1
X1
X2
X2
X2
X1
SMALL Clear Plastic Bags
Towels
Blankets
Suction Tubing (In clear Plastic Bag)
Neopuff Set
Paediatric Yankauer Suction catheter
Argyle Suction Catheter Size 12ch
Argyle Suction Catheter Size 10ch
Argyle Suction Catheter Size 6ch (For ET Suction)
Hanging on Hook RIGHT SIDE OF RESUSCITAIRE
Disposable Bag valve mask with reservoir bag and size 00/01 round facemasks –
disposable, and Oxygen connection tubing
X1
Attached to BACK of RESUSITAIRE
Oxygen cylinder size ‘E’ more than 3/4 FULL & TURNED OFF
Air cylinder size ‘E’ more than 3/4 FULL & TURNED OFF
Key to turn Cylinders on/off
X1
X1
X1
When to request a new Oxygen or Air Cylinder –
* Air and Oxygen Cylinders must be changed when the Gauge reads ¾ FULL
To leak check a cylinder *
*
*
*
*
*
With the flowmeter turned off, turn the cylinder valve on
Observe the contents gauge
Turn the cylinder valve off
Observe the contents gauge for about 1min
If the gauge stays stable - no leak.
If the gauge drops - there is a leak, call EBME 2492/2499
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 10 of 13
Appendix Two
Resuscitaire Equipment List for
Juno/ Coastal MLU’s
(Basinet Juno) (Fisher Paykel Cosycot Coastal MLU’S)
X1
X1
X1 each
X1
X2
X1
X1
X1
X1
X1
X1
X2
X 1 each
X1
X1
X1
X1
X1
Facemask (round) size 0
Facemask (round) size 0/1
Hats - Small Medium Large
Sheet to cover Mattress
Towels
Neopuff Manometer (Disposable)
Suction Tubing
Paediatric Yankauer Mini Sucker
Argyle Suction Catheter Size 10ch
Argyle Suction Catheter Size 12ch
Stethoscope
Blankets
Oropharyngeal airways: Sizes 000; 00; 0; & 1 (Guedal)
Laryngoscope Size 0 Miller (Short Blade)
Laryngoscope Size 1 Miller (Long Blade)
Clear plastic bag (for unexpected premature births)
Pulse Oximeter
Pulse Oximeter Skin Probe
Appendix Three
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 11 of 13
Resuscitaire Checklist Documentation
Ward………………………Resuscitaire
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EBME Code (Red & White ID Code)…………………
The resuscitaire contents (See laminated check list attached to resuscitaire) to be
checked and documented a minimum of once a day.
On the first day of each month all contents checked, items to expire that month are to
be replaced.
If the resuscitaire is used it must be checked and missing items are to be replaced.
DATE
Dd/mm/yy
Checked as per
equipment list?
Medical Gas
supply checked
Comments / Actions
Taken
SIGNATURE
Please send this form to the Resuscitation Officer each month – Critical Care Support Services Office,
CGH. Also make a copy and send it to Elke Cattermole for Delivery Suite / Lexden and Jenny Collins for
Jenny Collins For Midwifery Led Units
Appendix Four
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 12 of 13
Resuscitation Equipment List for Home Births/ Halstead Birthing Centre
Each midwife is responsible for ensuring their equipment is checked and
that the portable suction equipment is taken to the birth.
Disposable Bag valve mask with reservoir bag and size 00/01 round facemasks –
disposable and Oxygen connection tubing
Oropharyngeal airways: Sizes 000; 00; 0; & 1 (Guedal)
Hats – Small Medium Large
Towels
Clear Plastic bag (for unexpected Premature births)
Suction Tubing
Paediatric Yankauer Mini Sucker
Argyle Suction Catheter Size 10ch
Argyle Suction Catheter Size 12ch
Oxygen Cylinder (Size D) more than 3/4 FULL & TURNED OFF
Date of Original document; July 2001
Date Amended: April 2012 Version 4
Review date; April 2015
X1
X 1 each
X1 each
X2
X1
X1
X1
X1
X1
X1
Guidelines Newborn Resuscitation
Guideline No: 1.5
Page 13 of 13

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