Guideline for the Resuscitation of the Newborn Infant at Birth University Hospitals of Leicester NHS NHS Trust Jan 2017 Jan 2020 Scope: This guideline is aimed at all Health Care Professionals involved in the care of infants at the time of delivery. Legal Liability (standard UHL statement): Guidelines issued and approved by the Trust are considered to represent best practice. Staff may only exceptionally depart from any relevant Trust guidelines providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible health professional it is fully appropriate and justifiable such decisions to be fully recorded in the patient s notes. Related UHL documents: Meconium Aspiration Guideline Persistent Pulmonary Hypertension of the Newborn Therapeutic hypothermia Difficult Airway Guideline Key Points 1. All staff involved with the care of newborn babies should be able to commence neonatal resuscitation 2. Resuscitation should be performed in line with the Resuscitation Council UK Newborn Life Support Guidelines 2015(1) 3. All registered staff should be current NLS providers Contents 1) Indications for Neonatal Attendance at Delivery within the hospital setting 2) Suggested resuscitation team 3) Resuscitation Equipment 4) Newborn Life Support Algorithm 5) Cord Clamping 6) Oxygen saturation monitoring 7) Deliveries outside the hospital setting 8) Advanced Resuscitation and Special Cases Appendix A Equipment for neonatal resuscitation on Delivery suite and postnatal Wards in UHL Appendix B Equipment for neonatal resuscitation in the Special Care Nursery Appendix C Equipment for neonatal resuscitation in the Community setting Appendix D Delivery Suite resuscitation summary form Resuscitation of the newborn infant at birth Author:Jonathan Cusack Consultant Neonatologist Contact: Neonatal Guidelines Lead Approved by: Neonatal Guidelines and Governance Groups The definitive version is held on Badgernet library and on Sharepoint Page 1 of 16 November 2014 Last review: Jan 2017 Next Review: Jan 2020
1) Indications for Neonatal Attendance at Delivery within the Hospital Setting Preterm delivery < 35 weeks completed gestation. Multiple pregnancy. Breech presentation. Known significant congenital abnormality (an abnormality which may cause difficulty at delivery or increase the likelihood of requirement for resuscitation.) Meconium-stained liquor Fetal distress. Emergency Caesarean section. Instrumental deliveries for fetal distress Deliveries where there are midwifery or obstetric concerns about the health of the baby 2) Suggested Resuscitation Team Infants > 32 weeks: Midwife Junior trainee or Advanced Nurse Practitioner Preterm infants 29-32 weeks and Term infants with fetal compromise: Midwife Junior Trainee or Advanced Nurse Practitioner Senior Trainee or Advanced Nurse Practitioner Neonatal Nurse with intensive care qualification Preterm infants 23-28 completed weeks gestation: Midwife Junior Trainee or Advanced Nurse Practitioner Senior Trainee or Advanced Nurse Practitioner Neonatal Nurse with intensive care qualification The Neonatal Consultant should be made aware of the delivery; The team should be led by someone with advanced resuscitation skills. The consultant may attend depending on the experience of the available staff It would not be usual practice to offer resuscitation to babies of less than 23+0 weeks gestation. If there is a doubt about the gestation at the limits of viability, senior help should be sought. Resuscitation of the newborn infant at birth Page 2 of 16
In an emergency, contact switchboard by dialling 2222 and ask for the Neonatal Team. This will call the junior trainee, the senior trainee and a neonatal nurse. A Consultant Neonatologist is available at all times by telephone: contact via switchboard. 3) Equipment Appendices A-D list suggested equipment for deliveries within the hospital and community settings. Resuscitation of the newborn infant at birth Page 3 of 16
4) UK Resus Council - Newborn Life Support Algorithm 2015 Resuscitation of the newborn infant at birth Page 4 of 16
5) Cord Clamping Following the delivery, provided the baby can be kept warm, there should be a delay of at least 60 seconds prior to cutting the cord. The baby can be assessed during this time. If the baby is in need of resuscitation, this takes priority: the cord should be cut and resuscitation should be started (2) Further studies regarding cord clamping during resuscitation in preterm babies are underway. 6) Oxygen Saturation Monitoring Current national guidelines (1) suggest commencing resuscitation using room air. If a baby fails to respond to initial resuscitation consider using supplemental oxygen. Oxygen saturation monitoring should be used, and supplemental oxygen should be titrated according to response. For resuscitation in hospital, a saturation monitor will be brought from the neonatal unit, when a need for resuscitation is anticipated or additional help at resuscitation is requested. Oxygen saturation should be measured in the right hand: In the arrest situation or where there is severe circulatory compromise, oxygen saturation monitoring may become unreliable. Oxygen should be considered and the heart rate assessed by auscultation. 7) Deliveries Outside of the Hospital Setting There should be two Midwives present at a planned birth that occurs in the community setting; one midwife to take responsibility for the mother and one to take responsibility for the baby. It is the responsibility of the Midwife to check his/her own equipment regularly on a routine basis and prior to every planned community birth. Deliveries outside of the hospital setting should be approached using the standard NLS guidelines outlined above. Resuscitation of the newborn infant at birth Page 5 of 16
Care should be taken to keep the baby warm. Preterm babies should be dried and wrapped in a warm towel: plastic bags should not be used unless a radiant warmer is available. Help should be called for babies that are in need of resuscitation outside of the hospital setting. An emergency ambulance should be requested by dialling 999. All neonatal intensive care is now performed at Leicester Royal Infirmary. Any baby in need of resuscitation should be transferred to Leicester Royal Infirmary. Delivery suite at the Royal Infirmary should be notified and the baby should be brought to the Delivery Suite at the Leicester Royal Infirmary 8) Advanced Resuscitation and Special Cases At all resuscitations, the priority is to manage the airway in line with NLS guidelines. The following special situations are considered: Advanced resuscitation should follow the Resus Council Advanced Resuscitation of the Newborn Infant Algorithm: Resuscitation of the newborn infant at birth Page 6 of 16
Meconium stained liquor: See also: Meconium Aspiration Guideline If the baby is vigorous, the airway is not obstructed: the standard NLS algorithm should be followed (3) If the baby is floppy and not breathing, the airway should be suctioned under direct vision. There should not be a delay in administering inflation breaths. Resuscitation of the newborn infant at birth Page 7 of 16
If the airway is obstructed by meconium and you have the skills to do so, consider intubation and suction of the airway using a large bore suction catheter or a meconium aspirator. Once the airway is cleared, resuscitation should follow the standard NLS algorithm. Preterm babies <30 weeks gestation born in hospital: Babies should be placed in a plastic bag without drying and nursed under a radiant heater.(4) Inflation breaths should commence at a pressure of 20-25 cm H20 PEEP should be used and ventilation pressures should be adjusted according to response. Consider elective intubation and surfactant treatment on delivery suite for babies of less than or equal to 28 weeks gestation. Babies at risk of Perinatal Asphyxia: See also: therapeutic hypothermia guideline Babies at risk of perinatal asphyxia may benefit from therapeutic hypothermia following resuscitation If there is a cord ph of <7.0 or a prolonged resuscitation consider passive cooling and seek expert senior advice Babies who require intubation: Following intubation, confirm endotracheal tube position by auscultation Apply an end-tidal carbon dioxide sensor (e.g.pedicap) and confirm the presence of CO2 If there are any doubts about endotracheal tube position, remove the tube and recommence ventilation using a mask with additional airway techniques as required Remember that colour change capnography is unreliable in babies with a poor cardiac output and in some small preterm babies. Capnography is a useful adjunct and should be used to confirm tube placement in conjunction with other clinical signs Resuscitation of the newborn infant at birth Page 8 of 16
Babies who require drugs during resuscitation Medications should be given in line with NLS guidelines: Drug Estimated Infant weight 1000g (1Kg) Estimated Infant Weight 2000g (2Kg) Estimated Infant weight 3000g (3Kg) Adrenaline 1 in 10,000 (1st dose = 0.1ml/Kg) 0.1 ml (10 microgram) 0.2 ml (20 micrograms) 0.3 ml (30 micrograms) Adrenaline 1 in 10,000 (2 nd dose = 0.3ml/Kg following bicarbonate) 0.3 ml (30 micrograms) 0.6 ml 60 micrograms) 0.9 ml (90 micrograms) 4.2 % Sodium Bicarbonate (2mmols/Kg) 4 ml (2 mmols) 8 ml (4 mmol) 12 ml (6 mmol) 10% Dextrose (2.5 ml/kg) 2.5 ml 5 ml 7.5 ml Volume (0.9% Saline or Blood) 10 20 ml 20 40 ml 30 60ml Babies who fail to respond to resuscitation: If there is no response after 10 minutes of good quality resuscitation, the prognosis is very poor and resuscitation should be discontinued after discussion with the team. A Consultant Neonatologist is always available by telephone for advice if needed and can be contacted via switchboard Resuscitation of the newborn infant at birth Page 9 of 16
Appendix A Equipment for neonatal resuscitation on Delivery suite and postnatal Wards in UHL 3 warm towels Medium gloves Stethoscope Yankhauer sucker and spares Suction catheter 8-10F (blue / black) Guedal airways ( 0, 00 and 000) Bag and mask T piece (meconium aspirator) Various mask sizes (small and large) 2 laryngoscopes (short and long blade) Spare batteries and spare bulbs ET tubes (2.5 / 3.0 / 3.5 / 4.0) at least 3 of each ET introducer ET hat (various sizes) ET tube clamps (2.0 / 2.5 / 3.0 / 3.5 / 4.0) Artery forceps Syringes (1 / 2 / 5 / 10 / 20mls) at least 5 of each Needles (orange / blue / green) NG tubes (sizes 5 / 6 / 8) Colour change capnography (eg Pedicap) Other checks: As well as checking the presence of the above the following should also be checked: Box of emergency drugs Oxygen and air cylinders present and working Working heater Working clock Working suction Working oxygen supply from the wall Working overhead light Any missing equipment must be replaced immediately. Malfunctioning equipment must be removed from service and replaced with correctly functioning equivalent equipment. Equipment for neonatal resuscitation is held in the Paediatric Resuscitation area in the Childrens Emergency department (ED) There is a box of equipment for managing a difficult neonatal airway on both neonatal units (see difficult airway guideline) Resuscitation of the newborn infant at birth Page 10 of 16 Contact: Neonatal Guidelines Lead Last review: March 2015 Approved by: Neonatal Guidelines and Governance Groups Next Review: March 2018 Guideline Register No: B--/2008 DMS ID Number: 10333 The definitive version is held on the Document Management System (DMS).
Appendix B Equipment for neonatal resuscitation in the Special Care Nursery Item T piece resuscitation device (eg Neopuff / Tom Thumb device) Laryngoscope / Airways Suction Heater / Light Timer Other Equipment Checks Flow meter able to be set to 8L/min Blender able to be change from air to 100% oxygen T piece set appropriately to 20 / 5 Maximum pressure valve set to 35 1 x 00 mask 1 x 01 mask Spare ventilator tubing 1 x handle working with batteries inside 1 x 00 blade 1 x 01 blade 1 x 1 blade 1 x 000 Guedel airway 1 x 00 Guedel airway 1 x 0 Guedel airway 1 x 1 Guedel airway Working 1 x Yankhauer 3 x black catheter 3 x blue catheter 3 x green catheter Device is movable Light is working Heater is working Working and powered Stethoscope Resuscitation of the newborn infant at birth Page 11 of 16 Contact: Neonatal Guidelines Lead Last review: March 2015 Approved by: Neonatal Guidelines and Governance Groups Next Review: March 2018 Guideline Register No: B--/2008 DMS ID Number: 10333 The definitive version is held on the Document Management System (DMS).
Appendix C Equipment for neonatal resuscitation in the Community setting (includes St. Mary s Birth Centre) 1. Clock or watch with second hand 2. Light source 3. Oxygen cylinders 4. TransWarmer heated mattress 5. Towels warmed when required for use (provided by parents) 6. Hat for baby (provided by parents) 7. Guedel airways (size 00 and 0) 8. Stethoscope 9. Cord clamps 10. Suction apparatus (trigger action recommended) The NLS course trains all candidates in the use of laryngoscopes and suction devices where appropriate. In line with national standards, the neonatal unit would support the use of a laryngoscope to directly visualize the oropharynx in cases of airway obstruction with foreign material. Resuscitation of the newborn infant at birth Page 12 of 16
Appendix D Delivery Suite resuscitation summary form Delivery Suite Resuscitation Summary Baby s Name Date Time of paediatric arrival Unit Number Time of Birth Infant dried and wrapped Assessment Colour Pink Blue White Breathing Regular Irregular Nil Heart Rate > 100 < 100 (slow) Nil Tone Good Poor Nil Time of initial assessment 5 minute Apgar 10 minute Apgar Resuscitation and Response TIME (in minutes) INTERVENTION / CONDITION Resuscitation of the newborn infant at birth Page 13 of 16
Blood Tests Time Site ph pco 2 BE Glucose Signature of Person completing form at resuscitation Print Name Time Arrival on NNU Temperature Communication and Comments Signature of Medical Staff Print Name Signature of Nursing / Midwifery Staff Print Name Resuscitation of the newborn infant at birth Page 14 of 16
Monitoring: Monitoring Process for monitoring: How often will monitoring take place: Population: Person responsible for monitoring: Auditable standards: Results reported to: Action plan to be signed off by: Person responsible for completion of action plan: Audit of documentation of availability and readiness for use of resuscitation equipment in all care settings Audit of records of resuscitation training for all registered staff attending neonatal resuscitation Monthly N/A Head of Nursing responsible for Quality Metrics; matron for ED; Senior Midwife for Community There is continual availability of resuscitation equipment in all care settings Resuscitation equipment is checked, stocked and fit for use in all care settings All registered staff attending neonatal resuscitation are trained in neonatal resuscitation techniques Neonatal Governance Group Maternity Governance Group Neonatal Governance Group Maternity Governance Group Senior Midwives for Intrapartum Services Resuscitation of the newborn infant at birth Page 15 of 16
References 1. Resuscitation Council UK: Newborn Life Support 4 rd Edition 2015 2. 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2010; 81S: e21-25 3. Vain NE et al. Oropharyngeal and nasopharyngeal suctioning of meconium stained neonates before delivery of their shoulders: multicentre randomised controlled trial. Lancet 2004; 364: 597-602. 4. Vohra S et al. Heat Loss Prevention (HeLP) in the delivery room: A randomised controlled trial of polyethylene occlusive skin wrapping in very preterm infants. Pediatrics 2004; 145: 750-3. 5. Resuscitation Council UK: Advanced Life Support First Edition 2014 Link to current Resuscitation Council Guidelines: https://www.resus.org.uk/resuscitation-guidelines/ Guideline Development 3/3/2015 Neonatal Guidelines Meeting 17/03/2015 Neonatal Governance Meeting Dec 2016 Guideline amended - New resuscitation algorithm Dec 2016 Neonatal Guidelines Meeting Jan 2017 Neonatal Governance Meeting Resuscitation of the newborn infant at birth Page 16 of 16