Pages

Tuesday, March 5, 2013

Attending Neonatal Deliveries And Performing Resuscitation – some notes


If you are in any doubt about your neonatal resuscitation technique or using the Resuscitaire during the initial induction training, please ensure you let your team know, and ask your registrar if he can come with you when you are called to your first delivery.   


It is recommended to attend the NLS (Neonatal Life Support) course – forms available from the resuscitation officer.  Click here for the basic NLS protocol


Pre-delivery

To state the obvious, gestation really matters; here's an example protocol of who should be there with you at a delivery:
  • 28 weeks or less
    • The full neonatal team is needed at delivery - your registrar and experienced neonatal nurse(s). 
    • Baby should be immediately placed into a food grade plastic bag without drying after birth under radiant heater. 
    • Neonatal nurse should bring the ‘grab bag’ (transparent bag containing intubation equipment and umbilical lines) and saturation monitor to the delivery room. 
    • Neonate should be transported from delivery room to NICU in a transport incubator 
  • 28 – 31 week 
    • Inform registrar and senior neonatal nurse and discuss whether steps above needed based on history
    • You should have registrar in attendance until confident 
  • 32 weeks plus 
    • if no complicating issues you should be able to manage these neonates on your own with increasing experience
Cardiotocographs (CTG)

You will be often called to a delivery because of a "pathological CTG".  More often than not, your baby will respond well to drying.  But beware of talk of prolonged bradycardia, prolonged decelerations, late deceletations or a sinusoidal pattern.  If this is coupled with the presence of thick meconium, beware even more.  This CTG Guide may be useful for some basic understanding.

At delivery

The NLS Algorithm should be known; some notes to the algorithm above:
  • Know your resuscitaire well.  Ensure you know how to set PIP and PEEP; in term babies PIP is set to 30 cm H20 and your PEEP to 5cm H20 before delivery.  Ensure you know how to adjust these settings and how to test it (don’t assume it will be set up for you - occasionally you will find the PEEP set too high or to 0).  Note that in many hospitals the T-Piece provided as standards may not have a PEEP valve 
  • Make sure you have a size 0 face mask available for preterm neonates 32 weeks or less (default is size 1).  PIP is typically 20-25cm H20.  
  •  Always remember to start the clock once the baby is delivered (ideally when the cord is cut).  It can be easily forgotten and is crucial in helping you decide when you need help.  Ensure the warmer is set too 
  • Assuming the baby is older than 30 weeks, first ensure the baby is dried well and the wet towel removed (Neonates of  30 weeks or less should be immediately placed into a food grade plastic bag without drying after birth under a radiant heater).  The only exception to this is floppy apnoeic babies born in thick meconium - see below
  • It sounds obvious, but when you are picking up the baby to get the wet towel removed, remember to support the baby's head with one of your hands! As I have learnt, rushing to pick up the baby with its head lolling around does not breed confidence in those around you.
  •  Remember to check for tone in addition to breathing and heart rate – it is a crucial part of the assessment.  The easiest way to do this is to pick up an arm and drop it 
  • Don’t rely on cord pulsation to check the heart rate
  • Remember to give adequate time for your inflation breaths – 2 to 3 seconds.  Look to see if the chest is rising and look at your airway pressure meter while giving breaths to see that 30cm H20 is reached 
  • If a baby delivered through meconium is floppy and apnoeic, then you should consider rapidly inspecting the laryngo-pharynx using laryngoscope and suction catheter to remove obstructions before applying inflation breaths.  Call for help early if you are in any doubt that your efforts are working.
  • Chest compressions should be rarely needed; if heart rate is not responding to your 5 inflation breaths and you are not sure that the chest is rising, reposition your away and consider using a 2 person ventilation technique with jaw-thrust; do not move to CPR if the chest is not rising.  If the heart rate is responding by increasing then you know your inflation breaths are effective even if the chest rise intially might not be that great.  Call for help early if you are in any doubt that your efforts are working. 
  • If a baby is making active respiratory effort but showing signs of respiratory distress, you can attempt to give a short period PEEP (if your T-Piece has a PEEP valve) via the facial mask – apply the face mask without occluding the T piece.  However, there is evidence to suggest that in term babies, this may increase the risk of pneumothorax.

No comments:

Post a Comment