Infant StablizationLET’S WATCH!
•How many babies expected?
•Any additional risk factors?
•Dry and stimulate
(DAVIDSON ET AL., 2020; WEINER, ZAICHKIN, & KATTWINKEL, 2016)
INITIAL STEPS
•Interventions
1 min 60-65%
2 min 65-70%
3 min 70-75%
4 min 75-80%
5 min 80-85%
10 min 85-95%
WHEN SHOULD RESUSCITATION BE INITIATED ON A NEWBORN?
A. After the one minute apgar if apgar score is <7
B. Before one minute if indicated by baby’s physical condition
C. Concurrent with the one minute apgar if score is <6
STABILIZATION
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Indications:
•Apnea
•Gasping
•Appears to be breathing but heart rate less than 100 bmp
•If the infant has not responded to initial steps within 1 minute of life, it is not appropriate to continue providing tactile stimulation
POSITIVE PRESSURE VENTILATION (PPV)
•PPV of a preterm newborn should be administered with a device that can give PEEP (positive end airway pressure)
•A rising HR is the most important indication of successful PPV
•The newborn’s HR should increase within the first 15 seconds of PPV
•If HR is not increasing, perform corrective measures (MR SOPA)
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•P – Increase pressure if no chest rise
•A – Consider alternate airway (intubate or LMA)
PPV
•Continue PPV at a rate of 40-60 breaths/minute
•If HR 60-99 bpm
•If HR less than 60 bpm
•Reassess ventilation, preform corrective measures, adjust oxygen concentration, insert alternative airway (ETT/LMA)
•If no improvement in HR but chest is moving
• Increase to 100% oxygen and begin chest compressions
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ASSESSMENT OF THE HEART RATE
•Initial assessment made with stethoscope
•If unable to assess and newborn is not vigorous, quickly connect to pulse oximetry and ECG leads
•When starting PPV, consider using cardiac monitor for accurate assessment HR
•An electronic cardiac monitor is the preferred method for assessing HR during chest compressions
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OXYGEN MANAGEMENT
•Free flow may begin with 30% oxygen using a blender, adjust as needed
•Newborns with labored breathing or those unable to maintain oxygen sats with 100% oxygen, consider CPAP
•PPV of newborns greater than 35 weeks should begin with 21% oxygen
•PPV of newborns less than 35 weeks begins with 21-30% oxygen
CHEST COMPRESSIONS
•3:1 Compressions: Ventilation ratio
SPECIAL CONSIDERATIONS FOR PRETERM INFANTS
•Increase room temperature in the room the newborn will receive initial care to 74 - 77 degrees
•For newborns less than 32 weeks
•Cover the newborn in food-grade plastic wrap or bag. Use a hat and thermal mattress
•Use cardiac monitor
• If newborn is breathing, consider using CPAP immediately after birth as alternative to intubation and surfactant administration
MECONIUM STAINED AMNIOTIC FLUID
•Newborns with meconium stained fluid (vigorous and non-vigorous) do NOT require routine intubation and tracheal suctioning
•Meconium stained fluid is a perinatal risk factor that requires the presence of one team member that I a trained for full resuscitation including intubation
•Initial steps may be performed at the radiant warmer
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SCENARIOS
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APGAR
•Assessment of physiologic state of neonate at birth and response to resuscitation
•Five categories for scoring:
APGAR
•Performed at 1 and 5 minutes of age
•Every 5 minutes for up to 20 minutes for score < 7
•Scoring reflects adjustment to extrauterine life:
•7-10 = reassuring, good condition, requiring only nasopharyngeal suctioning
•4-6 = moderately abnormal, need for stimulation
•0-3 = low, need for resuscitation
(AAP & ACOG, 2017; DAVIDSON ET AL., 2020)
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A Activity/Muscle Tone Limp Some flexing of
arms & legs
Active motion
G Grimace/Reflex Absent Grimace;
hands/feet blue
Completely pink
weak cry
APGAR – EXPANDED FORM
(AAP & ACOG, 2017)
APGAR SCENARIO - 1
•You’re assessing the one minute APGAR score of a newborn baby. On assessment, you note the following: heart rate 125, pink body and hands with cyanotic feet, weak cry, flexion of the arms and legs, active withdrawal and crying when stimulated. What is the neonate’s APGAR score?
A. 5
B. 8
C. 9
APGAR SCENARIO - 2
•You’re assessing the one minute APGAR score of a newborn baby. On assessment, you note the following: heart rate 105, cyanotic body and extremities, minimal response to stimulation, some flexion of extremities, and weak cry. What is the neonate’s APGAR score?
A. 5
B. 6
C. 7
APGAR SCENARIO - 3
•You’re assessing the one minute APGAR score of a newborn baby. On assessment, you note the following: weak cry, flexion of the arm and legs, active movement and cries to stimulation, heart rate 145, and pallor all over the body and extremities. What is the neonate’s APGAR score?
A. 6
B. 7
C. 8
APGAR SCENARIO - 4
•You’re assessing the five minute APGAR score of a newborn baby. On assessment, you note the following: pink body and hand with cyanotic feet, heart rate 109, grimace to stimulation, flaccid, and irregular cry. What is the neonate’s APGAR score?
A. 3
B. 4
C. 5
APGAR SCENARIO - 5
•You’re assessing the five minute APGAR score of a newborn baby. On assessment, you note the following: heart rate 97, no response to stimulation, flaccid, absent respirations, cyanotic throughout. What is your patient’s APGAR score?
A. 0
B. 1
C. 2
APGAR SCENARIO - 5
Which of the following nursing interventions will you provide to this newborn?
A. Some resuscitation assistance such as stimulation and oxygen administration, reassess APGAR score in 5 minutes
B. Administer PPV and reassess APGAR score in 5 minutes
C. Full resuscitation assistance (PPV and compressions) and reassess APGAR score in 5 minutes
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•Early term – 37 0/7 – 38 6/7 weeks
•Full term – 39 0/7 – 40 6/7 weeks
•Late term – 41 0/7 – 41 6/7 weeks
•Postterm – 42 0/7 and beyond
(DAVIDSON ET AL., 2020)
GESTATIONAL AGE ASSESSMENT
New Ballard Score •Measures infants as young as 20 weeks •Assesses 6 external physical and 6 neuromuscular signs •Each is assigned a score, cumulative score = maturity rating (GA) •Most accurate within 48 hours • Infants < 26 weeks – perform assessment at postnatal age of less than 12 hours • Infants >26 weeks – may be performed up to 96 hours after birth
•Neuromuscular adjustments after birth in extremely preterm infants requires a follow-up examination to validate findings •www.Ballardscore.com
(DAVIDSON ET AL., 2020; LOWDERMILK ET AL., 2020)
NEW BALLARD SCORE
•Intrauterine Growth Restriction (IUGR)
•Common complications of SGA/IUGR
(DAVIDSON ET AL., 2020)
•Head circumference
•Length
(DAVIDSON ET AL., 2020)
•Lung changes
•Symptoms
•Signs of respiratory distress for 1-2 hours after birth
•Resolves within 48-72 hours
•Intermittent grunting, nasal flaring, mild retractions
•Supplemental O2
•Lab
American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (2017). Guidelines for perinatal care (8th ed.). American College of Obstetricians.
Davidson, M., London, M., & Ladewig, P. (2020). Olds’ maternal-newborn nursing & women’s health across the lifespan (11th ed.). Pearson Education, Inc.
Lowdermilk, D. L., Perry, S.E., Cashion, K., & Alden, K. R. (2020). Maternity & womens’s health care (12th ed.). Elsevier.
Weiner, G. M., Zaichkin, J., & Kattwinkel, J. (Eds.) (2016). Textbook of neonatal resuscitation (7th ed.). American Academy of Pediatrics.
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