Learning Objectives
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Understand the basic steps of resuscitation of a newborn per Neonatal Resuscitation Program (NRP) guidelines.
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Anticipate the needs of a preterm infant at delivery and review the management of a preterm infant in the delivery room.
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List effective strategies in resuscitation of a preterm infant.
Preterm delivery is defined as delivery at <37 weeks gestation. In United States, the preterm birth rate is 9.9% of all births . With a history of preterm birth, there is a 22% increased risk of having a preterm birth in following pregnancy. There is an inverse relationship between gestational age at delivery and the risk of neonatal morbidity and mortality. Neonatal resuscitation is the most commonly provided form of resuscitation in the hospitals. Approximately 6–10% of very low birthweight and extremely low birthweight infants are reported to receive extensive cardiopulmonary resuscitation at birth. Teams providing neonatal resuscitation must always be prepared to provide this life-saving resuscitation at every delivery. Simulation-based training of the resuscitation teams will improve the cognitive, technical, and behavioral skills. Newborn resuscitation training should be recurrent and should occur more frequently than once per year to maintain optimal performance.
Risk Factors for Preterm Birth
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African-American race
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Extremes of maternal age
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Multifetal gestation
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Preterm labor/preterm premature rupture of membranes
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Preeclampsia/eclampsia
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Fetal growth restriction
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Fetal anomalies
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Maternal substance abuse
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Uterine anomalies
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Placental abnormalities/abruptio placenta
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Trauma
Delivery Room Checklist
General
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Room temperature 74–77°F
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Team briefing
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Introduce and assign roles
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Ask the following four prebirth questions:
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What is the expected gestational age?
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Is the amniotic fluid clear?
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How many babies are expected?
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Are there any additional risk factors?
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Assemble the necessary equipment and supplies
Nursing
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Radiant warmer on MANUAL and preheat, temperature probe and cover, hat, warm towels
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Bulb syringe
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Stethoscope
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Warming mattress, Neowrap or plastic bag if <32 weeks
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EKG leads
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Fluids/syringes and medications (normal saline, epinephrine 1: 10,000)
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Supplies for umbilical venous lines
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Supplies to document the events
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Know when and how to call for additional help if required
Respiratory therapy
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Surfactant and tubing
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Set up T piece resuscitator (initial settings PIP 20–25 cm H 2 O, PEEP 5–6 cm H 2 O (titrate PIP up, as needed) ( Fig. 3.1 )
Fig. 3.1
Resuscitation with (A) T-piece adaptor and (B) Neopuff.
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Flow-inflating or self-inflating bag ( Fig. 3.2 )
Fig. 3.2
Flow-inflating bag.
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Neonatal facemasks
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Laryngoscopes (straight blades with sizes 00,0 and 1) and endotracheal tubes (sizes 2.5, 3.0, 3.5) and LMA (size 1) ( Fig. 3.3 )
Fig. 3.3
Examples of (A) laryngoscopes and (B) endotracheal tubes.
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Carbon dioxide detector
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Meconium aspirator
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Endotracheal tube securing device
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Oxygen (blender set to 21% (21%–30% if <35 weeks gestation))
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Pulse oximeter with sensor and cover
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Preductal target oxygen saturation card
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10 or 12F suction catheter attached to wall suction, set at 80–100 mmHg
Management of a Preterm Infant at Birth per NRP Guidelines
Preparing for the preterm birth
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Assemble the team
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Team briefing
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Assess perinatal risk factors
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Review roles and delegate tasks
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Review the checklist and perform equipment check
After delivery of the infant
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Assess the need for delayed cord clamping (per unit policy)
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Place the infant on the back under radiant warmer on warm blankets covered thermal mattress
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Position the head and neck in “sniffing” position
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Cover with plastic wrap
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Place a hat
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Assess breathing, heart rate (HR) with stethoscope and tone
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Stimulate. Suction gently only if necessary (mouth before nose)
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Place the temperature probe and change to servo-control
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Pulse oximeter probe to the right hand
Interventions based on assessment ( Table 3.1 )
