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Newsletters > NIHE Talks Health April 2013
NIHE Talks Health April 2013

Apr 26, 2013

NIHE TALKS HEALTH—April 2013*
www.nationalhearted.com
*Look for the coupon at the bottom of this newsletter good for $20 off any ACLS Provider class registered on our website www.nationalhearted.com . This offer is good for any registration placed before May 6, 2013. We offer NO STRESS classes where you get your AHA card the day of the class, no waiting for it to be mailed to you, when you pre-register for the class.
In this issue:
1.    2013 Schedule of Classes posted on our website: www.nationalhearted.com Register NOW!!
2.   Enjoy our Heart Healthy Entree recipes for quick healthy meals!
3.   FREE CE course: “Neonatal Resuscitation Provider Review Part 1.”
4.   ACLS and PALS Prep courses. Get CE credit and be fully prepared for your ACLS or PALS class! See Dr. Stonebraker lecture live in our video based classes!
5.   April’s Coupon good for $20 off ALL ACLS Provider classes registered online in before May 6 , 2013
6.   Get a 50% discount for putting together a private class at your location. We bring ACLS, PALS, BLS, or NRP to your location for the same price as our regular classes if you have 8 or more students. The organizer gets 50% off the price of their certification just for organizing the class. Contact our program director at nihe@earthlink.net or call 800-773-8895 for details.
Heart healthy Entree Recipes for April 2013.
Eating a diet rich in foods as they are grown is one of the best ways to lower your risk for cancer, heart disease, diabetes, osteoporosis, and many more lifestyle diseases. Here are a couple of recipes that I use regularly. For a recipe to become a favorite in our household it not only has to be nutritious but it also, needs to taste good and be easy to prepare. Also, they need to be easy to prepare as like many folks we are extremely busy and don’t always have a lot of time to prepare healthy food.
Spanakopita (Spinach Pie)
2 bags frozen chopped spinach 1 onion chopped ½ tsp. salt or to taste
3-4 tsp. minced garlic Olive oil 1 pkg. phyllo dough
Tofu Cottage Cheese (see recipe to follow)
Saute onion and garlic in a little water. Cook spinach, & while cooking, add the sautéed onion, garlic, & salt. Add tofu cottage cheese to spinach while it cooks. In a 9 x 13 pan put 4-5 layers of phyllo dough on top of spinach. With a pastry brush, brush olive oil on the phyllo dough. Put 5-6 layers of the phyllo dough on the top, brushing each layer with the olive oil. Cut the spinach pie with a sharp knife into the size portions you want to serve. Then bake at 350 degress for 45 minutes. The phyllo dough should be slightly browned & crispy. Leftovers can be refrigerated and reheated . Serves 8
Tofu Cottage Cheese
4 cups tofu, extra firm, water packed 1 ½ tsp. salt 2 ¼ tsp. onion powder
½ tsp. garlic salt ¾ cup Better Than Sour Cream (tofu sour cream found at
better grocery stores
2 Tbs. chives 1-2 Tbs. lemon juice
Squeeze excess water out of the tofu by pressing ofu block between your hands. Crumble tofu in a bowl & add seasonings. Add lemon juice to the Better Than Sour Cream. Stir into tofu mixture. Mix in the chives. Makes four cups.

Roasted Cauliflower & Broccoli
4-5 cups of broccoli, stems trimmed 4-5 cups of cauliflower, stems trimmed
5-6 cloves of garlic, cut in long strips salt to taste
3-4 Tbs. extra virgin olive oil 1 fresh lemon
Wash vegetables & trim stems. Put veggies in a bowl & add garlic strips & salt, & drizzle olive oil on top. Mix veggie well & put on a cookie sheet & bake at 425 degrees for 20-25 minutes until tender. After baking squeeze the juie from a fresh lemon 7 drizzle over the vegetables. Serves 6-8

Is Your AHA ACLS, PALS, BLS, or NRP due to expire or do you need the full Provider class? We have lots of NO STRESS classes throughout California everyday as well as, the only AHA online BLS, AHA online ACLS, and AHA online PALS that will get you an AHA card. Upcoming ACLS, PALS, BLS, & NRP classes in: San Francisco, CA; Sacramento, CA; Loma Linda/Colton, CA, Torrance, CA, Fremont, CA; Walnut Creek, CA; Vacaville, CA; Culver City, CA; Pasadena, CA; San Jose, CA; Sherman Oaks, Ca; & Burbank, CA. Check out our website: www.nationalhearted.com for dates and times.

2013 Schedule of Classes is here!!
Go to www.nationalhearted.com and check out the Register Now pages. Click on your area and you will be taken to the registration page with all the new dates. Our calendar pages are still being updated but the Register Now pages are done for 2013!
Upcoming ACLS, PALS, BLS, & NRP classes in: San Francisco, CA; Sacramento, CA; Loma Linda/Colton, CA, Torrance, CA, Fremont, CA; Walnut Creek, CA; Vacaville, CA; Culver City, CA; Pasadena, CA; San Jose, CA; Sherman Oaks, Ca; & Burbank, CA. Check out our website: www.nationalhearted.com for dates and times. Always get your AHA card the day you complete the class.
Is Your AHA ACLS, PALS, BLS, or NRP due to expire or do you need the full Provider class? We have lots of NO STRESS classes throughout California everyday as well as, the only AHA online BLS, AHA online ACLS, and AHA online PALS that will get you an AHA card.

NEW ACLS & PALS Prep Courses Featured on our Website
If you need a little help preparing for your upcoming ACLS or PALS class check out our website, www.nationalhearted.com and click on the "Online CE" page for some great NEW ONLINE CE courses. ACLS Prep and PALS Prep cover how to identify the EKGs needed so that you can use the algorithms appropriately. They are great for not only preparing for your ACLS or PALS class but also, for follow-up to reinforce what you learn at the class. There are also, some great online courses about stroke.
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Do you need even more help to prepare for your ACLS or PALS class?
If you want a text that covers not only what to do during a code, check out the ACLS In Depth and PALS In Depth Home study Courses available at www.nationalhearted.com . Get CE credit for being the best prepared student in the class. Also, available, buy just the textbook as a reference text: ACLS Study Guide and PALS Study Guide. These textbooks have all details on why as well as what to do during resuscitation. Go to our product page Buy Books and Products Now to buy the ACLS and PALS Study Guides and go to the Home Study CE to get the ACLS In Depth and PALS In Depth home study courses good for Nursing CE. CA Provider #13886.
Earn Extra Money in Your Spare Time as an AHA Instructor
Nurses, Paramedics, EMTs, & Respiratory Therapists—Become an American Heart Association Instructor and teach for us in your spare time or start your own business teaching AHA classes. It is easy to get started quickly and be qualified to start teaching AHA courses for us. If you decide to start your own business we will be happy to mentor and assist you to be successful. Call us at 909-824-0400 or go online to Become an AHA Instructor to get started making good money in your spare time today.
April’s FREE CE Course   
Neonatal Resuscitation Provider Review Part 1
Author Linnea Stonebraker R.N., Ph.D. has four decades of experience in critical care nursing and nursing education. She has started and run community health education programs in several locations and is Regional Faculty for the American Heart Association in ACLS, PALS, & BLS. She is a Regional Trainer for NRP.

The purpose of this course is to enable nurses to prepare for the updated Neonatal Resuscitation Provider Certification 6th edition course and exam. Upon successful completion of this course you will be able to:
1.   Identify the changes in physiology that occur when a baby is born.
2.   Identify the risk factors that can help predict which babies will require resuscitation
3.   The steps for resuscitating a newborn
4.   Identify the equipment and staff needed for newborn resuscitation
5.   Explain the history of the development of today’s NRP program
6.   Explain the importance of communication and teamwork during newborn resuscitation

History of Newborn Resuscitation
   In the late nineteenth and early 20th centuries resuscitation of newborn babies was fairly simple. Basic techniques such as cleaning mucous from the mouth and providing warmth were tried and if not successful the baby was determined to be “asphyxiated”. It was common practice to leave small or “weak” infants alone until they died. If healthcare providers determined that the infant was of adequate size, they would work for hours attempting to resuscitate a newborn using techniques similar to adult resuscitation of the time or by providing counter stimulus. Counter stimulus techniques believed to stimulate breathing included:
a.    Rubbing infants forcefully & placing them near a source of warmth such as a fire
b.   Hot & cold contrast baths
c.   Vigorous rubbing or slapping the infant’s buttocks
d.   Dilation of the anus including blowing smoke or air into the rectum
Adult resuscitation of the time included:
a.   Mouth to mouth similar to what was done on drowned adults
b.    Swinging infants over the shoulders of the healthcare providers as this was believed to assist in the passive extension 7 compression of the thorax, causing passive inspiration & expiration
c.   Abduction & adduction of shoulders, arms or thighs to increase & decrease the intra-thoracic capacity.

Other techniques that were used included :
a.    Drawing blood from the umbilical vein as this was believed to release pressure on the right side of the heart thus relieving asphyxia
b.   Pulling on the newborn’s tongue multiple times as it was thought this would stimulate a reflex reaction to breathe.
Starting in 1927 as a result of studies on respiratory physiology, fetal development, & neonatal physiology new techniques were developed. As an understanding of fetal transition to newborn was developed studies were conducted on animals using blood gas analysis to provide data to assist with ventilation techniques. The following techniques were developed and tried in the following two decades:
a.    Suctioning of airway to clear mucous obstruction
b.   Oxygen and carbon dioxide administration via mask or endotracheal intubation
c.   Positive pressure ventilation with either oxygen or a combination of oxygen and carbon dioxide
d.   Negative pressure ventilation
e.   Continue use of previous techniques
In the two decades between 1950 and 1970 there were multiple discoveries that grew the science of newborn resuscitation. The use of carbon dioxide was found to be of no benefit and the focus moved to oxygen delivery, clearing of airways, stimulation, providing warmth, & assisting with ventilation. New techniques developed included:
a.    Use of Apgar scores to determine the need for resuscitation
b.   Used of a rocking device to tip the infant up and down as this was thought to assist with ventilation
c.   Incubators were developed to provide warmth and were also, used in conjunction with the rocking tables.
d.   Electrophrenic stimulation via electrodes on the neck to stimulate the phrenic nerve and thus the diaphragm
e.   Positive pressure ventilation by either face mask or endotracheal intubation with direct visualization
f.   They began to measure pressure needed to ventilate newborn’s lungs, using up to 40-50 cm H2O
The National Institutes of Health funded opportunities for neonatal education during the 1970’s. This program originally called Neonatal Education Program (NEP) later was developed by the American Academy of Pediatrics (AAP) in conjunction with the American Heart Association (AHA). Today the International Liason Committee on Resuscitation (ILCOR) reviews the most recent students on resuscitation and publishes their consensus recommendations every five years.
The latest recommendations were published in October 2010 and the AAP published the 6th edition of the Textbook of Neonatal Resuscitation shortly thereafter. This book has been designed to be a self-study course. It is divided into 9 chapters covering all aspects of newborn resuscitation. In order to obtain a NRP Provider certification after completion of the self-study, the student must complete the online exam offered on the AAP NRP website and a live skill & debriefing session. As NRP provider responsibilities vary from hospital to hospital, based on licensure, experience, and training the AAP only requires successful passing of chapter 1-4 & 9 for receipt of the an NRP Provider card. However, your hospital may require some or all of the other chapters to be completed to work at their facility. Chapters successfully completed are marked on the AAP NRP Provider card.

Which babies require resuscitation?
Although fewer than 1% of newborns require extensive resuscitation, approximately 10% of newborns will require some assistance to begin breathing at birth. The 90% of newborns that make the transition from intrauterine to extrauterine life requiring little to no assistance to initiate regular, spontaneous respirations & to complete the transition from the fetal to neonatal blood-flow pattern. We will discuss identifiable risk factors that will help with identifying newborns that will be more likely to need assistance, however, the healthcare provider must always be prepared to resuscitate the newborn, as some newborns without any risk factors will require resuscitation.
ILCOR changed the order of the recommendations for child and adult resuscitation in 2010 Compression, Airway, Breathing C-A-B instead of Airway, Breathing, Compression A-B-C. Since the etiology of newborn compromise is almost always a breathing problem, the resuscitation of newborns should focus first on the establishment of an airway & providing ventilation. Therefore, A-B-C, is still the recommended sequence for newborn resuscitation.
It is recommended that every birth have at least one person trained in the resuscitation of newborns present. Higher risk or more complicated births should have additional trained personnel present. All newborns need to be assessed for resuscitation needs, be provided with warmth, be positioned for ease of breathing and have their airway cleared if needed, be dried, & stimulated to breathe. Some newborns will need supplemental oxygen, assistance with ventilation with positive pressure, and even tracheal intubation. Occasionally newborns may also, need chest compressions and medications.
Physiology of the transition from intrauterine to extrauterine life
17 days after conception the unborn baby begins to produce his/her own blood cells and by 24 days of life the unborn baby’s heart has begun to beat regularly. By 56 days of life all of the unborn baby’s organ systems are functioning including their lungs. The fetal lungs are expanded in utero, but the alveoli are filled with fluid, not air and the arterioles are constricted due to the low partial pressure of oxygen in the unborn baby. Oxygen is essential for life before and after birth. Prior to birth, all oxygen is supplied from the mother through the placential membrane from the mother’s blood to the baby’s blood. Due to the constricted blood vessels in the unborn baby’s lungs causing increased vascular resistance, most of the blood flow from the right side of the heart can’t enter the lungs. The open ductus arteriosus allows most of this blood to flow into the aorta.
After birth, the infant will not have the placenta providing oxygenated blood from the mother and will need to receive oxygen from its own lungs to sustain life. This means that in just a few seconds the fluid in the lungs must be moved out of the alveoli so that they can fill with oxygen and the blood vessels in the lungs must relax so that they can quickly deliver large amounts of blood to the alveoli to pick up the oxygen that is essential for life. Immediately after birth three steps must occur for a healthy transition to take place.
1)    Fluid in the alveoli must be absorbed and the alveoli must fill with air
2)   Umbilical arteries constrict & when the cord is clamped this removes the low resistance placental circulatory system resulting in an increase in the newborn’s blood pressure
3)   As the alveoli fill with air resulting in increased oxygen levels in the alveoli, the blood vessels in the lungs relax, decreasing resistance to blood flow through the lungs.
As a result of above steps 2 & 3 there will be a dramatic rise in the pulmonary blood flow and a decrease in blood flow through the ductus arteriosus. This results in increased oxygenated blood flowing to the left side of the heart where it is pumped out to the newborn’s body. Almost always, room air (21% oxygen) provides sufficient oxygen to initiate relaxation of the pulmonary blood vessels and cause the ductus arteriosus to begin to constrict. Most newborns initial cries are sufficient to move the fluid from their lungs and begin this process. As oxygen enters the newborn baby’s blood they will turn from grey/blue to pink. This transition process begins within a few minutes of birth but may take hours or even days to complete as it may take 12-24 hours to achieve functional closure of the ductus arteriosus and months to get full relaxation of the pulmonary vessels. Studies have shown that it may take up to 10 minutes to achieve an oxygen saturation of 90% or greater.
Problems that can occur at transition
Problems may begin before labor begins, during labor, or after birth. If the difficulty occurs in utero, either before or during labor, it is usually indicative of a compromise of the uterine or placental blood flow. The most common clinical sign of this occurring is a deceleration of the baby’s heart rate. Improving oxygen delivery to the baby by having the mother turn on her side or giving her oxygen and thus resolving this issue usually result in an improved baby’s heart rate. After birth the difficulties are more likely to be with the newborn’s airway, lungs, or both. For instance the baby’s initial breaths may not be strong enough for push the fluid out of the alveoli or if there is meconium present air may be blocked from entering the alveoli. Thus the lungs may not fill with air even when spontaneous respiration are occurring and the blood circulating through the lungs may not receive adequate oxygen. This would be inadequate ventilation. If there is excessive blood loss or neonatal ischemia or hypoxia bradycardia or poor cardiac contractility may occur resulting in systemic hypotension. If partial or complete failure of gaseous distention of the alveoli occurs after birth the pulmonary arterioles may remain constricted causing persistent pulmonary hypertension PPHN. This will result in decreased oxygen delivery to all organ systems.
When normal transition does not occur oxygen supply to most organ systems is decreased. Blood flow to the heart & brain will be maintained initially, but if oxygen deprivation continues eventually the myocardial function and cardiac output will decrease, blood pressure will fall and blood flow to all organs will decrease. The result of this oxygen deprivation to the major organs may be brain damage and even death.
The newborn that is at risk may demonstrate the following clinical findings:
1)   Depressed respiratory drive from poor oxygen delivery to the brain
2)   Bradycardia from poor oxygen delivery to the heart
3)   Tachypnea from failure to absorb fluid from the alveoli
4)   Poor muscle tone from poor oxygen delivery to the brain, organs, and muscles
5)   Hypotension from blood loss, insufficient placental blood flow before or during birth, or poor oxygen delivery to the heart
6)   Continuing cyanosis or low oxygen saturation readings on pulse oximetry as a result of poor oxygenation
These clinical findings can also, be the result of infection, hypoglycemia, or medications given to the mother prior to birth such as narcotics that result in decreased respiratory drive.
Apnea-primary & secondary

Perinatal stress may result in a period of rapid breathing followed by a period of no breathing (primary apnea). Stimulation such as drying or slapping of the feet will cause breathing to resume during primary apnea. However, if cardiorespiratory compromise continues, the newborn will have a period of resumed gasping breaths followed by another cessation of breathing. This is called secondary apnea and stimulation will not restart the newborn’s breathing once this state has been entered. Assisted ventilation must be begun immediately in order to reverse this. During primary apnea the baby’s heart rate will decrease but blood pressure will usually hold stable until the start of secondary apnea when it will begin to fall, unless the cause of the initial problem was hypotension caused by blood loss.
The healthcare provider may not be present at the onset of this cycle of events. Thus it may be difficult to initially determine if the baby is in primary or secondary apnea. Stimulating the baby will help to determine whether it is primary or secondary apnea. If the baby begins to breathe as soon as it is stimulated it is primary not secondary apnea. If not, it is secondary apnea and assisted ventilation must be begun immediately. The longer the baby has been in secondary apnea the longer it will take for spontaneous breathing to resume, however, usually positive pressure ventilation results rapidly in an increased heart rate. If it does not the baby may have been compromised so long that myocardial function has deteriorated and blood pressure has fallen. Chest compressions and possibly medications may be needed for successful resuscitation.
Newborn Assessment and Steps for Initial Resuscitation
The healthcare provider who is present at birth to care for the newborn should ask three questions to determine the initial response.
1)   Is the newborn term?
2)   Is the newborn crying or breathing?
3)   Does the newborn have good tone?
If the answer to all three questions is “yes” the baby should stay with the mother. Provide warmth by covering with a towel and placing him with his mother. If not, the initial steps of resuscitation should be started. (Note each of these steps will be covered in more detail in succeeding chapters)
Step One: Airway
1)   Provide warmth in a radiant warmer on a resuscitation table
2)   Position the head to open the airway and clear the airway as necessary. If suctioning is needed suction mouth first, then nose.
3)   Dry the baby, discarding wet towels, and stimulate to breath by tapping on feet. Reposition head to maintain open airway
4)   These steps should not take more than 30 seconds. If the newborn is not breathing or heart rate is less than 100 immediately move on to Step Two.
Step Two: Breathing
1)   Provide positive pressure ventilation PPV or continuous positive pressure airway CPAP with a mask if the baby is not breathing or the heart rate is less than 100.
2)   Attach oximeter to determine the need for supplemental oxygen. (We will discuss how to determine the need for oxygen in a later lesson.)
3)   After 30 seconds of ventilator assistance reevaluate the heart rate. Usually the ventilator assistance will cause the heart rate to increase. However, if the heart rate is below 60 go to Step Three. If it is above 60 but still below 100 continue providing ventilator assistance for another 30 seconds and again reevaluate. If the heart rate is above 100 stop assisted ventilation gradually.
Step Three: Circulation
1)   Begin chest compressions combined with assisted ventilation. Give three compressions to one breath every two seconds.
2)   Consider endotracheal intubation at this time (strongly recommended)
3)   Reevaluate heart rate after 30 seconds If heart rate is still below 60 continue breathing and chest compressions and go to Step Four. If it is above 60 but below 100, discontinue chest compressions but continue to assist with ventilations. If it is above 100 discontinue assisted ventilation gradually.
Step Four: Drug
4)   Administer epinephrine as you continue to do chest compressions and assist with ventilations. Reevaluate heart rate after 30 seconds If heart rate is still below 60 continue breathing and chest compressions. If it is above 60 but below 100, discontinue chest compressions but continue to assist with ventilations. If it is above 100 discontinue assisted ventilation gradually. Supplemental oxygen can be administered, if necessary but care should be taken to not exceed 95% oxygen saturation.
The new Neonatal Resuscitation Provider will need to learn how to evaluate the newborn baby’s condition and how to perform each of these resuscitation steps well enough to be able to perform each step in just a few seconds. Thinking in terms of 30-second intervals will simplify this process.
•   As soon as the baby is born and is handed to the team of neonatal providers, the team should begin to ask the initial three questions. After delivery a baby in need of resuscitation should be move quickly to the radiant warmer where providers can begin to provide the assistance needed and evaluate the need for further support. Asking the initial three questions and providing the initial step in resuscitation should take approximately 30 seconds. Slightly more time may be required if special actions, such as suctioning meconium, are required. We will cover this in a later chapter.
•   No more than 30 more seconds should be allow for stimulating the baby to breathe. These first two 30 second segments are called the “Golden Minute”. Continuing to stimulate an apneic baby longer than this is a waste of precious time. If stimulation and clearing the baby’s airway have not resulted in improvement PPV should be begun immediately.
•   The third 30 –second segment should be used to evaluate respiration, heart rate, oxygenation, and starting respiratory support measures if needed and not already begun. Now is the time to call for additional team members (please see the section on personnel below) If the heart rate has not improved, be sure to assess the effectiveness of PPV and make any corrections to assure that adequate ventilation is being provided. If adequate ventilation has not been provided, make the corrections needed and reassess in 30 seconds. Do not proceed to providing chest compressions until adequate ventilation is assured. Begin providing chest compressions once 30 seconds of adequate ventilation has NOT resulted in an improved heart rate above 60 beats per minute. Also, if there is a spare provider now is the time to prepare an umbilical catheterization in preparation for medication administration, should this begun necessary.
•   Once chest compressions have been started the heart rate should be reevaluated every two minutes. It is important not to interrupt the chest compressions too frequently to evaluate the heart rate as this will interrupt the blood flow to the brain and heart resulting in significant drops in coronary artery perfusion pressures resulting in poor oxygenation to the cardiac muscle and slower increases in the heart rate.
•   If the heart rate remains below 60 beats per minute PPV and chest compressions should continue while the administration of epinephrine is instituted and underlying causes and their possible treatment are considered.
Apgar Score
The Apgar score is a measurement of a newborn’s condition starting one minute after birth. However, if resuscitation is needed it must be initiated before the one minute mark. Therefore, for the determining whether resuscitation is needed, what type of assistance to give, and when to give it , the Apgar score is not used. Instead, the NRP provider uses three signs to determine whether to begin resuscitation. They are respirations, heart rate, and oxygenation status as determined by color or oximetry. Neurologic status is also, evaluated, by checking muscle tone and reflex irritability.
The Apgar score is assigned at one minute and five minutes. If the five minute score is less than 7, then it should be reevaluated every 5 minutes for up to 20 minutes. Each sign is assigned a value of 0, 1, or 2. The five values are then added together to determine the Apgar score. Following is an explanation of the signs and how to evaluated them

Sign
    0    1     2
Heart Rate    Absent    <100    >100
Breathing    Absent    Weak Cry or Hypoventilation    Good, Crying
Color    Blue or Pale   Acrocyanotic   Completely pink
Muscle Tone   Limp   Some flexion   Active Motion
Reflex Irritability   No Response   Grimace   Cry or Active Withdrawal

Apgar scores should be recorded , but resuscitation should not be delayed to perform or record Apgar measurements.
Personnel and Equipment Needed for Delivery

At least one person who is available to be assigned exclusively to the newborn and capable of providing the initial assessment and resuscitation steps should be present at every delivery. There should also, be immediately available, another person who is capable of providing complete resuscitation including endotracheal intubation if the first provider does not have all of these skills. Immediately available means no more than 1-2 minutes from the delivery room, if not in the delivery room. Having someone “on call” is not acceptable.
If the delivery is high risk because of the presence of high risk factors identified before the birth such as premature delivery or meconium staining of the amniotic fluid , more advanced resuscitation may be needed. Under these circumstances, at least two providers should be present in the delivery room and assigned exclusively to providing for the needs of the newborn. At least, one of these providers must have complete resuscitation skills.
Ideally, there should be a “team of resuscitation providers” with a designated leader and designated roles for each team member. Note: if there are multiple births, a separate complete team should be available for each baby. In high risk situations these team may have 2-5 team members with varying levels of skills. One team member, with complete resuscitation skills would server as the team leader and would be responsible for positioning the baby, opening the airway, and intubating the trachea if necessary. Two others would assist with drying, suctioning, positioning, and giving oxygen. They would administer PPV and chest compressions as directed by the team leader. The fourth team member would administer medications and assist the team leader with an umbilical catheter if needed. The fifth team member would document events as they occur. This position could possibly be done by the fourth team member if the fifth team member is not available. Too many providers can actually get in each other’s way, so the need for more than five team members should be assessed carefully before calling for extra personnel.
All of the equipment needed for newborn delivery should be present in the delivery and fully functional. It is the responsibility of the team members to ensure prior to the arrival of the mother that all equipment is present and working. This means that all team members should know how to check the equipment. An effective team will establish a regular routine for checking for adequate supplies and whether the equipment is functional prior to every delivery. Having a checklist that can be quickly checked will expedite this process. The following items are suggested as a starting point for developing this checklist.
Neonatal Resuscitation Equipment and Supplies
Warming Equipment
1.    Radiant warmer or other warming device such as a table with hot water bottle covered with several layers of blankets
2.   Several blankets, preferably warmed
3.   Reclosable, food grade polyethylene bag or wrap(for preterm infants)
4.   Incubator for transport to maintain baby’s temperature if preterm
Ventilation Equipment
1.    Bulb syringe
2.   Mechanical suction and tubing
3.   Suction catheters size 5F or 6 F, 8 F, 10F, 12F, & 14F
4.   Meconium aspirator
5.   Feeding tube 8F and 20 ml syringe
6.   Face masks both newborn and premie sizes preferably with a cushioned rim
7.   Device capable of delivering positive-pressure ventilation at 90% to 100% oxygen
8.   Oxygen source
9.   Compressed air source
10.   Oxygen blender to mix oxygen and compressed air with flow meter (flow rate up to 10L/min) and tubing
11.   Pulse oximeter and infant sized probe
Intubation equipment
1.    Laryngoscopes with straight blades size 0 (preterm ) and 1 (term)
2.   Extra bulbs and batteries for laryngoscopes
3.   Endotracheal tubes 2.5mm, 3.0mm, 3.5mm, 4.0 mm internal diameter
4.   Stylet for ET tube (optional)
5.   CO2 detector or capnograph
6.   Laryngeal mask airway sized for infant
7.   Tape or mechanical device for securing ET tube
8.   Scissors
9.   Alcohol sponges
Medications
1.    Epinephrine 1:10,000 (0.1 mg/mL) 3 mL or 10mL ampules
2.   Isotonic crystalloid (NS or LR) for volume expansion 100 mL or 250mL
3.   Normal Saline for flushes
4.   Dextrose 10% 250mL
5.   Naloxone 1.0 mg/mL solution
Umbilical Vessel Catheterization Supplies
1.    Sterile Gloves
2.   Scissors or scalpel
3.   Antiseptic prep solution
4.   Umbilical tape
5.   Umbilical Catheters 3.5F and 5F
6.   Three-way stopcock
7.   Syringes 1, 3, 5, 10, 20, 50 mL
8.   Needles 18, 21, and 25 gauge or puncture device for a needless system
Miscellaneous Supplies
1.    Glove and PPV for all personnel
2.   Stethoscope with a neonatal head
3.   Clock with a second hand viewable by all personnel
4.   Tape ½ or ¾ inch
5.   Cardiac Monitor and electrodes or pulse oximeter and probe
6.   Oropharyngeal airways 000, 00, 0 size or 30mm, 40mm, and 50mm length
Needed for extremely Preterm babies
1.    Size 00 Laryngoscope blade
2.   Chemically activated warming pad
3.   Recloseable, food grade plastic bag (1 gallon size) or plastic wrap
4.   Transport incubator to maintain baby’s temperature during transport to the nursery.

Risk Factors Associated with the Need for Resuscitation
The provider in the delivery room should always be prepared to resuscitate the newborn assigned to their care, even though the newborn may not have any risk factors present. However, there are some common identified risk factors that have been associated with a higher risk of the need for resuscitation.
Antepartum Factors
Maternal Diabetes    Post-term gestation      Multiple gestation
Size-dates discrepancies   No prenatal care      Gestational hypertension
Preeclampsia         Maternal infection      Chronic hypertension
Fetal hydrops         Fetal anemia         Bleeding in 2nd or 3rd trimester
Isoimmunization      Maternal cardiac disease   Maternal renal disease
Maternal thyroid disease   Maternal pulmonary disease   Maternal neurological disease
Polyhydraminios      Oligohydramnios      Mother older than 35 years of age
Decreased fetal activity   Adrenergic agonists      Drug therapy such as magnesium
Maternal substance abuse   Fetal malformation or anomalies

Intrapartum Factors
Macrosomia         Premature labor      Forceps or vacuum-assisted delivery
Precipitous labor      Emergency C-section      Category 2 or 3 fetal heart rate
                        patterns
Abnormal presentation   Prolonged labor      Use of general anesthesia
Prolapsed cord      Placenta previa      Uterine tachysystole with fetal    
                        decrease in heart rate
Abruptio placentae      Significant intrapartum   Administration of narcotics to
            bleeding         mother within 4 hours of delivery

Many of these risk factors may result in a baby being born prematurely, prior to 37 weeks gestation. Babies that are born prematurely are anatomically and physiologically different from babies that have completed at least 37 weeks of gestation. These characteristics include:
•   Immature brain development which may decrease the respiratory drive and inability to thermoregulate
•   Surfactant deficiency in the lungs which may make ventilation difficult
•   Higher likelihood of being born with an infection and not sufficiently developed immune system
•   Weak muscular system which may result in tiring making respiration difficult
•   Thin skin and large body surface area with decreased fat, all of which increase heat loss
•   Blood vessels are very fragile especially in the brain which may bleed during periods of stress
•   Small blood volume which magnifies the effect of hypovolemic blood loss
•   Tissue development is immature which may increase the damage from hyperoxygenation
Any time a pre-term birth is expected the team should seek extra help due to the above risk factors. We will discuss specific precautions and procedures related to preterm birth in a later chapter.
Team Dynamics
Teamwork, leadership, and effective communication are essential to the success of newborn resuscitation. Many times there may be several teams working simultaneously in the delivery room (obstetrics, anesthesiology, neonatology). Coordination of interventions is critical and these require effective planning, preparation, training, and communication between the teams of providers and the individual providers. A study done at Lucille Packard Children’s Hospital at Stanford University suggests that communication skills may be as essential to the success of neonatal resuscitation as skilled performance of ventilation and chest compressions. (see http://www.cape.lpch.org) Therefore, resuscitation skills, effective team communication, and assignment of roles should be practiced regularly by neonatal resuscitation providers with their regular team members in their regular setting for providing resuscitation using the equipment they will have available to them to use during live resuscitations. This has been found to result in increased positive outcomes.
Post-resuscitation Care
Babies who have received resuscitation care are at higher risk even after their breathing and heart rate have returned to normal ranges for a newborn. The longer a baby was compromised after birth the longer resuscitation will take. We will discuss two levels of post-resuscitation care.
Routine Care
Babies who simply need Routine care are: most (nearly 90%) of newborns are vigorous full-term babies with no risk factors and babies who had prenatal or intrapartum risk factors but responded to the initial steps of resuscitation. These babies may not need to be separated from their mothers after birth or have close monitoring or need any further stabilization. Simply dry the baby, return to mother’s chest and cover with dry linen. Warmth is provided by the skin-to-skin contact with mother. Wipe the baby’s mouth and nose to clear the upper airway. Suctioning, even with a bulb syringed, after birth is no long recommended except for babies who have an obvious obstruction or who need PPV. Observation of breathing, activity, and color should be continued to determine need for further interventions.
Advanced Care
Decreased activity, breathing, or heart rate; the need for supplemental oxygen to reach target SPO2 levels; or color changes are indications of the need for closer monitoring and possible need for further interventions. Frequent evaluations should be done on these babies as their risk for developing further problems associated with perinatal compromise. Some may be able to be admitted to the newborn nursery and observed closely, others will require admission to a nursery where higher staffing ratios allow for more frequent cardiorespiratory monitoring and frequent vital sign checks. These babies may require ongoing support such as supplemental oxygen, CPAP, or mechanical ventilation. They are not only at risk for having episodes of altered cardiorespiratory status but also, developing complications from an abnormal transition. Even in the most closely monitored situations such as an intensive care nursery the parents should be encouraged to see, touch, and if at all possible hold their baby frequently. We will discuss the details of Post-resuscitation care in a later chapter.
Points to Remember
1.   All newborns require an initial assessment to determine the need for resuscitation. Many babies who may need resuscitation can be identified early by assessing the antepartum and intrapartum risk factors associated with the need for neonatal resuscitation.
2.   Every birth should have at least one trained neonatal resuscitation provider assigned to assess the baby after birth and start the resuscitation process if needed. If the baby is high risk then at least two neonatal resuscitation providers should be in the delivery room assigned to provide for the baby’s needs. At least one of them should be capable of providing all the skills needed for neonatal resuscitation, including intubation if needed.
3.    Most newborn babies are born vigorous and require no resuscitation. Approximately 10% of newborns will require some assistance after birth and only about 1% will need significant resuscitation (intubation, chest compressions, and/or medications)
4.   The most important and effective action in neonatal resuscitation is to ventilate the baby’s lungs.
5.   After birth if there is a lack of adequate ventilation to the baby’s lungs the pulmonary arterioles with constrict, resulting in arterial blood not receiving oxygen. Prolonged lack of oxygen to organs will result in damage to the brain, heart, and lungs and can result in death or disability.
6.   If the newborn is compromised there is an initial period where there is attempted rapid breathing and decreasing heart rate followed by primary apnea. Primary apnea can be reversed with stimulation by touch. However, if the compromise continues secondary apnea occurs. The heart rate and blood pressure will fall. Secondary apnea can’t be reversed with stimulation. Only assisted ventilation will reverse this downward spiral.
7.   Most of the time, PPV will result in a rapid increase in heart rate when provided during secondary apnea.
8.   Resuscitation should be provided rapidly taking no more than 30 seconds to provide each step and assess the need to move on to the next step if needed.
9.   Teamwork is essential to the successful outcome of neonatal resuscitation
10.   The four steps of neonatal resuscitation are:
1)   Airway
a.    Provide warmth
b.   Position head and clear airway if needed
c.   Dry and stimulate and assess breathing
d.   Evaluate respirations, heart rate, and oxygenation
2)   Breathing
a.   Provide PPV and apply pulse oximeter if heart rate less than 100
b.   After 30 seconds evaluate heart rate
3)   Circulation
a.    If heart rate is still less than 60 begin chest compressions
b.   After 30 seconds evaluate heart rate
4)   Drug
a.    If heart rate is still less than 60 consider administering epinephrine
b.   Continue PPV and chest compressions and reevaluate every two minute












Neonatal Resuscitation Provider Review Part 1 Post-test
1.    __________% of newborns will require some assistance after birth to breathe normally.
a.    1
b.   5
c.   10
d.   25
2.    Before birth the baby’s lungs are _____________________.
a.   Collapsed
b.   Filled with air
c.   Filled with blood
d.   All of the above
3.    All babies who will need resuscitation can be identified prior to birth by identifying the risk factors.
a.    True
b.   False
4.    Determining the Apgar score after birth should precede any analysis of the need for resuscitation as it will give a baseline that will help with determining the success of the resuscitation
a.    True
b.   False
5.    Primary Apnea should be reversed by
a.    PPV
b.   Tactile stimulation
c.   Chest compressions
d.   All of the above
6.    Restoration of adequate ventilation in a newborn needing some assistance after birth will usually result in:
a.   Increased heart rate
b.   Decreased heart rate
c.   Decreased respiratory drive
d.   All of the above
7.    Premature babies require additional assistance after birth due to:
a.    Thin skin and decreased fat stores
b.   Fragile capillaries
c.   Higher likelihood of infection
d.   All of the above
8.    Every delivery should have at least ________ provider(s) capable of initiating resuscitation if needed and assigned solely to the care of the new born
a.   1
b.   2
c.   3
d.   4
9.    When twins are expected how may providers should be available in the delivery room to care for the newborns?
a.    1
b.   2
c.   4
d.   8
10.    Chest compression, medications, and intubation are frequently needed for newborn resuscitation.
a.    True
b.   False
11.    If the baby doesn’t begin breathing in response to stimulation the baby is in ____________apnea.
a.    Total
b.   Complete
c.   Primary
d.   Secondary
12.    It is more important for team members to be skill proficient as neonatal resuscitation providers than it is to worry about how they will communicate.
a.    True
b.   False
13.    When a baby is expected to be born compromised, the equipment in the delivery room should be unpacked and ready to be used.
a.    True
b.   False
14.    Suctioning is no longer recommended except for babies who have an obvious airway obstruction or who require PPV.
a.    True
b.   False
15.    A baby who received suctioning for meconium, PPV, and chest compressions will require ____________ post-resuscitation care.
a.    Routine
b.   Advanced
c.   Higher level
d.   Intensive


References
1.   Neonatal Resuscitation Provider Textbook, 6th edition John Kattwinkel, MD, FAAP
2.   2010 International Consensus on Cardiopulmonary Resuscitation and Cardiovascular Care Science with Treatment Recommendations Circulation
3.   American Academy of Pediatrics, American College of Obstetricians and Gynecologists. IN: Lockwood D., Lemmons J., editors Guidelines for Perinatal Care 6th edition American Academy of Pediatrics 2007:205
4.   Kamlin CO, O’Donnell CP, Davis PG, Morely CJ, Oxygen Saturation in health infants immediately after birth, Journal of Pediatrics 2006 148:585-589
5.   Perlman Jm, Risser R., Cardiopulmonary Resuscitation in the delivery room and associated clinical events. Pediatrics 2006 118

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