1. Orientation to the world of newborn

2. Topics covered The NICU ◦ where to go ◦ what to do Delivery room set up Review of neonatal resuscitation

3. Learning Objectives Understand ◦ various mode of thermoregulation ◦ importance of communication ◦ steps in resuscitation of newborn

4. The NICU 2 nd floor at Lakeside Hospital Please be at NICU by 7.30am 3 minute scrub prior to entering NICU Wear gloves for all patient contact Wash hands between patients Please use the baby’s individual stethoscope (found at baby’s bedside)

5. Scrub before entering NICU

6. Waterless Hand Wash

7. The NICU Attend at least 1 delivery with NNP or residents If parents ask questions, please refer them to medical team Mute cell phone & talk softly around babies Please wear scrubs while in the NICU

8. The NICU People you will see in the NICU ◦ Charge nurse ◦ Bedside nurse (usually have 2-3 babies per nurse) ◦ Respiratory therapists (usually 2 in NICU) ◦ Neonatal nurse practitioners  Nancy Wood  Kathy Smith  Shelly Holcomb  Julie Evans  Angie Noya

9. The NICU Assigned patients by the residents ◦ Review history and physical with residents ◦ Pre-round with residents ◦ Review laboratory and radiology results with residents ◦ Talk to RNs about patient and prior to examining patient

10. Isolation Room – Gown & Glove

11. Isolette

12. The NICU Present patients during rounds (usually starts around 8.30-9.00am) ◦ Brief history and current problems ◦ Issues overnight ◦ Vital signs, current weight & change in weight ◦ Brief review of physical examination

13. The NICU Present patients during rounds ◦ Intake (Type of feeds, TPN, amount, nipple/gavage) ◦ Total intake (mL/kg/day) and output (mL/kg/hr) ◦ Laboratory, radiology, consult results ◦ List of medications ◦ Assessment and plan for the day

14. The NICU Rounds usually end by 11.30am Noon conference (for residents) Please remind attending and residents on days you will not be present in the afternoon In the afternoon or prior to leaving for the day ◦ Check up on your patient ◦ Review assessment and plan with residents

15. The Delivery Room Need to wear ◦ Head cover ◦ Mask ◦ Shoe cover ◦ You may be asked to scrub and wear scrub gown to receive baby Stand around radiant warmer Speak softly Be aware of sterile fields!

16. Hats, masks, shoe covers before entering OR

17. Scrub area in OR

18. Neonatal Resuscitation Most newborn transition to extrauterine life without complications ~10% require some intervention 10-20% from above require aggressive intervention

19. Preparation prior to delivery Adequate personnel ◦ Open communication with OB team ◦ Should have minimum of 3 person trained in NRP for high risk deliveries ◦ Good communication within team ◦ Good coordination of function for each team member

20. Preparation prior to delivery Obtain information from OB nurses ◦ Gestational age of baby ◦ Why are we delivering? ◦ Is meconium present (if membranes ruptured) ◦ Any pertinent maternal history?  Fever  Pertinent labs  Complications during pregnancy/labor Pass above information to rest of team!

21. Preparation prior to delivery Equipments ◦ Radiant warmer ◦ Warm blankets (lots of it!) ◦ Stethoscope ◦ Plastic wrap for babies <1000g ◦ Bag-mask ventilation ◦ Oxygen blender ◦ Laryngoscope ◦ Endotracheal tubes ◦ Suction

22. Preparation prior to delivery Radiant warmer ◦ Switch on when enter delivery room ◦ Provides radiant heat ◦ Make sure sides are up to prevent convective heat loss Warm dry blankets ◦ Provides conductive heat ◦ Prevents evaporative heat loss

23. Radiant warmer in DR

24. Preparation prior to delivery Check equipments ◦ Put on gloves! ◦ Resuscitation bag, air flow & oxygen ◦ Suction device (bulb and wall suction) ◦ Meconium aspirator (if meconium present) ◦ Laryngoscope and endotracheal tube

25. Preparation prior to delivery Ensure have adequate personnel Assign roles to team members ◦ Be specific (who, what, when) ◦ Be aware of what and how team members are performing Vocalize findings/difficulties to team members Do not be afraid to CALL FOR HELP

26. Initial Resuscitation Provide warmth ◦ Turn on radiant warmer ◦ Place baby on warm dry blanket Dry and Stimulate ◦ Dry baby with warm dry blanket ◦ Remove wet linen from baby

27. Initial Resuscitation Airway ◦ Clear airway with bulb syringe  Mouth 1 st, nose 2 nd ◦ Position baby to open airway

28. Initial Resuscitation Breathing ◦ Primary apnea  Can be reversed by stimulation  Rub backs and flick heels  Do NOT turn baby upside down! ◦ Secondary apnea  Require bag and mask ventilation  May require endotracheal intubation

29. Initial Resuscitation Pick the right size of mask ◦ Fit from bridge of nose to chin ◦ Do not cover eyes Wood FE et al; Arch Dis Child – Fetal and Neonatal Ed 2008;93:F230-4

30. Flow-inflating bag

31. Initial resuscitation Breathing ◦ Term infant may require peak PIP 20-30 cmH 2 0 initial inflation pressure ◦ Provide 30-60 breaths a minute

32. Initial resuscitation Circulation ◦ Assess color, tone and heart rate ◦ Palpate brachial and umbilicus for pulse ◦ Tap out heart rate ◦ Chest compression if needed  2 different techniques

33. Assessing Heart Rate Palpation for brachial pulse Palpation for umbilical pulse and Auscultation by stethoscope

34. Chest compression techniques 2 finger technique 2 hand technique – thumbs side-by-side over midsternum

35. Transport Isolette

36. Apgar Scores Developed by Virginia Apgar in 1953 To assess effectiveness of resuscitative efforts Assess heart rate, respiration, color, tone and grimace

37. Apgar Scores (How Ready Is This Child?) 0 Points1 Point2 Points Heart rateAbsent<100bpm>100bpm RespirationApneaGasping, irregularStrong cry IrritabilityAbsentFacial grimaceSneeze, cough, pulls away ToneAbsentArms & legs extended Active movements ColorBlue-gray, pale all over Pink body, blue extremities Pink all over

38. Assessment of tone Normal tone in term newborn

39. Assessment of color Acrocyanosis Cyanotic newborn

40. Algorithm of resuscitation Birth Term? Amniotic fluid clear? Breathing? Good tone? Warm Position Clear airway Dry, stimulate, reposition Yes Routine care - Warm - Dry - Clear Airway - Assess color No

41. Algorithm of resuscitation Evaluate breathing, HR, Color & tone HR <100 or apnea 30s Positive pressure ventilation HR <60 30s Ensure effective inflation Start chest compression HR <60 30s Medications

42. www.exutero.wordpress.com Visit this link while in NICU rotation For Students: review articles Complete test (may work in group) For Interns: complete 4 consecutive (weekly) resident readiness tests ◦ Email completed tests to Priscilla Busch  pbusch@tulane.edu pbusch@tulane.edu  Completion of assigned test(s) is mandatory.  Failure to Complete a test will result in failure of the rotation (for students or interns).

43. THANK YOU! QUESTIONS?