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NRP Flowchart, Start Chest Compressions, NO!, "We have a [ETT size]…

- - - - IS BABY VIGOROUS?
        
        YES
        
        Delay cord clamping & stay w Mom
        
        RAPID ASSESSMENT
        1) Term - "Does baby appear term?"
        -Preterm babies more likely to req interventions during transition to extrauterine life Eg more difficulty aerating their lungs or est good resp effort
        2) Tone - "Does baby have good muscle tone?"
        -Good tone = active, flexed
        -Bad = Limp, flaccid (req intervention)
        3) "Is baby breathing or crying?"
        -Clear indicator of strong resp effort
        -Gasping = req interventions
        
        YES
        
        Stay with mom for initial steps, routine care, ongoing evaluation
        -baby on mom chest or abd & initial steps performed there
        
        1 more item...
        
        NO!
        
        Cord is clamped & baby is brought to warmer
        
        RAPID ASSESSMENT
        1) Term - "Does baby look estimated gestation?"
        -Preterm babies more likely to req interventions during transition to extrauterine life Eg more difficulty aerating their lungs or est good resp effort
        2) Tone - "Does baby have good muscle tone?"
        -Good tone = active, flexed
        -Bad = Limp, flaccid (req intervention)
        3) "Is baby breathing or crying?"
        -Clear indicator of strong resp effort
        a) Gasping = PPV
        b) Apnea = PPV
        
        NO!!
        
        Initial Steps
        1) WARM
        -Keep body temp bwn 36.5-37.5 celsius
        2) DRY
        -Prevent evaporative heat loss
        Drying not necessary for preterm < 32wks gestation bc should be covered immediately in polyethylene plastic which reduces evap heat loss
        3) STIMULATE
        -Rub baby's back, trunk, or extremities
        -Drying will frequently provide enough stim to initiate breathing; however, if baby doesn't have adequate respirations, tactile stim may stimulate breathing
        4) POSITION AW = SNIFFING
        -Little towel placed underneath shoulder blades
        -Head & neck neutral or slighly ext
        -Eyes straight forward
        5) SUCTION MOUTH & NOSE
        -M before N
        -Suction mouth so nothing for bb to aspirate if bb gasps when nose is suctioned
        
        1 more item...
- - - - Leader - Keeps updated on the time & contingency plan in case chest compressions don't work
        Eg "20 more seconds of chest compression, we'll start setting up for a UVC if we don't have an increase in HR"
      - REASSESS HR AFTER 1 MINUTE OF CHEST COMPRESSIONS
        -NURSE TO CONFIRM ELECTRICAL HEART ACTIVITY WITH MECHANICAL THRU AUSCULATION
        
        HR INCREASED, > 60bpm & CONTINUES TO CLIMB
        
        HOLD CHEST COMPRESSIONS & CONTINUE PPV @ 40-60bpm
        -Prem = 60 breaths/min
        1) Monitor baby's color, tone, & spontaneous respirations
        2) Adjust FiO2 to meet target sats
        
        If tone & HR improving or spont respirations
        Eg HR > 100bpm, muscle tone improving, some spont respirations
        
        Decrease Ventilation Rate & Re-assess
        
        POST RESUSCITATION CARE CONSIDERATIONS
        Leader = "Lets start post-resuscitation care"
        a) Secure ETT
        b) Call NICU for admission
        c) Thermoregulation
        d) Continue PPV
        e) Target SpO2 w oxygen saturation table
        Leader - We'll get this ETT secured, call the NICU & let them know we're bringing an intubated, post resuscitated baby, attach our temperature probe, think about thermoregulation & post resuscitation care"
        
        Leader - "Is baby making spontaneous efforts?"
        
        Yes!
        
        No!
        
        Continue PPV @ 40-60breaths/min
        Term = 40
        Preterm = 60
        
        1 more item...
        
        Nurse - Once HR given, can confirm with auscultation
        "Sounds the same on auscultation"
        
        Leader - "Lets pause chest compressions & check HR now
        
        HR still under 60bpm & not increasing
        
        INDICATES NEED FOR UVC
        
        Leader - "Okay so we're set up for a UVC
        
        If awaiting UVC insertion
        1) Administer ETT epinephrine
        "While we wait for that, I'm going to give 1ml/kg of 1 in 10,000 epinephrine down the ETT. Pause chest compressions for a second"
        Once put ETT epinephrine down, follow that with a few PPV breaths to flush meds down
        "____ml of 1 in 10,000 epinephrine down the ETT tube. Continue compressions"
        
        "Is our UVC in yet?"
        
        1 more item...
- - - - HR < 60bpm, not increasing?
        "HR is still not coming up so we'll set up for intubation as well"
      - HR 60-99bpm?
        
        HR improving?
        
        1) Continue PPV as baby showing steady improvement
        "HR is ___ and rising, we'll continue PPV"
        2) Assess ventilation technique
        -Is chest moving? Ventilating at 40-60bpm? Hear breath sounds?
        3) Perform MRSOPA if necessary
        4) Monitor sats & adjust FiO2 to meet target sat range
        
        HR not improving?
        
        If HR not improving
        "HR is not coming up so we'll set up for intubation as well"
      - HR > 100bpm or equal to 100bpm?
        PPV successful
        "HR has increased to __, we'll continue effective PPV at 40-60bpm & continue to monitor HR, respiratory effort, & sats
        1) Continue ventilating @ 40-60breaths/min
        2) Monitor baby's chest mvmt, HR, & respiratory effort
        3) Adjust FiO2 as needed based on sats
        
        When HR consistently > 100bpm, gradually reduce PPV rate
        
        Observe for any spont breaths
        
        Continue PPV until spont effort
        
        Discont PPV when bb has HR continuously > 100bpm AND sustained spont breathing
- - - - ONCE RT & NURSE READY, INTUBATION BEGINS
        -Should be completed within approx 30 seconds
        
        Once tube thru cords, intubator holds tube against soft palate
        
        Nurse places ETCO2 on tube & disconnects mask & places t-piece with ETCO2
        "If you can provide PPV, I will listen for bilateral A/E"
        
        "Do we have chest rise?"
        
        "Do we have color change on ETCO2?"
        
        Color might not change due to low HR
        
        1 more item...
        
        No color change & chest not moving = ETT not inserted properly
        
        1 more item...
        
        Chest rise & color change = Cont PPV for 30s & reassess HR
        
        1 more item...
        
        Chest rise but no color change = low HR
        -Baby's chest moving, bilateral A/E, pulse ox no signal
        
        Nurse can ask for bilateral air entry