WK7: Neonatal resuscitation, NST, Neonatal injections

Question 1

Outline the steps for a neonatal resus.

Answer 1

DRSABACD
Danger
- other equipment in the room

Response
- term?
- does it look term?
- muscle tone?
- breathing or crying?
NO- tactile stimulation, maintain temp, ensure open airway
YES- maintain temp + obs

Access + airways
- HR below 110bpm?
- Gasping or apnoea
Yes= initiate positive pressure ventilation, have O2 sats on baby, suction if necessary

Breathing
- 1min to assess if baby needs breathing
- normal infant breathing= 40-60 per minute
Abnormal breathing
- gasping
- apnoeic
- laboured breathing
- ? persistent cyanosis

Action:
- Put neopuff around baby nose and mouth
- Give 40-60 breaths per minute
- Put sats monitor on to get HR
- Looking for improvement in HR
- If not improvement, improve neopuff
- Rate: 40 – 60 breaths per minute
- Improvement in heart rate is the primary measure of adequate ventilation

Compressions
- 3:1 compressions to breaths
- start when HT <60 despite good ventilation

Drugs
- Blood
- adrenaline
- IV fluids/volume exmanders

Question 2

What is the ideal position for a baby in resus?

Answer 2

• Assist baby to get into a supine open/sniffing position
• Lie baby as flat as possible
• If caput is forcing babys chin down you can use towel under shoulder to tilt head back.

Question 3

What are some important points regarding suctioning?

Answer 3

• Only suction what you can see
• Suction the nose before mouth (nose breather)

Suctioning is recommended when:
- There is obvious blood
- Mucous
- meconium

Use a Fg 10 or Fg 12 suction catheter

The negative suction pressure used should not exceed 100 mmHg (13 kPa, 133 cmH2O, 1.9 Psi)

Be quick (no more than 5 – 6 seconds) and gentle, as over-vigorous suctioning can cause laryngeal spasm, bradycardia, trauma and delay the onset of spontaneous breathing.

Question 4

Why is mec aspiration an risk? How do we manage it?

Answer 4

MSAF= me stained amniotic fluid
AS= mec aspiration syndrome

A risk of sepsis and resp depression as it is a thick substance that compromises the lung capabilities.

Management=
- Vigorous at birth? Breathing + tone?
- Tactile stimulate at birth
- If non-vgorous= endotrachiale suctioning intubation by peads
- Ventilate before suctioning (no evidence for endotrachael sucktioning)

Question 5

When should PPV be commenced?

Answer 5

IF HR < 100/min or inadequate breathing= commence ventilation (PPV)

Question 6

What is PPV, what device is used to provide it and what should it be set to?

Answer 6

Positive pressure ventilation gives a breath but on exhale, does not fully relax the lungs to ensure they are easily expanded on the next inspiration.

Provided via a T piece or neo puff

30/5

Question 7

What should a neopuff be set to? and why?

Answer 7

Peak inspiratory pressure (PIP)= is set to 30cmH20
- Push of air into the lungs
- When pressing down on the neo puff

Positive expiratory end pressure (PEEP)= at 5-8cmH20 for term infants at birth (different for preterm or not immediate birth resus)
- Little bit of effort at the start of plowing a ballon
- Holds the lungs slightly open

Question 8

What is the importance of the peep?

Answer 8

Without peep
- Lung aeration is not achieved as quickly
- Functional residual capacity (FRC) is not established

With PEEP
- FRC is established and maintained
- Oxygenation is improved

PEEP of 5 – 8 cm H2O during resuscitation of newborn infants if appropriate equipment available

Question 9

What should the O2 and air bet set to?

Answer 9

21%= initially
100%= resus
- O2 introduced when no improvement in pulse oximetry despite ventilation efforts.
- Increase oxygen to 100% for chest compressions

Question 10

What are some key signs of effective ventilation?

Answer 10

• Keys sign= increase HR of above 100beats/min
• Other signs= a rise and fall of the chest + oxygenation improves
• Reassess the HR every 30 secs whilst providing PPV
• Intubation may be indicated
  If it hasn’t improved. ?am I ventilating effectively
• Ventilate at a rate of 40 – 60 inflations per minute

Question 11

Where should the pulse oximeter be placed?

Answer 11

on the right wrist or hand (preductal oxygen saturation)
- The right side is the most oxygenated blood and this refectlts brain stem oxygen delivery.

Question 12

What are the target O2 sats after birth

Answer 12

Time from birth Target saturations
1 minute 60 – 70%
2 minutes 65 – 85%
3 minutes 70 – 90%
4 minutes 75 – 90%
5 minutes 80 – 90%
10 minutes 85 – 90%

Question 13

What should the pip and peep flow rate be set at? (in L)

Answer 13

Pip= 30cmH20
Peep= 5cmH20

Question 14

When are external chest compressions indicated?

Answer 14

HR is <60BPM despite adequate assisted ventilation.

Question 15

What is the rate of chest compressions to breaths at what % of O2?

Answer 15

Commence chest compressions with PPV at a ratio of 3:1 with 100% oxygen
- Aim for 120 events/minute

Question 16

Describe effective chest compressions

Answer 16

• Aim for 120 events/minute
• Use 2 thumb encircling method or 2 finger technique
• Chest compressions are performed over the lower third of the sternum
• The person providing the chest compressions should verbalise (out loud): “One – and – two – and – three – and – breathe, one – and – two – and – three – and – breathe.”

Question 17

What is the first line drug used in a neonatal resus?

Answer 17

Adrenaline
- 1:10,000
- given via ETT or IV
- amount depends on size of baby and route

Question 18

What is the second pharmacological drug used in neonatal resus?

Answer 18

• Normal saline or blood
• 10mL/kg (average baby is 3.5kg)

Question 19

When should you stop a resus?

Answer 19

Discontinue if:
- Compressions if HR >60bpm and rising
- PPV when HR is >100bpm and baby is breathing normally
- Continue PPV until HR >100bpm

Question 20

What is the newborn screening test?

Answer 20

A blood test that is free to all aus babys with the aim to to test babys for metabolic symtpoms prior to the onset of symtpoms to reduce morbidity and mortality.

Question 21

Why is the NST or NBST important?

Answer 21

• It helps identify medical conditions at birth that have no signs of symptoms
• Late or no diagnosis may mean possible lifelong disability; in rare cases the condition may cause death.
• It can help detect conditions before they develop symptoms and get effected.
• Quick, safe, effective

Question 22

When is the NBS ideally collected?

Answer 22

Collected via heel prick 48-72 hours after birth

Question 23

What is some key education he midwife should provide to the parents about the NST?

Answer 23

• Screening for many conditions
• will test for a number of metabolic conditions where early detection increases outcomes.
  e.g. cystic fibrosis, congenital hypothyroidism, phenylketonuria (PKU)
• Will not be contacted if the sample is normal
• May be contacted for a repeat test

May be asked to give a second sample if:
- Total Parenteral Nutrition
- Poor sample
- Contaminated card
- Borderline/inconclusive result
* Most second samples are within normal range

Question 24

What is cystic fibrosis? its incidence? pathophysiology? clinical manifestation? treatment?

Answer 24

Pathophysiology= The child’s cells cannot transport salt properly resulting in thick, sticky secretions in the lungs and the gut.

Incidence= Affects 1 in 3,300 babies

CM=
- results in frequent respiratory tract infections (as the mucus is unable to transport/cough pathogens away from the lungs as mucus is so thick)
- Scaring on the alveoli can occur due this= poor lung funciton
- difficulty digesting food properly
- babies may have loose stools & poor weight gain

Tratement=
- Several treatments available to help these babies
- non-pharm treatments include vibrating vests to bring up secretions in lungs

• Primarily a respiratory disorder, it is an autosomal (non-sex chrosomed) recessive condition, carriers are healthy.
  = Means both parents carry the recessive gene

Question 25

What is Congenital Hypothyroidism (CHT)? its incidence? pathophysiology? clinical manifestation? treatment?

Answer 25

= The thyroid gland is absent or has not developed properly in these children

Incidence: Affects 1 in 2,200 babies in Victoria
Patho= causes of abnormal thyroid development during pregnancy are unclear. It is not inherited but occurs spontaneously. Also occurs in countries with low levels of iodine in the diet

Complications:
- Low thyroid hormone levels can lead to intellectual disability, growth problems, deafness

Treatment= a dose of thyroxine evey day for the rest of babys life.
- Early thyroid hormone replacement is very effective treatment in correcting the deficiency and its devastating effects.

Question 26

What is fatty acid oxydation disorders? its incidence? pathophysiology? clinical manifestation? treatment?

Answer 26

Incidence= Affects 1 in 12,000 Victorian babies

Patho= Defective enzymes that turn fat into energy

Complications= If untreated can result in
- muscle problems
- poor feeding and digesting
- vomiting
- seizures
- sudden death

Treatment: dietary modification= avoiding certain fatty acids in the diet.

Question 27

What or some other metabolic conditions and their treatments?

Answer 27

• A group of over 20 different conditions that affect the breakdown of amino acids or fats
• About 9 babies a year will be detected by the NBST with a rare metabolic condition
  - Mild conditions and special treatment is needed only when the child has an episode of illness such as a viral infection

Treatments: treated with special diets or vitamin supplements, or with special medications
- Very rarely, abnormalities detected in the baby that are caused by the mother herself having nutritional deficiencies or one of these conditions

Question 28

What is the reccomended timing of the NST?

Answer 28

48-72hrs old (regardless of feeding or gestational age) *recommended to be performed in this time frame
- Allows time for baby’s metabolism to establish itself and avoids delay of diagnosis
- Can be collected at the first home visit if discharged early
- If taken at an older age, it should be noted down the time of the sample
- Taken at the same time to standardise
- The early sample may gove false negative as baby’s metabolism has not had time to establish itself.
- To late, delay of diagnosis and treatment also some metabolites decline with age
- A poor quality sample can require a recollection, creating anxiety for parents and distress for babies.
In some cases parents may refuse the request for recollection, leaving the baby without a meaningful result.

Question 29

Why might re-testing have to take place?

Answer 29

• poor sample
• Preterm babies may require retesting when they reach term equivalent age
• palliated infant
• Infant receiving blood or blood products

Question 30

What are the two consents that are recorded on the NST card?

Answer 30

1. consent for the test
2. consent for the sample to be used for medical research purposes

Question 31

What are the important steps for collecting a sample?

Answer 31

• Gain consent
• Card filled out completely before heel prick
• Parent education and consent
  - Explain they have all info
  - NIPT or amniocentesis may know some of the condition
• Correct site for collecting a sample
  - Shaded area indicates safe puncture site areas
  - (Draw an imaginary line from middle of big toe, and b/w 4th & 5th toes to the heel then go on the outside of that)

1. If alcohol swab is used to prepare the area, needs to be properly dried before taking sample (dont need to swab the area but does prevent contamination)
2. Do not use petroleum jelly for NST
3. Hold the hell in ok position
4. Press tenderfoot into foot
5. First drop of blood should be wiped away with cotton ball (to reduce contamination)
6. Aim to fill at least 2/3rds of the area of each spot, ensuring blood has soaked through to the back of the card
7. Insufficient blood cannot be tested

Question 32

What are some strategies to position the baby and ensure it is comfortable in the procedure?

Answer 32

• Breastfeeding (works as a natural pain relief)
• Help upright by parents (gravity so blood flows ot foot)
• Warm feet (with warm towel to get blood to the site)
• Consider sucrose (not ideal to bring this into the babys gut)

Question 33

Explain the use of sucrose?

Answer 33

• Use for procedural pain in neonates, where BF is not possible
• Small amounts of sweet-tasting solution on anterior of tongue results in a calming effect on baby
• Taste thought to influence endogenous opioid release
• Analgesic effect lasts 5-8mins, enhanced by other measures such as non-nutritive sucking, swaddling, cuddling, skin-to-skin
• Most effective in the first month of life

Question 34

What happens to the sample after the test?

Answer 34

• Air dryed for >4hrs (with no heat applied)
• Place in an individual envelope or with plain paper between samples
• Mailed immediately once dry, not in plastic
• Nominate hospital liaison person mails cards directly to newborn screening lab

Question 35

What are reasons that a card may not be sampled and requested to be retaken?

Answer 35

• Cards not filled out properly
• Contamination urine, faeces, petroleum jelly
• Blood spots inadequate
• Too little or clotted
• Cards not air dried
• Dried artificially or sent in a plastic bag
• Delivery, stockpiling

Question 36

Discuss the process of refusal/declining the NST for parents.

Answer 36

• within their right
• ensure adequate education and understanding of the various consents for different uses.
• Document it on the card
• Parents must sign written statement of refusal- Still fill out a card just tick the ‘no’ consent box and sent off as normal
• Referral to Genetic Health Counsellor (they will go though the history)
• Refusal is documented and signed, placed in mother’s/baby’s file
• NST card should have information completed, with ‘refusal’ written on it
• Card sent as evidence to Newborn Screening Laboratory

Question 37

Explain the storage of the NST

Answer 37

• All samples and information are securely stored in accordance with privacy legislation and access to the card is restricted according to agreed protocols
• Cards stored in a secure facility of the laboratory for two years and then in an off-site secure storage facility which has been approved by both the Department of Health and Human Services (DHSS) and the Public Records Office.
• Samples stored for at least 25 years as recommended by the National Pathology Accreditation Advisory Council of Australia and the Public Records Office.
• A minimum period of two years of storage is essential for quality assurance purposes (so they can go back and restest so they can test quality control)
  e.g. if a few children are diagnosed with a metabolic condition the NST didn’t pick up they will restest all those form that time period to ensure they weren’t at fault.
• Parents can request the transfer of their child’s card to their custody once the child is two years of age
• Parents can nominate that there is no secondary access to the card without their explicit permission

Question 38

What are some additional uses of the NST?

Answer 38

Quality assurance
- Access to the blood spot is essential in case of misdiagnosis, e.g. If a child is diagnosed with a condition that was not identified by newborn screening.
E.g. if a child gets to 5 years and is diagnosed with CF all the cards tested at that time need to be reviewed to ensure there was no issue or a problem on that card itself
- Access to anonymous newborn screening cards

Diagnosis
- The newborn screening card is a convenient way of transporting blood samples for special individual testing interstate when a particular test is not available in Victoria.
- Retrospective diagnosis for the child.
- For the benefit of close blood relatives in a deceased child.

Forensic identification
- Only by court order at the request of the Coroner’s Court, for identification of deceased persons.
- E.g. missing persons or coroners court

Research
- Strict criteria for approval from the research ethics committee

Question 39

What are the risks of the test?

Answer 39

there is a small risk of infection; this is minimised by using gloves and cleaning the heel prior to collection.

Question 40

How do you gain NST consent?

Answer 40

• Complete all personal details and check with the parents they are correct.
• ensure adequate information is provided
• consent for test?
• They have to sign and tick for secondary research or not
• Making the card available for research use is a personal choice and should not interfere with the decision for screening.
• It should be documented in the mother’s file that discussion about the newborn bloodspot screening test has occurred, that consent was provided, and the date and time the sample was collected.

Question 41

What is the Vit K injection? and why is it reccomended?

Answer 41

• Not an immunisation, a supplement
• to prevent VITK deficiency bleeding

Vit K is required for;
- bone formation on the fetus
- forming the clotting factors VII, IX, X
- Forming anti-clotting factors protein C and S in the liver

Question 42

What does Vit K do in the body?

Answer 42

• Stored= in liver

Obtained from:
- the diet (green veg, veg oils, eggs, cows milk) (K1)
the gut flora (K2)
- The fetus stores up Vit K in their last month in utero. However, concentrations are lower than maternal, and the placenta acts as a partial barrier to transfer.

• All infants have some form of deficiency at birth
• Before gut flora is established in the neonate after birth, the healthy neonate has low intake of Vit K, especially those that BF.
  - Baby forms microbiome from BF, skin on skin, injecting flora on mothers skin, kissing from mother
  - Important for influencing immune function, line the intestines, break nutrients, avoid infections, hormone function, produce kit K.
• There is a transient decline in Vit K dependent clotting factors and anti-clotting factors in the first few days after birth
• Offer vit K for BF babys (not those formula feed), mix fed
• Prophylactic administration of Vit K prevents the physiological decline, and decreases the risk of VKDB
• Colostrum is high in Vit K compared to breast milk

Question 43

Explain the diagnosis, classes and risk factors of Vit K deficiency bleeding?

Answer 43

Diagnosis:
- Spontaneous or excessive induced bleeding at any site (e.g. NST) with decreased activity of Vit K dependent coagulation factors yet the normal activity of Vit K independent factors fibrinogen levels and platelet count.

Classes of VKDB
- Early (in the first 24hrs) (highest risk)
- Classical (24-7days)
- late (6-8 months)
- based on the presentation

Incidence for early and classical is approximately 0.25%-1.7%, late onset is approx. 4.4 to 7.2 per 100,000 births (reports from Europe and Asia)
- As an example, administering a single oral dose the rate of late onset for exaple decreases to 1.4 to 6.4 per 100,000 births

Risk factors for VKDB
- Instrumental birth
- Prolonged birth
- Shoulder distocia
- Traumatic birth
- Insults from birth
- Child abuse + neglect (in later life)

Question 44

Describe the Vit K drug and its administration.

Answer 44

Konakion
- IM, IV or oral
Oral: 2mg
IM/CS: 1mg

Question 45

What is some education regarding the hep B vaccine? Describe the process of informing parents and what Hep B is.

Answer 45

• First immunisatino on the regiestary
• Up to the parent to make the informed decision
• Talk about what is in the injection

Hepatitis B= is an infection caused by a virus
Transmittion= can be transmitted by contact with bodily fluids (needles, sexual intercourse, babys get it from parents) of an infectious person (perinatal, parenteral, mucosal)

What it does:
After infection, some people can become chronically infected and it affects the liver.

Chronic Hep B is associated with death from cirrhosis or hepatocellular carcinoma (liver cancer) in up to 25% of cases.

• Not particulary common in aus. Most common in south easy Asia

Women with hep b:
- Women who test positive for Hep B surface antigen (HBsAg) will be recommended and prescribed that their baby have a single dose of Hep B immunoglobulin (HBIG) as well as the H-B-Vax II immunisation

Hepatitis B immunoglobulin= VF is prepared from human plasma containing high levels of antibody to surface antigen of the hep B virus

*** a blood product

Must follow procedures for blood product administration

Question 46

Describe the administration of hep B including the dose.

Answer 46

Administration
- recommend within 24 hours of birth, then 2, 4, 6 months of age
- Given IM
- (opposite leg to H-B-Vax II)
- Use 25 gauge needle
- Must be stored in the fridge
- Best used within 5mins of being out of the fridge

Question 47

What group is likely to decline the Hep B vaccine and why?

Answer 47

Jehavas whitness’

*** as it is a blood product

Question 48

Where should new born injections be administered?

Answer 48

• Anterolateral thigh is the prefered placement for infants under 12 months (the bulkiest part of the vastus lateralis through muscle)
• in the upper middle third of the infants thigh.

Question 49

What is the procedure of the injection?

Answer 49

1. Make sure there is a written medication order on the medication chart.
2. Check the correct drug/dose/time/interval/route/patient.
3. Draw the medication up into the syringe using the large bore needle.
4. Change to the 23 g 25 mm needle or 25 g 16 mm needle.
5. Be aware that a second staff member to help position the infant on his/her back on an appropriate surface may be required.
6. Administer sucrose.
7. Undo the infant’s nappy to locate the junction of the upper and middle thirds of the vastus lateralis thigh muscle.
8. Place your forearm across the infant’s pelvis and secure the thigh between your thumb and forefinger if you are the clinician performing the injection.
9. Position the limb to relax the muscle.
10. Pierce the skin at an angle of 90 degrees to the skin. Provided an injection angle of > 70 per cent is used, the needle should reach the muscle layer. The following figures of the thigh show the recommended injection site.

Question 50

Questions regarding newborn injections

Answer 50

1. When administering a neonatal IM injection what gauge and length needle should be used?
2. What part of the thigh muscle should be injected?
3. At what angle should the needle pierce the skin?
4. What is the recommendation regarding the use of alcohol swabs?
5. What can be done or used to relieve a baby’s distress?
6. As there are no large blood vessels in the recommended sites, aspiration before injection of vaccines (pulling back on the syringe plunger after needle insertion but before injection) is not necessary.
7. Slowly inject the medication for even distribution and to minimise the infant’s discomfort.
8. Remove the needle.
9. Check the injection site for bleeding and apply cotton wool ball if necessary. Observe the site for local inflammation.
10. Dispose of the needles and syringe into a labelled puncture proof container to prevent needle stick injury or reuse.
11. Document the administration of the IM injection on the medication chart and/or child health record (where appropriate).