NLS

Question 1

Why is delivery through the birth canal an anoxic event?

Answer 1

Respiratory exchange by the placenta is interrupted for the 50-75 second duration of the average contraction

Question 2

For how long can the heart of the newborn baby function despite anoxia?

Answer 2

20-30 mins

Question 3

When does fluid resorption in the neonates lungs begin?

Answer 3

During labour

Question 4

How much fluid do babies born vaginally at term still have in their lungs?

Answer 4

100ml

Question 5

What proportion of babies born at term will initiate spontaneous respirations?

Answer 5

85% - within 10-30 seconds

Question 6

What is the crucial intervention in NLS?

Answer 6

The aeration and ventilation of babies

Question 7

How quickly will the remaining fluid in the average 3.5kg baby be cleared from the lungs?

Answer 7

Within a matter of minutes, unaided

Question 8

How much warmer is the human fetus than its mother?

Answer 8

0.5 oC

Question 9

How low can a baby’s temperature fall within 5 minutes if left naked and wet?

Answer 9

33 oC

Question 10

By what degree does risk of mortality increase in very low birth weight babies for every 1 oC below the 36.5 oC baseline?

Answer 10

28%

Question 11

What should be assessed in the baby whilst the umbilical cord is still attached?

Answer 11

Colour
Tone
breathing
Heart Rate

Question 12

How should colour be assessed in a newborn?

Answer 12

By looking at the trunk, lips and tongue

Question 13

Is the cord pulsation a reliable indicator of heart rate?

Answer 13

If >100 pulsations a minute - likely all i well, but if pulsations less than this, it is not necessarily an indicator of true heart rate, and thus should be assessed with a stethoscope

Question 14

What is the fetal circulation fed by?

Answer 14

Both the right and left ventricle - 55% by the right ventricle, 45% by the eft ventricle

Question 15

What is the combined ventricular outfit in the near-term fetus?

Answer 15

465ml/kg

Question 16

75% of the right ventricle output supplies what?

Answer 16

Through the ductus arteriosus to supply the abdomen, lower body and placenta

Question 17

75% of the left ventricle output supplies what?

Answer 17

Perfuses the upper body - the head, neck and arms

Question 18

What is the total fetal lung fluid in a near-term infant?

Answer 18

20-30ml/kg (equivalent of functional residual capacity)

Question 19

What would happen should there be insufficient amniotic fluid (and thus fetal lung fluid)?

Answer 19

Adversely affected fetal lung development, causing pulmonary hypoplasia

Question 20

What is it about labour that bring about the cease in production of lung fluid secretion from the fetus’s alveolar cells?

Answer 20

Adrenaline production by the fetus

Thyrotropin production by the mother

Question 21

What is it that bring about loss of fetal lung fluid?

Answer 21

Primarily = the hydrostatic pressures generated by inspiration + secondarily, postural changes imposed on the fetus during uterine contractions > than the ‘vaginal squeeze’ affect

Question 22

How do the hydrostatic pressures generated by inspiration work?

Answer 22

Spontaneous inspiratory movements by the fetus generates a transepithelial pressure gradient between the interstitial tissue and airway lumen, the lung fluid being drawn from the proximal airways into the distal ones, which is then cleared across the distal airway wall into the surrounding interstitial tissue space

Question 23

How many breaths is it before gas exchange typically occurs?

Answer 23

7 - before carbon dioxide is detected on exhalation

Question 24

When does exhaled carbon dioxide peak after birth?

Answer 24

Within the first 2-3 minutes of birth

Question 25

Why do newborns recover from periods of oxygen deprivation more so than adults?

Answer 25

1. Conservation of energy by shutting down circulation to all but vital organs in response to hypoxia 2. Activity of automatic spinally generated gasping activity following primary apnoea 3. Anaerobic respiration, the newborn's heart utilising glycogen, as an alternative fuel to maintain circulation

Question 26

At what saturation would you NOT start inspired oxygen?

Answer 26

>/=95%

Question 27

At <28/40 gestation, what concentration of inspired oxygen would you start with?

Answer 27

30%

Question 28

At 28/40-32/40 gestation, what concentration of inspired oxygen would you start with?

Answer 28

21-30%

Question 29

At >32/40 gestation, what concentration of inspired oxygen would you start with?

Answer 29

21%

Question 30

How long minimum of adequate ventilation should be performed before chest compression be started if inadequate HR?

Answer 30

30 seconds

Question 31

What concentration of oxygen would you give if chest compressions need to be started?

Answer 31

100%

Question 32

What are the acceptable R arm saturations 2 minutes after birth?

Answer 32

65%

Question 33

What are the acceptable R arm saturations 5 minutes after birth?

Answer 33

85%

Question 34

What are the acceptable R arm saturations 10 minutes after birth?

Answer 34

90%

Question 35

What is the usual HR in term and well pre-term babies after 2 mins?

Answer 35

>100

Question 36

What are the different methods of assessing heart rate during resuscitation?

Answer 36

Stethoscope Pulse oximetry ECG monitoring

Question 37

Why are oximetry readings take in the R arm of newborn infants?

Answer 37

Measurements are pre-ductal. Pre-ductal saturations represent the oxygen going to the brain

Question 38

What pressures of inflation should be started with with a term infant for inflation breaths?

Answer 38

30cm of water, 2-3 seconds inspiratory time

Question 39

What pressures of inflation should be started with with an infant <32/40 for inflation breaths?

Answer 39

25cm of water

Question 40

At what rate should ventilation breaths be performed?

Answer 40

30 breaths/minute, 25cm of water, 1 second inspiratory time

Question 41

What response suggests the infant had been suffering with terminal apnoea?

Answer 41

Gasping in nature

Question 42

How long does it usually take for the heart to respond to chest compressions?

Answer 42

Usually, only 20-30 seconds

Question 43

How is access achieved in a newborn infant?

Answer 43

Umbilical vein catheter or IO

Question 44

How often should adrenaline be given if CPR is be performing?

Answer 44

Every 3-5 minutes

Question 45

What may be going on if the HR is still not improving after CPR?

Answer 45

Hypovolaemia Tension pneumothorax Diaphragmatic hernia Complete heart block

Question 46

What are the fetus antenatal RFs for neonatal resuscitation at delivery?

Answer 46

- Prematurity - IUGR - Multiple pregnancy - Serious congenital abnormality - Oligo/poly-hydramnios - Fetal anaemia, including hydrops

Question 47

What are the maternal antenatal RFs for neonatal resuscitation at delivery?

Answer 47

- High BMI - Short stature - PET - Lack of intrapartum steroids in pre-term - PIH - GDM - Maternal sepsis

Question 48

What are the intrapartum RFs for neonatal resuscitation at delivery?

Answer 48

- Evidence of fetal compromise - e.g. pathological CTG - Meconium-stained liquor - Vaginal breech - Instrumental delivery - Significant maternal PPH - C-section before 39/40 - Emergency section - GA

Question 49

What is near enough the only condition that requires early intubation?

Answer 49

Congenital diaphragmatic hernia

Question 50

What special consideration should be given to neonates with abdominal wall defects?

Answer 50

- Passing an NG tube when positive pressure ventilation is required in order to minimise intestinal distension - IO may be required for access as umbilical vein catheterisation may be impossible

Question 51

What can be done in relation to the umbilical cord if DCC is not practicable, but immediate cutting is not required?

Answer 51

Cord milking

Question 52

At what gestation should cord milking NOT be performed?

Answer 52

<28 weeks gestation

Question 53

What are the benefits of DCC in a term infant?

Answer 53

1. Avoidance of bradycardia 2. Improved early haematological; indices 3. Improved iron stores in infancy

Question 54

What are the benefits of DCC in pre-term infants <34/40?

Answer 54

1. Improved survival 2. Improved early haematological indices 3. Improved cardiovascular stability in first 24 hours - improved BP and lower use of inotropes 4. Reduce need for blood transfusions and reduced total number of transfusions

Question 55

When may DCC NOT be advisable?

Answer 55

1. Cases with interruption of the placental blood flow/oxygenation - e.g. maternal haemorrhage/seizure/arrest, placental abruption, vasa praevia, cord avulsion 2. TTTS 3. Fetal hydrops, any underlying cause

Question 56

How much additional blood is conveyed to the infant during cord milking?

Answer 56

3-5 'milks' = 50ml

Question 57

What are the reasons for difficulties with breathing at birth?

Answer 57

1. Loss of respiratory drive 2. Mechanical obstruction of airway 3. Inability to breathe

Question 58

What causes a loss of respiratory drive in neonates?

Answer 58

Congenital brain abnormality | Acquired depression of the neurological centres - e.g. infection, drugs, perinatal stress and hypoxia

Question 59

What causes a mechanical obstruction of the airway in neonates?

Answer 59

Foreign body - e.g. mec or vernix Anatomical abnormality of the airway - Pierre-Robin sequence Loss of muscular tone affecting patency of the airway - unconscious baby

Question 60

What causes an inability to breathe in neonates?

Answer 60

Neurological and muscular disorders | Lung immaturity

Question 61

What are the 2 manoeuvres that open a neonate's airway?

Answer 61

1. Head in neutral position, supporting chin and jaw | 2. Moves the jaw forward using a two-handed jaw thrust

Question 62

How can the head be kept in a neutral position without holding it?

Answer 62

There is a tendency for the neonates neck to be flexed due to the prominence of the occiput - this can be overcome, holding the head in neutral position by a 2cm pad being placed under the shoulders

Question 63

Which pieces of equipment can be used to deliver positive pressure ventilation?

Answer 63

1. T-piece or 2. Self-inflating bag

Question 64

How do you minimise face mask leaks?

Answer 64

3 P's: POSITION - rolling the mask on to the face PRESSURE - balancing the pressure exerted on the mask by the finger and thumb PULL - lifting or pulling the jaw up in to the mask

Question 65

What size face mask should be used for 23-26/40?

Answer 65

35mm

Question 66

What size face mask should be used for 27-28/40?

Answer 66

35mm or 42mm

Question 67

What size face mask should be used for 29-32/40?

Answer 67

42mm

Question 68

What size face mask should be used for 33-36/40?

Answer 68

42mm or 50mm

Question 69

What size face mask should be used for 37/40?

Answer 69

50mm

Question 70

What size face mask should be used for term IUGR/38 weeks?

Answer 70

50mm or 60mm

Question 71

What size face mask should be used for >39/40 or LGA?

Answer 71

60mm

Question 72

When would you expect the chest to start moving on giving inflation breaths?

Answer 72

4th or 5th breath

Question 73

If needed, at what rate should ventilation breaths be given?

Answer 73

30/min

Question 74

When can an iGel or LMA be used?

Answer 74

In those >2000g or >34/40

Question 75

What size laryngeal mask (LMA or iGel) should be used in neonates, and how should it be inserted?

Answer 75

Size 1 | Should be inserted with a laryngoscope (unlike in adults)

Question 76

How should the head be positioned when inserting a laryngeal mask?

Answer 76

With the neck in a slightly extended position

Question 77

What do you do if inflation breaths do not work?

Answer 77

Consider obstruction - consider using laryngoscope to inspect the oropharynx and a large bore suction catheter to relieve the obstruction

Question 78

What are intubation rates in neonates in the UK?

Answer 78

0.4-2%

Question 79

What are the chest compression rates in neonates in the UK?

Answer 79

0.3%

Question 80

What proportion require adrenaline?

Answer 80

0.05% - 1 in 2000

Question 81

What is the technique for two-thumbed chest compressions?

Answer 81

Overlapping thumbs, lower third of the sternum, in the centre of the chest, just below the imaginary line between the nipples

Question 82

At what rate should CPR be performed in neonates?

Answer 82

3:1 - 90 chest compressions:30 breaths (120 events)/minute

Question 83

What drugs should be given with prolonged resuscitation?

Answer 83

Glucose and sodium bicarbonate

Question 84

How often should adrenaline be given whilst CPR is ongoing?

Answer 84

Every 3-5 minutes

Question 85

What is the preferred route of adrenaline in neonates?

Answer 85

IV, but IO can be used

Question 86

What is the recommended dosage of adrenaline IV or IO in resuscitation?

Answer 86

20 microgram/kg

Question 87

What is the recommended dosage of adrenaline when given intra-tracheally in resuscitation?

Answer 87

100 microgram/kg

Question 88

What level of CPAP should be used to stabilise pre-term infants if needed?

Answer 88

5-8cm water

Question 89

What is the appropriate PEEP for a ventilated pre-term infants if needed?

Answer 89

5cm

Question 90

What is the first sign of recovery from terminal apnoea?

Answer 90

Once the circulation is restored, agonal gasps, occurring every 5-8 seconds is the first sign

Question 91

What is the cause of primary apnoea?

Answer 91

Unclear airway