CARIOPULMONARY RESUSCITATION

INTRODUCTION: The word resuscitation means to arouse again and is a life saving skill,
hence the all health care professional attending the mother during delivery are required to be
competent in resuscitation. Ensure availability of the supplies and persons skilled to provide
neonatal advance life support including intubation and umbilical vein catheter insertion.

Team leader must be identified and he should perform pre resuscitation briefing, identifying
the intervention required .he should assign role and responsibilities to the member.

Be prepared for neonatal resuscitation.

Know what to do, be gentle and fast.

In what order.

Be able to work quickly in coordination.

Document/ record.

Maintain strict asepsis.

Focus on mother as well as newborn’s need.

PURPOSES:
Purpose of resuscitation is to assist adaptation to extrauterine life by:

*ventilating the lungs of neonate abd providing oxygen.

*providing cardiac compression if required.

*Administering medication if needed.

Various steps for resuscitation include

Preparation

Rapid assessment

Initial step

Ventilation
Chest compression

Intubation

Medication

REQUIREMENTS:

*A draught free, warm room with temperature 26-28’c (to prevent hypothermia)
*A clean, dry and warm delivery surface ( in order to prevent infection and hypothermia)

*A radiant warmer (to maintain temperature)

*A source of oxygen.

*A source of regulated suction device.

*two trained person for one neonate.

ARTICLES:
Suction device (mucus extractor for single use) and catheter 5F,8F,12F,and 14F).

Two clean warm towel /cloth with cord clamp and thread tie.

*two folded piece of cloth to position the baby.

*neonatal resuscitation bag(240-500ml) with oxygen reserviour face mask ,term (1) preterm
(0) size.

*pulse oxymeter

Endothracheal tube(size 2.5-4.5 mm)

*gloves, flow meter

*T connector

*umbilical catheters(2.5-5 french)

*syringes 1ml, 5ml,10ml

*tapes and scissors

*A clock with seconds

*laryngoscope ( with size 0 and 1 blade extra bulbs with batteries)

Medications

Epinephrine , normal saline

STEPS OF PROCEDURE:

PREPROCEDURAL STEPS:
*Switch on the radiant warmer 15 -20 minutes prior to anticipated time of birth and keep two
sterile draw sheets to warm.

*Ensure that self inflating bag are working well and all the parts are attached correctly.

*Ensure availability of humidified oxygen and humidification chamber. Fill the chamber with
distilled water upto the level marked.

*Switch on the saturation moniter and ensure that saturation probe is working

Well. Clean the probe and its tubing with spirit swab and keep it ready for use.

*Check the laryngoscope and its blade. The blade should fit well, the bulb must be screwed
light.

*Ensure availability of two health care personals trained in neonatal advance life support.
*Alert the team.

INTRAPROCEDURAL STEP:
ROUTINE CARE: routine care include providing warmth, cleaning the airway if necessary and
performing ongoing evaluation.

umbilical pulsation for 6 seconds .

RESPIRATION: Is assessed by observing the chest movement.

SATURATION: Is assessed by applying saturation probe on the right hand of neonate. The
saturation reaches upto 85% by 10 min .

PROVIDING WARMTH: By placing the baby under a radiant heat source

PPV: if the newborn is apenic or grasping or if the heart rate is <100/min after the initial step
start PPV.

Initial breath and assisted ventilation ;

The primary measure of adequate initial ventilation is prompt improvement in HR.

 Chest wall movement should be assessed if HR does not improve.
 In case the baby is preterm ,start PPV with 30% FiO2.

CHEST COMPRESSION:

Chest compression consist of rhythmic compression of sternum that compresses the heart
against the spine, increases the intrathoracic pressure and circulate blood to the vital organ.
Chest compression must always be accompanied by ventilation with 100% oxygen to assure
the blood circulating is well oxygenated.

 Use two finger of one hand or compress the chest and place the other hand under the
back to provide support.
 Compress the sternum to a depth of approximately 1/3of anteroposterior diameter of
the chest and with sufficient force to cause a palpable pulse . The finger should remain
in contact with the chest between compression.
 Use 3 compression followed by 1 ventilation of 120 each minute . This provide 90
compression and 30 ventilation each minute, pause for half second after every third
compression for ventilation.
 Check the heart rate after every 30 second .if it is 60beats per minute or
more ,discontinue compression but continue ventilation until the heart rate is more
than 100beats / min and spontaneous breathing begins.

ENDOTRACHEAL INTUBATION:
INDICATION:

 Heart below 60/ min in spite of bag and chest compression.

 Presence of meconium in the amniotic fluid.

Procedure:

 Ensure all the required equipment are within reach of the person who are intubating.
  Place infant with head slightly extended with a rolled towel under the shoulder.
 Introduce the laryngoscope over the baby’s tongue at the right corner of the mouth.
 Advance 2-3cm while rotating it to midline, until the epiglottis is seen. Elevation of the
epiglottis with the tip of laryngoscope reveals the vocal cord .
 Suction secretion if needed.
 Pass the endotracheal tube a distance of 1.5-2cm into the trachea ,hold it firmly but
gently in place and withdraw the laryngoscope slowly.
 Attach the endotracheal tube to the adapter on the bag.
 Ventilate the oxygen by bag. An assistant should check for adequate ventilation of both
lungs with stethoscope.

MEDICATION:
Medication should be administerd , if despite adequate ventilation with 100% oxygen and
chest compression the heart rate remains at 80beats /min.

Epinephrine 0.1- 0.3 ml/kg in 1:10,000 dilution is given i.v when there is persistant bradycardia.
Intratracheal administration can also be given . it may be repeated after every 5 min . sodium
bicarbonate to combat the metabolic acidosis IV( 4ml/kg of 0.5meq/ml) is given.

 Naloxone 100mg/kg is given to the baby by IV, IM or endotracheal.

 Volume expansion is needed when blood pressure is low and tissue perfusion is poor.
Whole blood , 5% albumin or packed RBCs is given.
 Dopamine infusion may be given for hypotension.

RECORDING:

Record the procedure in nurses record. Document the baby’s condition before and after
procedure.

POST PROCEDURAL STEP:

 Carefully observe the neonate after intubation for temperature , heart rate , breathing
and spo2.
 Replace the article at proper place after washing and disinfection.
 Keep the resuscitation trolley with all required article for intubation and emergency
drugs in the trolley near the child.
 Wash hands thoroughly to prevent infection .
 Never leave the neonate alone.
 Watch and maintain open airway.
 Prevent displacement of tube.
 Watch for complication such as laryngeal edema, tracheal stenosis , hemorrhage etc.s