Covering the birth suite can be wonderful and terrifying. Neonatal resus should be both easy and scary, every time. If you’re not even a little, tiny bit scared, you’re quite possibly “doing it wrong”, and almost always, sticking to the algorithm ensures that you do the right thing for the patient.
This post shares a few of my own tips and idiosyncrasies in preparing for and undertaking neonatal resus, particularly in the regional setting where a tertiary NICU isn’t just a buzzer and a short walk away. It’s by no means the full course; I strongly recommend you do a NeoResus course with simulation training before you’re anywhere near the Birthsuite. This post is more along the lines of tips, tricks and philosophies to augment the standard of care you’ll learn on the NNR program.
1. Where’s your backup?
The big yellow stripe down the side of the Neonatal Resus algorithm is there for a good reason. If you’ve been called, the birth suite team has identified that you’re the first point of escalation. At a minimum, the consultant on call and your nursery number should be in the back of your head. It’s also good to write down the number on either the whiteboard in theatres, or somewhere you can point to, like the sheet of the resuscitaire at a point that’s unlikely to be obstructed or bloodied. Even better if there’s a neonatal code team with or without emergency buzzers, know where it is and what the number is.
2. Get familiar
I’ve become more fastidious about this after doing a few years at regional centres with variable assistance and support available. Resus is a ‘hard to control’ situation, and if you’re lucky enough to be given a ‘heads up’ then it makes sense to have things in a way that’s functional.
I cannot emphasize enough the importance of getting to know your resus trolleys before you need to do a resus. Early in your first shift or set of shifts, going to birth suite, introducing yourself to your new colleagues and having played with whichever trolley/resuscitaire/panda they have and understanding the gas supplies will do you a world of help when it comes to the crunch; and especially when transitioning to transport to your nursery.
Same goes for the layout of the birth suite and the staff. If you’re on a six-month or year-long posting, the chances are you’ll do a resus with almost every member of staff. Establish a good working relationship with your midwifery colleagues in times of low stress.
If you know you’re covering the birth suite – in addition to other roles – walk through there at the start of each shift. It makes sense to have an idea what might be coming up over the next 8-14+ hours, and probably allows you to plan the shift a bit more effectively.
3. Start the timer/clock when the baby is born
Time can melt away in a resus situation. Being time-aware is essential not only to trigger certain actions but for noting significant events during the resus. In most neo resus situations, the person leading will start the clock; however, the job can be delegated then rechecked by the senior within a few seconds.
Set your suction at <120mmHg. Nelson suggests that pressures higher than this can be associated with oesophageal rupture. I use size 8 FG suction catheters because size 10 (in most brands) has fenestrations which can drag on surfaces you’re not intending to suction. Size 12 tends to be a bit large for most neonatal nostrils.
Your backup is your lungs. One of my NICU consultants tells me this was the standard in the 70s and there are a few much more recent stories of a quick-thinking registrar saving the day after a suction failure at an inopportune moment; a heroic action, but with a real risk of exposing yourself to hepatitis C in some patients.
Aside from meconium deliveries, it’s rare to have a primary (large) airway problem. The ventilation devices you use most commonly rely on your ability to make a seal and do airway manoeuvres. This is also a good time to palpate +/- visualize the palate to ensure there’s not a cleft hiding away there. A lot of neonatal resus programs, in my opinion, over-emphasize the importance of intubation; in practice, it’s more important and much much more common to use the basics first.
Take note of the sizes of the masks; they range from 72mm down to 40mm, so you need one that’s the appropriate size. I’ll load up a 60mm at term and 50mm if the baby is <35/40 or <2kg, and stay aware of where the alternatives are kept.
In Australia, the T-piece is a commonly used airway. The brand Neopuff has been around for a while, so I’ll continue to use the term here. I set the pressures at 30/8 in a term neonate. Most neonatal resus programs will quote a PEEP of 5-8cm. I tend towards 8cm, after reading this study by Probyn et al, which suggests no increased risk of pneumothorax in 26-week equivalent lungs. It’s worth a read, here.
Some units, often those attached to a NICU, may use an anaesthetic bag (Mapleson C) as first-line. They need a gas source and a bit of practice to use but allow for a better ‘feel’ of the lungs for the experienced operator.
The next level of airway is:
- Intubation & ventilation
- ETT 3.5 @ term x2
- Laryngoscopes w/ size 1, 0 (straight or curved, as per preference).
- Attach your ETT to a capnograph and either the Neopuff or a bag-mask valve for transport to the NICU/SCN.
- Under 1kg, the capnograph is unlikely to have sufficient CO2 output to change the colour, so think about all the other signs of a correctly placed ETT.
Always, ALWAYS find and check your backup, a self-inflating bag, 250mL. It’s also good for babies born in the car park or ward, so knowing where to grab one in a hurry can be quite useful. If, however, the baby is spontaneously ventilating, this option is off the table, as they’ll not have the exhalation strength to overpower the pressure valve, thus effectively asphyxiating the child. To be avoided.
Say to the birth assistant;
“There’s meconium, so do not stimulate the child.”
If the child is spontaneously crying, vigorous with a good heart rate, it’s appropriate to stimulate, warm & dry the child immediately; communicate that you’re happy for this to be done.
The Cochrane review of intubation for meconium says
“Routine endotracheal intubation at birth in vigorous term meconium-stained babies has not been shown to be superior to routine resuscitation including oro-pharyngeal suction. This procedure cannot be recommended for vigorous infants until more research is available.” (Halliday et al).
I tend to think of meconium posing two threats; firstly, a large plug in a major airway leading to hypoventilation/asphyxia, and secondly, the more distal effects causing small airway plugging, and eventually inflammation and meconium aspiration syndrome.
The meconium aspirator aka the yellow rocket.
If you’re an ‘experienced operator’ then neonatal intubation is a good way to clear the cords. There’s a growing trend away from ETT suctions for meconium, alluded to in the 2010 revision of the ILCOR NRP guidelines. My impression is that time tends to be wasted placing the tube, attaching the yellow rocket, the ventilating the child. Whilst it’s a very important skill to have, the main outcome for the baby is time to airway; the sooner, the better. If in doubt, I use a ‘wiggly worm’ 8FG in the oropharynx and nares and start ventilating. The counterpoint to this, of course, is that visualization of the cords with direct laryngoscopy allows you to see if there really is meconium between the cords. You need to do what you’re comfortable with. Remember, if you’ve done the ETT suction and the child needs a definitive airway for ongoing management, you’ll need a fresh ETT.
7. SpO2 probe
A SpO2 trace is now the standard in neonatal resus. The old adage of treating the patient, not the numbers is essential here; but if the child’s SpO2 are low, titrate your FiO2 to match. The right hand is best, as it’s pre-ductal. The probes themselves can be challenging to attach or have poor traces, so one with a visible waveform is helpful. Also helpful is some thick tape (Microcosm is my preferred), as often the infrared sensor and infrared heater on a wet, sticky hand can cause the probe to simply not read.
8. Nasogastric tube and 20mL syringe
These can be helpful if you’ve been giving baby PEEP or IPPV for a prolonged period. A significant amount of gas inevitably makes its way into the gut, and 20+mL in the abdomen can have a compressive effect on the thorax. Learn to put them in – the Special Care nurses are usually more than happy to teach you how to measure and put them in on some of the babies who are ‘feeding and growing’.
Ask your assistant to tap the heart rate. Saying “it’s fine” isn’t quite the level of detail you need, particularly if the rest of the clinical picture doesn’t fit. It saves time on the practice of counting for 6 seconds and multiplying by ten, a challenging calculation in the heat of a resus. Best of all, tapping the rate gives you ‘real-time’ data. Importantly, if the assistant is struggling to palpate or auscultate a pulse, you can listen yourself and move to the appropriate level of the algorithm.
If the baby is flat but physiologically not terrible, think about hypoxic ischaemic encephalopathy. For any prolonged resus, check a BSL early.
11. Cord gases
In most centres, the Paeds reg is only called for medium to high-risk deliveries. In these situations, cord gases are indicated. If you’re called unexpectedly to a flat baby, likewise, cord gases are indicated. If things aren’t going to plan in a delivery, it’s easy to forget to take cord gases, asking for them early can allow the obstetric team to double clamp the cord, and take gases when mum is safe – my obstetric colleagues tell me that within 30 minutes a reliable gas can be obtained, although the literature states up to 60 minutes, provided the cord has been double clamped (Armstrong et al).
Turn the heater to 100% on arrival. Have at least two warm wraps and two towels. You want enough wraps to be able to warm, dry and stimulate the neonate well, accounting for the aim of going to mum afterwards. It is unlikely that doing chest compressions on a huge pile of fluffy towels is effective, so make sure the base of the trolley has some firmness to it, just in case. It’s nice to give babies a hat early on, and frankly essential if they’re to stay warm in the well-chilled operating theatres with Mum afterwards.
As a resus progresses, it’s easy to overheat them. Turn the temperature down, and if the bub feels warm and there’s a spare set of hands, you can ask for a temperature early.
13. Cord clamps
Often in theatres, or after an instrumental delivery, a baby may be passed across with the metal cord clamps attached. These can get very hot very quickly, so if there’s a prolonged resus be sure to move them away from the baby’s skin and, in particular, away from the genitals.
So, with the above in mind, I set my up resuscitaire the same way every time. It makes sense that if you need something in a hurry, you don’t want to have to be searching for it or fumble around. Thus, I arrange my trolley this way:
- Is it plugged in and on?
- Oxygen/medical air, suction attached?
- Heater to 100% initially.
- A couple of towels/wraps, as above.
- Left front, under the corner of the mattress, is the laryngoscope, with a #1 Straight/Miller.
- On the left side are the Neopuff mask and tubing. Check the pressures are set at 30/8.
- Right front, at the edge of the mattress, is an ETT with introducer. I don’t cut them for length.
- On the right side is the suction, with a size 8 FG attached.
- On the right side of the trolley are the SpO2 probe and a length of tape.
- In the back right corner is the meconium aspirator.
15. Vitamin K
Although preparation of this is usually left to the midwifery staff, it’s good form to help check it is being drawn up if there’s no one else available. There can occasionally be trepidation or resistance from parents to the use of IM Vitamin K; I won’t go into the large body of evidence for the prevention of vitamin K-deficient bleeding in the newborn. It also means you can ask for it to be given when you’re in need of some additional stimulation during a resus.
16. The spiel
Somehow, I got in the habit of running through a spiel with my assistant prior to any delivery I attended with some time up my sleeve. The spiel is almost identical when given to med students, midwifery students and midwives who I’ve resuscitated more than a few times.
- Firstly, demonstrate that I’ve checked the trolley, pressures, and backups.
- Next, identify roles.
- Talk through the likely scenarios.
“I’m happy to start the clock, whilst you bring baby over (in theatre or instrumental). If bub comes out pink & squawking, we’ll warm, dry and stimulate.
Otherwise, I’ll be on the airway, and you’re going to tap out the heart rate. We know that this (tapping at 120+/min) is good, and this (tapping at 40/min) is bad. In the middle we can work out. I
f you can’t feel a heart rate, listen to the chest, and I’ll listen too.
If the HR is less than 80, we’ll breath for the child.
If the child is not breathing, we’ll breath for the child.
If the heart rate is still less than 60, I’ll ask you to do compressions.
If you’re not happy or there’s something I’m not seeing, I want you to tell me.”
17. Communication with parents and supporters
Before the birth
- Introduce yourself to the parents – from their point of view, you should be so lucky to be at the birth of their child!
- Ask the parents’ names.
After the birth and resus
- Congratulate them!
- Explain what has happened.
- Provide appropriate reassurance.
- Invite questions.
Explain the expected course. If the child is well, rather than saying “Nothing for me to do here”, say “Another doctor will check your baby before you go home. If you are worried, tell the nursing staff and they’ll let me know.“
For a baby requiring ongoing respiratory support, a cuddle with mum is not appropriate, but it’s good to try and enable mum to touch or see her baby. This isn’t always possible, but acknowledging it tends to help; it is a very fine line between the perception of saving the baby and stealing the baby away to the nursery. Don’t whisk the baby away without tags – they need to be adequately identified before leaving the room!
If the baby is now well but requires an IV for antibiotic prophylaxis for presumed sepsis, explain the process; if there’s been an ‘unexplained resus’, or there’s any other setup for sepsis, that’s what will be happening next. Invite a support person to accompany the baby to the special care nursery.
18. When it gets hairy
- Respect your own limits.
- In addition to the consultant, call for your experienced SCN staff early.
- Have them bring the ‘cat 1’ box of tricks, which will include:
- Umbilical lines
- Chest drains
- Remember, in pinch, anaesthetists may have recent infant intubation skills.
Most of this post is about the things you can do if there’s time to prepare. sometimes, it’s a “flat baby, come now” situation. Get to the basics – suction & ventilation and specifically ask:
“What is the gestation?”
“Was there any meconium in the liquor?”
“How long has the baby been out?”
Remember your PPE, there is always time to put on a pair of gloves. Start the clock if it hasn’t been started already, and don’t forget to say who you are to the team and parents.
20. In summary…
Neonatal resus is both simple and scary. The bottom line is:
Do a NeoResus course
Stick to the basics of A,B, C and D.
Set up the same way each time.
Get someone to TAP the heart rate.
Introduce yourself and explain what is going on.
ARC guidelines for Newborn Life Support – https://resus.org.au/?wpfb_dl=8
Armstrong L, Stenson BJ. Use of umbilical cord blood gas analysis in the assessment of the newborn. Archives of Disease in Childhood Fetal and Neonatal Edition. 2007;92(6):F430-F434. doi:10.1136/adc.2006.099846. – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2675384/
Halliday HL, Sweet DG. Endotracheal intubation at birth for preventing morbidity and mortality in vigorous, meconium-stained infants born at term. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD000500. DOI: 10.1002/14651858.CD000500. https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000500/abstract;jsessionid=C698844E8E4F962282FE64763EF88FE6.f01t02
Probyn ME et al. Positive end expiratory pressure during resuscitation of premature lambs rapidly improves blood gases without adversely affecting arterial pressure. Pediatr Res. 2004 Aug;56(2):198-204. Epub 2004 Jun 4. – https://www.ncbi.nlm.nih.gov/pubmed/15181198
NeoResus programme – https://www.neoresus.org.au/pages/index.php
Perlman, J et al. on behalf of the NEONATAL RESUSCITATION CHAPTER COLLABORATORS. Special Report Neonatal Resuscitation: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Pediatrics published online Oct 18, 2010; DOI: 10.1542/peds.2010-2972B – https://www.neoresus.org.au/pages/documents/SpecialReportNeonatalResuscitation2010Consensus.pdf
I’ve adapted my teaching recently to include a “trigger phrase” for attending deliveries. There’s the inevitable lag between being called to the delivery (and how long it takes to set up) and the resus proper; I’ve been encouraging colleagues to use the phrase “Time of birth…” as their own trigger phrase to switch on / change gear at the time of birth.