(C) AMBULANCE VICTORIA

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1 The Newborn Baby: Definitions and Contacts Newborn definition 'Newborn' refers to the first min to hours post birth. For the purpose of resuscitation, AV accepts up to the first 24 hours from birth in the newborn definition. This is due to the adaptations of the respiratory and cardiovascular systems in this time. Preterm infant (24-37 completed weeks gestation) Gestational age has an effect on the development of lung and pulmonary circulation and therefore influences how well these newborns establish effective respiration. The primary focus in prehospital Mx is establishing and maintaining effective ventilation and preventing hypothermia. Newborns > 32 and < 37 weeks gestation require Tx to a Level 2 Hospital (paediatrician and midwife staff on site 24/7). Newborns < 32 weeks gestation or any infants who are intubated require Tx to a tertiary centre: Mercy Hospital for Women (MHW), Monash Medical Centre (MMC), Royal Women's Hospital (RWH) or Royal Children's Hospital (RCH). Consult with PIPER for an appropriate receiving hospital. In rural Victoria, proceed to the nearest base hospital (or hospital with maternity services) and contact PIPER via the Clinician. Transport Where available, MICA assistance should be sought early when preterm birth is considered a possibility. Expeditious Tx to the nearest most appropriate hospital should occur without delay. Emergency contacts Paediatric Infant Perinatal Emergency Retrieval (PIPER) (formerly known as NETS, PETS and PERS) for all advice and assistance in newborn care and Mx contact via Clinician or Version Page 1 of 4 CPG N0101 The Newborn Baby: Definitions and Contacts CPG N

2 The Newborn Baby: Normal Values Weight: Average full term weight = 3.5 kg Normal blood volume: 80 ml/kg Heart rate: bpm HR is the most important indicator for resuscitation. Respiration: breaths per min Skin: Colour - may be dusky and peripherally cynanosed in the first few minutes after birth. Blue-ish / purple hand and feet are normal in the first 24 hr after birth and are not an indication for supplemental O 2. It may take 7 10 min post birth for SpO 2 to reach > 90% and for colour to become centrally and peripherally pink. Conscious state: Active motion, grimace and/or crying. Temperature: Aim for normothermia ( ºC per axilla). Newborns lose heat via the large surface area of the head and by evaporation from their wet bodies once outside the uterus. BGL: mmol/l Version Page 2 of 4 CPG N0101

3 The Newborn Baby: General Care Body temp: Maintain normothermia (per axilla temperature of ºC). Place the newborn naked, skin to skin with the mother to maintain warmth and cover them both with warm blankets if the newborn is vigorous and not requiring ongoing resuscitation. If resuscitation is required, place the newborn on a warm, flat surface, cover with bubble wrap and warm wraps. Place a woollen hat or the corner of a warm blanket on the newborn s head to maintain warmth. Following birth, preterm infants < 28 weeks gestation should be placed immediately (without drying body) into a polyethylene (Glad zip lock) bag with the head (dried) outside. If AV arrive after the birth, dry the infant, cover the head with a hat or the corner of a warm blanket and cover the body with bubble wrap and warm blankets. Cutting the cord: Cutting the cord in the vigorous newborn is not urgent. Apply general care and cut the cord when it stops pulsating. The cord must be cut in the non vigorous newborn earlier to allow effective resuscitation. This would usually be after initial basic tactile efforts and commencement of IPPV. Version Page 3 of 4 CPG N0101 The Newborn Baby: General Care CPG N

4 The Newborn Baby: Airway Position: Place head and neck in a neutral position avoiding neck flexion and head extension. Suctioning: The vigorous newborn does not require suctioning unless born through meconium stained amniotic fluid. They usually clear their own airway very effectively. Newborns who are not vigorous at birth (not breathing and poor muscle tone) only require airway suctioning if born through meconium stained amniotic fluid or if the infant has obvious blood in the oropharynx. The mouth should be suctioned followed by the nose. The newborn is a nasal breather and may gasp pharyngeal fluid if the nose is cleared first. Intubation and suction of the trachea (if a person with the expertise to intubate is present) should follow where necessary in Mx of the non vigorous newborn. Pharyngeal suctioning can cause laryngospasm and bradycardia through vagal stimulation, thus suctioning must be gentle and brief (5 6 sec) to avoid compromising the newborn further. A 10 or 12 FG catheter is the recommended size for suctioning the oropharynx of a newborn. Version Page 4 of 4 CPG N0101

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6 Newborn Resuscitation: Advanced Airway OPA: size 00, 0 May be useful if there is an airway abnormality or the infant's tongue is large and impeding effective BVM ventilation. Not recommended for routine use in newborns with a normal airway as it can cause obstruction and vagal reactions. Laryngoscope blade: Straight Miller blade. Size 1 for term. Size 00 preterm LMA: Portex size 1 for newborn > 2000 g or 34 weeks gestation Indicated for failed BVM and failed intubation. EtCO 2 : An EtCO 2 detector (Pedi- Cap ) is recommended to verify successful tracheal intubation in the newborn. Paediatric EtCO 2 is to be continuously monitored via the paediatric MRx attachment where available. <1 kg or < 28 weeks extremely preterm 1 3 kg or weeks moderately preterm > 3 kg or > 36 weeks term or near term ETT size mm Lip length (wt in kg + 6 cm) ETT suction catheter NG tube cm 6 FG 6 FG cm 6 FG 8 FG cm 6 FG 8 FG Version Page 1 of 6 CPG N0201

7 Newborn Resuscitation: Ventilation Ventilation: The majority of newborns needing resuscitation at birth are apnoeic and bradycardic but rarely asystolic. Hypoxia eventually depresses respiratory drive and causes bradycardia. Effective ventilation is the key to newborn resuscitation. Pulmonary pressure changes are integral in effecting necessary fetal circulation changes. Prompt improvement in HR > 100 bpm (assessed using a stethoscope over the apex of the heart) is the primary indicator of adequate ventilation. Increased pressure may be required for initial breaths. Ventilation rate: inflations per min. Tidal volume: 5-10 ml/kg initially with room air. If HR remains < 100 bpm after at least 30 sec of effective BVM ventilation on room air, supply high concentration O 2. PEEP: Where available use a 5 cm H 2 O PEEP valve attached to BVM during IPPV. PEEP is important in improving lung vol and establishing and maintaining FRC particularly in preterm newborns. Version Page 2 of 6 CPG N0201 Newborn Resuscitation: Ventilation CPG N

8 Newborn Resuscitation: Circulation Chest compressions: Chest compressions are rarely required unless the HR is below 60 bpm despite effective ventilation for at least 30 sec. The first min of resuscitation should not compromise airway techniques and ventilation where the HR < 100 bpm. If after 30 sec of effective BVM ventilation the HR remains < 60 bpm, compressions should be commenced. CPR: 3:1 compression:ventilation ratio. Achieve 90 compressions and 30 ventilations per min with 0.5 sec pause in ventilation (120 events per min or two per sec). There is no pause post intubation. HR: Reassess every 30 sec until HR > 60 bpm where compressions may be ceased. Continue IPPV / APPV until HR >100 bpm and the newborn is breathing effectively. Cardiac monitor: Attaching electrodes for routine cardiac monitoring of preterm newborns may result in damage to the fragile dermis of the skin. ECG electrode attachment should be reserved for emergency resuscitation circumstances. Pulseless VT and/or VF are unlikely to be observed in the resuscitation of a newborn. Should these rhythms be observed defibrilate as for other age children using 4 J/kg at 2 min intervals as required. Pulse oximeter: Where available, attach newborn O 2 saturation probe to right hand (pre-ductal) to allow continuous evaluation of heart rate and SpO 2. This negates need to stop chest compressions to evaluate the HR. Version Page 3 of 6 CPG N0201

9 Newborn Resuscitation: Circulation Compression method: Hand encircling 2 thumb method The 2 thumb method is preferred in the 2 rescuer setting. Alternative 2 finger method The 2 finger alternative preferred in single rescuer situations to minimise transition time. Compression Depth: 1/3 depth of chest diameter. Version Page 4 of 6 CPG N0201 Newborn Resuscitation: Circulation CPG N

10 Newborn Resuscitation Status 8 Assess Birthed Is the newborn moving Breathing present moving or crying Not breathing not moving or crying Vigorous newborn Routine care Dry (especially the head) Keep warm (skin to skin with mother) Clear airway only if needed (see airway) Assess HR, breathing, colour Is the newborn crying or breathing Non-vigorous newborn Assess APGAR at 1 min and 5 min post birth 8 Assess By 30 sec Is the newborn breathing Is the HR > 100 bpm Clear airway only if needed (see airway) Stimulate by drying (then maintain warmth) Place head and neck into a neutral position Version Page 5 of 6 CPG N0201

11 HR > 100 bpm and breathing adequately Routine care Continue to observe HR, breathing, colour, tone, activity If centrally cyanotic after 7 10 min post birth - Commence O 2 L/min via nasal cannula until pink By 60 sec HR > 100 bpm and breathing adequately Cease IPPV Observe HR, breathing, colour, tone and activity closely By 90 sec HR > 100 bpm and breathing adequately Cease IPPV and ECC Observe HR, breathing, colour, tone and activity closely Cease high flow oxygen if centrally pink and/or SpO 2 > 90% 8 Assess Status Stop 8 Assess 8 Consider MICA Action Evaluate HR and breathing 8 Assess Evaluate HR and breathing HR bpm and inadequate breathing Continue min until HR > 100 bpm and breathing adequately. Add supplemental high concentration O 2 Continue to reassess after 30 sec IPPV HR bpm and inadequate breathing Continue min until HR > 100 bpm and breathing adequately. Continue high concentration O 2 Continue to reassess after 30 sec IPPV HR < 100 bpm and/or inadequate breathing IPPV with room min until HR > 100 bpm and breathing adequately Reassess after 30 sec IPPV HR < 60 bpm and inadequate breathing Commence 3:1 ratio aiming for 90 compressions and 30 ventilations per min IPPV with high-flow supplemental O 2 Continue to reassess after 30 sec CPR HR < 60 bpm Continue CPR with supplemental O 2 Mx as CPG N0202 Newborn Advanced Resuscitation Continue to 30 sec intervals Newborn Resuscitation CPG N

12 Newborn Advanced Resuscitation Continue CPR if pulseless or HR < 60 bpm Reassess every 30 sec IV / IO Adrenaline 10 mcg/kg 3/60 intervals Intubate If unable to obtain above vascular access - Adrenaline 100 mcg/kg ETT Normal Saline ml/kg IV or IO Asystole or severe bradycardia persists Asystole or severe bradycardia persists Asystole or severe bradycardia persists Asystole or severe bradycardia persists - Repeat if necessary If pulse returns At early opportunity, assess BGL If BGL < 2.6 mmol/l, consult with PIPER for administration of 10% Dextrose or Glucagon Version Page 1 of 2 CPG N0202

13 Newborn Advanced Resuscitation Adrenaline 1:10,000: 10 mcg/kg IV or IO (100 mcg/kg via ETT). Do not use 1:1,000 unless diluted to 10 ml. Normal Saline: ml/kg IV or IO. Repeat if necessary. If BGL < 2.6 mmol/l: Consult with PIPER for drug and dose administration advice for Mx using Dextrose 10% or Glucagon. Sodium Bicarbonate: Not indicated / should not be administered. Atropine: Not indicated / should not be administered. Naloxone: Not indicated / should not be administered even in the setting of suspected opioid overdose. It can lead to acute withdrawal and seizures in the newborn. Sedation: Not usually required to maintain ETT. Consult PIPER for further advice if necessary. Version Page 2 of 2 CPG N0202 Newborn Resuscitation CPG N

14 Newborn Baby: APGAR scoring system APGAR scores should not be used as a guide for resuscitation. The time intervals used for resuscitation are contained elsewhere within this CPG. The APGAR score should be conducted 1 min after delivery and repeated 5/60 until APGAR score > 7. A score of: 7 10 Satisfactory 4 6 Moderate depression and may need ongoing respiratory support (IPPV) 0 3 Newborn requiring ongoing resuscitation (including ETT and drug therapy) 0 points 1 point 2 points Appearance Blue, pale Body pink, extremities blue Totally pink Pulse Absent < 100 > 100 Grimace None Grimaces Cries Activity Limp Flexion of extremities Active motion Respiratory effort Absent Slow and weak Good strong cry Version Page 1 of 1 CPG N0301

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