GUIDELINE FOR RESUSCITATION OF NEWBORN INFANTS

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1 GUIDELINE FOR RESUSCITATION OF NEWBORN INFANTS This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and/or carer. Health care professionals must be prepared to justify any deviation from this guidance. INTRODUCTION Passage through the birth canal is, by adult standards, a relatively hypoxic experience for the fetus since significant respiratory exchange at the placenta is prevented for the seconds duration of the average contraction. Though most babies tolerate this well, some do not and these few may require help to establish normal breathing at delivery. For most babies a clear airway and a warm environment are all that is required. Please refer to related Guidelines:- WAHT-PAE-031 Guideline for when to request Paediatric attendance at deliveries WAHT-PAE-032 Guideline for paediatric attendance at preterm deliveries WAHT-PAE-020 Guideline for the management of a baby with meconium present at delivery The patients covered by this guideline are newborn babies delivered in hospitals within Worcestershire Acute Hospitals NHS Trust including babies born at home within the Worcestershire region. THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS: Basic neonatal resuscitation workshop, NLS Newborn Life Support Course provider status or compliance with your Royal College recommendations if different. Andrew Short Karen Kokoska Lead Clinician(s) Consultant Neonatologist Midwife Risk Manager Approved by Obstetric 17 December 2012 Clinical Governance Committee on: Extension approved by Trust Management Committee on: 22 July 2015 This guideline should not be used after end of: 1 August 2016 WAHT-NEO-003 Page 1 of 12 Version 6.1

2 Key amendments to this guideline Date Amendment By: Information on designated link paediatricians, availability of neonatal resuscitation equipment, contact details for clinicians R Rees/ K Day with advanced neonatal life support skills, 24 hour availability of consultant paediatrician, and expectations for staff training and monitoring of compliant with these requirements. 17/04/12 Agreed by Paediatric Clinical Governance Committee to extend Dr A Short for a further 2 months without amendment 02/05/12 Guideline updated to incorporate changes in NLS guideline A Short delayed cord clamping, resuscitation with air initially, then using a blender and oxygen saturation monitoring to determine optimal concentration of oxygen 15/10/12 Deletion of the Newborn Assessment and Airway Management R Rees Tool Checking processes for community midwives detailed Small revisions to formatting throughout Specific references to Maternity Services Training Needs Analysis 01/05/15 Document extended for 3 months Dr A 14/08/15 Document extended for 12 months per TMC paper approved on 22 nd July 2015 Gallagher TMC WAHT-NEO-003 Page 2 of 12 Version 6.1

3 GUIDELINE FOR RESUSCITATION OF NEWBORN INFANTS INTRODUCTION Passage through the birth canal is, by adult standards, a relatively hypoxic experience for the fetus since significant respiratory exchange at the placenta is prevented for the seconds duration of the average contraction. Though most babies tolerate this well, some do not and these few may require help to establish normal breathing at delivery. For most babies a clear airway and a warm environment are all that is required. Please refer to related Guidelines:- WAHT-PAE-031 Guideline for when to request Paediatric attendance at deliveries WAHT-PAE-032 Guideline for paediatric attendance at preterm deliveries WAHT-PAE-020 Guideline for the management of a baby with meconium present at delivery WAHT-NEO-033 Umbilical cord clamping guideline Rationale: CNST Maternity states that It is expected that wherever the birth of a baby is anticipated there must be available equipment and trained personnel to initiate basic life support at birth and in the immediate postnatal period, should it be required. Paediatric junior medical staff on 4 or 6 monthly rotations will receive basic newborn resuscitation training either on Induction programme or as a one-to-one with an appropriate senior colleague. No paediatric junior doctor should be unsupported on call until they have completed basic neonatal resuscitation. No paediatric registrar should be on call unless an NLS (or equivalent) course has been successfully completed or his or her competency has been assessed on mandatory training session or induction programme. Basic neonatal resuscitation is part of student midwives training and are competent at the point of registration. Any midwife who does not feel competent should not undertake a delivery without identifying a suitable colleague to provide basic newborn life support. Midwives will receive annual mandatory skill drill training on neonatal resuscitation. Attendance will be recorded on the Trust ESR database and is also held locally by the audit & training midwives. Additionally, all staff trained in neonatal resuscitation are expected to be up-to-date with the recent changes to the Resuscitation Council Guidelines (resuscitation in air and then using a blender and oxygen saturation monitor see below for details). These changes are demonstrated in the NLS, skills drills and obstetric emergencies training sessions. A training video is also available on the Trust s Intranet site under Paediatrics/Education and Training The Audit & Training Midwives will keep evidence of all staff who have watched the training video. It is recommended that team leaders, community midwives and midwives wishing to work within a Midwifery Led Unit should complete a Resuscitation (UK) Council Newborn Life Support (NLS) Course funded by the Trust. WAHT-NEO-003 Page 3 of 12 Version 6.1

4 GUIDELINE Prior to the birth of the baby the attending clinician should ensure the environment is warm and that all necessary equipment has been checked and is in full working condition. A brief maternal history of labour/gestation should be obtained. BASIC LIFE SUPPORT There is now considerable evidence to show the benefits of delayed cord clamping. This is strongly recommended for at least 30 seconds, and should only be omitted if the baby is clearly severely compromised at delivery (pale, floppy and heart rate less than 60bpm). Please see umbilical cord clamping guideline for further details. As the baby is delivered note the time of birth/start the clock. Immediately after delivery the baby should be dried, the wet towel removed and then wrapped in a warm towel. Place a hat on the baby as this reduces the risk of heat loss - WARMTH is VITAL. After cutting and clamping the cord if the baby is pink & breathing regularly place baby either skin to skin or hand baby to the mother. Make an initial assessment of the baby s COLOUR, TONE, BREATHING and HEART RATE. If not breathing.. Open the airway, place baby s head in neutral position. The commonest reason for airway obstruction in the unconscious newborn infant is not obstruction with liquor, mucous, meconium, or blood therefore head position NOT suction is important Place a rolled towel under baby s shoulders if necessary to ensure neutral position. Ensure that the blender delivering the gas supply to the neopuff (or bag/valve/mask system ) is set to air ( 21% Oxygen ) and give FIVE INFLATION BREATHS (each 2-3 seconds duration) slow sustained breaths will replace the existing lung fluid with air. Babies lungs in utero contain approximately 30ml/kg of lung fluid, about 1/3 is drained away during a normal vaginal delivery. Failure to reabsorb lung fluid is common after elective caesarean section producing a benign form of respiratory distress known as transient tachypnoea of the newborn (TTN). Check for visible CHEST MOVEMENT and increase in HEART RATE. Remember 98% of babies will recover within 2-3 minutes once air enters the lungs. If there is no response (no chest movement and no increase in heart rate) check head position and apply jaw thrust, Repeat 5 inflation breaths, confirm a response VISIBLE CHEST MOVEMENT or increase in HEART RATE. If baby fails to respond ensure appropriate skilled help is called. Request the emergency trolley to be brought to the room and ask your helper to apply an oxygen saturation probe to the baby s right wrist, connect the probe to the saturation monitor and switch it on Allocate a SCRIBE to record events. CHECK airway, aid with chin lift or jaw thrust REPEAT INFLATION BREATHS. Check the oxygen saturations and if these are abnormally low see chart increase the oxygen concentration gradually. WAHT-NEO-003 Page 4 of 12 Version 6.1

5 If no response. Inspect oropharynx under DIRECT VISION consider suction then REPEAT INFLATION BREATHS (in the presence of Meconium refer to WAHT-PAED-020 guideline). Consider oropharyngeal (Guedal) airway REPEAT INFLATION BREATHS. At all stages confirm a response/improvement in baby s heart rate. Use the saturation monitor to confirm heart rate and to determine the concentration of oxygen to deliver Ensure equipment working i.e. air and oxygen supply switched on, flow rate set at 5 litres, appropriate inspiratory pressure limit on neopuff. Ensure Baby s airway is open, head in neutral position. If skilled person present consider intubation. If not continue with bag value mask or T Piece ventilation. When the chest is moving continue with ventilation breaths per minute if there is no spontaneous breathing. Check heart rate if slow <60pbm or not detected commence CHEST COMPRESSIONS. It is vital to confirm chest movement..if chest not moving return to airway. Ensure appropriate help is available start chest compressions at a rate of 3:1. 3 COMPRESSIONS to 1 BREATH for 30 seconds. Place hands around baby s chest; your thumbs should be over lower 1/3 of sternum, i.e. one fingers breadth below the inter-nipple line. Your thumbs may be placed side by side or overlapping in smaller babies. Depress chest up to 2-3 centimetres (approximately 1/3 of the anterior-posterior chest diameter) at a rate of approximately 120 events a minute, 90 compressions & 30 ventilations. Ensure that compressions are effective rather than too fast or too shallow. Reassess HEART RATE. If improving and above 100 stop compressions, continue to support baby s breathing until regular effective respiration If heart rate remains slow continue with ventilation and chest compressions. Inform the consultant paediatrician on call & proceed to obtaining venous access and drugs at this stage if this will not compromise delivery of effective basic life support. If resuscitation is prolonged and the Apgar score is still less than 5 at 10 minutes, consider whether the baby will be a candidate for cooling and review the thermal control. Neonatal resuscitation can be stressful for both the parents and staff concerned. Ensure patient records are completed as soon as possible. Debrief parents explaining fully what actions where taken and why. If baby transferred to NICU/Mother & baby unit ensure baby is labelled prior to transfer. REMEMBER DON T BE PROUD ASK FOR HELP AT ANY STAGE YOU FEEL YOU NEED IT In the presence of meconium, remember: Screaming babies - have an open airway Floppy babies - have a look. WAHT-NEO-003 Page 5 of 12 Version 6.1

6 WAHT-NEO-003 Page 6 of 12 Version 6.1

7 Trust arrangements for Neonatal Resuscitation: 1. Designated link paediatrician for the labour ward and neonatal service, responsible for the clinical standards in relation to care of the newborn The designated link paediatrician is Consultant Andrew Short The name of the paediatric consultant-on-call should be written on the on-call board on delivery suite (taken from the monthly rota) On-call rota readily available on Delivery Suite 2. Neonatal resuscitation equipment should be available and ready for use at all times in all care settings where births may occur; including the emergency department Mobile resuscitaires are available in the following areas: WRH: o Delivery Suite o Obstetric Theatre o Antenatal Ward o Transitional Care Unit (TCU) o Postnatal Ward: use resuscitaire from TCU o NNU An emergency grab bag, containing neonatal resuscitation equipment is kept on delivery suite for emergency deliveries in A&E and outside of the maternity unit Alex: o Delivery Suite o Obstetric Theatre o Ward 15: use resuscitaire from SCBU o SCBU An emergency grab bag, containing neonatal resuscitation equipment is kept on delivery suite for emergency deliveries in A&E and outside of the maternity unit All resuscitaires to be checked by a midwife daily, and after every incident, to ensure in good working order, appropriately equipped and with oxygen cylinders that are at least ¾ full. o Laminated list of equipment available on each resuscitaire o Newborn life support algorithm available on each resuscitaire o Midwife/Nurse checking the resuscitaire must sign appropriate checklist/book to evidence checking All grab bags to be checked weekly and after every incident to ensure appropriately stocked as per individual checklist All community teams should hold basic neonatal resuscitation equipment Each community team should formulate a system/process for checking their emergency equipment and should have the following as standard: o List of equipment available in emergency bag o Newborn life support algorithm WAHT-NEO-003 Page 7 of 12 Version 6.1

8 o Midwife checking the equipment must sign the appropriate checklist to evidence checking as per locally agreed process In addition, a difficult airway box is available at in the NNU at WRH for when there are difficulties intubating neonates Availability of a clinician (doctors, advanced neonatal nurse practitioner, midwife) with advanced neonatal life support skills (including endotracheal intubation) at a delivery if required: Names of on-call paediatric doctors on on-call notice boards with relevant contact details (bleeps) on Delivery Suite, Antenatal Ward, TCU and Postnatal Ward at WRH and on Delivery Suite and Ward 15 at the Alex. For neonatal emergencies, on-call paediatric doctors available through 2222 emergency call system, citing neonatal emergency Emergency buzzer system operated for neonatal emergencies. 4. Process for 24 hour availability in the obstetric unit, within 30 minutes, of a consultant paediatrician (or equivalent staff and associate specialist grade) trained and assessed as competent in neonatal advanced life support On-call paediatric consultant available through the switchboard available 24 hours a day 5. Expectations in relation to staff training are outlined in the Maternity Services Training Needs Analysis (WAHT-CG-502: Maternity Training Policy Appendix A) 6. Process for monitoring compliance with all of the above requirements, review of results and subsequent monitoring of action plans Equipment library held by Technical Services annual audit/checking of all equipment Check lists on all resuscitaires. Archived lists are held with the Training & Audit Midwives Technical Services book held on Delivery Suite for input of all faulty resuscitaires job number etc On-call rotas (stating staff and grade) available to Maternity Services and held by the Medical Secretary Annual PDRs, supervisory meetings, central database of all training undertaken WAHT-NEO-003 Page 8 of 12 Version 6.1

9 MONITORING TOOL How will monitoring be carried out? Retrospective case note audit Who will monitor compliance with the guideline? Paediatric and obstetric Clinical Governance Committee STANDARDS % CLINICAL EXCEPTIONS All babies requiring active resuscitation will initially be 100% None resuscitated with 21% oxygen Oxygen saturation will be monitored and recorded in all 95% Lack of good quality trace babies who subsequently receive additional oxygen All resuscitaires will be provided with a supply of both 100% None air and oxygen Resuscitaire checks will be recorded daily to ensure fit 100% None for use. Emergency grab bag checks will be recorded daily 100% None Newborn life support skills training monitored via 6 monthly training report 75% Maternity leave. Long term sickness. Short term locum staff REFERENCES Resuscitation of the Newborn a Practical Approach. BFM Butterworth-Heinemann Resuscitation Council (UK). Newborn Life Support Provider Manual, London American Heart Association, Emergency Cardiovascular Care Committee Guidelines. Neonatal resuscitation. Circulation 2000; 102 Suppl I: I I 356 Hamilton P. (Chairman). Resuscitation of Babies at Birth, Royal College of Paediatrics and Child Health, Royal College of Obstetricians and Gynaecologists. BMJ Publishing Group, London ISBN WAHT-NEO-003 Page 9 of 12 Version 6.1

10 CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Andrew Short Consultant Neonatalogist/Clinical Director Karen Kokoska Midwife Risk Manager Rachel Rees Audit/Training Midwife Circulated to the following individuals for comments Name Designation Dr N Ahmad Dr M Ahmed Dr T Bindal Dr D Castling Dr T Dawson Dr T El-Azzabi Dr G Frost Dr A Gallagher Dr M Hanlon Dr L Harry Dr B Kamalarajan Dr Y Lakhani Dr K Nathavitharana Dr C Onyon Dr J E Scanlon Dr V Weckemann Vicky Bullock NICU Manager Margaret Stewart Matron Rachel Carter Matron Alison Talbot Matron Circulated to the following CD s/heads of dept for comments from their directorates / departments Name Directorate / Department Judi Barratt / Rachel Duckett Obstetrics Guidelines Leads Patti Paine Heads of Midwifery Chris Doughty Resuscitation Head of Department Circulated to the chair of the following committees and its members for approval Name Committee / group Miss Rabia Imtiaz Clinical Governance Committee WAHT-NEO-003 Page 10 of 12 Version 6.1

11 Supporting Document 1 Checklist for review and approval of key documents This checklist is designed to be completed whilst a key document is being developed / reviewed. A completed checklist will need to be returned with the document before it can be published on the intranet. For documents that are being reviewed and reissued without change, this checklist will still need to be completed, to ensure that the document is in the correct format, has any new documentation included. 1 Type of document Clinical guideline 2 Title of document Resuscitation of newborn babies 3 Is this a new document? Yes No If no, what is the reference number WAHT-NEO For existing documents, have you included and completed the key amendments box? Yes 5 Owning department Neonatal Medicine/Paediatrics 6 Clinical lead/s Dr A Short 7 Pharmacist name (required if medication is involved) 8 Has all mandatory content been included (see relevant document template) 9 If this is a new document have properly completed Equality Impact and Financial Assessments been included? 10 Please describe the consultation that has been carried out for this document 11 Please state how you want the title of this document to appear on the intranet, for search purposes and which specialty this document relates to. n/a Yes Yes No No No Circulated to the individuals on the contribution list and to members of the Obstetric Governance and Paediatric Clinical Governance Committees Resuscitation of newborn babies Once the document has been developed and is ready for approval, send to the Clinical Governance Department, along with this partially completed checklist, for them to check format, mandatory content etc. Once checked, the document and checklist will be submitted to relevant committee for approval. WAHT-NEO-003 Page 11 of 12 Version 6.1

12 Implementation Briefly describe the steps that will be taken to ensure that this key document is implemented Action Person responsible Timescale Publicise to medical staff in department meetings, handovers and inductions Dr A Short December 2012 Publicise through O&G Effective Handover and via to community midwives team leaders Rachel Rees December 2012 Plan for dissemination Disseminated to Date All staff via publication on Intranet December 2012 Information shared at Paediatric CG Committee meeting December Step 1 To be completed by Clinical Governance Department Is the document in the correct format? Yes No Has all mandatory content been included? Yes No Date form returned 2 Name of the approving body (person or committee/s) Andrew Short on behalf of Paediatric Clinical Governance Committee Step 2 To be completed by Committee Chair/ Accountable Director 3 Approved by (Name of Chair/ Accountable Director): Dr A Short Obstetric Governance Committee Miss R Imtiaz 4 Approval date Please return an electronic version of the approved document and completed checklist to the Clinical Governance Department, and ensure that a copy of the committee minutes is also provided. Office use only Reference Date form Date document Version No. Number received published WAHT-NEO-003 date date WAHT-NEO-003 Page 12 of 12 Version 6.1

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