One of the most stressful jobs you’ll attend is a neonatal resuscitation. Though it is fortunately quite rare, the cognitive overload and emotional stress will be high. In this post, I’ll outline how I personally set up my resuscitation area. There will be many different approaches/takes, but the general principles should be the same.
Goals of the resus area
- A clean, warm and well-lit environment
- Easy access to equipment
- Minimize need to look away from the patient to grab equipment
- Have equipment laid out to provide visual prompts for management
- Allow 360 degree access to neonate whilst not having to clamp/cut the umbilical cord
Components of the resus area
- Obstetrics kit x2 (this allows for redundancy)
- Blanket
- Towels x2
- Oxygen
- Paediatric airway kit (including paediatric laryngoscope, Y-suction catheter and neonatal BVM)
- Monitoring (including appropriate sized SpO2 probe)
Set up
Airway
- Airway positioning is achieved by placing the neonate in a neutral position. Place a blanket down for warmth/cleanliness, then place a folded towel (approx 2cm thick) down. The baby will be placed with the shoulders/body on the towel and the head on the blanket. The large occiput of the newborn means this will result in neutral positioning
- Attach and test your suctioning. For newborns a Y-suction catheter should be used. Check that the suction pressure does not exceed 100mmHg
- Prepare a suitable sized laryngoscope and blade. Although inspecting the upper airway is often not required, easy access to a light source can help with inspection of the upper airway
- Note OPAs are not recommended in neonates, as they frequently worsen the obstruction. Airway management should be achieved through positioning or advanced airways (ETT/SGA)
Breathing
- Effective ventilation is the cornerstone of neonatal resuscitation
- Ventilation should be performed using a dedicated neonatal bag valve mask (BVM). The one we use (Mercury CPR-2) has a volume of 240mL and a one-handed volume of 90mL
- Initial resuscitation should be performed on room air, with supplemental oxygen added later as per your local guideline
Circulation
- Usually the issue in newborns is respiratory… rarely they can develop arrhythmias (usually in a structurally abnormal heart)
- CPR should be commenced in a neonate with HR < 60
- Heart rate is used to guide the effectiveness of resuscitation – hypoxia will cause bradycardia, effective ventilation will improve the heart rate
- Ensure umbilical cord is clamped effectively – even a small amount of blood loss can be detrimental (term newborn has a blood volume of 280mL!)
- MICA and hospital staff can obtain IV access through the umbilical cord, so ensure it is clamped with enough space for this (10cm from neonate)
Defib
- Defib pads should be applied if you suspect an arrhythmia, but this is not the priority
Environment
- Bubble wrap can be used as an insulator
- Warmed blankets or towels are ideal – this can be achieved by placing them in a dryer for a few minutes on ‘warm’ setting (ensure they are not hot!)
Where to set up
- Generally mum will be labouring on or near a bed. If possible, she should have her head at the head end of the bed (whether supine, semi-recumbent or on all fours). This allows you to set up the resus area at the foot of the bed, close enough for the umbilical cord to remain attached. You can put your oxygen bag on the floor if necessary
- Sometimes the labouring parent will be in a bathroom or toilet, with no good surface to set up on. You may find it nearly impossible to move mum to another room! In this situation, bring your bed as close as possible and set up the resus station on that. Using the bed length-wise allows the neo-resus to occur in the middle, placing the oxygen bag on the left and monitor on the right
- Worst case scenario, you’re delivering the baby in the back of the ambulance. In this case you’ve pulled over and your partner is in the back to assist you. In this case your monitor will usually be secured and you have access to wall oxygen and suction. You will likely perform the resus either on mums belly or in your lap. Set up your towels there
Bottom Line
Perfect preparation prevents poor performance. For these low frequency, high stress jobs – having a system helps. Game plan out the worst case scenarios and think about how you will manage them.
