FOUR CORE STEPS

in Immediate Newborn Care

EINC Station 1
Objectives
• To perform the Four Core Steps in immediate newborn care
• To know the recommended practices in the care of the newborn
Steps in Essential Newborn Care
• Metacards activity
Recommended Newborn Practices
• Antenatal steroids
• Thermoregulation (room temp at 25-28°C)
• Immediate and thorough drying
• Skin-to-skin contact 4 Core Steps
• Properly-timed cord clamping
• Non-separation of mother and baby
• Dry cord care
• Early breastfeeding
Immediate and Thorough Drying
• After delivery, momentarily place newborn prone to allow any
secretions to drain
• Then turn over newborn into supine position
• Dry thoroughly for at least 30 seconds
• Follow organized sequence:
Face (5 secs) → head (5 secs) → trunk (5 secs) → back (5 secs) →
arms (5 secs) → legs (5 secs) → total of 30 seconds
• Use different parts of the towel in each step of drying
• Stimulate and check breathing while drying
Show
 Immediate and Thorough Drying

• If baby is not breathing at birth, STIMULATE by DRYING!

• DO NOT slap, shake or rub the baby
• DO NOT ventilate unless the baby is floppy/limp and not breathing
• DO NOT suction unless the mouth/nose are blocked by secretions
Skin-to-Skin Contact
• If breathing or crying:
- position prone on the mother’s abdomen/chest
- cover the newborn
• Put dry linen on back
• Put bonnet on the head
• Temperature Check
- Room: 25 - 28°C
- Baby: 36.5 - 37.5°C

Show
Properly-Timed Cord Clamping

• Prior to delivery, wash hands thoroughly

• Don 2 pairs of gloves (if solitary health worker)

• After delivering baby, remove 1st set of gloves

• Using 2nd pair of sterile gloves, palpate the umbilical cord

• Wait 1-3 minutes or until cord pulsations have stopped

 Properly-Timed Cord Clamping

Clamp cord using a sterile Clamp again at 5 cm from Cut the cord close to the
plastic clamp or tie at 2 cm the base plastic clamp
from the umbilical base
 THE EVIDENCE IS SOLID
The Four Core Steps in Immediate Newborn Care will save lives:
Thank you for listening!
LECTURE 3:

POSITIVE PRESSURE VENTILATION

(PPV)

MODULE 5: Newborn Resuscitation

 Objectives

At the end of this activity, the participants will be able to:

✦ Know when to ventilate.

✦ Provide effective positive pressure ventilation and assess
effectiveness.
✦ Use ventilation corrective steps.
✦ Administer continuous positive airway pressure
Indications for PPV

Ventilation of the lungs is the single

A Apnea/Gasping
most important and most effective step
in cardiopulmonary resuscitation
of the compromised infant

B Bradycardia or
HR<100/min

C Cyanosis despite
100% FiO2 or CPAP
Types of Positive- Pressure Devices

Self-inflating bag

Flow-inflating bag

T-piece resuscitator
Self-inflating Bag

Advantages Disadvantages
✴Bag will work without a gas
source; ensure that oxygen
is connected
✴Always refills after being ✴Requires tight face-mask
squeezed seal to inflate the lungs
✴Inflates without a ✴Requires oxygen reservoir
compressed gas source to provide high
concentration of oxygen
✴Pressure release (pop-off)
valve makes over-inflation ✴Cannot give free-flow
less likely oxygen through the mask
✴Cannot be used for CPAP.
No PEEP without special
valve
 Control of Oxygen

✤An oxygen with reservoir must be attached

to deliver high concentrations of oxygen using
a self-inflating bag

✤Without reservoir the bag delivers only

about 40% oxygen, which may be insufficient
for neonatal resuscitation
 Control of Oxygen

✤With reservoir, 90% to 100% oxygen delivered to patient

How much oxygen?

TERM INFANTS (≥35wks GA and above)

If blended oxygen is not available, resuscitation should

be initiated with air (21%). (Class IIb, LOE B)

PRETERM INFANTS

Newborns less than 35 weeks should be

resuscitated with low oxygen (21-30%) and
titrated as needed
How much oxygen?

✦Oxygen concentration should be titrated to achieve

the target preductal oxygen saturation (Class I, LOE
B-R)

✦Initiating resuscitation of preterm newborns with high

oxygen (65% or greater) is not recommended. (Class
III—No Benefit, LOE B-R)
PPV: Preparation

• Select appropriate-sized mask

• Clear airway

• Position baby’s head

• Position yourself at baby’s side

or head
PPV DEMO
PPV: Demonstration
PPV: Demonstration
PPV using T-piece Resuscitator
Breathe….2….3
SLIDE 25 OGT OGT insertion
RETURN DEMO
Ventilation Corrective Steps

Ventilation corrective steps

Apnea / gasping
Mask adjustment or HR < 100 bpm?

Reposition airway
Suction mouth and nose
YES
Open mouth
Pressure increase
9. Ventilation corrective steps
Airway alternative 10.Intubate if needed
Ventilation Corrective Steps
Continuous Positive Airway Pressure

Apnea /
N Labored
gasping breathing
or HR < O
or
100 persistent
cyanosis?
bpm?

Y Y
E E
S S
9. Ventilation
corrective steps a. Position and
10.Intubate if needed clear airway
b. SpO2 monitoring
c. Supplemental O2
as needed
d. Consider CPAP
HR <
60
bpm
?
STATION 2:

POSITIVE PRESSURE VENTILATION

(PPV)

Newborn Resuscitation SCORPIO

MODULE 5: Newborn Resuscitation
 LECTURE 4:

ENDOTRACHEAL INTUBATION

Module 5: Newborn Resuscitation

Objectives
At the end of this activity, the participants will be able to:

• Recognize the need for endotracheal intubation during resuscitation.

• Select and prepare the necessary equipment for intubation.
• Perform endotracheal tube insertion.
• Determine proper tube placement.
 Indication for Intubation

• HR remains <100bpm and NOT increasing AFTER PPV

• BEFORE starting chest compression
• PPV is prolonged
• Direct tracheal suction
• Surfactant administration
• Newborn with suspected diaphragmatic hernia
• Administer epinephrine while IV access is being established
Upper Airway Anatomy and
Landmarks
Equipment Preparation
Endotracheal Tubes
• Select tube size based on weight
and gestational age
• Consider shortening tube to 13 to 15 cm

Tube internal
diameter size Weight Gestational age
(mm) (g) (wks)
2.5 <1000 <28
3.0 1000-2000 28-34
3.5 2000-3000 34-38
3.5 >3000 >38
Tip-to-Lip Measurement (Depth)

Weight Depth of insertion

(kg) (cm from upper lip)
1 7
2 8
3 9
4 10

Nose Septum to Tragus +1

Consider using a stylet
• To provide additional rigidity and curvature
• Important to ensure that the tip is not protruding from either the end or side
hole of the endotracheal tube
Positioning the Newborn
Holding the Laryngoscope
• Always hold the laryngoscope in your LEFT hand with your thumb resting on
the upper surface of the laryngoscope and the blade pointing away from you
Correct Tube Placement

⚫ Limit each attempt to intubate to less than 30 seconds.

Checking Tube Position
The tube is not likely in the trachea if:

• Newborn remains cyanotic and bradycardic

• No breath sounds over lungs

• Abdomen becomes distended

• Air noises over stomach

• No mist in endotracheal tube

• Chest not moving symmetrically

with positive-pressure breaths
ET Tube Placement: Radiographic
Confirmation
 DEMO
&
RETURN DEMO
Advanced Resuscitation
STATION 4
Module 5: Newborn Resuscitation
Objectives
At the end of this activity, the participants will be able to:

❑Recognize the need for chest compressions

❑Perform coordinated chest compressions and positive pressure
ventilation
❑Recognize the need for umbilical catheterization
❑Administer necessary medications during resuscitation
Chest Compressions

• Indication
Heart rate remains less than 60 beats per minute (bpm)
despite 30 seconds of effective positive-pressure ventilation

• Rhythm used during coordinated chest compressions and

ventilation
One-and-Two-and-Three-and-Breathe-and… (to be said by COMPRESSOR)

• Ratio of ventilation and chest compression

3 compressions + 1 ventilation every 2 seconds
 Chest Compressions

• Recommended technique
Two thumb technique
place thumbs below imaginary nipple line and above xiphoid

• Depth of compressions
Depress sternum 1/3 of the AP diameter of the chest

• Oxygen delivery
Increase FiO2 to 100% once chest compressions are initiated
Advanced Resuscitation

DEMO
 Chest Compressions

• Stopping compressions
Reassess heart rate after 60 seconds of coordinated PPV and chest compressions

1. HR > 60 bpm
Discontinue chest compressions
Continue positive pressure ventilation

2. HR >100 bpm and able to breathe spontaneously

Discontinue chest compressions
Slowly withdraw positive pressure ventilation
Chest Compressions

3. HR < 60bpm
Intubate
Give epinephrine
Place emergency vascular access
Resume coordinated PPV and chest compressions
Conduct a recheck
Medications: Epinephrine

• Indications
When the heart rate remains <60 beats per minute
despite
30 seconds of assisted ventilation followed by
60 seconds of coordinated compressions and ventilation

• Recommended preparation
1: 10,000 solution
Epinephrine 1mg/ml ampule 1 ampule plus 9 ml diluent
 Medications: Epinephrine

• Recommended dose
IV = 0.2ml/kg (range 0.1 to 0.3 ml/kg of 1:10,000 solution)

*ET = 1ml/kg (range 0.5 to 1 ml/kg of 1:10,000 solution)

• Recommended route and rate

INTRAVENOUSLY as rapidly as possible
May repeat every 3-5 minutes as needed
Volume Expansion

• Indications
Baby is not responding to resuscitation, AND any of the ff:
1. appears in shock
2. has a history of a condition associated with fetal blood loss

• Recommended fluid
Normal saline (isotonic crystalloid solution)
Volume Expansion

• Recommended dose and rate of infusion

10ml/kg over 5-10 minutes steady infusion

• Expected response
❑ Heart rate becomes normal
❑ Pulses stronger
❑ Pallor lessens
Emergency
Umbilical Venous Catheterization

• Indication for Emergency Insertion

Need to give medications and/or volume expanders

• Positioning
Personnel doing compressions moves to the head of the baby
Personnel doing ventilation moves to one side of the baby
Personnel to insert UVC stays on the other side
Advanced Resuscitation

RETURN DEMO