Textbook of Neonatal Resuscitation (NRP) Eighth Edition

Book Preface

Founations of Neonata Resuscitation

What you will learn

Why neonatal resuscitation skills are important
Physiologic changes that occur during and after birth
The format of the Neonatal Resuscitation Program® Algorithm
Communication and teamwork skills used by effective resuscitation teams
How implementing quality improvement methods can improve outcomes

Key Points

– Most newborns make the transition to extrauterine life without
intervention.
– Before birth, pulmonary blood vessels in the fetal lungs are tightly
constricted, and the alveoli are filled with fluid, not air.
– Newborn resuscitation is usually needed because of respiratory
failure.
– The most important and effective step in neonatal resuscitation is
to ventilate the baby’s lungs.
– Very few newborns will require chest compressions or medication.
– Teamwork, leadership, and communication are critica! to
successful resuscitation of the newborn.

The Neonatal Resuscitation Program

The Neonatal Resuscitation Program (NRP®) will help you learn the cognitive, technical, and teamwork skills that you need to resuscitate and stabilize newborns. Most newborns make the transition to extrauterine life without intervention. Within 30 seconds after birth, approximately 85% of term newborns will begin breathing. An additional 10% will begin breathing in response to drying and stimulation. To successfully transition, approximately

• Five percent of term newborns will receive positive-pressure ventilation (PPV).
• Two percent of term newborns will be intubated.
• One to 3 babies per 1,000 births will receive chest compressions or emergency medications.

The likelihood of requiring these lifesaving interventions is higher for babies with certain identified risk factors and those born before full term. Even though the majority of newborns do not require intervention, the large number of births each year means that timely intervention can save many newborn lives. Because the need for assistance cannot always be predicted, health care providers need to be prepared to respond quickly and efficiently at every birth.

During your NRP course, you will learn how to evaluate a newborn, make decisions about what actions to take, and practice the steps involved in resuscitation. As you practice together in simulated cases, your team will gradually build proficiency and speed. The most gratifying aspect of providing skillful assistance to a compromised newborn is that your efforts are likely to be successful. The time that you devote to learning how to resuscitate 11ewborns is time very well spent.

Why do newborns require a dif f erent approach to resuscitation than adults?

Most often, adult cardiac arrest is a complication of coronary artery disease. It is caused by a sudden arrhythmia that preve11ts the heart from effectively circulating blood. As circulation to the brain decreases, the adult victim loses consciousness and stops breathing. At the time of arrest, the adult victim’s blood oxygen and carbon dioxide ( C0 2) content is usually normal and the lungs remain filled with air. During adult resuscitation, chest compressions maintain circulation until electrical defibrillation or medications restore the heart’s function.

In contrast, most newbor11s requiring resuscitation have a healthy heart. When a newborn requires resuscitation, it is usually because respiratory failure interferes with oxygen and C0 2 exchange.

• Before birth, fetal respiratory function is performed by the placenta instead of the fetal lungs. When the placenta is functioning normally, it transfers oxygen from the mother to the fetus and carries C0 2 away from the fetus to the mother. A healthy fetus makes breathing movements, which are important for normal lung growth.
• When placenta! respiration fails, the fetus receives an insufficient supply of oxygen and C0 2 cannot be removed. Acid increases in the fetal blood as cells attempt to function without oxygen and C0 2 accumulates.
• Fetal monitoring may show a decrease in activity, loss of heart rate variability, and heart rate decelerations. If placenta! respiratory failure persists, the fetus will make a series of reflexive gasps followed by apnea and bradycardia.
• If the fetus is born in the early phase of respiratory failure, tactile stimulation may be sufficient to initiate spontaneous breathing and recovery. If the fetus is born in a later phase of respiratory failure, stimulation alone will not be sufficient and the newborn will require assisted ventilation to recover. The most severely affected newborns may require chest compressions and epinephrine. At the time of birth, you may not know if the baby is in an early or a late phase of respiratory failure.

• After birth, the baby’s lungs must take over respiratory function. They must be filled with air to exchange oxygen and C0 2• Respiratory failure can occur if the baby does not initiate or cannot 1naintain effective breathi11g effort.
• If respiratory failure occurs either before or after birth, the primary problem is a lack of gas exchange. Therefore, the focus of neonatal resuscitation is effective ventilation of the baby’s lungs.

Many concepts and skills are taught in this program. Establishing effective ventilation of the baby’s lungs during neonatal resuscitation is the single most important concept emphasized throughout the program.