NEONATAL CARE
SPECIAL NOTE: Maternal estimates of “due date” may be inaccurate. Very premature infants and infants of certain other high-risk pregnancies may be very small. Determination of fetal viability is best left to trained hospital personnel. As such, attempts should be made to resuscitate all infants, unless BioTel or a Medical Command Physician advises otherwise.
Basic Level
- Within the first 30 seconds:
- Warm and dry the infant – take care to avoid hypothermia (increased ambient temperature).
- Position the infant to facilitate drainage of airway secretions.
- Stimulate by gently rubbing the back.
- Clear the airway, if needed, for clear or meconium-stained amniotic fluid, if the infant cannot clear his/her own airway due to apnea or “drowning” in secretions:
- Perform deep tracheal suctioning before instituting other resuscitative measures. Refer to the CHILDBIRTH-ABNORMAL Special Procedures section or contact BioTel for detailed instructions.
- Assess respirations:
- If respirations are inadequate or gasping after suctioning or heart rate is less than 100, gently assist ventilations at a rate of 40 to 60 per minute, using an infant BVM with room air.
- Monitor the infant’s SpO2 on the right hand or wrist – supplemental oxygen to achieve mean per-minute goal saturations** (see next page) is secondary to effective ventilation.
- Assess heart rate:
- If the heart rate remains less than 100 after respiratory interventions, take corrective steps to improve ventilation, according to the “MRSOPA” algorithm:
- Mask: check the seal
- Reposition: make sure infant is in the sniffing position (do not flex or hyper-extend the neck)
- Suction (mouth before nose)
- Open the mouth
- Pressure increase (gentle!)
- Alternative airway (either intubate or place LMA, if available: advanced level providers only)
- If heart rate remains less than 60, increase oxygen concentration to 100% and begin chest compressions:
- Use the 2-thumb/encircling hands technique (thumbs side by side, just below nipple line).
- Compression-to-ventilation RATIO for neonates is 3 to 1.
- The compression rate is 120 events per minute (90 compressions interspersed with 30 ventilations).
- Assess skin color (for APGAR score only – see next page):
- Score: Blue/pale = 0 points; Body pink/extremities blue = 1 point; Completely pink = 2 points.
- Provide oxygen supplementation to maintain mean per-minute goal saturations** (see below).
- Clamp and cut the umbilical cord; place a vigorous infant skin-to-skin on the mother’s chest to retain warmth.
- Calculate and record the APGAR score at 1 minute and again at 5 minutes postpartum (see next page).
- Once advanced level providers arrive on-scene, give report and transfer care.
- Notify the receiving hospital or contact BioTel as early as possible for destination recommendations and early receiving hospital notification.
- Monitor ECG and SpO2 continuously on the infant’s right hand or wrist until hospital arrival; prevent heat loss and hypothermia.
- Oxygen may be supplemented to achieve mean per minute goal saturations**, but this is secondary to effective ventilation.
- If the infant does not respond to CPR, obtain vascular access with Normal Saline and perform POC glucose analysis:
- For hypoglycemia (POC glucose less than 45 mg/dL) administer:
- 10% dextrose @ 2 mL/kg IV/IO; OR
- Glucose (40%) gel @ 0.5 mL/kg (0.2 g/kg), massaged into the mucosa of the cheek pocket:
- Exercise extreme caution administering to a depressed infant without a gag reflex
- For heart rate less than 100 bpm during CPR, administer epinephrine 1:10,000 0.01 mg/kg (0.1 mL/kg) IV/IO, followed by a flush with 5 mL Normal Saline; repeat every 3 to 5 minutes, as needed.
- For suspected narcotic toxicity, provide positive pressure ventilation with supplemental oxygen, as needed, to maintain mean per-minute saturation goals**, until transfer of care to hospital personnel.
- Transport as soon as possible.
- For additional patient care considerations not covered under standing orders, consult BioTel.
*APGAR Score:
|
0 Points |
Appearance |
Blue, pale |
Pulse Rate |
Absent |
Grimace |
No response |
Activity |
Limp |
Respirations |
Absent |
|
|
1 Point (each) |
Appearance |
Body Pink, extremities blue |
Pulse Rate |
Less than 100 per minute |
Grimace |
Grimaces |
Activity |
Some flexion |
Respirations |
Slow, irregular |
|
|
2 Points (each) |
Appearance |
Completely pink |
Pulse Rate |
Greater than 100 per minute |
Grimace |
Cough, sneeze, cry |
Activity |
Active motion |
Respirations |
Good, crying |
|
|
**Oxygen Saturation (SpO2) Goals per Minute of Life
Time (minutes) |
O2 Saturation (SpO2) Goal |
1 |
60-65% |
2 |
65-70% |
3 |
70-75% |
4 |
75-80% |
5 |
80-85% |
10 |
85-95% |