Pengurus Pusat IDAI & UKK Neonatologi IDAI

berkolaborasi dengan
American Academy of Pediatrics (AAP)

Preparation of Neonatal Resuscitation

 Learning Objectives

1. To recognize the antepartum and intrapartum risk factors

which increase the need of neonatal resuscitation
2. To understand how to build a neonatal resuscitation team
3. To understand the environment and the equipment
prepared before performing neonatal resuscitation in
advanced and/or limited facilities.
4. To understand how to implement infection control during
neonatal resuscitation
 I. Preparation Resuscitation
Identified neonatal risk factors

Neonatal resuscitation team preparation

Enviromental Preparation

Preparation of neonatal resuscitation tools

and equipment

Prevention of infection transmission

RESUSITASI BBL

100% bayi lahir perlu didampingi oleh

seseorang/tim ahli resusitasi

10% bayi baru lahir butuh intervensi

setingkat Bag & Mask ventilation
untuk dapat bernapas saat lahir

1% bayi lahir butuh intubasi sampai

bantuan obat-obatan

Barkemeyer(BM.(Cri-cal(Concepts(NICU.([diakses(pada:(24(Januari(2012].(Diunduh(dari(:(URL:(www.medschool.lsuhsc.edu.(((
(
BAYI BUGAR 90 % BAYI Sesak /Merintih 9 % BAYI Apnea 1 %

IMD CPAP VTP

Persiapan sebelum Resusitasi

!Edukasi dan Persetujuan Keluarga

!Pembentukan dan Pengarahan Tim
Resusitasi
!Persiapan Alat Resusitasi
!Persiapan Tranportasi & Ruang
Perawatan BBL
 Tim Resusitasi Neonatus

Komunikasi Mengurangi
Efektif! Pembagian tugas yang
jelas(
kesalahan dalam
resusitasi

Maternal information: Baby Information:

Riwayat Kehamilan Taksiran Usia Gestasi
sebelumnya Jumlah bayi (satu, kembar, triplet)
USG antenatal High-risk neonate which are requiring
Riwayat Penyulit dalam resuscitation
antenatal Ketuban hijau kental
Risiko infeksi kehamilan Variasi dari denyut jantung janin
Riwayat obat yang dikonsumsi Kelainan Kongenital
ibu
 2!=!Circula(on

Tim Resusitasi

JANGAN SENDIRIAN .....!!!

1!=!Airway.Breathing
3(obat(dan(alat
 Persiapan Alat Resusitasi BBL

Airway Breathing Circulation Thermoreg

Semua kelahiran Airway Box Pompa dan sungkup Kotak emergensi Radiant warmer 75%
Stetoskop Oksigen 40% -UVC kit
Penghisap dan selang Oksimeter -- epinefrin
penghisap -- NaCl

Tambahan untuk <27 Ett 2,5 + mandrin Surfaktan <27 Pasokan PIV Suhu ruangan 24-270
minggu Laringoskop + 0 minggu D10W C
blade Vi-drape
CO2 detektor Penutup kepala
Trim Stabilizer Matras pemanas
Inkubator transport
370 C
 T Thermoregulation

! Ruangan yang optimal untuk bayi

dilahirkan

! Hembusan angin AC jangan mengenai langsung

BBL
! Suhu ruangan resusitasi 24-26 C
! Tidak ada aliran angin/jendelatertutup
! Meja resusitasi /pemancar panas/ handuk
hangat
! Inkubator hangat
! Pakaikan topi
! Plastik pada bayi < 1500 gr
10
 Airway

! Alat untuk membuka jalan napas: pengisap lendir - DeLee

atau bola karet, kateter & Vakum, laringoskop, selang
endotrakeal dll

11
 Breathing
Circulation
Drugs
! Persiapan Alat Resusitasi

! Balon & Sungkup untuk ventilasi, atau Tabung & Sungkup

! Kotak Alat Resusitasi isi lengkap

! Sarung Tangan

! Jam atau pencatat waktu

12
 I. Identification of the risk factors
Mother Factors: ! Chronic disease (anemia,
cyanotic CHD)
! Premature rupture of
membranes 18 hours ! Fever
! 2nd and 3rd trimester bleeding ! Infection
! Hypertension in pregnancy ! Chorioamnionitis
! Drug abuse! narcotics etc
! Sedation
! Teenage pregnancy or more
than 35 years old pregnancy ! Previous fetal or
mother neonatal death
! Drug Consumption (ex: lithium,
magnesium, adrenergic blockers, ! No antenatal care
narcotics)
! Diabetes mellitus
 introduction of risk factors

Fetal factors: ! Polyhydramnion and

oligohydramnion
! Multiple pregnancies ! Reduced fetal movements
(double, triplet) before delivery
! Premature ( GA <35 weeks) ! Congenital abnormality that
! Postmature ( GA > 41 weeks) affects the respiratory,
! Large gestational age cardiovascular
! IUGR ! Intrauterine infection
! Autoimun hemolytic disease ! Fetal hydrops
(ex: anti-D, anti-Kell, especially if
there is anemia / hydrops fetalis) ! Breech presentation
! Shoulder dystocia
 Identification of the risk factors

Intrapartum factors:
! Fetal heart rate patterns are ! Meconium-stained
suspicious at CTG ! Anesthetics drug 4 hours of
! Abnormal presentation labor
! Cord prolapse ! Births with forceps
! The birth with vacuum
! Prolonged Labor
! General anesthesia in mothers
! Fast Labor
! Emergency cesarean section
! Antepartum haemorrhage (eg,
placenta abruption, placenta
previa)
 II. Building Neoatal Resuscitation Team
1. Communication and Information

effective job description ( reduces the risk

communication ! maternal and fetal info ( of resuscitation
errors

Maternal information: Baby Information:

History of pregnancy
Antenatal Ultrasound
History of Antenatal care
The risk of maternal
infection (GBS )
Maternal medication history
Gestational age
Estimated number of infants (single, twin)
High-risk neonate which are requiring
resuscitation
Meconium staining
Baby's heart rate variation
Congenital abnormalities
 Building Neonatal Resuscitation Team
3. Resuscitation team

Helper competence is determined according to risk category of labor

Very high risk labor :

! Gestational age <30 weeks / <1500 g

! Age 26 weeks ! neonatologist should bepresent if possible
! Delivery of multiple age <32 weeks
! Rhesus incompatibility / fetal hydrops
! Antenatal diagnosed congenital malformations (ex: diaphragmatic hernia, congenital heart disease)
! Cord prolapse, suspected severe intrapartum hypoxia , severe antepartum haemorrhage.
! Emergency cesarean section (ex: fetal distress, antepartum haemorrhage massive)

! Other high risk deliveries identified by the obstetrician and pediatrician / neonatologist
disscussion.

Attended by at least 1 neonatologist / pediatrician

 Resuscitation Team Building

Delivery of high or moderate risk :

! Gestational age 30-36 weeks / multiple births 32 weeks.
! mild-moderate Rhesus incompatibility
! IUGR
! Suspected intrapartum hypoxia
! breech delivery
! shoulder dystocia
! Meconium-stained amniotic fluid
! Emergency caesarean section (a state that can harm the fetus or mother)

! Elective caesarean section with additional risk factors

.
Attended by at least one person a pediatrician or general practitioner
 Resuscitation Team Building
2. Team Members

2!=!Circula(on First person = captain / resuscitation team leader .

Position : in front of of baby's head
Had the best competence of neonatal resuscitation
The main task: ventilation (airway and breathing).

The second person = assistant circulation

Position: Right side baby
Responsibilities: infant circulation
Include: listening to baby's heart rate, regulate PIP and
FiO2 requirements, provide cardiac compression,
umbilical catheter to put fluid resuscitation)
3(=(Drugs& 1!=!Airway.
Equipment Breathing

The third person = assistant equipment and drugs

Position: Left side baby
Responsibilities: stand by for timer, saturation monitors , thermometer, suction equipment,
resuscitation medicines and other.
 Resuscitation Team Building

Multiple delivery :
! delivery 35 weeks ! 1 team / baby
! delivery 30 weeks ! additional doctors.
! If there are complications ! 2 physician / baby.
! the
baby will get at least 1 palliative care ! neonatologist /
pediatrics
 III. Neonatal resuscitation environment

1. Room
! Resuscitation room and delivery room/operating room should be
very close
! Resuscitation room:
! warm (to prevent newborns lose body heat)

! light (Bright enought to assess mother-infant clinical status )

! large (enought space for the movement of resuscitation team)

! when multiple delivery ! larger room with multiple warmer and infant
resuscitation set according to the number of babies who will be born
 Resuscitation environment

2. temperature
! Keep the baby's body temperature between 36.50 C to
37.50 C
! Efforts temperature settings include:
! that warm room temperature (26o C)
! Do not put the baby under the air conditioner
! infant warmer is turned on before the baby was born Infant&warmer
(to warm the mat, cloth, hats and baby blankets)
! Using warm and dry cloth
(to dry the baby)
! Using a clear plastic wrap for infants with gestational age <28 weeks
and / or weight <1500 g
! Put a hat at baby head
Warms baby with a plastic
cap and wrap
 Resuscitation environment

Using a transport incubator / transport to move the baby

kangaroo method to the treatment room

Stages of the Kangaroo Method

Transport to the kangaroo method Incubator transport

 IV. resuscitation equipment
1. equipment
1. Heater / Warming
! Dry and warm linen and cap
! Warm towel for wrapping
! Plastic and hats for neonates <1.5 kg
Infant&warmer&with&overhead&heater
! infant warmer
2. Suction / Suction
! Suction with negative pressure (should not
exceed 100mmHg)
! Appropriate suction catheter
! Meconium aspirator
Meconium(aspirator
 Resuscitation equipment

3. Ventilation

! Self inflating bag(volume 250 ml) and

appropriate mask, equipped with
PEEP (Positive End Expiration
Pressure) valves.
! T-piece resuscitator can provide PIP
and PEEP constantly so that the baby
can increase his/her tidal volume and
functional residual capacity
! Intubation equipment (laryngoscope,
endotracheal tube, stylet)
! Containment laryngeal / Laryngeal
Mask Airway (LMA)
 Resusitation equipment

Oxygen tube with Y-Connection is connected to Jackson-Reese

 Resusitation environment
Resusitation equipment

4. Circulation Acces Support

! Peripheral venous catheter and line Pulse&&
! Umbilical catheter Oxymeter&
! Resuscitation drugs (adrenaline, atropine), liquid
(NS, Dex 10 % and blood)

5. Transportation : incubator transport that

previously has been warmed or kangaroo method
equipment

6. Others
! Neonatal stethoscope
! Glucosemeter
! Pulse oxymetri
Transpor((Incubator(with(
(Oxygen&blender
 Resusitation environment
Resusitation equipment

7. Pressure
There are two types of pressure:
! Inspiration Pressure Peak / Peak Inspiratory Pressure (PIP) and or
! Positive End Expiratory Pressure / Positive-end expiratory pressure
(PEEP) (Chapter 1).
 Resusitation environment
Resusitation equipment

! PEEP / CPAP should be given as soon as possible to

premature babies eith respiratory disstres by theese
methodes:
a. Complete facilities Nasal prong
Single nasal prong! in babies
! T-piece resuscitator that use: transferred / transport
mask

Binasal prong
 Resusitation environment
Resusitation equipment

(a)
(b)

T>piece&resuscitator&&
(a)&Neopu&(b)Mix>safe
 Resusitation environment
Resusitation equipment
b. Limited Facilities :
7

6
Jackson Rees spesification 5
8

1. Green pipe: hose is connected to the sources of inspiration of oxygen

2. Manometer : Serves to measure the pressure given to infants ( PIP and PEEP)
3. Neonatal facemask
Part of circuit connects to the nose and mouth of the baby
4. Elbow
5. White Pipe : An expiratory hose 1
6. T-connector 4
7. PEEP Valve : Serves to maintain PEEP
8. Balloon : maintain PEEP and provides PIP when squeezed 2
3

Jacson Rees
Reservoir bag with various sizes:
- 0,5 L (PIP max. 30 cm H2O)
- 1 L (PIP max. > 30 cm H2O)
- 2 L
- 3 L
 Resusitation environment
Resusitation equipment
Application of infant T-piece system on
Jacson Rees:

! Wash hands
! Make sure the equipment works properly
! Attach manometer at the end of the Infant T-
Piece System
! Connect the hose to the oxygen tank inspiration
! Set the oxygen flow (flow) minimum 6 LPM
! PIP settings according to the desired flow ! set
while pumping reservoir bag
! Setting PEEP valve APL !turn to the right or left
! ETT pipe can be directly connected to the elbow
(if the patient is intubated or during patient transport) Jackson&Rees&with&lid(or(nasal&
prong
 Resusitation environment
Resusitation equipment

VTP (PIP and PEEP) for the apnea / gasping baby

! Complete facilities
!T-piece resuscitator

! Limited Facilities
a. Self inflating bag
!Can provide PEEP (PEEP valve if
installed)
Figure 2.25
!Cannot deliver the PIP measurable,
PEEP valve
unless fitted with a manometer
 Resusitation environment
Resusitation equipment
PIP
PEEP!
valve
1 4

4
3

(PEEP(valve(
Specifications: (
oxygen hose ! delivered oxygen from the oxygen source to the balloon and (
(
containment
(
Balloon 250 ml ! PIP can give to the baby (
Hoods face neonates (
PEEP valve ! to maintain PEEP (
 Resusitation environment
Resusitation equipment
Application of balloons and lid with
PIP + PEEP:
! wash hands
! Select the required PEEP valve
! Select the appropriate size of the mask with the patient
! Attach PEEP valve at the end self inflating bag
! Attach manometer at the bottom of the self inflating bag (before hatch)
! Make sure the equipment works properly
! FiO2 21% O2 ! without hoses or reservoir
! FiO2 O2 40% ! connected with the oxygen source but without the reservoir
! FiO2 100 % !O2 is connected to the source and reservoir
! PIP will be read on the manometer when the bag is pressed
 Resusitation environment

b. Jackson Rees
!Can provide PEEP
!Can not provide the VTP

The weakness of using Jackson Rees:

when the PIP will be given by pressing a balloon, then
the function of PEEP will disappear as soon as the
manometer indicates zero. Therefore, Jackson Rees is
not recommended for the award of VTP.
 Resusitation environment
Resusitation equipment

The advantages and disadvantages of the use of

pressure paraphernalia
Tool( Scalable Scalable PEEP ! PIP ! VTP (PIP
PIP ! PEEP ! + PEEP) !

T-piece resuscitator( ! ! ! ! !
Jackson Rees( -! ! ! -! -!
Self inflating bag( -! -! -! ! -!
Self inflating bag+ PEEP valve ( -! ! ! ! !
!
Self inflating bag + PEEP valve and ! ! ! ! !
! !
manometer PIP(
 Resusitation environment
Resusitation equipment
Gas Source
To generate PIP or PEEP requires a gas source which are :
1. Oxygen: 2. Air :
! O2 in Cylinders - Air in Cylinders
! Oxygen Concentrator - Compressor
is a tool that can take oxygen from the air

Oxygen Oxygen concentrator

concentrator with with a t-piece
self inflating bag resuscitator
Air in cylinders
oxygen incylinders
 Resusitation environment
Resusitation equipment

! Oxygen and air must be blended before they are given

Several methods for mixing the gases are:

! complete facilities
! Oxygen blender

! limited facilities
! Blender

! Oxygen and air cylinders are connected to the Y-connector

 Resusitation equipment

%! Pressurized air (liters / min)!

conc. O2! 1! 2! 3! 4! 5! 6! 7! 8! 9! 10!
1! 41%! 37%! 34%! 32%! 31%! 30%! 29%! 28%!
2! 61%! 53%! 47%! 44%! 41%! 38%! 37%! 35%! 34%!
3! 80%! 68%! 61%! 55%! 51%! 47%! 45%! 43%! 41%! 39%!
4! 84%! 74%! 66%! 61%! 56%! 52%! 50%! 47%! 45%! 44%!
5! 86%! 77%! 70%! 65%! 61%! 57%! 54%! 51%! 49%! 47%!
6! 88%! 80%! 74%! 68%! 64%! 61%! 57%! 54%! 53%! 51%!
7! 90%! 82%! 76%! 71%! 67%! 64%! 61%! 58%! 56%! 54%!
8! 91%! 84%! 78%! 74%! 70%! 66%! 63%! 61%! 58%! 56%!
9! 92%! 86%! 80%! 76%! 72%! 68%! 65%! 63%! 61%! 58%!
10! 93%! 87%! 82%! 77%! 74%! 70%! 67%! 65%! 63%! 61%!
 Lingkungan Resusitasi
The tools available in the peripheral areas which can be used as an alternative:
R e s u s c i t a t i o n Ideal! Modification!
components!
Thermoregulation! Radiant warmer ! The resuscitation table
temperature in the resuscitation
room is 26 C!
Vacuum! Suction unit! Midwifery suction catheter!
Ventilation! Tool that can provide continuous TPAE premature infants with
respiratory distress!
T-piece resuscitator! Jackson Rees!
Tool that can provide positive pressure ventilation!
T-piece resuscitator! Balloon lid with TPAE!
Tools that can mix 100% O2 with compressed air!
Oxygen cylinders and compressed air
Oxygen blender!
tube connected to the Y-connection
Sirkulation! Installation of umbilical lines!
With umbilical catheter! Oral Gastric Tube!
Transportation! Transport incubator Kangaroo method!
 Lingkungan Resusitasi

2. Checking manual ventilation tool

T-piece resuscitator
! Connect the source of pressurized oxygen gas into the inlet port, adjust the
pressure of 8 L / min.
! Connect the circuits of patients with T-piece resuscitator through the outlet
port

! Close the end of the patient circuit (mask holes and holes PIP) for the next 2
stages
! Play "Safety Valve PIP" one turn clockwise until the desired pressure seen in
the manometer. Adjust the maximum pressure until the manometer
indicates 50 cm H2O
 Resusitation environment

2. Checking manual ventilation tool....

T-piece resuscitator....(continue)
! Set the desired peak inspiratory pressure by turning the "Valve PIP" looks up the
required pressure on the manometer. The recommended initial pressure was 30
cm H2O for term infants and 20-25 cm H2O for preterm infants.

! Maintain patient closing the outlet end of the T-piece, but the open end of the
outlet and turn the PEEP valve until the manometer indicates the desired number
of PEEP (5-8 cm H20)

! Choose the right sized face shield

! Provide ventilation in newborns with closing and opening holes in the PEEP valve.
Do as much time 40-60x/menit with inspiration around 0.3-0.5 seconds
 Resusitation environment

2. Checking manual ventilation tool....

Safety(Valve(PIP
Valve((PIP
 Resusitation environment

2. Checking manual ventilation tool....

 Lingkungan Resusitasi

Self-inflating bag

If you have a source

Make sure the
Check the of oxygen, stream
pipe or
equipment up 10L/menit (even
reservoir bag
correctly though it does not
available
need oxygen intake)

Provide ventilation in Close the open hole

At the end of
newborns with that leads to the lid,
inflation, check
compressing the bag squeeze Ambu bag to
the bag can be
during 40-60 x / min open the pressure
quickly re-
0.3-0.5 seconds with a valve that leads to
inflation
time of inspiration the reservoir
 Resusitation environment

Flow-inflating bag
!Check the equipment up correctly and make
sure the attached manometer

!Set
the oxygen flow 10L/menit (this tool
requires a source of oxygen)

!Closethe open hole that leads to the lid.

When closing the hole in part, note whether
the air bag filled quickly.
 Resusitation environment

Flow-inflating bag...(continued)
! Continue
to close the hole, give the bag and note the
compression pressure is reached.

! Consideralso whether the bag can be quickly re-inflation

at the end of inflation when the bag is not being
compressed

! Provide ventilation in newborns with a squeeze bag

between the thumb and index finger (to maintain PEEP),
then squeeze the bag to produce a positive pressure.
Perform 40-60x.menit 0.3-0.5 seconds with a time of
inspiration.
 Resusitation environment

3. Current Infection Control Resuscitation

1. hand hygiene

Wash clean hands with aseptic /

hands examiner should not
antiseptic and alcohol-
before based antiseptic handrub
wear jewelery,
and after without water artificial nails and nail
resuscitati (chlorhexidine gluconate polish when in contact
on 2-4%). with patients
 Resusitation environment

Material
! Liquid antiseptic containing chlorhexidine 2% and or with alcohol
! Liquid handrub in developing countries based on the recommendation
of WHO. Komposition in 100 mL of solution:
! 84.20 mL of 96% ethanol
! 3% H2O2 : 4.17 m
! 98% Glycerol qs
! Lemon perfume qs
! 100 mL of distilled water ad

! running water
! Disposable wipes
 Resusitation environment
How to Hand Wash
 Resusitation environment

2. Personal Protective
!Head cap
!Mask
!Gloves
!Sterile gown
!boots
 Resusitation environment

3. Resuscitation equipment
sterilization
Ideally resuscitation equipment
is only used one time.
To save costs ! then
decontamination, high level
disinfection and sterilization of
various instruments are allowed,

Sterilization ! plasma
sterilizer, ethilen oxide,
autoclave, dry heat (oven),
chemical sterilization or
radiation
 Resusitation environment

Waterproof mattress is used when the

baby is cleaned after each
resuscitation with:
! Low risk of transmission of infection ! use
detergent
! High risk of transmission of infection
!detergents and disinfectants are
customized with multi-resistant organisms.

resuscitation trolley and other which are

not connected directly to the baby (pulse
oximeter monitor, infusion pump)!
cleaned every time we use with the
detergent
 Resusitation environment
Reuse lid Laerdel Bag:
Procedure: Processing of medical devices used in accordance with the type of non-critical
equipment that begins with a high level decontamination process.

1. Decontamination Process:
Soak lid into Rinse with
Wash Remove the lid Gigazyme 0.5%
hands warm water
from the solution (5 ml containment.
Laerdal Bag gigazyme mixture in
950 ml of water) for
15 minutes.
Once the lid is
dry, do Dry the lid in Soak the lid back
containment the cupboard Rinse with into Gigasept 4%
packaging, or temperature warm water solution (40 ml
send for 50-70 C for at containmen gigasept mixture in
sterilization least 30 t 960 ml of water)
minutes
process is for 15 minutes
carried out
 Resusitation environment

2. Plasma sterilization using the machine:

Medical goods to be sterilized in containers

labeled indicators and internal indicators

then stacking the cassette tray and H2O2 has

been in a state filled in the machine

Machine in standby

Open the machine door open ! press,

medical goods that will enter in a sterile,
then close the door press the close button
 Resusitation environment

2. Plasma sterilization using the machine:...(continued)

Press the start button 2 times then the sterilization

process will take place automatically

After all sterilization processes complete, open

the door of the machine by pressing the open
button

Goods that have been issued and delivered sterile

to sterile storage room through the window
 Resusitation environment

3. usage

7 steps of hand Remove the lid from Check and make

washing with an a sterile medical sure the lid was Wipe the surface
antiseptic goods storage area, intact, not torn or with a gauze lid
place it on the table damaged. When the
solution and and open the lid is broken or alcohol before
water, dry with a previously prepared damaged, replace it use.
clean tissue sterile with a new lid
 Resusitation environment
Cleanup and containment balloon:
1. Decontamination and Disinfection:

Perform hand All components were Soak all components

Remove the lid, rinsed in running into the warm water
hygiene with
patient valve water, soak in warm
an antiseptic that has been mixed
components, and water for 2 minutes with detergent and
solution and
components of before cleaning with
water, dry with clean all parts with a
the intake valve water containing toothbrush.
a clean tissue
detergent.
 Resusitation environment

Cleanup and containment balloon:

1. Decontamination and Disinfection
(continued) :

Containment, patient valve

Rinse components, parts intake valve Soak in the solution for 15
Rinse Gigasept 4%
with Gigazyme soaked in a solution of
0.5% for 15 minutes. (How to
with minutes (40 mL Gigasept
warm dissolve: 5 mL Gigazym + 995 mL warm Instru AF + 960 mL boiled
water. water that has been boiled and
boiled water that has been boiled water. then allowed to cool 100oC)
and then allowed to cool 100oC).
 Resusitation environment
2. usage
Rinse with warm water

Dry the lid, patient valve components, and

components of the intake valve in the closet
temperature 50-700C until dry (at least 30
minutes)
7 steps of hand washing with an antiseptic
solution and water, dry with a clean tissue
Remove the lid, patient valve components,
and components of the intake valve sterile
medical goods storage area, place it on the
table and open the previously prepared
 Resusitation environment

2. Usage .... (continued)

Check and make sure the lid, patient valve

components, and components of the intake valve was
intact, not torn or damaged. When the lid is broken or
damaged, replace with a new lid.

Use sterile gloves

Re-assemble all components

Perform function test balloon and lid (see

attachment)
Containment, patient valve components, and intake
valve components packed in plastic packing.
Thank You