Learning Objectives
By the end of this section, you will be able to:
- Discuss the indications for oxygen and assisted ventilation in a newborn
- Identify the importance of temperature monitoring and maintenance
- Describe how to safely administer surfactant to a newborn
The goal of neonatal care at birth is to support the transition from the womb to extrauterine life. “The most important priority for newborn survival is the establishment of adequate lung inflation and ventilation after birth” (American Heart Association [AHA], 2020). Newborns who cannot breathe on their own need timely interventions from the administration of oxygen to full resuscitation.
Temperature
A newborn’s temperature is monitored frequently after birth to maintain a temperature between 36.5° C and 37.5° C (97.7° F and 99.5° F) through admission and stabilization (Department of Reproductive Health and Research [RHR], World Health Organization [WHO], 1997). A measured axillary temperature below 36.5° C is considered hypothermia and is associated with increased neonatal mortality and morbidity (AHA, 2020; Laptook et al., 2018) and can easily be prevented with the use of warmers, drying the newborn, swaddling, or skin-to-skin contact if further resuscitation is not needed. A hypothermic newborn is at risk of hypoglycemia, respiratory distress, metabolic acidosis, and jaundice (Weiner, 2021).
Oxygen and Ventilation Therapy
Most newborns will spontaneously breathe within 30 to 60 seconds after birth. Simple drying and tactile stimulation may encourage ventilation, or effective breaths that result in chest rise with air entry to the lungs (AHA, 2020) (see Figure 22.4). If the newborn does not start breathing within that first minute, bradycardia, a heart rate under 100 beats per minute in a neonate, will be ongoing. The nurse should clear the airway, mouth, and nose, if needed. Providing positive pressure ventilation (PPV), with breaths at a rate of 40 to 60 per minute, is the treatment to both improve heart rate and facilitate ventilation for the newborn. As appropriate ventilation occurs, the heart rate will increase. This increasing heart rate is the first reassuring sign during resuscitation measures. A three-lead cardiac monitor or electrocardiogram is the recommended tool for assessment rather than direct auscultation or readings from pulse oximetry (AHA, 2020; Balest, 2022). For neonates, respiratory failure occurs first, followed by cardiac arrest, while in adults this is reversed. This physiologic response of the newborn requires that resuscitation prioritize PPV (Ersdal et al., 2012; Pallapothu, et al., 2023). “Delays in initiating ventilatory support in newly born infants increase the risk of death” (AHA, 2020).
Continued increased respiratory effort, tachycardia or bradycardia, and central cyanosis all indicate a need for supplemental oxygen. An oxygen saturation under 92 percent or an arterial oxygen pressure (PaO2) under 60 substantiates the necessity of oxygen administration (Vento & Saugstad, 2019). Supplemental oxygen is administered via nasal cannula with humidified and warmed air to prevent drying of the nares and cold stress to the neonate (Figure 25.12).
Supportive ventilation for the newborn may continue beyond the delivery and move from PPV to noninvasive nasal continuous positive airway pressure (CPAP). If the newborn is unable to protect or maintain their own airway, intubation and a ventilator are required to both ventilate and oxygenate. Ventilation is the physical delivery of breath to the lungs, while oxygenation is the exchange of gases at the cellular level. Continuous pulse oximetry and frequent monitoring of the patient are required when using respiratory supportive devices. Too much oxygen can be dangerous to the neonate. Careful titration of oxygen and monitoring of saturation reduce the risk of complications of oxygen therapy such as retinopathy of prematurity (ROP) and bronchopulmonary dysplasia (BPD) (Bancalari & Schade, 2022; Sahni & Mowes, 2022).
Mechanical ventilation, the use of a ventilator, is necessary any time hypoxemia or hypercapnia cannot be corrected with other interventions. Mechanical ventilation may be necessary for infants who have apnea with bradycardia, ineffective respiratory effort, shock, asphyxia, infection, meconium aspiration syndrome, or respiratory distress syndrome (RDS). High-frequency ventilation (HFV) provided with jet ventilators, oscillators, or high-frequency flow interrupters, gives very frequent small breaths at low pressures to the neonate compared to traditional mechanical ventilators. HFV decreases the risk of barotrauma to the infant lungs and the risk of BPD (Ethawi et al., 2016).
Unfolding Case Study
Newborn Care: Part 3
See Newborn Care: Part 2 for a review of the patient data.
| Flow Chart | Newborn assessment data at 30 minutes of age Data obtained after transfer to transitional nursery Data obtained 60 minutes after nursing actions |
| Provider’s Orders | Transfer to transitional (intermediate care) nursery VS every 30 minutes Observe respiratory status closely Place under radiant warmer Continuous pulse oximetry Continuous oxygen per oxygen hood NPO Monitor intake and output until discharge Chest x-ray |
Escalated Therapies
Nitric oxide (NO) is a strong direct pulmonary dilator when delivered as a gas via inhalation. It is used to decrease pulmonary hypertension, pulmonary vasoconstriction, acidosis, and hypoxemia and also to treat meconium aspiration syndrome, congenital diaphragmatic hernia, persistent pulmonary hypertension, and sepsis (Barrington et al., 2017; Vento & Saugstad, 2019).
Another extreme, complex, and expensive life-support method, called extracorporeal membrane oxygenation (ECMO), involves a modified form of heart-lung bypass. ECMO allows for treatment of any disease or trauma that has resulted in intractable hypoxemia due to severe cardiac and/or respiratory failure (Figure 25.13). ECMO essentially provides oxygen to the lungs and body while the lungs are treated for any underlying disease process or insult. ECMO does require anticoagulation that can escalate the risk of intraventricular hemorrhage and is contraindicated in very small or preterm infants under 34 weeks’ gestation (Amodeo et al., 2021).
Link to Learning
The Cincinnati Children’s Hospital Medical Center provides updates on neonatal resuscitation and describes the function of ECMO for neonates.
Neonatal Resuscitation
A quick visual assessment allows the nurse to identify newborns who need resuscitation at birth or soon after. Newborns who are breathing and/or crying are best cared for skin-to-skin with their parent. These infants do not need routine tactile stimulation or suctioning, even if the amniotic fluid was notable for meconium. Suctioning the airway should be done only as necessary because doing it routinely can cause bradycardia (Wyckoff et al., 2020). This is an evidence-based approach. Previously, newborns were intubated and suctioned for meconium. Studies within the published literature identified that the risks did not outweigh the benefits, and this practice was changed. Is the newborn breathing and crying? Do they have good muscle tone? If not, the newborn needs assistance. The nurse clears the airway with suction, keeps the infant warm, dries them, and attempts to reposition the airway so that the infant can breathe on their own. If breathing is not spontaneous, the next step is to start external ventilation. If that is unsuccessful, the nurse calls for assistance and begins resuscitation (American Heart Association [AHA], 2020).
Link to Learning
The American Heart Association (AHA) has a “Top 10” list of priorities for health-care professionals during resuscitation of neonates. Guidelines from the AHA are evidence based and peer reviewed and are updated regularly to give the most accurate resuscitation information.
Risk factors associated with neonates requiring resuscitation include
- no, or limited, prenatal care;
- gestational age < 36 weeks or ≥ 41 weeks;
- multiple gestation;
- forceps- or vacuum-assisted delivery;
- emergency cesarean delivery;
- meconium-stained amniotic fluid;
- shoulder dystocia, breech, or other abnormal presentation;
- abnormal heart rate in the fetus;
- infection in the infant or birthing person (Balest, 2022); and
- maternal drug consumption, chronic or acute use.
Surfactant Administration
A surfactant is any agent that decreases surface tension between two surfaces, thereby improving the exchange of oxygen and carbon dioxide. Pulmonary surfactant decreases the surface tension between the gaseous-aqueous interface in the lungs. Pulmonary surfactant is a surface-active phospholipid secreted by the alveolar epithelium and produced by the alveolar type-II (AT-II) cells of the lungs (Moraes et al., 2022).
Sterile surfactant is collected from animals and administered to newborns at risk of not having, or not having enough of, their own surfactant. Sterile surfactant is delivered via an endotracheal tube. Lung-surfactant development starts at 24 weeks’ gestation, but not until at least 32 weeks does the fetus make adequate amounts of it (Sarfaroj, 2021).
Surfactant can be used with oxygen and/or ventilation. Several doses are given in series via the endotracheal tube. After administration, the infant is monitored for side effects, the most severe being patent ductus arteriosus and pulmonary hemorrhage.
Pharmacology Connections
Surfactant
Many clinical trials over the past decades have shown that surfactant replacement therapy is a safe and an effective treatment that significantly decreases the occurrence of air leaks and pulmonary interstitial emphysema along with ventilatory requirements.
Generic Name: beractant
Trade Name: Survanta
Action: provides exogenous surfactant to promote lung maturity
- Route/Dosage: airway, 4 mL/kg, variable frequency
- Premature neonates: Endotracheal: 4 mL/kg (100 mg phospholipids/kg) as soon as possible after birth, preferably within 15 minutes; as many as four doses may be administered during the first 48 hours of life, no more frequently than every 6 hours; usually requires no more frequent dosing than every 12 hours unless surfactant is being inactivated by an infectious process (Sanchez Luna, et al., 2022).
- Administration: through an endotracheal tube using a 5 French end-hole catheter: The infant should be stable before proceeding with administration. Insert a 5 French end-hole catheter into the infant's endotracheal tube. Administer the dose in four 1 mL/kg aliquots. Each quarter-dose is instilled over 2 to 3 seconds followed by at least 30 seconds of manual ventilation or until stable; each quarter-dose is administered with the infant in a different position; slightly downward inclination with head turned to the right, then repeat with head turned to the left; then slightly upward inclination with head turned to the right; then repeat with head turned to the left. Following administration of one full dose, withhold suctioning for 1 hour unless signs of significant airway obstruction occur.
- Indications: lung immaturity; reduce the severity of RDS in premature infants
- Adverse Reactions/Side Effects: oxygen desaturation, transient bradycardia, alterations in blood pressure
- Nursing Implications: Frequent monitoring of the patient. Diuresis may occur with improvement. Newborn may be weaned off ventilation and oxygenation support as oxygenation improves (Vallerand & Sanoski, 2019; Vento & Saugstad, 2019).
- Parent/Family Education: Provide information about the underlying reason for administration. The newborn does not have their own supply and are being given an outside source of surfactant.