Sneha Sood MD HIGH RISK DELIVERIES AND THE

Sneha Sood, MD HIGH RISK DELIVERIES AND THE NEED FOR NEONATAL RESUSCITATION TEAMS

Neonatal Resuscitation Teams Definition: A neonatal resuscitation team can be compared to an adult rapid response team or “code” team. They should be in-house and available 24/7.

Why Have a Neonatal Resuscitation Team? Safety-net at Community Hospitals that do not have in-house Pediatric coverage by a physician or NNP/PA. Rapid response of team could be life-saving to a neonate in the delivery room or nursery. Can stand-by at emergency C-sections if Pediatrician unable to arrive in time. Trained team to manage newborn emergencies; other health care professionals who do not routinely take care of babies are usually not comfortable with neonatal intubations and line placement so it is difficult to have an adult rapid response team attend neonatal emergencies. Team also valuable in assisting Pediatrician with neonatal stabilization.

NRP Guidelines . NRP is used as the “gold standard” for Neonatal Resuscitation. NRP states that “at every delivery there should be at least one person who can be immediately available to the baby as his or her only responsibility and who is capable of initiating resuscitation. Either this person or someone else who is immediately available should have the skills required to perform a complete resuscitation, including endotracheal intubation and administration of medications. It is not sufficient to have someone “on call” (either at home or in a remote area of the hospital) for newborn resuscitations in the delivery room. When resuscitation is needed, it must be initiated without delay. “

Potential Team Members Physicians, usually Pediatricians or Family Practice Physicians, Emergency room physicians, anesthesiologists CRNA Neonatal nurse practitioners Resident physicians Nurses Respiratory therapists

Proposed Model for Community Hospitals Nurse/Respiratory therapist team Work as a two-member team

Long Term Goals and Skills for Team Members Good general resuscitation skills (both nurses and respiratory therapists) Airway management (both nurses and respiratory therapists) Neonatal intubation (respiratory therapists or nurses) Stabilization UVC, other access (Nurses) Ability to administer emergency medications (nurses and respiratory therapists) Possible cross-over of skills based on the goals of the individual community hospitals or as team gains experience May take several years of ongoing experience and training for team members to feel comfortable in their role

Risk Factors Associated With the Need For Neonatal Resuscitation: Antepartum From: Neonatal Resuscitation Handbook Maternal diabetes Pregnancy-induced hypertension Chronic hypertension Previous fetal or neonatal death Maternal infection Maternal cardiac, renal, pulmonary, thyroid, or neurologic disease Polyhydramnios Oligohydramnios PROM Fetal hydrops Post-term gestation Multiple gestation Size-dates discrepancy Drug therapy, such as Magnesium, adrenergic –blocking drugs Maternal substance abuse Fetal malformations or anomalies Diminished fetal activity No prenatal care Age < 16 or > 35 years

Risk Factors Associated With the Need For Neonatal Resuscitation: Intrapartum (From Neonatal Resuscitation Handbook) Emergency C-section Forceps or vacuum-assisted delivery Breech or other abnormal presentation Premature labor Precipitous labor Chorioamnionitis Prolonged rupture of membranes (> 18 hours before delivery) Prolonged labor (> 24 hours) Prolonged second stage of labor Macrosomia Persistent fetal bradycardia Non-reassuring fetal heart rate patterns Use of general anesthesia Uterine hyperstimulation Narcotics administered to mother within 4 hours of delivery Meconium-stained amniotic fluid Prolapsed cord Abruptio placentae Placenta previa Significant intrapartum bleeding

Preparation for Neonatal Resuscitation Teams at Community Hospitals Consider developing working committee to work with HI-CHI to develop and maintain neonatal resuscitation teams. Presentation of need and implementation plan and timelines to appropriate hospital administration, staff, and physicians. Identify composition of neonatal resuscitation team (e. g. physician, NNP, nurse/respiratory therapist, etc. ) Advanced role and skills need to be endorsed by the hospital (e. g. endotracheal intubation, placement of stabilization UVC) and these skills written into the appropriate hospital bylaws and/or job description, development of policies and procedures.

Preparation for Neonatal Resuscitation Teams at Community Hospitals Define team members (e. g. specifically identify those individuals to receive training) List of anticipated deliveries that need to be attended by the Neonatal Resuscitation Team How will the team be activated when they are needed for anticipated high risk deliveries and unanticipated situations. Pager Phone Overhead How will team members be trained? How will skills be maintained? Will there be regular drills to maintain skills? How will “certification” of team members be maintained (e. g. number of intubations, stabilization UVCs, deliveries attended)

Possible Indications for Calling Neonatal Resuscitation Team Each hospital should design their own list of indications; these can be based on guidelines provided by training course and by other hospitals, NRP. Should include indications for calling: Neonatal Resuscitation team alone Both Neonatal Resuscitation team and Pediatrician

Examples (Based on guidelines from Kapiolani Medical Center) Pediatric Resident/Neonatal Nurse Practitioner EFW < 2000 grams or > 4000 grams < 36 weeks or 42 weeks and greater Maternal eclampsia or AICU Increased maternal/neonatal risk of bleeding Meconium-stained fluid Immature lung profile C-section Fetal distress/poor biophysical profile Vaccum/forceps/breech vaginal deliveries Major congenital malformation and/or chromosomal anomaly Multiple gestation

Examples Neonatal Resuscitation team (includes Neonatologist) < 33 weeks completed gestation Maternal eclampsia or AICU Increased maternal /neonatal risk for bleeding Immature lung profile Sustained fetal bradycardia or poor biophysical profile Breech vaginal delivery Major congenital malformation and/or non-lethal Emergency C-sections

Neonatal Resuscitation Teams Please remember that the training team can help you establish guidelines and protocols and will continue to work with you to maintain skills for neonatal resuscitation! We would recommend quarterly drills to keep up skills; also consider regular on-site training at Kapi’olani Medical Center for Women and Children. However, the ability to do this training likely to be determined by budget. Consider working with other Community Hospitals on neighbor islands to establish universal guidelines?

HI-CHI Recommended training schedule Prerequisites: NRP and S. T. A. B. L. E. Neonatal Resuscitation Course every two years (HI-CHI) Advanced Neonatal Resuscitation Course every two years; still in development (HI-CHI) Hands-on training at Kapiolani Medical Center for Women and Children Quarterly reviews utilizing simulation (HI-CHI, core staff) Ongoing mentoring at home institution by Pediatricians and other experienced professionals Each institution can mandate how skills are maintained annually; can work with HI-CHI and other hospitals to standardize.