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A practical program to maintain neonatal

resuscitation skills

David E. Walker, BSc, MD, CCFP; Linda Balvert, RN

Resume: La mise en oeuvre dans les hopitaux du programme de reanimation des nouveau-nes (PRN) a etabli une norme 'a l'egard des techniques de reani-

mation des nouveau-nes. Malheureusement, les reani- mateurs perdent rapidement leur technique s'ils ne la

pratiquent pas regulierement. Pour corriger le pro-

bleme, les auteurs ont mis au point un programme

pratique de maintien de la competence en reanima-

tion des nouveau-nes des professionnels qui oeuvrent

dans un hopital communautaire. Ce programme est base sur les exercices reguliers, la creation d'un poste de travail permanent, un systeme de scenarios pra-

tiques fondees sur celles du PRN et des rappels non

fondes sur la confrontation. Parce qu'il met l'accent sur le maintien des competences, le systeme semble benefique pour tous les participants, qui acquierent

un sentiment de confiance et de competence, ap- prennent 'a travailler en equipe et a se respecter mu-

tuellement. Apres une evaluation plus poussee, on

pourra appliquer un tel programme 'a des hopitaux de toutes tailles.

A primipara 19 years of age at 30 to 31 weeks' gestation was in advanced active labour when she arrived at Alexandra Marine and General

Hospital, a level I birthing facility in Goderich, Ont. Be- cause of the precipitate nature of her labour, there was no opportunity to send her to the nearest level III hospi-

tal, some 110 km away.

Staffprepared for the birth and anticipated the need for resuscitation, support and, when the baby had be- come stable, transport. The vaginal birth 50 minutes

later was unremarkable. The baby girl cried sponta- neously, and she was moved to the preheated radiant warmer. In 10 to 20 seconds she was dried, positioned

and provided with suction of her mouth and nose. The

baby's respirations were adequate, and her heart rate was

more than 100 beats/min. She was acrocyanotic. A 1-minute Apgar score of 7 was assigned. After 2 minutes her respirations were becoming increasingly laboured and irregular; bag and mask ventilation with 100% oxy- gen was started. The heart rate remained over 100

beats/min and the baby's colour, which had become paler, improved. Intubation was attempted with an endo- tracheal tube of 3.0 mm internal diameter, prepared and

precut to 13 cm. This attempt was aborted because of in-

ability to insert the tube within 20 seconds. The baby was given positive pressure ventilation with 100% oxy-

gen between the first and a successful second attempt at

intubation. An orogastric tube was inserted within 2

minutes. An umbilical vein catheter was also inserted for intravenous access while staff awaited the transport team. Unfortunately, during the insertion of the catheter

the endotracheal tube was inadvertently dislodged. The

apneic baby quickly became pale, and her heart rate fell below 60 beats/min. Fortunately, the situation was

quickly reversed. External cardiac massage was started,

the endotracheal tube was removed, the baby was given

ventilation with 100% oxygen, and the tube was re- placed and taped securely in place. Within 30 seconds

the baby's heart rate was over 100 beats/min, her colour

was pink, and she was making spontaneous movements. The transport team arrived 2 hours after the birth. The baby was stable, and she was being given ventilation with 75% to 80% oxygen to maintain the oxygen satura- tion above 90%. The baby was kept warm by the radiant

Dr. Walker is chairman of the Maternal and Newborn Committee of Alexandra Marine and General Hospital, Goderich, Ont., and a member of

the Neonatal Resuscitation Program Advisory Group of the Heart and Stroke Foundation of Ontario, and Ms. Balvert is the head nurse for

obstetrics and a member of the Maternal and Newborn Committee of Alexandra Marine and General Hospital, Goderich, Ont.

Reprint requests to: Dr. David E. Walker, Alexandra Marine and General Hospital, 120 Napier St., Goderich, ON N7A IW5

<-- For prescribing information see page 368

CAN MED ASSOC J 1994; 151 (3)


warmer, a well-heated birthing area and warm, moistur- ized oxygen. The physicians and nurses who cared for this infant felt confident and organized in their approach to the re-

suscitation. Three days before the birth they had at-

tended the monthly hospital perinatal rounds, which had

included a review of neonatal resuscitation and a prac-

tice session. While they awaited the birth they took the

opportunity to "run through some scenarios" at the

neonatal resuscitation workstation, which is set up per-

manently in the birthing area.

Life support is needed in the birthing room or nurs- ery for 6% of all newborns and for a much higher per- centage of low-birth-weight newborns.' All of those

involved in delivery, including physicians, nurses, anes-

thetists and respiratory therapists, must possess the skills

needed to perform neonatal resuscitation. In hospitals in which the number of births is rela- tively low or physicians attend few births, neonatal re- suscitation skills may be used infrequently. Because the response must be swift and accurate if resuscitation is needed, staff must maintain these skills in the meantime. Canadian guidelines for neonatal resuscitation have existed since 1989.2 These guidelines have been sup- ported by all professional groups involved in resuscita- tion. There is also a training program, the Neonatal Re-

suscitation Program (NRP), contained in an excellent

education manual endorsed by the Canadian Paediatric Society, the Heart and Stroke Foundation of Canada, the American Heart Association and the American Academy of Pediatrics.3 The manual follows a self-paced learning format. It

begins with an introductory section including pathophys-

iology followed by a series of lessons on the different activities associated with neonatal resuscitation. Each lesson builds on the skills learned in the previous one. Lessons include initial evaluation and management of newborns at risk, preparation and use of equipment for assisted ventilation, performance of chest compression

and endotracheal intubation, and the use of drugs for se- verely illinfants.

To achieve the CMA's stated goal of every hospital being able to provide effective newborn resuscitation4 it was necessary to establish provincial training programs. Training programs that follow the NRP have been set up in regional perinatal centres in each province through the Heart and Stroke Foundation. Instructors at the regional

perinatal centres provide training for hospital-based in-

structors, who, in turn, train NRP providers.5 In Ontario, for example, the NRP Advisory Group of the Heart and

Stroke Foundation of Ontario oversees and promotes such training programs.

There is still wide variation in the implementation of training programs from region to region in Ontario. According to the Review of Maternal and Newborn Hos- pital Services in Ontario,6 the proportion of hospitals in a

region that have guidelines for neonatal resuscitation

300 CAN MED ASSOCJ 1994; 151 (3)

ranges from 16.7% to 73.2%. There is also wide regional variation in the number of hospitals that have completed


In southwest Ontario, where Alexandra Marine and General Hospital is located, more than 700 providers and 100 instructors have been trained. Still, many medical

personnel have not yet taken provider courses. Ways of

promoting provider courses to them are sought. Many of

the providers in the region have been reregistered after 2

years. A review of articles about the NRP showed that

most deal with the establishment of the program.`

review of early experience with the NRP, Byrd' con- cluded that there are four successful features of the pro- gram: it addresses a topic of concern to all institutions

regardless of size (neonatal resuscitation), the material permits full staff participation, the training of hospital-

based instructors creates enthusiasm and promotes the

continuity of the program, and the use of regional centre faculty to train the hospital-based instructors strengthens relationships and communication. Singhal and associates' investigated changes in atti- tudes and resources (written protocols and resuscitation

equipment) after the introduction of the NRP. Trainees

from 35 hospitals participated in NRP workshops. They

were asked to fill out questionnaires before and after the

workshops. Results from these surveys showed that par- ticipants' beliefs and attitudes toward resuscitation, and

especially theirconfidence, changed significantly.

In a

Two studies have evaluated and assessed adherence to the standards for neonatal resuscitation.""' McCulloch and Vidyasagarl' concluded that the educational materi- als of the NRP provide standards for the management of newborn infants. They used the NRP standards success-

fully to assess the quality of neonatal resuscitation in the

birthing areas of their study hospital. They concluded

that education, followed by systematic, continuing eval- uation of birthing area personnel, improves professional


Dunn and associates" undertook a randomized con- trolled trial to evaluate a neonatal resuscitation education program. Half of the 190 nurses involved were assigned to the experimental group and half to the control group. Directly after they took the program the nurses in the ex- perimental group had significantly improved knowledge and skill performance. Six months later their knowledge was maintained but their skill performance was not. The investigators also found a significant relation between

the subjects' self-rated knowledge level and their results

on knowledge testing. Since all of the subjects failed the 6-month skill test, although 23% had rated themselves as competent, the skill self-rating appeared to have minimal

value. The investigators concluded that future studies should focus on ways to increase the retention of skills. Moser and Coleman'" showed similar results in their review of retention of skills in adult cardiopul- monary resuscitation. Retention of skills was poor in all

LE Ic''AOUJT 199)4

groups, with significant loss after only several weeks. Skills consistently returned to pretraining levels 1 year after training. Furthermore, the perception of this skill loss was poor; physicians, in particular, overestimated their performance skills. Frequent use of skills did not appear to improve retention significantly. Only practice with correction of errors had a proven benefit. Staff at the Alexandra Marine and General Hospital agreed thatthe NRP seta laudable standard forallhospi- tals with birthing facilities, but they anticipated that skill maintenance might be difficult in a small hospital. Therefore, they created a practical program to maintain neonatal resuscitation skills. The Alexandra Marine and General Hospital is a community hospital with 50 acute care beds that serves a

population of 7500. It is located 110 km northwest of London, Ont., which is the regional centre for south- western Ontario. There are between 100 and 135 births per year at the hospital. Two hospital-based NRP instructors were trained in London in July 1990. The first provider course was given at the hospital in November 1990. Within 18 months all obstetric nurses, supervisors and operating room nurses were registered. Five of the seven physi-

cians providing obstetric care and one of two anes- thetists have completed provider courses. All providers who have been registered for 2 years have completed reregistration requirements. The hospital's Maternal and Newborn Committee sought input from both nurses and physicians, through a survey and round-table discussion at perinatal rounds, to

identify the obstacles to maintaining neonatal resuscita-

tion skills.

Nurses identified several obstacles. They were not

always able to attend formal review sessions, such as

those conducted during rounds, because of shift work.

Because of staff cutbacks and increased workload, nurses found it difficult to make the time to practise their skills during shifts. They cherished any breaks they

might have. Most worked part-time and were infre-

quently involved with births. They all found formal

practice and test sessions stressful, especially when per-

formed with physicians.

Some of the obstacles identified by physicians were

the following. Most felt constrained by lack of time and felt that they were "spread too thinly." Maintenance of

skills for neonatal resuscitation, although felt to be very

important, was just one of many continuing medical edu- cation demands. In general, physicians did not like to be put on the spot and preferred to avoid formal sessions in which they might have to perform, especially with nurses present. They recognized that lack of practice due

to inadequate caseloads was a major problem. Many

physicians who attended few births felt that they did not

need the course.

Having identified these obstacles, we realized that

convenience and minimizing of stress were important.

AUGUST 1, 1994

With these in mind, we designed a program to provide ways of maintaining confidence and competence for all neonatal resuscitation providers.

Program description

The practical program to maintain neonatal resusci- tation skills is based on the following elements: review

and practice, a dedicated workstation and area, a method for correction of errors and audit, and a method for re- minders and motivation.

Practise, practise, practise - regularly

Before studying for the NRP provider level, many health care professionals were sceptical of the program

or felt they already possessed the knowledge and skills

needed for effective neonatal resuscitation. It rapidly be- came apparent from the training manual and the provider course that the simplicity and the reproducibility of skill

performance flow from regular practice. If regular prac-

tice is lacking, there is a rapid loss of these aspects of skills. Regular practice builds not only competence but also cooperation, mutual respect and a team approach among physicians and nurses. At the Alexandra Marine and General Hospital pro-

fessionals practise as part of perinatal rounds, during in- formal sessions with a "buddy" and during formal re- view and reregistration exercises.

Once a month the Maternal and Newborn Commit-

tee organizes rounds that bring together physicians and nurses involved with obstetric and newborn care. Topics of interest and case presentations generate discussion.

Every 3 months, at least a portion of this time is used by

the hospital-based instructor to demonstrate neonatal re- suscitation and to update staff on any practice changes. Such sessions are called megacode reviews (the mega- code is the algorithm that summarizes the steps of neonatal resuscitation). Providers must attend one such session yearly to qualify for reregistration. At such ses- sions, there is an opportunity to practise informally in

pairs with the use of predesigned scenarios picked at

random. Informal, nonstructured practice sessions are possi- ble at any time with the use of a permanent, fully set-up

workstation (Fig. 1). This type of session works best with two "buddies" who alternately select scenarios from the NRP-Skill Maintenance Scenarios, created by

us and based on the NRP megacode and the course ma-

terial dealing with medications."3"3 In the absence of a

"buddy," solo practice is still beneficial. This type of

learning is completely self-directed and, therefore, not

stressful. Practice also occurs at structured reregistration ses- sions. Although they are valuable, these sessions are not a substitute for regular practice. In our hospital, pro- viders who do not practise regularly (a minimum of one

CAN MED ASSOC J 1994; 151 (3)


practice session every 6 months) are ineligible to rereg- ister and are requested to complete the NRP training course again.

Create a workstation

The creation of a workstation (Fig. 2) at which all of the equipment is ready for use, night or day, in a

readily accessible area is an essential part of this pro-

gram. For busy physicians, nurses and respiratory thera- pists, having to get out mannequins, intubation equip- ment and so on is a serious disincentive to practising. For this reason, a spacious table approximately the

height of an infant warmer was set up with all of the

equipment needed to conduct all of the scenarios in a

megacode. Even oxygen and suction equipment are pro- vided to simulate the real resuscitation situation as closely as possible. The table is on wheels so that it can

be moved conveniently to other areas for teaching and practice.

The workstation must be located conveniently, close to the work area. In our hospital the workstation is set up in the birthing area so it is readily accessible to

physicians for practice while awaiting a birth and to

nurses who have some time on a quiet shift.

nurses who have some time on a q u i e t shift. Fig. 1: Health

Fig. 1: Health care professionals practise neonatal resusci- tation techniques informally at a permanent workstation

established for this purpose.

302 CAN MED ASSOCJ 1994. 151 (3)

,i,.: ~~~~iI


A file-card box containing the NRP-Skill Mainte-

nance Scenarios and a Provider Practice Record card for

each registered provider is

kept at the workstation.

Created scenariosfacilitatepractice


and correction of errors

from the most easy

The eight NRP-Skill Maintenance Scenarios range

to the most difficult, and four in-

volve the presence of meconium.

The scenarios are classified as follows.

Al: Active and healthy newborn - stimulation

with or without free-flow oxygen may be indicated.

A2: Active and healthy newborn - meconium


Bi: Bag and mask ventilation indicated.

B2: Bag and mask ventilation indicated - meco-

nium present.

Cl: Chest compressions indicated.

C2: Chest compressions indicated - meconium


meconium present.


DI: Drugs indicated.

D2: Drugs indicated

The clinical information to be given to providers

being tested is highlighted (Fig. 3). They must talk about

what they are doing and

ask for appropriate


organized ap-

as they perform the scenario.

The scenarios provide an easy and

proach, facilitate informal testing and review for

providers and instructors,

and provide a method for cor-

recting errors. Providers

who successfully contend with

all eight of these scenarios

of neonatal resuscitation.

will have a sound knowledge

years to com-

Providers have 2

plete all eight scenarios.

Creating other scenarios with

the same format adds interest and fun to the program.

Post reminders in work areas

Signs posted in

work areas


'. -- -. a ; rewi., sE .I

Fig. 2: At the workstation all

equipment needed to prac-

tise neonatal resuscitation, including mannequins and

equipment for suction,

intubation and ventilation with


oxygen, is ready for use day and

I-E I 'AOUJT I1994

SAVE A NEWBORN - visit our NRP workstation")

act as a reminder. We hope that such signs nudge the

conscience betterthan written reminders, which are gen- erallyreceived begrudgingly.

This program has been in place for more than 1 year. Of the 30 providers registered 6 are physicians and 24 are registered nurses. During the first year of the pro- gram monthly rounds included a review of the NRP

megacode and, on seven occasions, a practice session.

The workstation has been used on 45 occasions to prac-

tise 130 scenarios. Of the 30 providers 18 (60%) have used all eight scenarios, 5 (17%) have used four to

seven, and 7 (23%) have used fewer than four. Four

(13%) have failed to maintain the minimum standard of one practice session every 6 months. Providers are given an outline of the program. The Provider Practice Record cards kept in the file-card box at the workstation furnish an easy method of evaluating

the use of the workstation. They also indicate the fre-

quency with which scenarios are used and by whom. The record cards include a column in which the provider can grade (on a scale from 0 to 5) his or her level of con- fidence after performing each scenario; this is intended to improve providers' perception of their skills. It is the

providers' responsibility to keep their cards up to date.

The date of practices, which scenarios have been per- formed and the date of attendance at megacode reviews are important not only for self-audit but also to indicate whether guidelines forreregistration have been met. The hospital-based instructors are responsible for

the skill maintenance program. Their enthusiasm is es- sential and serves as a motivating force. They are also


responsible for maintaining the workstation and auditing its use. If providers do not meet the guidelines, a verbal or written reminder may be necessary.


The establishment of active training programs for

neonatal resuscitation based on national guidelines has been recommended for all Ontario hospitals with obstet-

ricunits. At our hospital the NRP is widely known, and

neonatal resuscitation techniques are frequently prac- tised as a result of the practical reinforcement program.

There are no published reports of similar programs. The strengths of this program are its simplicity and conve- nience. The scenarios are easy to use, and the program is simple to monitor.

The main limitation of this program is that its suc-

cess depends primarily on the motivation of the provider because it is largely self-directed. This program provides a basis for skill maintenance for the NRP. We plan to evaluate the program in two re- gions of Ontario through a controlled study, endorsed by the Neonatal Resuscitation Program Advisory Group of the Heart and Stroke Foundation of Ontario. The knowl- edge and skills of NRP providers in level I, II and III hospitals will be tested before and after training. Simi- larly matched neonatal resuscitation providers will be as- signed to study and control groups; the study group will follow the practical program for skill maintenance, and the control group will have no structured program. The two groups will be retested 1 year later. If previous ob-


Healthy full term pregnancy. No anticipated concerns.

Cord tightly around the neck once at birth. Amniotic fluid Is clear

Note time of birth

Place infant on preheated radiant warmer

Dry amniotic fluid from body and head Remove wet linen from contact with infant

Position infant on flat surface with neck slightly extended

Suction mouth, then nose

Evaluate respirations (GASPING)

Slap foot, flick heel, or rub back briefly (optional) Evaluate respirations (APNEIC)

Indicate need for bag and mask ventilation Select bag, connect to 02 source capable of delivering 90-100% 02

Select correct size mask

Test bag

Check infant's position

Ventilate for 15-30 seconds

* Rate: 40-60 times per minute

* Pressure: a slight rise and fall of chest attained (normal 15-20 cm H20)

Evaluate if chest moving satisfactorily.

Rise? (YES)

Note: Apparatus should be kept in full working order

C N.R.P. - S.M.S., 1994


Fig. 3: A portion of one of the Neonatal Resuscitation Program-Skill Maintenance Scenarios.

AUGUST 1, 1994

CAN MED ASSOC J 1994;151 (3) *


servations hold true and if this program is successful, there should be a significant observed difference in skill levels between the two groups." This practical program provides a model for future studies that seek to improve the retention of skills in

those trained in resuscitation.

Material support was received from Alexandra Marine and

General Hospital, Goderich, Ont.

We thank Dr. Graham W. Chance, chairman, Division of

Neonatal-Perinatal Medicine, St. Joseph's Health Centre,

London, Ont., forhis review and suggestions.














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National Guidelines for Neonatal Resuscitation, Canadian Insti-

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Bloom RJ, Cropley C: Textbook of Neonatal Resuscitation, Amer-

ican Heart Association and American Academy of Pediatrics,

Dallas, 1990

Special Committee on Obstetrical Care, Canadian Medical Asso-

ciation: Obstetrics 1987: a report of the Canadian Medical Associ- ation on obstetrical care in Canada. Can Med Assoc J 1987; 136

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Chance GW: The national neonatal resuscitation program. Ont Med Rev 1993; 60 (3): 3 1-32

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of Health, 1991: 91-93


Bailey C, Kattwinkel J: Establishing a neonatal resuscitation team in community hospitals. Am J Perinatol 1993; 10: 294-298

Byrd FH: Early experience with the neonatal resuscitation pro-

gram. Neonatal Netw 1990; 9 (3): 35-39

Singhal N, McMillan DD, Lockyer JM et al: Attitudinal and re- source changes after a neonatal resuscitation training program. Neonatal Netw 1992; 11 (4): 37-40

McCulloch KM, Vidyasagar D: Assessing adherence to standards for neonatal resuscitation taught throughout the perinatal referral area. Pediatr Clin North Am 1993; 40: 431-438

Dunn S, Niday P, Watters NE et al: The provision and evaluation of a neonatal resuscitation program. J Contin Educ Nurs 1992; 23:


Moser DK, Coleman S: Recommendations for improving car- diopulmonary skills retention. Heart Lung 1992; 21: 372-380

13. Provider Renewal Megacode, American Heart Association and American Academy of Pediatrics, Dallas, 1993

304 CAN MED ASSOC J 1994; 151 (3)


continuedfrompage 296

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