so this is a summative neonatal OSCE for year three student midwives I will be
taking the role of the Assessor and Jo will be taking the role of the student
midwife we will be running through a scenario and demonstrating a full
resuscitation technique for a baby
Jo welcome to your newborn life support summative OSCE for the purposes of the
scenario I'd like you to assume that all your equipment is checked and working
correctly I'm going to read you a scenario and then I would like you to
demonstrate to me how you are going to resuscitate this baby okay
okay are you ready all ready so Jo a spontaneous normal birth of a baby on
labour ward there have been no antenatal complications at birth
the Midwife is concerned with the condition of the baby the cord is
clamped and cut and the baby is handed to you the baby is blue floppy and not
breathing okay all right I'm going to start the
clock okay so first thing I'm going to do is I'm going to call for help so I'm
going to pull my emergency buzzer and I want somebody to call me the double
2 double 2 number so that I can have a neonatal team and also the midwifery
coordinator as well and then I'm going to make sure that I thoroughly dry this
baby and then I'm going to get rid of the wet towel that the baby is lying on and I'm going to put
the baby onto a nice dry towel I'm going to wrap the baby up to stop it from getting
cold and then I'm going to assess the baby so the color? the baby is blue and
what's the baby's tone? the baby is floppy, okay so I'm going to check the
baby's heart rate and then I would tap it out. Okay the heart rate is very slow
okay and is the baby breathing? Baby's not breathing. okay right so I want to
then put the baby's head into the neutral position to see, has that made
any difference? There's been no change. okay right so I know I need to give this
baby some inflation breaths so I'm going to size the
baby's mask, so I'm going to check to see, that looks like a good fit so I'm going
to place that on there and then I'm going to give the baby five inflation breaths
head in a neutral position so I'm going to use my C and E shape so I'm
going to give five inflation breaths which lasts two to three seconds each so
1 2 3 off, 2 2 3 off, 3 2 3 off, 4 2 3 off, 5 2 3 off. So I'm going to reassess the baby
now and what's the baby's color tone breathing and heart rate and did I see
any chest movement? So although you may have seen chest movement for the
purposes of this scenario there was no chest movement. The baby is still blue
floppy and not breathing the heart rate is still very slow. OK get the stethoscope.
Right so what I'm going to do now then is, I could use a different airway position but have
I got any help yet? No your help is not arrived yet. Ok so what I'm going to do
is then just check that neutral position is right and then I'm going to
reattempt and give 5 inflation breaths again, 1 2 3 off
2 2 3 off, 3 2 3 off, 4 2 3 off, 5 2 3 off. So I need to reassess the baby again now so
color tone breathing I also need to check the baby's heart rate? Ok so the
baby is still blue the baby is not breathing the heart rate is still very
slow. Did I see any chest movement? You saw chest movement. Ok all right that's
great so I'm seeing some chest movement so I now just need to confirm then so the
baby's still blue and floppy and it's not breathing and it's got a very slow
heart rate but I did see chest movement so now I'm going to move on and give 30
seconds of ventilation breaths so I'm going to roll the mask back over, hold the face
mask onto the baby's face the ventilation breaths are shorter they
last for 1 to 2 seconds and I'm going to do this for 30 seconds, 1 second on, 1
second off, 1 second on, 1 second off. so that's 30 seconds. Ok so after 30
seconds of ventilation breaths then I really need to assess the baby again so
I'm going to ask you what is the color tone breathing and heart rate of the
baby and did I see any chest movements? Okay so the baby is still blue floppy
and the baby is not breathing the heart rate is still very slow
you did see chest rise and your help has now arrived
oh that's great so because we now have got five successful inflation breaths into
the baby and 30 seconds of successful ventilation breaths in the baby the
baby's heart rate is still very slow so we need to give chest compressions and
so could you help me please? Yes so for purposes of this I will
manage your baby's airway. Ok thank you so for my chest compressions I'm going
to use the encircling technique so I'm going to put my thumbs on top of the
baby's sternum just below the nipple line one on top of each other and I'm
going to compress by about a third and I need to do a ratio of 3 compressions if
you could do one ventilation. Ok 1 2 3, 1, 2 2 3, 1, we're going to do
this for 30 seconds before I reassess the baby, 2 2 3
3 2 3 assume that's now 30 seconds. Right so 30 seconds is up
So I'm just going to reassess the baby then, so what's the baby's colour tone
breathing and heart rate and did I see the chest move? So the baby is now
slightly pinker the baby is still floppy the heart rate is now normal. Okay.
But the baby is not breathing. Right okay so the baby's still not breathing so we
need to continue with ventilation breaths. Do you want me to continue the that? okay
I need to continue with ventilation breaths and I also need to do this for
30 seconds before I reassess the baby, I need to make sure that senior help
is on its way. Okay so you've now done ventilation breaths
for 30 seconds Jo okay so we're going to stop the scenario there. Okay
so I'm now going to demonstrate to my considerations so I'm going to
demonstrate a single and a double person jaw thrust if that's okay, so my single
person jaw thrust then, I've got my bag valve mask ready so I'm going to
splint the head, thumbs on the cheek bones I'm going to use my middle finger to
lift up the baby's jaw, roll the mask back over the nose and mouth and then
I'm going to give my inflation breaths in that position. My double person jaw thrust, if you
could help me, I would splint head, thumbs on the cheek bones use my index
fingers to lift up the baby's jaw and then if you could roll the mask over the
baby's nose and mouth, I would hold on there and could you give inflation
breaths of two to three seconds and five in total? Thank you
So other considerations then I need to make sure that I maintain my
professional conduct throughout I need to ensure that the resuscitation drugs
and equipment are available for the neonate I need to make sure that we
assess the cord ph's so I need to ask someone to take those for me
while we are resuscitating the baby, I need to make sure that there are
identification labels ready to attach to the baby should the baby need to be
transferred to the neonatal intensive care unit, there's going to have to be
ensure appropriate communication with the parents and that's during the
resuscitation but also after so it's important that duty of candor is
acknowledged we need to make sure that there is effective communication with
the multi professional team so looking at communication strategies for that
important to keep timely record-keeping ensuring that the health and safety is
taken into consideration so that's useful personal protective
equipment from ourselves also maintaining a safe environment for the
team as well, we need to make sure that risk management is attended to so an
incident form will need to take place afterwards and it's important to also
make sure the professional midwifery advocate has been informed for support
of the professionals. Ethical considerations that need to be taken
into account is to have an acknowledgement that there may be a time
limit for resuscitation of a baby and also to acknowledge that there may be
some consent implications as well. Okay thank you Jo that now concludes your
newborn life-support OSCE
so for the initial assessment of the baby it's really important that the baby
is dried thoroughly
the baby then needs to be taken off the wet towel which is really important to
do and then placed on a dry towel
to keep warm. It's important then to assess the baby's colour to assess the
baby's tone to check to see if whether they've got good tone or whether their
floppy and it's also important to check the baby's heart rate and whether
they're breathing or not. So checking the baby's heart rate it's important to use
a stethoscope
so I have an adult's stethoscope here but a newborn one is also appropriate
so I'm going to place the stethoscope on the baby's chest and I'm going to listen
and I'm going to tap out the baby's heart rate we're going to note whether
the baby's heart rate is actually present whether it's very slow that is
below 60 or whether it's actually slow which is below 100 or whether it's normal
i.e. above 100
when sizing a baby's facemask it's really important that the baby's head is
in the neutral position. We've got three different types of face masks here
I'm going to check to see which one fits the baby's face appropriately. Let's
start off by dropping the facemask into the cleft of the baby's chin and rolling
it over the baby's nose and mouth. As you can see from this one
the mask is actually too small. Check again, into the cleft of the chin rolling
over the baby's nose and mouth, as you can see this one is too big because it
goes back to into the baby's eye area
the third one I'm going to check and that's probably the most appropriate fit
for this baby it's really important at that point you take it off the baby's
face in order to place it onto your equipment
and then once it's been placed on properly
we would then correctly apply it to the baby's face, again rolling it over. It's
really important next to hold the mask on appropriately so we're going to use a
C-shape to hold the mask down onto the baby's face and then
we've got these three fingers here which are shaped in an E which we hold on to
the baby's chin
the slight chin lift up into the mask, and this is how then I'm going to
deliver my air to the baby
it's very important that you squeeze the bag very slowly remember what you're
trying to do and understand the physiology of trying to inflate the
baby's lungs so it's very important not to squeeze the mask too hard because
you can cause damage to the baby's chest
so I'm now going to demonstrate the jaw thrust. A single person first and then
a double person jaw thrust
so we've got the bag valve mask and that's all been sized correctly so going to splint the head, thumbs
onto the cheekbones to steady and then I'm going to jaw up
and then I'm going to roll the mask over the face of the baby look putting my two fingers on
like that and then I'm going to continue with my inflation breaths. So that's version
one
two persons jaw thrust. So I'm going to splint the head, thumbs on the baby's
cheekbones I'm going to keep my index fingers free
because this is version one and going to lift the jaw up into the air, you roll the
mask onto the baby's nose and mouth and I'm going to lift my fingers up into the
to C shapes and then you can continue with inflation breaths. So version two of
the two-person door thrust would be where I splint the baby's head, thumbs on
the baby's cheek bones, I'm going to use my index fingers to lift the baby's jaw up
you roll the mask over the baby's nose and mouth and then I'm gonna bring my
thumbs up comfortably to hold the baby's head in position while you give your
inflation breaths. Position of hands when baby's head is in neutral position it's
all about the hands thumbs and fingers
picture demonstrates physiology of jaw thrust position note the mannequin's face
covering removed to clearly display the jaw
masks in position to show version one of two person jaw thrust using two C shaped
thumb and fingers seen from above
mask in position to show version one of two person jaw thrust
using two C-shaped thumb and fingers seen from side view
version two of two-person jaw thrust using thumbs on the mask and index
fingers for the jaw thrust
so we're going to demonstrate cardiac compressions, if you could take the
airway please Mandy? I'm going to use the encircling technique, I'm going to
find the nipples and go slightly below and then I place one thumb on top of
each other and I'm going to compress the chest by about a third of the depth and
then release because my recoil is equally important to allow the heart to
refill with blood and then you can do one ventilation please. 1 and I can
confirm I can feel the chest move and then we're going to do that in a ratio
of three compressions to one breath so 1 2 3, 2 2 3,
3 2 3, I need to do this for 30 seconds before we reassess
so the second technique of chest compressions is using the two-finger technique and this
is if you can't manage the encircling technique. So Mandy if you could take
the airway I'm going to place my two fingers in the same place just below the
baby's nipple line on the sternum and I need to compress in a nice straight line
downwards by a third. So it's
1 2 3, 2 2 3, 3 2 3, 4 2 3 and once again that would be four thirty seconds before
we would reassess