NEONATAL RESUSCITATIO

N PROGRAM

Dr Anagha Anand

Neonatal Resuscitation is intervention after a baby is born to help it breathe and to help its heart beat.

Of the 25 million infants born every year in India, 3-5% experience asphyxia at birth

Neonatal resuscitation skills are essential for all health care providers who are involved in the delivery of newborns

The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) have updated the resuscitation guidelines that are being propagated world wide through the NEONATAL RESUSCITATION PROGRAM (NRP)

Anticipation

A radiant heat source ready for use

All resuscitation equipments immediately available & in working order

At least 1 person skilled in neonatal resuscitation

Preparing for Resuscitation

Neonatal Resuscitation Supplies & Equipments

-Suction Equipment

Mechanical suction

Suction catheters 10,12, or 14 F

Meconium aspirator

-Bag and Mask Equipment

Neonatal resuscitation bags ( self limiting)

Face-masks ( for both term & preterm babies)

Oxygen with flow meter and tubing

-Intubation Equipment

Laryngoscope with straight blades no.0 (preterm)& no.1 (term)

Extra bulbs & batteries ( for laryngoscope)

Endotracheal tubes ( int diameter 2.5, 3, 3.5 & 4)

Medications

Epinephrine

Normal saline or Ringer Lactate

Naloxone hydrochloride

Miscellaneous

Linen, shoulder roll, gauze

Radiant warmer

Stethoscope

Syringes 1,2,5,10,20,50 ml

Feeding tube 6 F

Umbilical catheters 3.5, 5 F

Three way stopcocks

Gloves

Based primarily on 3 signs

Respiration

Heart rate

Color

Evaluation

Performed at 1min & again at 5 min after birth.

But resuscitation must be initiated bfr 1 min score is assigned

Not used to guide resuscitation

But can reflect how well the baby is responding to resuscitative efforts

Should be obtained every 5 min for upto 20 min, if the score is < 7

Term / Preterm ? Term: smooth transition Preterm : stiff, under-developed lungs,

insufficient muscle strength, can’t maintain temperature

Breathing/Crying ? Watch baby’s chest Gasping is a series of deep, single or

stacked inspirations that occur presence of hypoxia/ischemia. Treated as apnea.

Steps of Resuscitation

Good tone ? Term: flexed extremities Preterm/sick: flaccid/limp, extended extremities

Steps of Resuscitation

Provide warmth : Radiant warmer, don’t cover with blankets or towels.

Position head and clear airway if necessary Placed on her back or side with neck slightly

extended. Brings post pharynx, larynx & trachea in line Place a rolled blanket or towel under the

shoulders, elevating them 3/4th or 1 inch off the mattress.

Suction mouth first, then nose “M” before “N” To prevent aspiration of mouth contents If copious secretions present → head

should be turned to one side Never insert catheter too deep in mouth or

nose for suction → stimulation of post pharynx → vagal response → bradycardia or apnea

Max time limit – 15 sec

Steps of Resuscitation

Management of infant born through MSL

For non-vigorous babies initial steps are modified as:

Place under radiant warmer. Postpone drying & suctioning to prevent stimulation

Remove residual meconium in the mouth & post pharynx by suctioning under direct vision using laryngoscope

Intubate & suction out meconium from the lower airway

Dry, Stimulate and Reposition Stimulate : Flicking the soles/ drying & rubbing

the back

Steps of Resuscitation

Respirations

Heart rate: Best is auscultation, alternatively pulsations at base of cord is felt. Count for 6s and “x”10

Color- look at tongue, mucous membranes & trunk

Evaluation

Evaluation If baby has good breathing, HR>100/min, no

cyanosis →no additional intervention

If baby has laboured breathing or persistent cyanosis

-preterm babies → CPAP -term babies→ supplemental oxygen

If baby is apneic, has gasping breathing or HR < 100/min → PPV is needed

PPV – using a self-inflating bag & face mask

Positive pressure ventilation

Indications: Gasping/apnea HR < 100/min Persistent central cyanosis despite

administration of 100% free flow oxygen

Contraindications: Diaphragmatic hernia Non vigorous babies born through MSL, B & M

ventilation carried out only after tracheal suctioning

PPV

Appropriate SizesMask should Rest on Chin Cover Mouth& Nose

PPV

When n/l rise of chest is observed start ventilating.Ventilation should be carried out at a rate of 40-60 breaths per min, following a ‘squeeze, two, three’ sequence

PPV may cause abd distension as gas escapes into the stomach via oesophagus.

↓Presses on diaphragm & compromises the ventilation

So orogastric tube should be inserted & left open to decompress the abdomen

PPV continued more than several minutes

Rhythmic compression of the sternum →compress heart against spine → ↑se intrathoracic pressure → circulate blood to the vital organs

Always accompanied by BMV so that only oxygenated blood is circulated

Chest compressions

Indications : HR <60/min even after 30 sec of effective

PPV Once HR>60/min CC should be

discontinued.

Chest Compressions

Thumb technique: 2 thumbs depress the sternum, hands encircle the torso and the fingers support the spine. Preferred technique

2 – Finger technique: Tips of middle & index/ring finger of one hand compresses sternum, other hand supports the back.

Methods

A positive breath should follow every third chest compression

In 1 min 90 compressions & 30 breaths are administered

To determine the efficiency of CC, the carotid or femoral pulsations should be checked periodically

Rate

After 30 sec HR is checked:

HR<60 → CC should continue along with B & M ventilation. In addition medications have to be given

HR>60 → CC should be discontinued. BMV should be continued until the HR > 100/min & the infant is breathing spontaneously

Evaluation

Endotracheal Intubation

When tracheal suction is required ( non vigorous babies born through MSL)

When prolonged BMV is required

When BMV is ineffective

When diaphragmatic hernia is suspected

Indications

Laryngoscope with extra blades and bulbs Straight blades Term – 1 Preterm – 0

Endotracheal Intubation

ET tube – Vocal cord guide

Infant’s head should be in midline & neck slightly hyper extended.

Laryngoscope is held in left hand b/w thumb & the first three fingers, with the blade pointing away from oneself

Stand at the head end, the blade is introduced in the mouth & advanced to just beyond the base of tongue

Procedure

Position

Position Once the glottis & vocal cords are

visualized, he ET is introduced from the right side of the mouth

Its tip is inserted into the glottis until the vocal cord guide is at level of the glottis

1. Epinephrine (1:1000) Indication :HR< 60/min after 30 sec of effective PPV & CC. Effects: Inotropic, chronotropic, peripheral vasoconstrictor Dose: 0.1-0.3ml/kg Route: i.v, through umbilical vein, directly into tracheobronchial tree through ET

Medications

NS, RL Indication: Acute bleeding with hypovolemia Effects: increase intravascular volume, improves perfusion Dose: 10ml/kg Route: umbilical vein

Medications

Naloxone (0.4mg/ml) Indication: Respiratory depression with maternal history of narcotic use within 4 hr of birth Effects: Narcotic antagonist

Dose: 0.25ml/kg(0.1mg/kg) Route: i.v preferred, delayed onset of action with i.m use, administer only after restoring ventilation

Medications

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