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Neonatal Resuscitation
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Neonatal Resuscitation/ Helping Babies Breathe
(HBB)
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Neonatal Resuscitation
• Of the 130 million babies born each year, about 4 million die in the first 4 weeks of life. A quarter of these deaths are due to asphyxia.
• It is estimated that an additional million develop problems such as cerebral palsy and other disabilities.
World Health Report 200521/04/2020 4
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Inverted Pyramid
of Neonatal Resuscitation
Medications
Chest
Compressions
Positive-Pressure
Ventilation
Initial Steps: Drying,
Warmth, Clearing the
Airway, Stimulation
Assessment at Birth and
Simple Newborn Care
All infants
Some infants
Few infants
Wall, Lee, Niermeyer et al. IJGO 2009
136 million
babies born
Approx 10
million babies
Approx 6
million babies
< 1.4 million
babies
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Old resuscitation methods
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Since the second quarter of the twentieth century, the basis for resuscitation of the newborn has changed. With increased knowledge, many earlier methods which depended on uncomfortable stimuli to initiate the onset of breathing like
intermittent traction on the tongue,
spanking the feet or buttocks,
dilation of the anal sphincter
alternate immersion of the infant in hot and cold water have been found to be injurious and wasteful of precious time which can be used more effectively.2,7-9
Bloxsom positive pressure oxygen-air lock,
Historical aspects
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Body rocking Brain injury, intracranial bleed
Intragastric oxygen gastric distension, splinting
of diaphragm
Hyperbaric oxygen: oxygen toxicity
Analeptic drugs severe hypotension, CBF
Electrical stimulation of the phrenic nerve
Hypothermia which were once thought to be effective
have also been discarded when controlled animal
experiments were undertaken.
Some Recommendations for
Resuscitation (1850-1950)
•Rectal stimulation
(stretching of the
rectum with
a corn cob)
•Tobacco smoke
blown into the rectum
•Immersion into cold water(+ alternating
with warm water)21/04/2020 9
Some Recommendations for
Resuscitation (1850-1950)
•Intragastric oxygen
•Rhythmic traction of the tongue
•Rubbing, slapping, and pinching
•Raising and lowering of the arms, while an assistant compresses the chest
O2
O2
O2
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Current observed dangerous neonatal resuscitation practices1
Methylated spirit
Intramuscular Vitamin K
Intramuscular Aminophylline
Intramuscular Steroids (Hydrocortisone)
Analeptics (Doxapram, Nikethamide{Couramine})
Hot water stimulations
Cold water immersion
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1. Adebami et al. Neonatal resuscitation at the Nigerian Primary and Secondary Health institutions: An
evaluation of ongoing practices.Nig J Paediatr 2007;34:8-13
Methylated Spirit Instilled into the nostrils, rubbed on the skin for tactile stimulation or instilled
into a swab placed under the nostrils of the baby. is a denatured absolute ethyl alcohol commonly used in the hospital for
preparation of the skin, wound dressing and as a cleaning agent. It consists of 2 percent methanol, less than 6.2 percent water and over 90
percent of ethanol It is known to be irritant to the eyes, mucous membranes, upper respiratory
tract and skin. It causes :
central nervous system depression, convulsions, ataxia and coma. pulmonary damage, alteration in gastric secretion, nausea, vomiting and other gastrointestinal
changes.
However, no known study has documented the direct immediate and long term effect of its use on newborns.
WASTE TIME FOR EFFECTIVE ACTION AND CAUSES DAMAGE
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Parenteral Aminophyline Aminophylline is a combination of theophylline with
ethylenediamine.
It is a xanthine derivative.
It improves contraction of the diaphragm
Theophylline is a CNS stimulant therefore dangerous to an ischaemic or hypoxic brain
Can precipitate convulsions, bleeding
Gastric bleeding.
WASTE TIME AND VERY DANGEROUS!!!
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Parenteral Steroids Steroids have not been shown to be of any benefit
in birth asphyxia,
Predispose the baby to abnormal bleeding, increased intracranial pressure, pseudotumour cerbri and increased mortality. Animal studies have also shown increased mortality and lack of any improvement in the extent of neurological injury just as has been similarly found in human adult patients with head trauma, stroke and hypoxic ischaemic encephalopathy (HIE).2
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2. Levene-MI; Sands-C; Grindulis-H; Moore-JR. Comparison of two methods of predicting
outcome in perinatal asphyxia. Lancet 1986; 11: 67-9.
Hypothermia Hypothermia regulated to between 33oC and 34oC in
Full Term babies if initiated as soon as possible after delivery has been observed to reduce mortality and disability in babies with hypoxic ischaemic encephalopathy.2
However, extreme cooling and hypothermia are known to induce neonatal cold injury and result in grave consequences.3,4
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Respiratory Analeptics Drugs that stimulate CNS and respiration centre
Developed to treat CNS and respiratory depression
Reduces cerebral blood flow
Increased cerebral oxygen requirements
Reduces blood pressure and causes hypotension
Examples: Nikethamide (Couramine), Doxapram
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Consequences of Poor
Neonatal Resuscitation
• Increased Death
• Increased Disability
• Emotional & Financial Burden
• Family crises
• Poor utilization and confidence
in health facilities utilization
• Direct Community Costs
• Loss of Productivity21/04/2020 17
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Global Causes of Neonatal Death
UNICEF 2007Lee, Wall, Cousens et al. Int J Epidemiol (in press)
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Big Target of Helping Babies Breathe
Lawn JE et al. IJGO 2009; 107:S5
1 million “stillbirths” due to asphyxia
830,000 neonatal deaths due to asphyxia
Helping Babies Breathe®
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Helping Babies Breathe
Sustainability
• Simple and evidence-
based
• Low-cost and effective
• Easy to integrate with
other essential parts of
NB care
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Dawes Foetal and Neonatal Physiology. Year Book Medical Publishers Inc; 1968.
Pathophysiologic Cardio-Pulmonary
Consequences of Asphyxia
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Helping Babies Breathe®
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HBB: Action Plan
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Identify a helper and review the emergency plan
Prepare the area of delivery: Clean, Warm and well-lighted
Wash hands with Soap and water
Prepare an area for ventilation and check equipment:- +Gloves; +Sunction device;+ Ventilation (Bag and mask); +Cloths x2;
+Stethoscope; +Timer (Clock/Watch);
+Scissors; +Tiles; +Cap (Head covering;
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If meconium, sunction Mouth, then Nostrils (M before N)!
Then DRY THOROUGHLY!!!
Change wet cloth to dry
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Do Routine care◦ Keep Warm Skin to Skin on mother
◦ Cover baby with warm, dry cloth and a cap
◦ Postpone bathing baby and weighing
Check breathing
Cut cord
Encourage breastfeeding
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Routine Care• Clearing the airway if
meconium present
• Drying infant
• Recognize crying
• Keeping warm
• Cutting the umbilical cord
• Encouraging breastfeeding
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Clear Airways and Stimulate breathing◦ Keep warm by position skin-to-skin and cover with
cloth
◦ Position the head- extend the head slightly
◦ Clear the airway by removing secretions from mouth, then nose (M before N)
◦ Stimulate breathing_ rub the back once or twice
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Keep baby warm
Position the head
Clear the airway
Stimulate breathing
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Do Routine care◦ Keep Warm Skin to Skin on mother
◦ Cover baby with warm, dry cloth and a cap
◦ Postpone bathing baby and weighing
Check breathing
Encourage breastfeeding
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Cut the Cord immediately
BABY MUST BE VENTILATED IN THE FIRST MINUTE CALLED: “THE GOLDEN MINUTE”
A baby not breathing well means◦ Gasping with shallow, irregular, slow breathing
◦ Not breathing at all.
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The Golden Minute®
• Recognizing infant not
crying
• Positioning head
• Clearing the airway
• Stimulating
• Recognizing breathing
• Initiating ventilation by
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To Ventilate Place the baby on a clean, warm, dry area with good light. Stand at the baby’s head. Select the correct mask that covers the chin, mouth, and nose, but
not the eyes. Attach the mask to the ventilation bag. Position the head slightly extended, with the nose higher than the
forehead or chin. Support the chin with the middle finger. Move the jaw upward and
forward. Position the rim of the mask on the chin, and then place the mask
over the mouth and nose. Make a firm seal between the mask and face by pressing on the top
of the mask with the thumb and index finger while gently holding the chin up toward the mask.
Squeeze the bag to produce a gentle movement of the chest. Give 40 breaths per minute
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Baby Still NOT BREATHING OR CRYING! ie NOT GETTING RESULT!
Check your method!
If Baby still not breathing well: Use MR SOPA! M = Adjust Face mask R = Reposition head S = Suction mouth and nostrils O = Open mouth P = Increase the ventilating Pressure by squeezing the bag
more and a little faster A = Use Alternate airways: Laryngeal mask or
Endotracheal intubation CALL FOR HELP AND USE THE EMERGENCY PLAN
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Evaluate the Heart rate Feel the pulse in the umbilical cord where it attaches
to the baby’s abdomen.
If you cannot feel a pulse, listen over the left chest with a stethoscope and count the heartbeat.
Pause ventilation for several seconds in order to hear the heartbeat.
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A Baby still not breathing Refer for Advanced Care!
Maintain ventilation during transfer
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Welcome to :
ADVANCED CARE
This takes place in the hospital with
basic facilities for resuscitation
Maintain ventilation during transfer to the hospital for advanced care
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NRP Now
Textbook of Neonatal Resuscitation, 6th Edition, 201121/04/2020 55
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When bag and mask is not effective enough to improve oxygenation or SPO2◦ No clinical improvement
◦ No adequate Chest rise with bag and mask
◦ If Chest compression is needed, intubation provides better coordination with bag and mask ventilation
◦ To administer drug like Adrenaline, Sulfactant
When other Special conditions are present
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Adrenaline
Normal Saline or Ringers lactate
10% Dextrose in water
8.4% Sodium bicarbonate
10% Calcium gluconate
Ionotropes like Dopamine
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Every Baby CountsSo
Count Every Baby
THANK YOU
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