Neonatal Resuscitation

DR. EKHLAS ALI

Neonatal resuscitation

10% neonates require some assistance at birth.

1% neonates need extensive resuscitative measures.

Asphyxia accounts for 20-25% newborn deaths.

How does a baby receive oxygen before birth?

Oxygen diffuses across placenta from mother’s blood to baby’s blood.

Lungs receive very little blood.

Alveoli are fluid filled rather than air.

After birth

•Fluid in the alveoli is absorbed

Alveoli

• Expand

• Get filled with air (O2)

1.

After birth

Umbilical arteries and veins are clamped

Sudden increase in systemic blood pressure

2.

Pulmonary vessels dilate, causing increased blood flow to lungs

3.

Apgar score

Calculated at 1 & 5 min after birth

Consequences of interrupted transition

The compromised baby may exhibit 1 or more of the following clinical findings:

1. Low muscle tone

2. Respiratory depression (apnea / gasping)

3. Bradycardia

4. Cyanosis

Antepartum Risks

Maternal diabetesChronic maternal illness Cardiovascular Thyroid Neurological Pulmonary renal

Pre eclampsiaMaternal infectionPolyhydramniosOligohydramnios

Premature rupture of membranesIUGR/pretermFetal malformationMaternal substance abuseNo antenatal carePost term gestationMultiple gestationAnaemiaAge <16 or > 35

Intrapartum Risks

Emergency CSInstrumental deliveryAbnormal positionPremature labourPrecipitous labourChorioamnionitisProlonged rupture of membranesProlonged labour > 24 hrsProlonged 2nd stage of labour

Fetal bradycardiaNon-reassuring fetal heart rate patternGeneral anaesthesiaNarcotics administered within 4 hours of deliveryMeconium stained liquorProlapsed cordAbruptio placentaePlacenta previa

Fetal asphyxia

Primary apnoea Apnoeic Blue Heart rate Resuscitate easily

Secondary apnoeic White, floppy Heart rate Require active resuscitation

Equipment Needed for Resuscitation

Radiant warmer

Warm towel and blankets

Resuscitation bag and mask Self inflating bag Anaesthetic bag

Endotracheal tubes

Laryngoscope

Stethoscope

Oxygen source and tubing

Suction source and tubing

Drugs and fluids

Syringes, needles, cannulae, IV lines

+/-Umbilical lines

Equipment Needed

Overhead radiant warmer

Normal Delivery Procedures

Place under warmer and towel dryUse bulb syringe to clear mouth, then noseTactile stimulation if not breathing yet Auscultate heart and lungs & assess colorFree flow O2 as needed

Steps in Resuscitation

Warmth and stimulation and assessment for the 1st 30 seconds Use warm cloth Replace when wet Rapidly assess

Tone Colour Respiratory effort

Steps in Resuscitation - ABCDE

Airway Clear airway if required Removal of secretions if present

Suction mouth and nose DO NOT SUCTION IF AIRWAY IS CLEAR

Positioning Supine or lateral Head in neutral or slightly extended position

Neonatal Position for Opening the Airway – ‘neutral position’

Incorrect: Neck Hyperextension

Incorrect: Neck Under Extended

Correct: Neck Slightly Extended

Head flexed by large occiput

Head in neutral or ‘sniffing’ position

Acceptable methods of stimulation

Steps in Resuscitation - ABCDE

Breathing

Assessment of respiratory effort and colour

Indications for oxygen administration Cyanosis Respiratory distress Give free flowing oxygen 5L/min

Breathing: Indications for positive pressure ventilation

Apnoea

Gasping respiration

HR < 100 bpm

Persistent central cyanosis despite 100% O2

40-60 breaths/min

No response

Watch for slight rise of chestRate is 40-60

Indications of endo-tracheal Intubation

Prolonged positive-pressure ventilation (PPV) required

Bag & mask ineffective: Inadequate chest expansion

If chest compressions required: Intubation may facilitate

coordination and efficiency of ventilation

Tracheal suction required

Steps in Resuscitation - ABCDE

Circulation

Assessment of heart rate and response to previous measures Umbilical arteries Apex beat Auscultation

Chest Compressions

HR < 60 bpm despite adequate vent with 100% O2 for 30 seconds

2 techniques 2 thumb (preferred) 2 finger 3:1 ratio 1/3 of AP diameter

TechniquePosition of Hands on Chest

Thumb technique

( preferred )

TechniquePosition of Hands on Chest

Two finger technique

Chest (cardiac) compressions

“Two-thumb” technique is usually preferred

Steps in resuscitation - ABCDE

Drugs

Adrenaline

Volume Expanders

Naloxone

Epinephrine Indications

HR <60 /min after PPV & CC for 30 secs

Route of administration

Intravenous

Endotracheal route (when I.V line is not secured ) Recommended

Conc. – 1:10,000 (0.1mg/ml)

Route – UVC/ IV

Dose – 0.01-0.03 mg/kg , (0.05-0.1mg/kg E.T)

Rate of admn. – as rapidly as possible

Repeat dose if no response after 60 seconds Now, intravenous route is first preferred route

Volume ExpanderVolume Expander Indications:

Poor response to other resuscitative measures

Evidence of blood loss or suspected ( pale skin, poor perfusion, weak pulse)

Crystalloid Normal Saline Ringer Lactate or O-negative blood cross-matched with mother’s blood

Dose – 10ml/kgRoute – Umbilical veinPreparation – large syringeRate of administration – 5-10 min

Naloxone Narcotic antagonistNaloxone Narcotic antagonist

Indications :

A history of maternal narcotic administration within the

past 4 hours

Severe respiratory depression is present after PPV has

restored a normal HR & color

Recommended

Concentration: 1.0 mg/ml

Route: Intravenous

Dose: 0.1 mg/kg

Meconium present and baby vigorous

Vigorous Baby- Strong respiratory efforts,

Good muscle tone,

Heart rate > 100 bpm

suction catheter or bulb syringe for suction of mouth or nose

ET suction not required

Meconium present and baby not vigorous

Insert laryngoscope

Clear mouth and posterior pharynx

Insert endotracheal tube into the trachea

Attach the ET to suction source

Apply suction as ET is slowly withdrawn

Repeat as necessary until no meconium or heart

rate indicates further resuscitation

What to do if still no improvement?What to do if still no improvement? If no improvement seen despite all efforts

Ensure adequate ventilation, chest compressions, drug delivery

If still HR < 60/min, consider Airway malformation Lung problems Pneumothorax Diaphragmatic hernia Cong. Heart disease

If HR absent or no progress Ethical considerations of when to D/C Resuscitation

Discontinuing Resuscitative Effort

Stop resuscitation, if HR remains undetectable for 10 - 15 min

Also take into consideration factors such as presumed etiology of the arrest, gestation of the baby, presence or absence of complications

Guidelines for Neonatal Resuscitation