Dr.Muhammad Saleem Laghari

Associate ProfessorDepartment of pediatrics

SZMC,RYK

Globally, about one quarter of all neonatal deaths are caused by birth asphyxia. Effective resuscitation at birth can prevent a large proportion of these deaths.

About 10% of all new born require some assistance to begin breathing just after delivery.

<1% of them require extensive resuscitation

Ref: BMC Public Health 2011 11(Suppl 3):S12

Basic Neonatal Resuscitation

1. Airway support

2. Breathing/ventilation

Advanced Neonatal Resuscitation

1. All the steps of basic neonatal resuscitation

2. Chest compression

3. Endotracheal intubation

4. Vascular cannulation

5. The use of drugs & fluids

Following scheme is recommended1.Preparation 2.Safety3.Shout for help4.Stimulate

1. Dry & rub the back with towel and cover the newborn

2. Gentle verbal / tactile stimuli in a neonate

5.Assess for breathing (crying/movement of chest)

6.Airway 1. Open 2. Clear

7. Reassess for breathing

8. BreathingInflation / ventilation / rescue breaths

9. Reassess for breathing and heart rate

10. Chest compressionsThumb/two finger technique

11. Reassess for breathing and heart rate

12. DrugsAdrenalineSodium bicarbonateDextroseVolume expenders

13. Reassess for breathing and heart rate

14. post-resuscitation care

Is the key to a successful outcome. Cooperation between obstetric and pediatric

staff is important. Review notes Communicate with the parents Wash hands & Use sterile gloves Thermoneutral environment Check for equipment

Resuscitation trolley/table Sterile linen Suction apparatus(Bulb/penguin/mechanical

sucker) Laryngoscope with straight blade #0, #1 Ambu bag and face mask Oral airways Oxygen with flow meter and tubing Endotracheal tubes # 2.5,3.0,3.5 & 4.0

Radiant warmer Stethoscope Adhesive tapes Syringes Butterfly needles Umbilical venous catheterization tray Umbilical catheter 3 and 5 fr Feeding tubes 5 fr. Disposable syringes

Epinephrine 1:10,000 Volume expanders i.e.

N/saline,Albumin5%, Ringer lactate, O-ve blood Sodium bicarbonate Dextrose water 10% Sterile water

1. Ensure your own as well as patient’s

safety

2. Look for the clues as to what may have

caused this emergency.

3. Wear gloves & do not perform direct

mouth to mouth breathing.

Do not hesitate to call for help

especially in high risk situations.

IN CASE OF NEWBORN: 1- Start the clock Timing to cut the cord Ascertain the duration of CPR 2- Dry the baby 3- Assess for breathing 4- Stimulate if not breathing 5- If baby starts breathing/ crying, no further help 6- if no response, then proceed furtherIN CASE OF NEONATE:

Stimulate the baby by gentle shaking of arms or rubbing of skin or by verbal stimuli

Assessment & reassessment is done after

every 30 seconds, and take no longer than 10

seconds.

Look: Chest movements

Listen: Breath sounds & heart sounds (auscultation)

Feel: Breaths and pulse

Open airway by Neutral position Chin lift Jaw thrust

Clear airway secretions, foreign body, vomits by

gentle suctioning of mouth first and then

nose.

In newborns after the airway is opened and cleared and the newborn is still not breathing, then it is necessary to aerate the lungs first with “inflation breaths” and then to continue with ‘ventilation breaths’

In case of a neonate inflation breaths are not required. Only ventilation breaths, called ‘rescue breaths’, are given.

Ventilation / rescue breaths are given at the rate 30/min.

Effective ventilation: Good chest movement Improvement of heart rate within 20-30 seconds

Chest compression is indicated

when heart rate <60/min despite of

adequate chest expansion with

ventilation, for 30 seconds.

Ventilation / rescue breaths need to be

continued alongside chest

compressions.

Technique Two thumbs technique Two fingers technique

At lower third sternum (between the xiphoid and a line draw between nipples)

Compression depth; approximately one third of the anterio-posterior diameter of chest

Duration of downward stroke of compression should be shorter than duration of release.

Don’t lift your thumbs or fingers off the chest between two compressions.

Chest compression must always be accompanied by positive pressure ventilation.

One ventilation interposed after every third compression (1:3).

Total of 30 breaths and 90 compression per minutes (120 events per minute)

One and two and three and breath and ……..

If heart rate not improving(below

60/min) despite adequate ventilation

and chest compressions for 30 seconds

then drugs should be considered.

Drug must be followed by 0.5-1.0 ml normal saline to clear the drug from catheter.

ADRENALINE: Preparation: 1:10,000 (1g/10,000ml,

100mg/l or 100µg/ml) Dose: 10µg/kg, 0.1ml-0.3 ml/kg (0.5-1.0

ml/kg via endotracheal tube) Route: Umbilical venous catheter or

endotracheal tube Rate: Rapidly

SODIUM BICARBONATE: Preparation: 4.2% (or 8.4% diluted 1:1) Dose: 1-2 mmol/kg (2-4ml/kg) Route: umbilical venous catheter Rate: 1mmol/kg/min

VOLUME EXPANDERS: Preparation:

Normal saline Ringer lactate O negative blood, cross matched with mother’s blood if

time permits (if prenatal diagnosis has suggested low fetal blood volume)

Dose: 10 ml/kg Route: Umbilical vein Rate: over 5-10 min

DEXTROSE Preparation: 10%

Dose: 250 mg/kg or 2.5 ml/kg

Route: umbilical vein

Reassess after every 30 seconds, and

take no longer than 10 seconds.

1. Ambu bagging not effective2. Prolonged ventilation is expected3. Suspected diaphragmatic hernia 4. Severe anatomical or functional upper

airway obstruction5. Need for high pressure to maintain

adequate oxygenation 6. Need for bronchial or tracheal suctioning

in meconium stained un-responsive baby7. Instability or high probability of any of

the above occurring before or during transport.

Different methods are used for its calculation

Formula 1:gestational age (weeks)/ 10 Formula 2:

Tube size Weight (g) Gestational age (wk)

2.5 < 1,000 < 28

3.0 1,000-2,000 28-34

3.5 2,000-3,000 34-38

3.5-4.0 >3,000 >38

Different methods are used for its calculation

Formula 1: baby’s weight (in kilograms) + 6

Formula 2: Length of tube according to weightWeight Depth of insertion

(in cm from upper lip)

1 7

2 8

3 9

4 10

1. The conditions suitable for a neonate should be maintained during the transfer.

2. Transferring team must be able to deal with any problems arising during transportation.

3. The receiving hospital should be informed before departure.

1. Monitor vital signs, glucose

2. Monitor events & complications

3. Care of endotracheal tube & vascular lines

4. Skin to skin contact with mother where

possible

5. Reassess the baby as required

6. Keep record

7. Communicate with parents

Neonatal Life SupportPreparation, Safety, Shout for help, Stimulate

Assess breathing

Not breathingStarts crying

No need of Resuscitation, Give to mother

Airway open & clear

Airway open & cleared ..... Reassess, baby not crying

5 Inflation / Rescue breaths

Reassess breathing

Reassess breathing

No chest movementGood chest movement

Ventilation/Rescue breaths

Repeat 5 inflation/rescue breathCheck chest movement

Good chest movement

Reassess HR

Reassess (every 30 sec)Regular breathing, good HR

Stop ventilation/Rescue breaths

Reassess, check airway

No chest movement

Consider ETT, Guedel airway

Good HR Slow HR

Chest compression

Reassess breathing

No good chest movement

Consider other possibilities

Chest compressions

Ventilation / Rescue breaths

Stop ventilation/rescue breaths

Reassess (after 30sec)

Reassess (every 30 sec)Regular breathing, good HR

Continue CC, ventilation / rescue breaths

Consider drugs

Reassess (every 30 sec)

Good HR Slow HR

Slow heart rate

Abandon resuscitation after 10 minutes of undetectable HR

Effective spontaneous breathing has been established as evidenced by: Increasing heart rate Spontaneous breathing

Senior staff and parents must be consulted before stopping positive pressure ventilation in cases of: Signs of established biological death The existence of DNR is established If there is no detectable heart rate for >10 min

despite adequate measures

Standard algorithm of ‘ABCD’ is used but

with minimal variation.

Attempts to aspirate meconium from nose & mouth of the unborn baby , while the head is still on the perineum is not recommended.

If at birth, a meconium stained baby has: Normal respiratory effort normal muscle tone heart rate grater than 100beats/min

Intervention:1. Use a bulb/penguin sucker or large bore suction

catheter to clear secretions from oropharynx and nose.

2. Do not intubate or do blind oropharyngeal suction.

If at birth, a meconium stained baby has: depressed respiration depressed muscle tone heart rate <100 beats/min Intervention:1. immediate endotracheal intubation and

direct suctioning of trachea is done without stimulation.

2.

Results from:Positive pressure ventilationLung malformation

If the chest is not expanding adequately despite proper positioning of airways , ambu-bagging, giving adequate pressure, placing Guedel airways and there is no improvement in heart rate, then this condition must be considered.

Removing obstruction of lung airways by external chest drainage of air through placement of needle or chest drain in pleural space.

In neonate it may results from:Hydrops fetalisChylothorax

Manage by chest drain insertion.

If Chest is not expanding adequately despite proper positioning of airways, ambu-baging, giving adequate pressure, placing Guedel airways and there is no improvement in heart rate.

Think CDH and confirm on examination.

Resuscitation with a bag and mask contraindicated.

Should have immediate endotracheal intubation and place a large orogastric catheter.

Babies are nasal breathers.

Should be considered where after proper airway opening and clearing maneuvers, good expansion of the chest cannot be obtained by ambu-baging.

Intervention:

Inserting a plastic oral airway will allow air to pass through mouth.

Developmental malformation of palate and oropharynx.

Small mandible results in critical narrowing of pharyngeal airway.

Tongue, posteriorly placed, falls back into pharynx and obstructs it just above larynx.

Maintain airway by positioning or use of plastic oral airway.

Get hypothermic earlier than term babies.

Fragile lungs and thus inability to breath effectively.

Maintain body temperature during resuscitation and use lower pressures for chest expansion.

Naloxone is no longer recommended as part of initial resuscitation in a delivery room.

Giving a narcotic antagonist is not the

correct first therapy for a baby who is not breathing.

The first corrective action is positive pressure ventilation.

Indications: 1. Continued respiratory depression after PPV has

restored a normal HR. 2. A history of maternal narcotic administration

during labour within 4 hours.

Naloxone : DOSE : 0.1 mg/kg I/V bolus.

Caution: Do Not give Naloxone to the newborn whose mother is suspected of being addicted to narcotics.