Fetal & Neonatal ResuscitationPresented by : Dr. Meenal AggarwalModerator : Dr. Ramesh

Important to both Obstetrician and Anaesthesiologist

Role of Anaesthesiologist:

During regional analgesia

When urgent delivery required (Emg LSCS)

Preanaesthetic evaluation is important

Need to evaluate the fetus intrauterine

Fetal Resuscitation

Adaptive responses of fetus to hypoxia:

Decreased HR

Reduction in O2 consumption secondary to cessation

of non essential functions such as gross body

movements

Redistribution of C.O. to preferentially perfuse vital

organs

Switch to Anaerobic cellular metabolism

Fetal Heart Rate monitoring: (Nonreassuring FHR)

Continuous Electronic monitoring during labour

(using surface USG, using scalp electrodes)

Normal: 120-160 bpm (tachy: Premature, infection, mild

hypoxia, hyperthyroidism, drugs)

(Brady: post maturity, heart block, asphyxia)

Normal variability: 5-25 bpm (scalp electrodes)

(dec variability: fetal sleep, Drugs like meperidine, fetal

hypoxia & acidosis)

Decelerations in FHR:

1. Early decelerations: correspond to uterine contractions,

normal (10-40bpm) (vagal discharges)

2. Late decelerations: occur after peak of contraction, s/o

fetal compromise (dec O2 at chemoreceptor of SA node)

3. Variable decelerations: m.c. type, vary in timing and

configuration, umblical cord compression (> 30bpm),

Asphyxia if >60bpm, >60sec, >30min

Fetal scalp pH Monitoring:

Helps FHR in suggesting fetal status (pH>7.2, vigorous

neonate, <7.2 Often depressed neonate )

Scalp lactate, Fetal ST segment analysis

Adv: Caused reduction in neonatal seizures

Disadv: Inc rate of CS and instrumental deliveries

Fetal pulse oximetry:

Probe inserted through cervix, placed b/w fetal cheek

and uterine wall

Values: 28-71%, < 30: Abnormal

Persistently low values l/t fetal acidosis

Adv: Early detection of fetal acidosis

Disadv: Inc cost of medical care

No reduction in overall CS rate

A better method to evaluate fetal well being in labour is

still required

Fetal Monitoring Devices

Intra Uterine Resuscitation:

Measures in attempt to improve hypoxia & acidosis

• Improving O2 delivery

• Improving blood flow

Causes of reductions in fetal oxygenation:

Aorto caval compression

Uterine hyperstimulation

Umblical cord compression

Maternal hypoxemia

Maneuvers to increase oxygenation :

Left lateral or knee chest position

Discontinuation of oxytocin infusion

Supplemental maternal O2 administration

Crystalloid infusion

Tt hypotension: vasopressors

Tocolysis: s/c Terbutaline, nitroglycerine

Amnioinfusion

Recommendations of Intrapartum Resuscitation

Neonatal Resuscitation

Introduction

Q. Why is it necessary?

- In case of failure to make changes in CVS and Resp

system at birth

Q. When to prepare for it?

- Before delivery of baby

Delay can be DISASTROUS!!

For a successful resuscitation:

Early detection of potential problems

- FHR monitoring (<100 grossly dec. C.O.)

- Fetal Blood Gases & pH (acidosis if inadequate gas

exchange or in case of right to left shunt in heart or

lung)

Being prepared to treat them

Assessment of baby at birth:

Apgar score: useful guide to neonatal well being

1min score: correlates well with acidosis & survival

5min score: +/- predictor of neurological outcome

Not fail-proof

Even very acidotic neonates may have relatively

normal Apgar score at 1 and 5 min

(have normal HR & BP but are vasocontricted, have

pallor)

Apgar Score

H.R. < 100: Dec C.O. & tissue perfusion

Breathing: begins 30 sec after birth, sustained by 90 sec, N: 30-

60bpm

Apnea/bradypnea: severe acidosis, infection, maternal drugs

Tachypnea: hypoxemia, hypovolemia, acidosis, HMD, CNS

h’age, maternal narcotics, pulmonary edema

Dec muscle tone: asphyxia, maternal drugs, CNS damage,

Myasthenia gravis

Not moving with stimulation: hypoxia, acidosis, CNS damage

Color: blue at birth, pink with blue extremities at 60sec

Central cyanosis beyond 90 sec: hypoxia, CHD, meth Hb

Equipment

General Care of New born at birth:

Trained person to be available at delivery

As the head is delivered: suctioning of mouth first then nostrils

Body delivered: dry with a sterile towel

Cord clamped: once it stops pulsating, breathing innitiated

Neonate placed in a radiant warmer, bed tilted in slight

trendelenburg position

If child is depressed: cord clamped early & immediate

resuscitation started

HR (base of umblical cord), resp rate (visible, auscultation)

Bulb Suctioning

Bulb Suctioning

Resuscitation equipment:

Beds: Allow positioning of head below level of lungs

Infrared heater: (36-37 degree)

(if asphyxia 34-35 degree for brain protection)

Suction device (pressure not below -100mmHg)

Equipment for intubation: Laryngoscope straight blade 0 & 00

ETT’s 2.5, 3.0, 3.5mm, suction catheters

Ventilation systems: allowing rates of 150bpm, PEEP

Prevent over-inflation, measure inflation pressures

JR circuit

Blood gases & pH measurements

Arterial blood pressure

Pulse oximeter

Normal SaO2: 87%-95% (starts at 60%, by 10min 90%)

Normal PaO2: 55-70mm Hg

Umbilical arterial catheter

Tracheal suctioning:

Suctioning done before starting ventilation if thick meconium, or

major vaginal bleed has occurred

If meconium present, pharynx and mouth suctioned as soon as

head is delivered

Suction applied to ETT and ETT withdrawn while suctioning,

laryngoscope left in place, tube reinserted

O2 continuously blowing over face of neonate

Monitor HR

Suctioning of stomach (may regurgitate and aspirate later)

If Apgar 9 or 10, tracheal suction not required (even if mec.)

Nasal Suctioning

Pulmonary Resuscitation:

If H.R. < 100 bpm & SaO2 <85%, consider intubation

IPPV at 30-60 bpm, start with room air (titrate with SpO2)

Hold every 5th breath for 2 sec, PEEP 3-5cm H2O

Avoid excessive pressures

Tracheal Intubation:

Head in neutral or sniffing position

ETT: 2.5 mm for <1.5 kg, 3.0 for 1.5-2.5 kg, 3.5 for >2.5 kg

Distance: 7,8,9,10 cm for 1,2,3,4 kg infant

Capnography: ?reliable (small VT, Low pulm bloodflow)

Positioning of Baby

Placement of Mask

Adequacy of ventilation:

B/L breath sounds: misleading (can be transmitted within

small chest)

Equal chest rise

Becomes pink, initiates breathing, Normal HR

P insp : < 25cm H2O, if stiff lung higher pressure required

(Pulmonary edema, meconium aspiration, diaphragmatic

hernia)

RR: 150-200 bpm, P insp: 15-20cm H2O

If PaO2 > 70-80mmHg or SaO2 > 94%, Dec FiO2

Monitor HR (hypoxic, prone to arrhythmia during intubation)

Bag & Mask Ventilation

Surfactant Administration:

Reduced incidence of HMD, Deaths, Interstitial emphysema

Dose: 5ml/kg into trachea at or shortly after birth

Briefly reduces saturation, then rises rapidly

Need to decrease inflation pressures (as compliance

improves)

Often supported with nasal CPAP (avoids intubation)

Volume Resuscitation:

If condition doesn’t improve with ventilation,O2 & stimulation

Umbilical A. catheter (ABG & volume expansion)

Correction of acidosis:

For Respiratory acidosis: Mechanical ventilation

For Metabolic acidosis: NaHCO3 (only if ventilation is

adequate or else CO2 retention occurs), THAM (Dec CO2)

If Apgar =< 2 at 2min or =<5 at 5 min, give NaHCO3

2meq/kg, while ventilation continues

If pH< 7.00, PaCO2 < 35mmHg, correct 1/4th base deficit

If pH > 7.10, Continue ventilation, delay HCO3

If pH decreases or unchanged, correct 1/4th of base deficit,

keep ventilating

Cause of metabolic acidosis: Poor tissue perfusion (hypovolemia,

heart failure)

pH < 7.00, may induce cardiac failure

Hypoglycemia may cause Heart failure (so monitor RBS during

resuscitation)

Expansion of intravascular volume:

Hypovolemia (if cord clamped early, intrauterine asphyxia,

placental abruption)

Detection of hypovolemia:

Arterial BP

Physical examination (skin color, capillary refill time, pulse

volume, extremity temperature)

CVP (2-8cm H2O)

Tt of hypovolemia:

Crystalloids, Blood (Rh –ve O Gp), Albumin

Usually 10-20ml/kg volume adequate (may be even 50% of

blood vol)

Avoid overexpansion, l/t Systemic HTN & I.C.bleed (in preterm)

Hypoglycemia, Hypo Ca, Hyper Mg (Ca gluconate)

Cardiac massage: Ratio: 3:1 (Compression: ventilation)

If HR at 1min < 80 bpm despite ventilation & stimulation,

intubation done & closed chest massage started

2 methods: 2 finger, 2 thumb techniques

Depth: 2-2.5cm

Rate: 120 times/min

Not to interrupt ventilation during chest compression

Effectiveness: ABG, Arterial BP, Pupils (should be midposition

or constricted)

If cardiac origion known, ratio 15:2

Methods of giving chest compressions

Drugs to be given in minimum volume of fluid (to prevent hypervolemia)

Post- Resuscitation care:

Temperature (36.5-37.5 degree C)

Therapeutic hypothermia: for babies with evolving moderate to

severe hypoxic-ischemic encephalopathy

Oxygenation (SaO2)

CO2: 35-45mm Hg

Blood sugar (70-100mg%), 2ml/kg D10 bolus f/b 6-8ml/kg/min

Tt in neonatal intensive care facilities

Thank You