Newborn resuscitation

Birth Asphyxia Definition• When the baby does not initiate and sustain adequate

breathing at birth is called birth asphyxia. Magnitude

• Of the deaths 3.3 million neonatal deaths that occur worldwide, 23% death occur due to birth asphyxia alone (WHO and Save the Children 2011).

Fetal Hypoxia• Concentration of oxygen that is less than normal in

fetus causing lack of oxygen for body’s cell and organs to perform normal function is called fetal hypoxia.

Factors associated with birth asphyxia

1. Fetal distress

• Meconium stain

• Abnormal presentation

2. Prolonged or obstructed labor

3. Medical disease of mother

3. Complicated, traumatic or instrumental delivery

4. Severe maternal infections

5. Maternal sedation, analgesia or anesthesia

6. Antenatal or Intrapartam hemorrhage

7. Pre-term or post-term birth

8. Congenital anomalies

Who will need resuscitation?

• 80 - 90% of newborns require no assistance to

initiate breathing at birth.

• 10% require some assistance to begin breathing.

• 1% out of 10% requires extensive resuscitative

measures to survive.

Sometimes the need for resuscitation can be

predicted, but often it cannot, so... PREPARE FOR

RESUSCITATION AT EVERY BIRTH

 

Neonatal Resuscitation

Introduction:

We cannot tell which babies will have asphyxia

at birth. Therefore we must prepared to do

newborn resuscitation at all births. If a few

minute pass before the starts to breath, baby can

suffer from brain damage or die. Preparing for

resuscitation include, warming the resuscitation

area, preparing clean surface for the resuscitation

and collecting the equipments and supply.

Principles of Newborn Resuscitation

According to Pediatric working Group of the International Liaison Committee on Resuscitation (ILCOR) the principles of newborn resuscitation are as follows:

• Personal capable of initiating resuscitation should attend every delivery to establish a vigorous cry or regular respiration, to maintain a heart rate >100 beats per minute and achieve good color and tone.

Preparation of newborn resuscitation

We cannot predict which baby will have asphyxia at birth. Therefore, we must be prepared to do newborn resuscitation at all births. When certain preparations are not done the time will be lost.

Preparations for newborn resuscitation include:• Preparation of the resuscitation area• Preparation of personnel• Preparation of resuscitation equipment and

supplies.

Preparation of resuscitation area• Room – warm and free from wind.• At home: do the resuscitation near a fire or other

heat source.• In health facility use a heater or light bulb above

the baby of 100-150 watts, 45 cm from baby. Turn on before delivery so warm by delivery time. Use a flat place that is clean, warm dry and covered with a warm cloth.

• Heat should avoided near the resuscitation area if possible

• Use a warm cloth to wrap the baby.

Preparation of personnel• Ideally at every delivery one person whose primary

responsibility is the baby and who is capable of doing resuscitation.

• Anticipated high risk birth-at least 2 person with varying degree of resuscitation skills.

• If only one person to care for both mother and baby: if baby needs resuscitation , do resuscitation in a place where you can observe the mother’s perineum for bleeding or ask a family member to look for bleeding.

Preparation of resuscitation equipments and supplies

1. Suction equipment :- Mucus extractor-Dee Lee’s or gauze

electrical or manual suction with suction catheters

2. Ventilation equipment :-

• Self inflating ambu bag with reservoir

• Face mask size 1 for normal weight newborn baby and

size 0 for low birth weight i.e. <2.5 kg baby.

• Oxygen with flow meter and tubing if available

3. Gloves (do not need to be sterile)

4. Firm or flat surface radiant warmer

5. Stethoscope

6. Two pieces of gauze or clean cloth: one to dry the baby’s mouth and one to use as protective barrier if doing mouth to mouth and nose resuscitation.

7. Pre warmed linen – 4 pieces of clothes

8. A cap to cover the baby’s head.

9. A clock or watch with second hand

Be prepared to cut the cord immediately if the baby needs resuscitation.

STEPS FOR RESUSCITATION

I. Evaluation

II. Decision

III. Action

STEPS IN NEONATAL RESUSCITATIONStep I: On Initial Assessment ask the following:At birth ask or look:• Meconium not present?• Breathing or crying?• Good muscle tone?• Color pink?• Term gestation?

If the answer to each question is yes, proceed with routine immediate newborn care, If the answer to any one question is no, then go to the next step.

Step II: Initial Steps of Resuscitation

Initial assessment, initial steps and first evaluation should be completed

within 30 seconds

I. Dry, stimulate, warm

• Immediately after delivery, put the baby on the mother’s abdomen. Rub

the baby’s whole body firmly with the covering cloth (dry and

stimulate at the same time). This first step often helps the baby to start

breathing regularly.

• If it is clear the baby needs resuscitation, cut cord quickly and wrap

baby with warm cloth take baby to resuscitation place.

• Near a heat source, have 2 warm cloths or towels ready on the flat

surface you will use for resuscitation.

• Quickly wrap the baby in the clean, dry, warm cloth.

• Do not cover the face and chest so you can evaluate the baby’s

breathing, color and heart rate.

II. Position , clear airway (as necessary)• Put the wrapped baby on its back with slightly extended the head.• Suction baby. If no suction device is available, wipe out baby’s

mouth with a cloth/gauze.• Always suction the mouth first (5cm) and then the nose (3cm).• If suction tube is used, suction only while pulling tube out, Not

while putting it in.• Do not suction deep in the throat as it may cause the baby’s heart

to slow or the baby may stop breathing. In case of meconium-stained amniotic fluid.

• Suction baby’s mouth and pharynx first then the nose, after the head is delivered before birth of the bady.

• After birth, if the baby is not vigorous, do not stimulate. Quickly dry, position and suction baby (mouth and pharynx first then nose) in preparation to ventilate.

III. Reposition• If the baby still not crying or breathing reposition the baby with

slightly extended the head. Some time the head may be flexed which may difficult for breathing.

IV. Stimulate for breathing*• If the baby is not breathing, stimulation can be provided by

flicking the bottom of the foot or rubbing up and down the back with your hand over the cloth while the other persons proceed with resuscitation and assessment.

V. Give O2 (as necessary)

*Important: If meconium present, baby not vigorous - do not stimulate until after clearing airway.

Evaluate• Respiration• Heart rate• Color

Decide action based on evaluation• Give supportive care: if the baby breathing, heart rate is above

100, the baby is pink and has good tone baby may be given to mother for warmth, breast feeding and love. This baby will need frequent assessment of color, tone and vial signs for the first six hours. It should be done within first 30 seconds.

• Keep warm, stimulate and give oxygen (if available): If the baby is breathing, heart rate is above 100 but baby has cyanosis. This baby will need frequent assessment of color, tone and vital signs for the first six hours.

• If the baby is not breathing or is gasping or the heart rate <100, Start Ventilation to the baby.

STEP III: Ventilate the baby• Explain to the mother and family that the baby needs help and

that you will give that help.

I. Make sure baby has neck slightly extended

II. Put the mask on the baby. Cover the baby’s mouth and nose (If using bag and mask).

III. Ventilate the baby 2 times and look for a gentle rise and fall of the baby’s chest.

If the chest does not rise:• Position the head• Re-position the mask to correct seal.• Suction the mouth and nose if fluid or secretion are present.• Squeeze harder.

IV. Ventilation the baby 20-30 times in 30 seconds.

• Evaluate chest rise with each breath.

• When the baby begins to breathe normally, stop ventilating

V. Re assess the baby’s breathing, heart rate and color after each

30 seconds of ventilation.

• If the baby breaths spontaneously and his heart rate is >100 stop

resuscitation and continue to give supportive care.

If the baby is not breathing or is gasping or the heart rate is <100,

continue to ventilate 20-30 times in 30 seconds and then re-

evaluate.

VI. If the baby does not breathe spontaneously after 2-3 minutes

of resuscitation:

• Refer the baby with continue ventilation (if it is possible ask the

family to get ready for referral)

In the health post or home setting or facility level id the baby still is not breathing after 20 minutes of resuscitation, stop resuscitation.

STEP IV. Provide positive pressure ventilation with chest compression

• If heart rate < 60 bpm despite adequate ventilation:

Support circulation by starting chest compressions while continuing ventilation. Then, evaluate again

Chest Compression:

Almost all babies needing help at birth will respond to successful lung inflation with an increase in heart rate followed quickly by normal breathing. However, in some cases chest compression is necessary.

in babies, the most efficient method of delivering chest compression is to grip the chest in both hands in such a way that the two thumbs can press on the lower third of the sternum,

just below an imaginary line joining the nipples with the fingers over the spine at the back.

Compress the chest quickly and firmly, reducing the antero-posterior diameter of the chest by about one third.

The ratio of compressions to inflations in newborn resuscitation is 3:1.

Techniques

 I. Positioning of thumb and fingers for chest compression

● Apply pressure to lower third of sternum

● Avoid xiphoid process

II. Thumb technique

• Pressure must remain on sternum

III. Two finger technique• Tips of middle finger and index or ring finger of one hand

compress sternum

● Other hand supports back.

Chest compressions to move oxygenated blood from the lungs back to the heart. Allow enough time during the relaxation phase of each compression cycle for the heart to refill with blood . Ensure that the chest is inflating with each breath.

In a very few babies (less than one in every thousands births) inflation of the lungs and effective chest compression will not be sufficient to produce an effective circulation. In these circumstances drugs may be helpful.

Drugs

Drugs are needed rarely and only if there is no significant cardiac output despite effective lung inflation and chest compression.

The drugs used include adrenaline (1:10,000), occasionally sodium bicarbonate (ideally 4.2%) and dextrose (10%). They are best delivered via an umbilical venous catheter.

The recommended intravenous dose for adrenaline is 10 mcg kg-1 (0.1ml kg-1 of 1:10,000 solution). If this is not effective, a dose of up to 30 mcg kg-1(0.3 ml kg-1 if 1:10,000 solution) may be tried.

If the tracheal route is used, it must not interfere with ventilation or delay acquisition of intravenous access. The tracheal dose is thought to be between 50-100mcg kg-1.

The dose for sodium bicarbonate is between 1 and 2 mmol of bicarbonate kg-1 (2 to 4 ml of 4.2% bicarbonate solution).

The dose of dextrose recommended is 250 mg kg-1 (2.5 kg -1 of 10% dextrose).

Clear the airway

Open the airway by

• If the newborn is breathing but central cyanosis is present, give oxygen

Positioning the bag and mask on face

• Stimulation for breathing

Care After Successful Resuscitation

Counsel/advice mother and family• Talk with them and answer questions• Teach mother to check for breathing and warmth• Encourage breast feeding• Recognition of danger signs and how to seek help

Given Care• Check newborn hourly for the next hours at least (color,

breathing, feeding, temperature)• Observe baby for possible problems (respiratory distress

syndrome, pneumonia, aspiration, hypothermia, hypoglycemia, poor feeding/feeding intolerance)

• Give normal care for a newborn

Care after resuscitation with referral

Counsel/advice mother and family• Talk with them and answer questions.• Explain the need for special care of baby and that referral is

recommended. Ask them if they will go.• Advise mother to accompany baby if referred• Explain need to keep baby warm.• If baby can (depending on baby’s condition), encourage

breastfeeding during transport.• Give care

- Continue to stimulate/resuscitate the baby

- Continue to monitor breathing, color and keep

warm

- Arrange referral (follow referral guidelines

- If possible, the health worker should accompany during referral

• Records

- Prepare a referral note

- Prepare records for health facility and for family to take home• Do follow -up

Care after unsuccessful resuscitation• Counsel/advice mother and family

- Talk with them about the baby’s death and answer their questions

- Ask the mother and family if they want to see and hold the baby

- Explain to the mother and family about the mother’s care

- Rest, support and good diet

- Management of engorged breasts• Records

- Recording and notification of baby’s birth and death

- Completion of required medical records for the delivery• Do follow-up care of the mother