.tndian ~7, Pcdiatr, 46 : 174. 1979

R ES USCITATION OF A NEWBORN BABY AT BIRTH*

MF.HAaBAN Stroll

Arew Ddhi

Birth asphyxia is the commonest medical emergency among newborn babies and is one of the leading causes of perinatal mortal i ty in this country. Survivors are

known to manifest a variety of clinical problems during early neonatal life (Singh

and Kalra 1978) and late sequelae such as cerebral palsy and seizures with or without mental subnormality (Scott 1976). Most babies are able to achieve a perfect transi- tion from foetal to independent neonatal existence by virtue of prompt cardio-respi-

ratory adjustments but 5-10% of infants

may. experience difficulties in initiating breathing at birth. It is possible to increase perinatal survival and improve the quality of human life through prompt and adequate

management of the newborn at birth (Cross 1966, Behrman et el. 1969. Cockburn 1971, Ohosh and Kumari 1973 and Banclari 1975).

Phases o f r e s p i n t o ~ . y fa i lure

The observations on sequence of events of respiratory failure in experimental ani-

mals offer useful guidelines for management of the asphyxiated baby at birth. When a newborn mammal is enclosed in a box containing nitrogen or submerged under water soon after birth, it passes through a characteristic cardio-respiratory sequence of

*From the Depar tmen t of Paediatrics, Al l - India Inst i tute

of Medical Sciences, New Delhi--110016.

Received on September 21, 1978.

Reprints request to Prof. Meha~ban Singh, Director, Institute of G-:hild Health, Kabul, Afghanistan.

5"~ 12S

~ so <

0

t * , L__ d[ Z �9 I0 14 i l Z2 26

A C U T [ MINUT~-'$ A N O X I A

A - DYSPNEA B-PRIMARy A p ~ [ A

C - S P O N T A N E o u s O - TF'RMINAL APNF..A GASPS

Fig. !. Schemat i c presenta t ion o f sequence o f r

of respiratory failure in experimental animals.

events (Fig. 1). Initial strangulation and laboured breathing is tollowed by gasping

and ultimately cessation of breathing termed as primary apnoea. Thereafter , there are

spontaneous gasps. I f the animal stays i~ the hypoxic environment, the heart slows, blood pressure falls and the youngling lapses into terminal apnoea and dies unless ventF lated after tracheal intubation. However, following primary apnoea, wilen spontaneous gesps appear and the animal is removed from the hypoxic environment, he becomes

pink and normal without any active assistance. Therefore, any method of resuscitation, whether physical or chemical stimulation, insertion of parrot's beak into the baby's redtum, sprittkling of cold water over the baby's face, exposme into a hypelbaric oxygen chamber, etc. would

[~[tAltSAl~ -~INOI4JRESU$0"ITATION OF A NEXVBORN BAnV AT BIRTH

Weceed if employed during the phase of primary aprtoea. During terminal apnoea, itothtng short of tracheal intubation and assisted breathing would salvage the infant (Oupta and Tizard 1967).

IloW to differentiate betweeu primary ~erminal apnoea in clinical

practice ?

The above referred sequence of events 0f. respiratory failure are common to all mammals but the duration of various phases hwecies specific and often prolonged by sedatives and hypothermia. When faced with anapnoeic newborn baby at birth, it f$often difficult to decide whether the ~fant is in a stage of primary or terminal lp~Oea, but certain guidelines do help. ~ e n c e of any evidences of foetal hypoxia, Jtable or improving heart rate, apnoea preceded by an initial cry (especially Itmong cesarean born) and the fact that the baby first gasps before he becomes pink tre suggestive of primary apnoea. On the ether hand, prolonged foetal nypoxia, severe bradycardia and cardiovascular collapse and absence of cry at birth, favour the possibility of terminal apnoea. Suce a baby demands immediate ventilation follow-

175

ing tracheal intubation and the baby's colour wo,.tld first become pink before he starts having spontaneous breathing.

Resuscitation a le r t

The existence of certain high risk factors during pregnancy and labour serve to lore-warn and alert the labour room staff that they should be fully prepared to meet the challenge of an asphyxiated baby (Table 1). In these situations it is desirable that a senior resident or a physician who has bees adequately trained in the art of tracheal intubation should be available at the time of delivery. In addition to close watch over time honoured dinlcal para- meters of foetal distress, it is desirable that high-risk pregnancies are monitored during labour by newly available tech- niques such as the oxytocin challenge test and foetal blood sampling for acid base analysis (Beard and Simon 1971, Garud a al. 1969, Huch a al. 1977). At times a baby may manifest severe birth alphyxia without any predisposing warning signals, thus emphasizing the need that all deli- veries should preferably be attended by a pediatric resident to meet such exigencies.

Tab le 1. Conditions demanding resuscitation alert.

1. Foetal distress

2. Placental insufficiency, toxaemia, hypertension, postmaturity

3. Prematurity (immaturity)

~. Antepartum haemorrhage

5, Malpresentation, df~cult and abnormal or operative delivery

6. Rhesus isoimmunization

7. Twins

176 I*'DtAS jomts^L o~, vzmA~lcs

Tab le 2. Apgar scot'no ~,~t:,n.

Voi.. 46, N ~

0

1. Respiration Nil

2. Heart rate Nil

3. Tone Flaccid

4. Reflex response Nil

5. Colour Pale or blue

Score

S,ow

L l~ ~ ~ jJ~ l In between F l e ~

Grimace C ~

Peripheral cyanosis P i i t ' ~

A s s e s s m e n t o f i n f a n t ' s c o n d i t i o n at b i r t h

Most paediatrician~ are quite conver-

sam with the Apgar scoring system- (Table

2) for objective auessment of the condition

of the newborn baby at birth. A one-minute Apgar score usefully predicts the immediate

neonatal outcome of the baby. while a 5-minute or a later Apgar score is fairly

predictive of the future mental prognosis ofuw.h infants. However, if you carefu!!y scru:inize the various items of the Apgar scgring system, you would realize that re.-piratory effort and heart rate per se are critical determinates while muscle tone,

response to reflex stimulus ~nd colour are dependent upon the cardio-respiratory status of the baby.

In addition, there are several ~ limitations of the conventional A p g a ~ ing system. It ignores the time oi" the cry which is important to identify differentiate between primary and t e rmi t l~ l apnoea. The peripheral cyanos.is is a w ' a ' ~ a score of one, although a m a j o r i t ~ , ~ healthy normally breathing babies are n e v ~ totally pink at one minute. Tone response to reflex stimulus are depende~l~ upon gestational maturity. Lastly, c e n t r a | ~ blue and totally pale babies are s c o r ~ identical, although the latter are m u r more serious due to combined ca rd i0~ respiratory failure.

In view of inherent limitations of ~h~ Apgar scoring system, it is suggested thit~l an action oriented assessment as outline/$

in Table 3 should preferably be used which

T a b l e 3. Modified action oritnt,d assesJm,nt

1. Foetal distress

2. Pethidine

3. First cry

4. Respiration

5. Heart rate

Yes/No Duration

Yes/No Hours before birth

.. . . . . . . minutes after birth

Absent/Stow-irregular/crying

Absent/ / 100/ /> 100 per minute

~ j ~ A j B A N $1NOII - - RESUSCITATION

0fl'erl immediate therapeutic guidelines for ll~naging an asphyxiated baby at birth.

revised assessment system may also help

to differentiate between a baby with pri-

tlarY versus terminal apnoea.

~rlnclples of the care o f the newborn a t birth

After birth, once the baby is severed ~otn his mother, he must breathe imme- alately or should be assisted to breath because there are no stores of oxygen in the body. The infant is born wet, naked and

plrtially asphyxiated in a room whose tll~oerature is geared to the comfort of the

~t l ie r ra ther ' than the needs of the baby. ~l~ea-elore, the newborn at birth tends to 10se heat rapidly unless effectively dried, iglequately covered and kept warm. Life tllreatening congenital malformations must be suspected at birth by quick clinical Iczeening of the baby (Apgar 1969), because their prognosis is directly related to the time taken to diagnose them. Establishment of

breathing, maintenance of body tempera- tare and early diagnosis of major malforma- tions at birth, therefore, should override all other considerations of care.

R e s u s c i t a t i o n Kit

The care of the newly born at birth needs preparedness, vigilant observation and prompt action. The old concept of

masterly inactivity in the labour room has been replaced by a well rehearsed panic- free, calmly conducted activity with a *ease of urgency. The equipment needed

for resuscitation should be available in perfect working order. The kit must be checked by the staff nurse of every duty

shift and rechecked by the physician before

delivery. The laryngosccpe with an infant

OF A N E W B O R N BABY A T B I a T i l 177

straight blade is preferred. Its light source and batterie~ sholtid be in working order.

Endotrachea~ tubes with an internal diame-

ter of 2 5 mm and mounted with adapters should be available. The electrical points

and suction should be in working order. Press bulb or oral suction mucus trap must be available in case of electrical failure. The oxygen cylinder should be checked for its contents. Ambu bag and mask are extremely useful and handy to resuscitate

an apnoeic baby. In addition, the kit should include endotraeheal and ordinary suction catheter, plastic oral airway, syringes and needles, sterile bowl with cotton swabs, umbilical ties, 7.5~ sodium bicarbonate, co/ dextrose solution or dis- ,o /O

tilled water and neonatal nalorphine ( l .0mg of nalorphine per ml). The bassinet on

which the baby is to be received should be kept warm and provided with an overhead radiant heat source. Above all, the physician

must be an adept in the art of intubatlon which can be perfected by continued practice on the stillborn and dead neonates.

It is desirable *.hat equipment is main-

tained in a sterile condition and the baby is received with due aseptic precautions.

Resusc i ta t ion o f the baby

The cord should be clamped after the first breath or few seconds after the breath

rather than immediately except in babies with severe birth asphyxia, cord around the neck and rhesus iso-immunization. The

head should be kept low and the baby received on a flat surface (Plate 1, Fig 2). The suction of the oral cavity, oropharynx

and nose should be done immediately by employing gentle negative pressure of 5-10 cm of water. Excessive and forceful suction may lead to mucosal damage,

|7~ INDIAN JOURNAL OF PgDIATRIOll

bleeding and reflex bradycardia. MoJt of the babies would be crying htstily and

actively moving their limbs and nothing more needJ to be done. The baby should be drl,",l, covered and kept warm. Quick clinical screening for orifice count and

detection of life threatening congenital malformations it mandatory before the izffant it transferred. Most babies are

sterile at birth and efforts should be made to avoid their contact with microbes by enforcing due aseptic precautions which are

deplorably unsatisfactory in mo~t of the

labour rooms in this country.

M o d e r a t e b i r t h a s p h y x i a

The breathing in such infants is slow, irregular or gasping and may be associated with bradycardia or normal heart rate. The suction of the glottic area under direct vision is desirable to remove any thick plug of mucm, blood or meconium. Physical stimulation should be imparted by flicking

the soles. Oxygen with bag ~.nd mask should be adminis:ered after inserting an oral phatynyngeal airway. The neck should be slightly extended and the cricoid cartilage compressed to obliterate the esop- hagus while giving oxygen through a mask. Nalorphine 0.2 mglkg intravenously through the umbilical vein is indicated, if the mother has eeceived pethidine or morphine within

4 hour~ before delivery. Heart rate should be closely monitored during the re.,uscttation procedure. In case the heart rate further slows, the child should be ventilated after intubation.

S e v e r e b i r t h a s p h y x i a The severely asphyxiated baby is

apnoeic at one minute and may be furth&r subelataified on the basis of its cardiac

statua.

Vot.. 46, No..D

a) Heart rate 7: 100/minute

b) lh.art rate L_ 100/mir, ute c) Absent heart brat (Fresh s t i l l -bi~

l~d..,ts ofsub 'ypes (a) and (b) t~h'l~ be managed by the same approach al lit~ed for babies with moderate ~ a~phyxia by keeping a close wateh ' ]~ ln

their cardiac statu~. Tile apparently , J t~ born baby. after thorough s .c t ion shou]Ida~ll immediately ventilated with intermiJf'~llb pnsitive pressure after intubation. E x t e ~ cardiac massage, by gentle r h y t h ~

posterior compressions of the m i d . n t e r ~ area with index and middle fingre/, rate of 5-6 compressions alternating w l ~ ventilations should be instituted " h ' l ~ taneoutly. There is no role for respirat~Jll stimulants, which may actually be harnfffl] because they increase oxygen needs attd may cause convulsions. I f c i rculat ionQ

not estabished within4-5 minutes, adrdnt line 1 ml of !:10,000 solution shouldhs

administered i , t ra-cardiac or intravenously

Those infants who are apnoeic at one-minU~ or when ventilation is unsatisfactory even at .5 ndnutes, should be administered 3-10 ml of sodium bicarbonate intravenously The alkali mu, t be dilu*.ed with equal volume of distilled water or 2 volumes of 5% dextrose attd administered slowly at

a rate of I mEq minute. Sodium bicar-

bolmte should be administered only when respiration has been established. Vitamin

K 0.5-1.0 nag imttamuscular is adminis- tered to all babies born with birth asphyxia

to safe-guard against bleeding following

relatively traumatic deliveries.

T e c h n i q u e o f t r a c h e a l i n t u b a t / o n

The technique of in tubat ion cannot be

taught but must be learnt and perfected by constant practice on still-born or dead

W~Aa~a.: .,,soa--gESUSClr^TtOS oF ^ sgv,~oaa . ^ ~ y ^ T Biafra

babies. The infant's shoulders should be dlghtly rai'.ed and neck extended. The is~ngoscope is held in the left hand and die blade is inserted as lar down the epi- ~ t l J as possible, by dispiacing the tongue to one side. The cricoid cartilage should be V.ntly displaced backwards by the little

ring fins ers of the left hand to occlude tM oesophagus (Plate I, Fig. 3). After ~Ua;tioning the glottic area, the oral el;do- tracheal tube is gently inserted upto the or |ha of the trachea. The suction must os repeated with a thin endotracheal g~r before the baby is ventilated. The Iig~onium covered baby must be most dS0rougnly sucked and this is the only situstiosx.where direct mtermittent suction ~ 0 u g h an endotracheal tube is permitted ~ safeguard against massive aspiration jqndrome and atelectasis. The opening i~rcssure for alveelar expansion is 40-50 cm of water while subsequently the blow-off valve should be adjusted between 12-15 cm of water to avoid alveolar tears and pncumothorax.

In case intubat;on fails, intermittent positive pressure ventilation can be effec- tively achieved with a tight fitting tacial

l ,

2, 3. 4,.

.

6. 7. 8. 9.

10.

179

mask and bag. Durit~g this procedure, the upper airways must be cleared of any debris, glossoptosis should be safeguarded by inserting a plastic oral airway and the oesophagus occluded by posterior compres- sion of the cricoid cartilage. There is a need for greater popularization of this simple technique of res.scitation with a bag and mask which can be effectively utilised in domiciliary midwifery. When bag and mask are unavailable, mouth to mouth breathing can be imparted by observing all the precautions outlined above and ensuring that one's oral rather than the tracheal or alveolar air is blown into the infant.

Ear ly neona ta l c a r e o f the a sphyx ia t ed b a b y

Infants with severe birth asphyxia should be admitted to a Special Care Nursery for close monitoring of respiration, heart rate, temperature, colour and seizures during the subsequent 12-24 hours. Their body temperature should be maintained by nursing them in a thermoneutral environment so that their oxygen needs are minimized. The conditions listed in Table 4 should be suspected if their ventila-

T a b l e 4. Condztion~ asso:ialqd with unsatfJfactory ven'ilation at 10 minutes.

Profound metabolic alterations Meconium aspiration or tracheal plug Pneumothorax Congenital malformations (choanal atresia, diaphragmatic hernia, esophageal atresia with TOP, lobar emphysema or cyst) Immaturity Intracranial haemmorrhage Shock (cardiac arrest or blood loss) Hydrops foetalis Diaphragmatic paralysis Excessive maternal sedation.

lP,0 INDIAN TOURNAI, f,P PlrDIATt~!CS Vow,. 46, No

tion remain, utnatisfactory even after 10 minutes of birth, A ,kiagram of rite chest is mandatory for further management of such an infant, Draiz~age of attires and thora- centeHs would improve respiration in hydrol,ie infants. Shock should be controlled by urgent admi.htration of plasma or blood. The stomach i, washed to remove any swallowed meconium and gastric aspirate should be examined for lung maturity by the "Shake Test" (Evans 1975). All infants with severe birth asphyxia or those with unsatisfactory ventilation at five minutes should be started on 10% dextrose infufion at birth at a rate of 30ml/kg w&h 5-10 ml of 7.5% sodium

bicarbonate during the following 12 hotirs.

Severely asphyxiated babies who are born following oxytocin augmentation of labour (Singh and Singhl 1978) or tho~e having subcutaneous bruising, are adminis- tered phenobarbitone 5.0-7.5 nag orally, twice a day for 4-5 days to safeguard against hyperbilirubinaemia. Phenobarbi- tone has alto been shown to protect the brain against hvpoxic damage in mice (Wilhjelm and Jacobsen 1970) and would raise the threshold for seizures. Prophylactic antibiotics are administered if additional indications coexist (Singh and Ghai 1976). Dexamethasone and/or mannitol have been recommended for the treatment of cerebral- oedema but results are controversial. Corticosteroids, however, are contraindicated for the management of meconium aspiration.

Prognosis

The brain of the newborn baby especial-

ly, that o f a preterm, is relatively resistant to the dameglng effects of hypoxia and

may with~'tand oxygen lack for 5-7 mi'Itwm without apparent sequelae. In an indivtdm baby .it is difficult to prognos t iea te~

future outcome. Relatively, an ad~[i outcome is anticipated if the infant WttllH terminal apnoea especially when the beats were absent at birth or the 5-~1I~ Apgar score was less than 3. Arterial bI~ pH of less than 6.9, occurrence of neon~ convulsions or abnormal neurologlm behaviour for more than 48 hours :qlll multiple diffuse chaotic spike patterrt electroencephalogram is associated with | unfavourable outcome. In general, gtuir~ ra'ther than hopeless prognosis should communicated to the parents to cushion- anxiety and to avoid deliberate negl~t

the child.

Refe rences

Apgar, V. Five minute diagnosis of h ' l ~

congenital anomalies. Conndtant, June, (1062)

Banclari, R. (1975). Re,uscitation of the newtXll

postgraduate Mid 57, 89.

Beard, R.W. Simons. E.G. (1971l. Din|heftS foetal asphyxta m labour. B,:t. J . Anaesth 43, 8"/t

Behrman, R.E., James L.S., Klaus, M., Nehd~ N , Oliver, T. (1-~69). rreatment of an asphyxia~a newborn.Cos'rent opinio:,s and practices as exprea by a panel..7. Pedia|r. "/4, 9B't.

Cockburn, F. (1971). Resuscitation o! the nt~t

born. Bd ~. AnacJth 43, 886.

Cro., K.W. (1966). Resuscitation of the asphyxn~_

ted infant. Brit ~91ed-Bull 22, 73.

Evans, J J . (1975) Prediction of respiratory dhtrcl syndrome by Shake test on newborn gastric asplrat~

J~,rtt~' E.II. .7. Mr 292, 115.

Garud, M.A., May, D.P.L., Simmons, $.C] (1989). Foetal blood sampling in the regional hospita0.

Brit, Med J. I, 349,

Ohosh, S.S. and Kumari, S. (1973). Resu.,r

of the newborn. In'dish Pr t0, 351.

~IItHARBAN glNGII- RESUSCITATIt),"; OF A I,~E%VBORF; BAD%" AT BI~;H

Gupta, J. M., Tizard, J.P.M. (1967). Tile sequence of events in neonatal apnoea. L~,cet 2, 56.

Huch, A, Huch, R., Schneider, H., Rooth, G., 0077). Continuous transcutaneous monitoring of foe- tal oxygen tension during labc~r. Brit. J . Ob#tn, and O)ntcol. Supplement No. 1,84, 1-$9.

Scott, H. (1976). Outcome of very severe birth ~phyxia. Arch. Dis. Childh 51, 7|2.

Singh, M., Ghai O.P. (1976j. In Care of the newborn. Sa&ar Publitations, p 154.

181

~ingh, M., Singhi, S. (10"/8). Oxytocin infusion d"~;-= labo::r aT;d neonatal jaundice. Indian Pcdiatr. 15, 399.

Singh, M., Kalra, V. (1978). Outcome of neonates

with severe birth asphyxia. Indian Psd, atr. (In Press).

Wilhejelm, BJ.,Jacobsn, E. (1~79). The protec. tire action of different barbituric acid derivatives against anoxla in mice. Acta. Pllarmar Toxir 28, 203.

j~IA.~ jouaNA~ oF PEDX^ratCS PLATE [

1111.12. Krie~elman lesuscitator. Stop- docki | useful to accurately time the ilqeenoe of events at birth.

Fig. 3. Technique for lsryr, goscopy. The gentle pressure over the hyoid cartilage with the little finger of the left hand obliterates oropharynx and facilitates intubation.

I~I~HARBAN SINGH- RE~USCIFATION OF A NE~VBORN AT BIRTH.