Dr Prachi PampattiwarJunior Resident

Dept of Paediatrics,RGMC & CSMH

KALWA

Newborn resuscitation

130 million infants are born every year 10% require some kind of intervention3% (~4 mill) develop birth asphyxia requiring

resuscitation900,000 of these die each year~1million develop sequela WHO 1998, AHA 2000The need for resuscitation is higher in preterm

than in term infants

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Goals of resuscitationMinimizing immediate heat lossEstablishing normal respiration and lung

expansionIncreasing arterial po2

Supporting adequate cardiac output.

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INDICATIONSMaternal IndicationNeonatal IndicationLabor & Delivery conditions

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MATERNAL CONDITIONMaternal feverMembranes ruptured for >24 hFoul smelling amniotic fluidHistory of sexually transmitted diseasePrecious delivery.Antenatal diagnosed congenital anamoliesOligohydromnia,polyhydromnias.Maternal illness

1.D.M.2.Rh or other isoimmunization without evidence of hydrops

fetalis. 3.hypertention. 4.Renal ,Endocrino, cardiac diseases. 5.Alcohol and other substance abuse.

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NEONATAL CONDITIONS

1.Maternal illness 8.Traumatic delivery2.STD 9.Prolapsed cord3.Malaria 10.Mec stained liquor4.Eclampsia 11.Congenital anomaly5.Maternal bleeding 12.Prolonged labour6.Maternal sedation 13.Breech/abn

presentation7.Fever during labour 14.PROM15 low birth weight.

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OTHER CONDITIONSSignificant vaginal bleeding .Pronged unusual or difficult laborAbnormal fetal presentation.Shoulder dystocia.

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ApnoeaPrimary ApnoeaSecondary Apnoea

Because after delivery of an infant it is impossible to differentiate between primary apnoea and secondary apnoea, assume the infant is in secondary apnoea and begin resuscitation immediately.

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WHO GuidelinesAnticipateBe prepared for every birth by having

skill to resuscitate and by knowing the institutions policy on resuscitation

Review the risk factors for birth asphyxiaClearly decide on the responsibilities of

each health care provider during resuscitation

Remember that the mother is also at risk of complications

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Neonatal Resuscitation Four CategoriesBasic steps including rapid assessments

and initial steps of stabilisationVentilation, including bag-mask or bag -

tube ventilationChest compressionAdministration of medications or fluids

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NECESSARY EQUIPMENT Radiant warmer. Oxygen source. Anesthesia bag with adjustable pop off valve (250 ml) Face mask. Suctioning instrument.{low presure suction maschine,doli’bulb suction} Infant feeding tube. Stethoscope Equiped emergency bag1.Laryngoscop2.Extra batteries3.ET tubes4.Drugs a.epineprin b.sodium bicarbonate, c. NaCl.5.Transport incubater.6.End tidal co2 moniter to check et tube position.

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Preparation of EquipmentEnsure that radiant warmer on ,warm towel

available,Turn on oxygen soarce,Test the aneasthesia bag for popoff control

&adequate flow.Laryngoscop light and an appropriate blade.Apropriate ET tubeEmergency drugs.

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APGAR SCORESIGN 0 1 2

Heart rate ABSENT <100 bpm >100bpm

Respiratary effort

ABSENT Slow irregular Good crying

Muscle Tone LIMP Some flexion extremities

Active motion

Reflex Irritability

NO RESPONSE grimace Cough or sneeze

Color BLUE,PALE Pink body blue extremities

All pink

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DURING DELIVERY

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Initial Steps for Neonatal Resuscitation in Delivery Room

A. Warm & Dry infant

Place infant under radiant heat warmer bed and dry infant

(tactile stimuli) .This helps prevent cold stress. B. Initiate ABC

A= Establish airway: position head in neutral position and bulb sx mouth and nose.

B= Breathing : Bag & Mask Ventilation or Bag & Et tube always with 100% FI02.

C= Circulation: Assess heart rate by listening to Apical pulse with stethoscope, pulse in umbilicus, or brachial pulse.

C. Evaluate infant for: 1. Colour: central vs. acrocyanosis. If centrally cyanotic give infant

facial oxygen.

2. Signs of Respiratory distress:

a. Increased WOB b. Nasal flaring c. Tachypnoea d. Grunting12/04/23 17

Bag and Mask Ventilation in the Newborn Indications for bag mask ventilation a. Apnoea

b. Heart rate less than 100 Pressure used a. Initial breath after delivery = 30-40 cm H20

b. Normal delivery = 15-20 cm H20 c. Diseased Lungs = 20-40 cm H20

5. Technique/Troubleshooting problems of Bag mask ventilation

a. Check for a good seal b. Check for a patent airway c. Are you using enough pressure ?

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Chest CompressionsIndications: If after 15-30 seconds of positive

pressure ventilation with 100% FI02 the heart rate is

a. below 60 b. between 60-80 and not increasing

Technique: a. 1 fingers breadth below nipple line, using 2 fingers b. 1/2 to 3/4 compression depth c. accompanied by ventilations, ratio is 3:1

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Intubation of the Neonate Indications for intubation a. Prolonged bag and mask ventilation

b. Bag and mask is ineffective c. Tracheal suctioning

ET tube sizes and correct suction catheter sizes: Weight of Infant ET tube Size Suction catheter size < 1000 gms 2.5 Et tube 5-6 french suction catheter 1000-2000 gms 3.0 Et tube 6 french suction catheter 2000-3000 gms 3.5 Et tube 8 french suction catheter >3000 gms 4.0 Et tube 8 french suction catheter

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DEMONSTRATION

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..\Intubation.3gp

Medications

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Naloxone Hydrochloride (Narcan) 0.4mg/ml: given if there is severe respiratory depression and a history of maternal narcotic administration within the past 4 hours.method iv push,im,sq,it{ 0.1-0.2mg/kg}

Sodium Bicarbonate 0.5: helps correct metabolic acidosis, indicated when there is a prolonged arrest that does no respond to other therapy. Because it is a hyperosmotic solution, give slowly in order to minimize the risk of intraventricular haemorrhage.method iv{2mEq/kg iv}

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WHO Guidelines Resuscitation practises not effective or

even harmfulroutine aspiration of babies mouth and noseroutine aspiration of stomachstimulation by slapping or flicking the soles

of its feetpostural drainage or slapping the backsqueezing the chest to remove secretionsroutine giving sodium bicarbonate to

newborns who are not breathing

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WHO GuidelinesCare after successful resuscitationdo not separate mother and newborn-

skin-to skinexamine the newborn (body temp, count

breaths, observe indrawing and grunting, malformations, etc)

record the resuscitation and the problems.

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Newborn ResuscitationAHA/AAP Guidelines

Meconium stained amniotic fluid: Endotracheal suctioning of the depressed - not the vigorous child

Hyperthermia should be avoided

Chest compression: Initiated if heart rate is absent or remains < 60 bpm despite adequate ventilation for 30 sec

Medications: Epinephrine 0.01-0.03 mg/kg if heart rate < 60 bpm in spite of 30 seconds adequate ventilation and chest compression

Volume: Isotonic crystalloid solution or 0-neg blood

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Summary of changes from 1992

DEMONSTRATION..\baby_not_breathing_.flv

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