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NEONATAL RESUSCITATIO
N PROGRAM
Dr Anagha Anand
Neonatal Resuscitation is intervention after a baby is born to help it breathe and to help its heart beat.
Of the 25 million infants born every year in India, 3-5% experience asphyxia at birth
Neonatal resuscitation skills are essential for all health care providers who are involved in the delivery of newborns
The American Heart Association (AHA) and the American Academy of Pediatrics (AAP) have updated the resuscitation guidelines that are being propagated world wide through the NEONATAL RESUSCITATION PROGRAM (NRP)
Anticipation
A radiant heat source ready for use
All resuscitation equipments immediately available & in working order
At least 1 person skilled in neonatal resuscitation
Preparing for Resuscitation
Neonatal Resuscitation Supplies & Equipments
-Suction Equipment
Mechanical suction
Suction catheters 10,12, or 14 F
Meconium aspirator
-Bag and Mask Equipment
Neonatal resuscitation bags ( self limiting)
Face-masks ( for both term & preterm babies)
Oxygen with flow meter and tubing
-Intubation Equipment
Laryngoscope with straight blades no.0 (preterm)& no.1 (term)
Extra bulbs & batteries ( for laryngoscope)
Endotracheal tubes ( int diameter 2.5, 3, 3.5 & 4)
Medications
Epinephrine
Normal saline or Ringer Lactate
Naloxone hydrochloride
Miscellaneous
Linen, shoulder roll, gauze
Radiant warmer
Stethoscope
Syringes 1,2,5,10,20,50 ml
Feeding tube 6 F
Umbilical catheters 3.5, 5 F
Three way stopcocks
Gloves
Based primarily on 3 signs
Respiration
Heart rate
Color
Evaluation
Performed at 1min & again at 5 min after birth.
But resuscitation must be initiated bfr 1 min score is assigned
Not used to guide resuscitation
But can reflect how well the baby is responding to resuscitative efforts
Should be obtained every 5 min for upto 20 min, if the score is < 7
Term / Preterm ? Term: smooth transition Preterm : stiff, under-developed lungs,
insufficient muscle strength, can’t maintain temperature
Breathing/Crying ? Watch baby’s chest Gasping is a series of deep, single or
stacked inspirations that occur presence of hypoxia/ischemia. Treated as apnea.
Steps of Resuscitation
Good tone ? Term: flexed extremities Preterm/sick: flaccid/limp, extended extremities
Steps of Resuscitation
Provide warmth : Radiant warmer, don’t cover with blankets or towels.
Position head and clear airway if necessary Placed on her back or side with neck slightly
extended. Brings post pharynx, larynx & trachea in line Place a rolled blanket or towel under the
shoulders, elevating them 3/4th or 1 inch off the mattress.
Suction mouth first, then nose “M” before “N” To prevent aspiration of mouth contents If copious secretions present → head
should be turned to one side Never insert catheter too deep in mouth or
nose for suction → stimulation of post pharynx → vagal response → bradycardia or apnea
Max time limit – 15 sec
Steps of Resuscitation
Management of infant born through MSL
For non-vigorous babies initial steps are modified as:
Place under radiant warmer. Postpone drying & suctioning to prevent stimulation
Remove residual meconium in the mouth & post pharynx by suctioning under direct vision using laryngoscope
Intubate & suction out meconium from the lower airway
Dry, Stimulate and Reposition Stimulate : Flicking the soles/ drying & rubbing
the back
Steps of Resuscitation
Respirations
Heart rate: Best is auscultation, alternatively pulsations at base of cord is felt. Count for 6s and “x”10
Color- look at tongue, mucous membranes & trunk
Evaluation
Evaluation If baby has good breathing, HR>100/min, no
cyanosis →no additional intervention
If baby has laboured breathing or persistent cyanosis
-preterm babies → CPAP -term babies→ supplemental oxygen
If baby is apneic, has gasping breathing or HR < 100/min → PPV is needed
PPV – using a self-inflating bag & face mask
Positive pressure ventilation
Indications: Gasping/apnea HR < 100/min Persistent central cyanosis despite
administration of 100% free flow oxygen
Contraindications: Diaphragmatic hernia Non vigorous babies born through MSL, B & M
ventilation carried out only after tracheal suctioning
PPV
Appropriate SizesMask should Rest on Chin Cover Mouth& Nose
PPV
When n/l rise of chest is observed start ventilating.Ventilation should be carried out at a rate of 40-60 breaths per min, following a ‘squeeze, two, three’ sequence
PPV may cause abd distension as gas escapes into the stomach via oesophagus.
↓Presses on diaphragm & compromises the ventilation
So orogastric tube should be inserted & left open to decompress the abdomen
PPV continued more than several minutes
Rhythmic compression of the sternum →compress heart against spine → ↑se intrathoracic pressure → circulate blood to the vital organs
Always accompanied by BMV so that only oxygenated blood is circulated
Chest compressions
Indications : HR <60/min even after 30 sec of effective
PPV Once HR>60/min CC should be
discontinued.
Chest Compressions
Thumb technique: 2 thumbs depress the sternum, hands encircle the torso and the fingers support the spine. Preferred technique
2 – Finger technique: Tips of middle & index/ring finger of one hand compresses sternum, other hand supports the back.
Methods
A positive breath should follow every third chest compression
In 1 min 90 compressions & 30 breaths are administered
To determine the efficiency of CC, the carotid or femoral pulsations should be checked periodically
Rate
After 30 sec HR is checked:
HR<60 → CC should continue along with B & M ventilation. In addition medications have to be given
HR>60 → CC should be discontinued. BMV should be continued until the HR > 100/min & the infant is breathing spontaneously
Evaluation
Endotracheal Intubation
When tracheal suction is required ( non vigorous babies born through MSL)
When prolonged BMV is required
When BMV is ineffective
When diaphragmatic hernia is suspected
Indications
Laryngoscope with extra blades and bulbs Straight blades Term – 1 Preterm – 0
Endotracheal Intubation
ET tube – Vocal cord guide
Infant’s head should be in midline & neck slightly hyper extended.
Laryngoscope is held in left hand b/w thumb & the first three fingers, with the blade pointing away from oneself
Stand at the head end, the blade is introduced in the mouth & advanced to just beyond the base of tongue
Procedure
Position
Position Once the glottis & vocal cords are
visualized, he ET is introduced from the right side of the mouth
Its tip is inserted into the glottis until the vocal cord guide is at level of the glottis
1. Epinephrine (1:1000) Indication :HR< 60/min after 30 sec of effective PPV & CC. Effects: Inotropic, chronotropic, peripheral vasoconstrictor Dose: 0.1-0.3ml/kg Route: i.v, through umbilical vein, directly into tracheobronchial tree through ET
Medications
NS, RL Indication: Acute bleeding with hypovolemia Effects: increase intravascular volume, improves perfusion Dose: 10ml/kg Route: umbilical vein
Medications
Naloxone (0.4mg/ml) Indication: Respiratory depression with maternal history of narcotic use within 4 hr of birth Effects: Narcotic antagonist
Dose: 0.25ml/kg(0.1mg/kg) Route: i.v preferred, delayed onset of action with i.m use, administer only after restoring ventilation
Medications
THANK YOU