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Neonatal resuscitation
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- 3. Neonatal resuscitation 10% neonatesrequire some assistance at birth. 1% neonates need extensive resuscitative measures. Asphyxia accounts for 20-25% newborn deaths.
- 4. How does ababy receive oxygen before birth? Oxygen diffuses across placenta from mother’s blood to baby’s blood. Lungs receive very little blood. Alveoli are fluid filled rather than air.
- 5. After birth •Fluid inthe alveoli is absorbed Alveoli • Expand • Get filled with air (O2) 1.
- 6. After birth Umbilical arteriesand veins are clamped Sudden increase in systemic blood pressure 2.
- 7. Pulmonary vessels dilate,causing increased blood flow to lungs 3.
- 8. Apgar score Calculated at1 & 5 min after birth
- 9. Consequences of interruptedtransition The compromised baby may exhibit 1 or more of the following clinical findings: 1. Low muscle tone 2. Respiratory depression (apnea / gasping) 3. Bradycardia 4. Cyanosis
- 10. Antepartum Risks Maternal diabetes Chronicmaternal illness Cardiovascular Thyroid Neurological Pulmonary renal Pre eclampsia Maternal infection Polyhydramnios Oligohydramnios Premature rupture of membranes IUGR/preterm Fetal malformation Maternal substance abuse No antenatal care Post term gestation Multiple gestation Anaemia Age <16 or > 35
- 11. Intrapartum Risks Emergency CS Instrumentaldelivery Abnormal position Premature labour Precipitous labour Chorioamnionitis Prolonged rupture of membranes Prolonged labour > 24 hrs Prolonged 2nd stage of labour Fetal bradycardia Non-reassuring fetal heart rate pattern General anaesthesia Narcotics administered within 4 hours of delivery Meconium stained liquor Prolapsed cord Abruptio placentae Placenta previa
- 12. Fetal asphyxia Primary apnoea Apnoeic Blue Heart rate Resuscitate easily Secondary apnoeic White, floppy Heart rate Require active resuscitation
- 14. Equipment Needed forResuscitation Radiant warmer Warm towel and blankets Resuscitation bag and mask Self inflating bag Anaesthetic bag Endotracheal tubes Laryngoscope Stethoscope Oxygen source and tubing Suction source and tubing Drugs and fluids Syringes, needles, cannulae, IV lines +/-Umbilical lines
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- 16. Normal Delivery Procedures Placeunder warmer and towel dry Use bulb syringe to clear mouth, then nose Tactile stimulation if not breathing yet Auscultate heart and lungs & assess color Free flow O2 as needed
- 17. Steps in Resuscitation Warmthand stimulation and assessment for the 1st 30 seconds Use warm cloth Replace when wet Rapidly assess Tone Colour Respiratory effort
- 18. Steps in Resuscitation- ABCDE Airway Clear airway if required Removal of secretions if present Suction mouth and nose DO NOT SUCTION IF AIRWAY IS CLEAR Positioning Supine or lateral Head in neutral or slightly extended position
- 19. Neonatal Position for Openingthe Airway – ‘neutral position’ Incorrect: Neck Hyperextension Incorrect: Neck Under Extended Correct: Neck Slightly Extended
- 20. Head flexed bylarge occiput
- 21. Head in neutralor ‘sniffing’ position
- 22. Acceptable methods ofstimulation
- 23. Steps in Resuscitation- ABCDE Breathing Assessment of respiratory effort and colour Indications for oxygen administration Cyanosis Respiratory distress Give free flowing oxygen 5L/min
- 24. Breathing: Indications for positivepressure ventilation Apnoea Gasping respiration HR < 100 bpm Persistent central cyanosis despite 100% O2 40-60 breaths/min No response
- 26. Watch for slightrise of chest Rate is 40-60
- 27. Indications of endo-tracheal Intubation Prolonged positive-pressure ventilation (PPV) required Bag & mask ineffective: Inadequate chest expansion If chest compressions required: Intubation may facilitate coordination and efficiency of ventilation Tracheal suction required
- 28. Steps in Resuscitation- ABCDE Circulation Assessment of heart rate and response to previous measures Umbilical arteries Apex beat Auscultation
- 29. Chest Compressions HR < 60bpm despite adequate vent with 100% O2 for 30 seconds 2 techniques 2 thumb (preferred) 2 finger 3:1 ratio 1/3 of AP diameter
- 30. Technique Position of Handson Chest Thumb technique ( preferred )
- 31. Technique Position of Handson Chest Two finger technique
- 32. Chest (cardiac) compressions “Two-thumb”technique is usually preferred
- 33. Steps in resuscitation- ABCDE Drugs Adrenaline Volume Expanders Naloxone
- 34. Epinephrine Indications HR <60/min after PPV & CC for 30 secs Route of administration Intravenous Endotracheal route (when I.V line is not secured ) Recommended Conc. – 1:10,000 (0.1mg/ml) Route – UVC/ IV Dose – 0.01-0.03 mg/kg , (0.05-0.1mg/kg E.T) Rate of admn. – as rapidly as possible Repeat dose if no response after 60 seconds Now, intravenous route is first preferred route
- 35. Volume ExpanderVolume Expander Indications: Poor response to other resuscitative measures Evidence of blood loss or suspected ( pale skin, poor perfusion, weak pulse) Crystalloid Normal Saline Ringer Lactate or O-negative blood cross-matched with mother’s blood Dose – 10ml/kg Route – Umbilical vein Preparation – large syringe Rate of administration – 5-10 min
- 36. Naloxone Narcotic antagonistNaloxoneNarcotic antagonist Indications : A history of maternal narcotic administration within the past 4 hours Severe respiratory depression is present after PPV has restored a normal HR & color Recommended Concentration: 1.0 mg/ml Route: Intravenous Dose: 0.1 mg/kg
- 37. Meconium present andbaby vigorous Vigorous Baby- Strong respiratory efforts, Good muscle tone, Heart rate > 100 bpm suction catheter or bulb syringe for suction of mouth or nose ET suction not required
- 38. Meconium present andbaby not vigorous Insert laryngoscope Clear mouth and posterior pharynx Insert endotracheal tube into the trachea Attach the ET to suction source Apply suction as ET is slowly withdrawn Repeat as necessary until no meconium or heart rate indicates further resuscitation
- 39. What to doif still no improvement?What to do if still no improvement? If no improvement seen despite all efforts Ensure adequate ventilation, chest compressions, drug delivery If still HR < 60/min, consider Airway malformation Lung problems Pneumothorax Diaphragmatic hernia Cong. Heart disease If HR absent or no progress Ethical considerations of when to D/C Resuscitation
- 40. Discontinuing Resuscitative Effort Stopresuscitation, if HR remains undetectable for 10 - 15 min Also take into consideration factors such as presumed etiology of the arrest, gestation of the baby, presence or absence of complications
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