Initial stablisation and resuscitation in newborn

1. Initial Stabilisation and Initial Stabilisation and
Resuscitation of the Resuscitation of the
Newborn InfantNewborn Infant

2. Learning OutcomesLearning Outcomes
Initial Stabilisation and Resuscitation of the Newborn InfantInitial Stabilisation and Resuscitation of the Newborn Infant
1.1.PreventionPrevention
1.11.1 Identify the factors that predispose to the development of Identify the factors that predispose to the development of
perinatal hypoxia.perinatal hypoxia.
1.21.2 Propose how perinatal hypoxia can be prevented. Propose how perinatal hypoxia can be prevented.
2. Principles of Diagnosis2. Principles of Diagnosis
2.12.1 Describe the pathophysiological changes that occur in hypoxia.Describe the pathophysiological changes that occur in hypoxia.
2.22.2 Recognise an asphyxiated newbornRecognise an asphyxiated newborn
2.32.3 Classify an asphyxiated newborn based on the predicted Classify an asphyxiated newborn based on the predicted
adverse outcomes (Sarnat staging)adverse outcomes (Sarnat staging)
3.3.Principles of ManagementPrinciples of Management
3.13.1 Resuscitate a newborn who is not adapting to the extra-uterine Resuscitate a newborn who is not adapting to the extra-uterine
transition. transition.
3.23.2 Describe the principles involved in the management of mild to Describe the principles involved in the management of mild to
moderate asphyxiated newborn.moderate asphyxiated newborn.

3. Perinatal Hypoxia-IschemiaPerinatal Hypoxia-Ischemia
Birth asphyxia - Failure to initiate Birth asphyxia - Failure to initiate
and sustain breathing at birth and sustain breathing at birth
CausesCauses
5.5.Fetal and Antepartum (90%)Fetal and Antepartum (90%)
7.7.Birth process (10%)Birth process (10%)

4. Fetal and Antepartum PathologiesFetal and Antepartum Pathologies
1.1.Inadequate oxygenation of maternal blood Inadequate oxygenation of maternal blood
- anesthesia, cyanotic heart disease, - anesthesia, cyanotic heart disease,
respiratory failurerespiratory failure
3.3.Inadequate flow of maternal blood Inadequate flow of maternal blood
(ischemia/hypotension) – spinal (ischemia/hypotension) – spinal
anesthesia, compression of IVC or aorta anesthesia, compression of IVC or aorta
by uterusby uterus
5.5.Abruptio placentaeAbruptio placentae
7.7.Uterine vasoconstriction (cocaine)Uterine vasoconstriction (cocaine)
9.9.Placental insufficiency (pre-eclampsia, Placental insufficiency (pre-eclampsia,
postmaturity)postmaturity)

5. Birth ProcessBirth Process
•BreechBreech
•Shoulder dystociaShoulder dystocia
•Cephalopelvic disproportionCephalopelvic disproportion
•Cord compression, knottingCord compression, knotting
•Uterine tetany (too much oxytocin)Uterine tetany (too much oxytocin)
•Uterine ruptureUterine rupture

6. Recognition of an Asphyxiated BabyRecognition of an Asphyxiated Baby
Oxygen supply to the fetus is Oxygen supply to the fetus is
reduced, resulting inreduced, resulting in
Apnea at birthApnea at birth
2.2.Low Apgar scores (severe if <5 at five Low Apgar scores (severe if <5 at five
minutes)minutes)
3.3.Neurologic sequelae (hypoxic-ischaemic Neurologic sequelae (hypoxic-ischaemic
encephalopathy) encephalopathy)
4.4.Metabolic acidosisMetabolic acidosis
5.5.Multi-organ failure: cardiovascular, Multi-organ failure: cardiovascular,
gastrointestinal, hematologic, gastrointestinal, hematologic,
pulmonary, renalpulmonary, renal

7. Apgar ScoresApgar Scores
All pinkBody pink,
extremities
blue
BlueColour
Cough,
sneeze
GrimaceNo
response
Response
to catheter
in nostril
ActiveSome
flexion
LimpMuscle
tone
Good,
crying
Slow,
irregular
AbsentRespiration
>100<1000Heart rate
210

8. ApneaApnea
11
00
Apnea Apnea: When asphyxiated, the infant responds initially : When asphyxiated, the infant responds initially
with tachypnea. If insult continues, the infant becomes with tachypnea. If insult continues, the infant becomes
apneic and bradycardic. The infant will respond to apneic and bradycardic. The infant will respond to
stimulation and 0stimulation and 0
2 2 therapy with spontaneous respirations. therapy with spontaneous respirations.
22
00
apnea apnea: When insult continues after 1: When insult continues after 1
00
apnea, the infant apnea, the infant
responds with a period a gasping respirations, bradycardia, responds with a period a gasping respirations, bradycardia,
and falling BP. The infant takes a last breath and then and falling BP. The infant takes a last breath and then
enters the 2enters the 2
00
apnea period. The infant will not respond to apnea period. The infant will not respond to
stimulation and death will occur unless resuscitation begins stimulation and death will occur unless resuscitation begins
immediately. immediately.
It is impossible to differentiate between 1It is impossible to differentiate between 1
00
apnea and 2 apnea and 2
00

apnea at delivery, assume the infant is in 2apnea at delivery, assume the infant is in 2
00
apnea and apnea and
begin resuscitation immediately.begin resuscitation immediately.

9. Pathophysiological changes in Pathophysiological changes in
AsphyxiaAsphyxia
StimulationResuscitation

10. Neonatal ResuscitationNeonatal Resuscitation

11. STEPS IN NEONATAL RESUSCITATIONSTEPS IN NEONATAL RESUSCITATION
Warm, dry, stimulateWarm, dry, stimulate
A – airway (positioning, suctioning)A – airway (positioning, suctioning)
B – breathing (spontaneous / B – breathing (spontaneous /
assisted ventilation)assisted ventilation)
C – external cardiac massage/ C – external cardiac massage/
medicationsmedications

12. Drying, Warming, Positioning,
Suction, Tactile Stimulation
Oxygen
Bag& Mask
Ventilation
Chest
Intubation
Medi-
cations
Compressions

14. Operating Theatre AnteroomOperating Theatre Anteroom

15. Operating Theatre Newborn Resuscitation BedOperating Theatre Newborn Resuscitation Bed

16. Thermoregulation: Turn Warmer OnThermoregulation: Turn Warmer On
Heating element
glows red
ON Button

17. Preparation:Preparation:
Turn on the Overhead Warmer to Manual ModeTurn on the Overhead Warmer to Manual Mode

18. Turning on the Overhead Warmer: Turning on the Overhead Warmer:
Push up warmer output to maximumPush up warmer output to maximum

19. Thermoregulation: Warm up the linensThermoregulation: Warm up the linens

20. Thermoregulation: Final Set-UpThermoregulation: Final Set-Up
Warmer on
Warmed
towels &
blankets
ready
SaO
2
monitor
ready

21. EQUIPMENT FOR NEWBORN RESUSCITATION

22. WALL SUCTION CATHETER

23. Neopuff® Positive Pressure Device
T-piece resuscitator
Capable of providing peak
inspiratory pressure (PIP) &
positive end expiratory pressure
(PEEP) for manual ventilation,
Can also be used to provide
continuous positive airway
pressure (CPAP)
Needs a constant gas flow to
work (air or oxygen)
Can be used with the
Resuscitaire ® set-up & gas
supply

24. NeopuffNeopuff®® Positive Pressure Device Positive Pressure Device
Oxygen/air (gas)
supply tubing/ inlet
(to Neopuff®)
Gas outlet
and tubing
(to patient)

25. NeopuffNeopuff®® Positive Pressure Device Positive Pressure Device
Circuit Pressure Dial
(Pressure Gauge)
Gas Inlet
MaximumPressure
Release Knob Gas Outlet
PIP Knob

26. Neopuff® and Resuscitaire® Positive Pressure Devices

30. BASIC STEPSBASIC STEPS
WarmthWarmth – radiant warmer, dry skin, remove wet – radiant warmer, dry skin, remove wet
linen, wrap in pre-warmed blanketslinen, wrap in pre-warmed blankets
PositioningPositioning – supine, head neutral or slightly – supine, head neutral or slightly
extended (open airway)extended (open airway)
SuctioningSuctioning – healthy, vigorous infants do not – healthy, vigorous infants do not
need suctioning (clear airway)need suctioning (clear airway)
Tactile stimulationTactile stimulation – flick the soles – flick the soles

31. Neck hyperextended
Neck slightly
extended
Neck
flexed
Airways - PositioningAirways - Positioning

33. EVALUATIONEVALUATION
Respiration Respiration Breathing or Apneic?Breathing or Apneic?
Heart rate Heart rate >100 or <100 (auscultate / palpate base of >100 or <100 (auscultate / palpate base of
umbilical umbilical cord)cord)
Colour Colour Pink or centrally blue?Pink or centrally blue?

34. POSITIVE PRESSURE VENTILATIONPOSITIVE PRESSURE VENTILATION
Indications: apnea / gasping, HR<100, persistent Indications: apnea / gasping, HR<100, persistent
cyanosiscyanosis
Bag and mask (self-inflating) with 100% OBag and mask (self-inflating) with 100% O
22
Adequate chest rise (rather than a particular Adequate chest rise (rather than a particular
manometer reading)manometer reading)
Rate – 40 to 60 breaths per minuteRate – 40 to 60 breaths per minute
Successful – improving HR and colour Successful – improving HR and colour
The key to successful neonatal resuscitation is The key to successful neonatal resuscitation is
establishment of adequate ventilationestablishment of adequate ventilation

36. Face MaskFace Mask
Positive Pressure Ventilation - Correct Positive Pressure Ventilation - Correct
Position & Size of Face MaskPosition & Size of Face Mask

37. CHEST COMPRESSIONSCHEST COMPRESSIONS
If after 30 seconds of adequate PPV with 100% OIf after 30 seconds of adequate PPV with 100% O
22 and and
HR<60, start chest compressions HR<60, start chest compressions
Ratio of 3 compressions : 1 breath, to give 90 Ratio of 3 compressions : 1 breath, to give 90
compressions and 30 breaths per minute (120 events per compressions and 30 breaths per minute (120 events per
minute)minute)
Depth of compression – 1/3 the depth of the chestDepth of compression – 1/3 the depth of the chest
Preferred technique – Two thumb-encircling handsPreferred technique – Two thumb-encircling hands
Compressions delivered on the lower third of the sternum Compressions delivered on the lower third of the sternum

39. Using the Neopuff® to give PPVUsing the Neopuff® to give PPV
When giving PPV, occluding the PEEP valve gives PIP
and uncovering it maintains PEEP.

40. Giving CPAP Using the NeopuffGiving CPAP Using the Neopuff
Do not occlude the PEEP valve when using for CPAP.

41. MedicationsMedications
1.1.AdrenalineAdrenaline
–Concentration 1 : 10 000 solutionConcentration 1 : 10 000 solution
–Dose 0.1 – 0.3 ml/kg Dose 0.1 – 0.3 ml/kg
–Route ETT or intravenousRoute ETT or intravenous
–Indication if HR < 60 bpm after 30 sec of effective PPV Indication if HR < 60 bpm after 30 sec of effective PPV
and chest compressionsand chest compressions
•NaloxoneNaloxone
–Dose 0.1 mg/kg, repeat dose if necessaryDose 0.1 mg/kg, repeat dose if necessary
–Route intramuscular, intravenous, ETTRoute intramuscular, intravenous, ETT
–For respiratory depression with maternal pethidine in For respiratory depression with maternal pethidine in
last 4 hourslast 4 hours
3.3.Volume expanders (normal saline) 10 ml/kg over 10 Volume expanders (normal saline) 10 ml/kg over 10
minutesminutes
5.5.Sodium bicarbonateSodium bicarbonate

42. Dept of NeonatologyDept of Neonatology

43. Multi-organ InjuryMulti-organ Injury
Hypoxia may leads to multi-organ involvement:Hypoxia may leads to multi-organ involvement:
–Brain injury: hypoxic-ischemic Brain injury: hypoxic-ischemic
encephalopathy (HIE)encephalopathy (HIE)
–Cardiac: hypotension Cardiac: hypotension
–Lung: respiratory distress, persistent fetal Lung: respiratory distress, persistent fetal
circulationcirculation
–Renal: oliguriaRenal: oliguria
–Adrenal: adrenal hemorrhage Adrenal: adrenal hemorrhage
–Hematological: DIVCHematological: DIVC
–Liver: abnormal liver functionLiver: abnormal liver function

44. Hypoxic-Ischemic EncephalopathyHypoxic-Ischemic Encephalopathy
Sarnat Stages of HIESarnat Stages of HIE
Stage One: Mild irritability and hyper-alert Stage One: Mild irritability and hyper-alert
Stage Two: Seizure Stage Two: Seizure
Stage Three: Stupor Stage Three: Stupor
OutcomeOutcome
Death or severe neurological sequelaeDeath or severe neurological sequelae
Stage 1 (mild)Stage 1 (mild) 0%0%
Stage 2 (moderate)Stage 2 (moderate)30 -50%30 -50%
Stage 3 (severe)Stage 3 (severe) 90 - 100%90 - 100%

45. Management of the Asphyxiated InfantManagement of the Asphyxiated Infant
•Optimise perfusionOptimise perfusion
•Optimise oxygenation, COOptimise oxygenation, CO
22
•Restrict fluidRestrict fluid
•Normal blood sugar, calcium, acid-base balanceNormal blood sugar, calcium, acid-base balance
•Treat seizuresTreat seizures
•Therapeutic hypothermiaTherapeutic hypothermia
•Cord stem cell infusion?Cord stem cell infusion?

46. Case 1Case 1
You are asked to attend an emergency LSCS You are asked to attend an emergency LSCS
delivery of a 41-weeks gestation infant with non-delivery of a 41-weeks gestation infant with non-
reassuring fetal cardio-tocogram (CTG). Mother reassuring fetal cardio-tocogram (CTG). Mother
is a 33 year old gravida one Chinese lady. She is a 33 year old gravida one Chinese lady. She
was admitted to hospital two days ago. Her labor was admitted to hospital two days ago. Her labor
was induced. She had good prenatal care and her was induced. She had good prenatal care and her
pregnancy has been uncomplicated. She suddenly pregnancy has been uncomplicated. She suddenly
felt sharp pain in lower abdomen. CTG, which was felt sharp pain in lower abdomen. CTG, which was
normal before that showed bradycardia. normal before that showed bradycardia.

47. Case 1Case 1
What are the possible conditions that What are the possible conditions that
you can think of in the mother you can think of in the mother
causing the problem?causing the problem?
What resuscitation equipments would What resuscitation equipments would
you prepare for delivery? you prepare for delivery?
Would you involve any other medical Would you involve any other medical
personnel? personnel?

48. Case 1Case 1
At delivery, you receive a floppy and At delivery, you receive a floppy and
blue male infant. His heart rate was blue male infant. His heart rate was
40/minutes and there is no 40/minutes and there is no
spontaneous respiration. Baby does spontaneous respiration. Baby does
not respond to stimulation.not respond to stimulation.
What is the initial Apgar score in this What is the initial Apgar score in this
baby? baby?
What are the initial steps you would What are the initial steps you would
perform? perform?

49. Case 1Case 1
You bring him to the radiant warmer, You bring him to the radiant warmer,
quickly positioned, dried, stimulated quickly positioned, dried, stimulated
the baby and give free-flow oxygen. the baby and give free-flow oxygen.
At 30 seconds of life, he remains At 30 seconds of life, he remains
apneic and cyanotic. His heart rate is apneic and cyanotic. His heart rate is
still 40 per minute.still 40 per minute.
What would be the next step in What would be the next step in
resuscitation?resuscitation?
How would you monitor the How would you monitor the
resuscitation? resuscitation?

50. Case 1Case 1
You administer bag and mask You administer bag and mask
ventilation with 100% FiO2. There is ventilation with 100% FiO2. There is
good chest expansion. After one good chest expansion. After one
minute of bag and mask ventilation minute of bag and mask ventilation
baby remained apneic. His heart rate baby remained apneic. His heart rate
is 60 per minute. is 60 per minute.
What would be your next step?What would be your next step?
What are the other possible What are the other possible
interventions you can think of at this interventions you can think of at this
point? point?

51. Case 1Case 1
You start chest compressions and You start chest compressions and
decide to intubate the baby. decide to intubate the baby.
How would you ensure proper How would you ensure proper
positioning of ETT? positioning of ETT?
How would monitor your How would monitor your
resuscitation? resuscitation?

52. Case 1Case 1
You check for equal air entry and expansion of You check for equal air entry and expansion of
lung field. Baby’s heart rate after two minutes of lung field. Baby’s heart rate after two minutes of
ventilation is 100/minutes. The color is still pale ventilation is 100/minutes. The color is still pale
and pulse volume is low. and pulse volume is low.
What could the possible reason for low volume What could the possible reason for low volume
pulse? pulse?
What intervention would you like to consider at What intervention would you like to consider at
this point? this point?

53. Case 1Case 1
You decide to give normal saline bolus 10-15 You decide to give normal saline bolus 10-15
ml/kg. ml/kg.
How can you secure an intravenous access How can you secure an intravenous access
quickly? quickly?
How fast do you want to administer the normal How fast do you want to administer the normal
saline bolus? saline bolus?
What are other types of fluid you can use? What are other types of fluid you can use?

54. Case 1Case 1
You cannulate the umbilical vein and You cannulate the umbilical vein and
administer the normal saline over administer the normal saline over
five minutes. Baby’s heart rate five minutes. Baby’s heart rate
improve to 150/minute and color and improve to 150/minute and color and
perfusion are better now. You have perfusion are better now. You have
decided to transfer the baby to decided to transfer the baby to
intensive care nursery. intensive care nursery.
What are the laboratory test you What are the laboratory test you
want to order? want to order?

55. Case 1Case 1
ABG shows following parameterABG shows following parameter
–pH 7.03 pH 7.03
–PCOPCO
22 52 mm of Hg 52 mm of Hg
–POPO
22 85 mm of Hg 85 mm of Hg
–Base excess –15 Base excess –15
–HCOHCO
33 12 12
–How would you interpret the ABG? How would you interpret the ABG?

56. Case 1Case 1
What are possible consequences in this baby?What are possible consequences in this baby?
–Clue: Organ systemsClue: Organ systems
–Clue: Short term and long termClue: Short term and long term
How would you monitor the baby? How would you monitor the baby?
–SymptomsSymptoms
–Laboratory testLaboratory test
How would you counsel the parents regarding prognosis of How would you counsel the parents regarding prognosis of
the baby? the baby?

57. Case 2Case 2
You are requested to ‘stand-by’ for delivery of a You are requested to ‘stand-by’ for delivery of a
term neonate. The mother is 32-year- old. This is term neonate. The mother is 32-year- old. This is
her first pregnancy. Her antenatal follow-up was her first pregnancy. Her antenatal follow-up was
irregular. She was admitted to hospital with labor irregular. She was admitted to hospital with labor
6 hours ago. The CTG shows persistent heart rate 6 hours ago. The CTG shows persistent heart rate
of 170/minutes. Amniotic membrane was of 170/minutes. Amniotic membrane was
ruptured spontaneously and it is heavily stained ruptured spontaneously and it is heavily stained
with meconium. with meconium.

58. Case 2Case 2
Name few conditions that may give Name few conditions that may give
rise to the problem described. rise to the problem described.
What are the resuscitation What are the resuscitation
equipments you would need? equipments you would need?
Ideally, how many medical personnel Ideally, how many medical personnel
you would need during resuscitation? you would need during resuscitation?

59. Case 2Case 2
The baby is delivered vaginally. The The baby is delivered vaginally. The
baby was found to covered with thick baby was found to covered with thick
meconium. There is no spontaneous meconium. There is no spontaneous
cry. The heart rate is 120/minute and cry. The heart rate is 120/minute and
the baby has some activity. the baby has some activity.
What would the role of obstetrician? What would the role of obstetrician?
What would be your first step in What would be your first step in
resuscitation?resuscitation?
What are the consequences of What are the consequences of
meconium aspiration? meconium aspiration?

61. Conditions That Requires Conditions That Requires DifferentDifferent
Resuscitation ApproachResuscitation Approach
Thick meconium stained liquorThick meconium stained liquor
Congenital diaphragmatic herniaCongenital diaphragmatic hernia
Feto-maternal or feto-placental Feto-maternal or feto-placental
hemorrhagehemorrhage

62. Reference and Further ReadingsReference and Further Readings
1.1.Neonatal resuscitation guidelines. Circulation Neonatal resuscitation guidelines. Circulation
2005;112:118– 95.2005;112:118– 95.
•Volpe J. Neurology of the Newborn. 5 ed. Volpe J. Neurology of the Newborn. 5 ed.
Philadelphia:W. B. Saunders Company; 2008 Philadelphia:W. B. Saunders Company; 2008
(Chapter on Neonatal Encephalopathy)(Chapter on Neonatal Encephalopathy)
•Nelson Textbook of Pediatrics 18Nelson Textbook of Pediatrics 18
thth
ed. 2007 ed. 2007
Chapter 99.5: Hypoxia-IschemiaChapter 99.5: Hypoxia-Ischemia

63. Thank YouThank You

64. Sarnat Stage 1Sarnat Stage 1
Mildest stageMildest stage
Hyperalert and irritableHyperalert and irritable
Normal toneNormal tone
Mild over-reactive tendon reflexesMild over-reactive tendon reflexes
Weak sucking reflex and exaggerated Weak sucking reflex and exaggerated
Moro’sMoro’s
No seizuresNo seizures
EEG - normalEEG - normal

65. Sarnat Stage 2Sarnat Stage 2
Moderately severe encephalopathyModerately severe encephalopathy
Lethargic and obtundedLethargic and obtunded
Mild hypotoniaMild hypotonia
Over-reactive tendon reflexesOver-reactive tendon reflexes
Weak or absent suckWeak or absent suck
Focal or multi-focal seizuresFocal or multi-focal seizures
EEG – low-voltage, seizuresEEG – low-voltage, seizures

66. Sarnat Stage 3Sarnat Stage 3
Severe encephalopathySevere encephalopathy
StuporousStuporous
Tone is diminished and flaccidTone is diminished and flaccid
Reflexes absentReflexes absent
Seizures uncommonSeizures uncommon
EEG – burst suppression or isoelectricEEG – burst suppression or isoelectric