Neonatal resuscitation

the first few minutes of life is the most important and vital period to understand and also identify the survivability of a newborn. Resuscitation is one of the emergency management technique when the neonate is unable to initiate respiration on their own.

1. NEONATAL RESUSCITATION Mrs. Tina Ann John Assoc. Professor Child Health Nursing

2. INTRODUCTION The successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth. Although most newborns successfully make this transition at delivery without requiring any special assistance, a small but significant number will require additional support, including resuscitation in the delivery room. 10% of all babies require resuscitation; 1% need extensive resuscitative measures. Globally, about one quarter of all neonatal deaths are caused by birth asphyxia. By appropriate resuscitation: Outcome of thousands of newborns may improve.

3. TABCD of Resuscitation T emperature A irway (position and clear) B reathing (stimulate to breathe) C irculation (assess heart rate and color) D rugs (Medications)

4. NEED FOR RESUSCITATION

5. What normally happens after birth? Three major changes occur THE FLUID IN THE ALVEOLI IS ABSORBED . THE UMBILICIAL ARTERIES AND VEIN CONSTRICT AND ARE CLAMPED Removes the low resistance placental circulation Increases the systemic vascular resistance. BLOOD VESSELS IN THE LUNG TISSUE RELAX Decrease resistance to blood flow

6. WHAT CAN GO WRONG DURING TRANSITION? BREATHS NOT FORCEFUL TO REMOVE ALVEOLAR FLUID OR FOREIGN MATERIAL BLOCKS AIR ENTRY OXYGEN NOT AVAILABLE. EXCESSIVE BLOOD LOSS/ POOR CARDIAC CONTRACTILITY SYSTEMIC HYPOTENSION. HYPOXIA CONSTRICTION OF PULMONARY ARTERIOLES, TISSUE OXYGEN DEPRIVATION (PPHN).

7. RESPONSE OF THE BABY TO AN INTERRUPTION IN NORMAL TRANSITION POOR MUSCLE TONE DUE TO INSUFFICIENT OXYGEN SUPPLY TO BRAIN, MUSCLES AND OTHER ORGANS. DEPRESSION IN RESPIRATORY DRIVE FROM INSUFFICIENT OXYGEN SUPPLY TO THE BRAIN. BRADYCARDIA Insufficient delivery of oxygen to heart, muscle and brain. LOW BLOOD PRESSURE POOR MYOCARDIAL CONTRACTILITY OR BLOOD LOSS TACHYPNEA FROM FAILURE TO ABSORB LUNG FLUID CYANOSIS FROM INSUFFICIENT OXYGEN IN BLOOD

8. INDICATIONS FOR RESUSCITATION

9. MATERNAL CONDITIONS: Diabetes Mellitus Pre-eclampsia, hypertension, chronic renal disease Anaemia Blood type incompatibilities Antepartum haemorrhage Drug or alcohol ingestion Previous neonatal death PROM with evidence of amnionitis Systemic Lupus Maternal cardiac disease

10. LABOUR & DELIVERY CONDITIONS: Forceps or vacuum extraction •Breech or abnormal presentation •Cesarean section •Cephalo-pelvic disproportion •Cord prolapse/compression •Maternal hypotension or hemorrhage

11. FETAL CONDITIONS Premature/postmature birth Meconium in amniotic fluid Abnormal heart rate pattern Macrosomia Oligo- or polyhydramnios Fetal cardiac dysrhythmia Fetal growth retardation Fetal malformations Hydrops fetalis Low biophysical profile Sepsis Multiple births, especially: Discordant twins Twin-twin transfusion syndrome with stuck twin Mono-amniotic twins

12. GOALS OF RESUSCITATION TO ASSIST ADAPTATION TO EXTRA-UTERINE LIFE. TO HELP IN INFLATING LUNGS, ESTABLISHING OXYGENATION AND VENTILATION. TO ESTABLISH ADEQUATE PULMONARY BLOOD FLOW. TO SUPPORT CARDIOVASCULAR FUNCTION.

13. SEQUENTIAL STEPS IN RESUSCITATION: • Maintain body temperature (dry infant and put under radiant warmer). •Clear airway and initiate ventilation. •Cardiac compressions, if needed. •Attach ECG leads, pulse oximeter and CO2 monitor and insert OG tube. •Catheterize umbilical artery/vein and measure blood pressures. •Give resuscitation drugs as needed. •Assign Apgar scores at 1 and 5 min and q5 min until score is ≥7.

14. KEY PRINCIPLES OF RESUSCITATION: ANTICIPATE AT EVERY DELIVERY- ATLEAST 1 PERSON WHOSE PRIMARY RESPONSIBILITY IS THE NEWBORN. EITHER THAT PERSON OR SOMEONE READILY AVAILABLE- SKILLS TO PERFORM A COMPLETE RESUSCITATION. IF NEED FOR RESUSCITATION IS ANTICIPATED- ADDITIONAL SKILLED PERSONNEL AND NECESSARY EQUIPMENT.

15. PREREQUISITES FOR RESUSCITATION

16. PREREQUISITES: PHYSICAL SETUP FOR RESUSCITATION FLAT SURFACE TO MAINTAIN POSITION OF NEONATE DURING PROCEDURE WARM AND CLEAN ENVIRONMENT STERILE EQUIPMENTS WITH DISPOSABLE MATERIALS ROOM TEMPERATURE OF 26 c FUNCTIONAL RADIANT WARMER WITH OVERHEAD LIGHT PRE-WARMED TOWELS

17. EQUIPMENTS DEE LEE TRAP MECHANICAL SUCTION SUCTION CATHETER (12 F AND 14 F) FEEDING TUBES (6F AND 8F) NEONATAL SELF INFLATING RESUSCITATION BAGS (500 ML) FACE MASKS (TERM AND PRETERM) OXYGEN WITH FLOW METER AND TUBING

18. INTUBATION EQUIPMENTS: LARYNGOSCOPE WITH STRAIGHT BLADES (No.1 for term, No. 0 for preterm) Extra bulbs and batteries Endo tracheal tubes (2.5, 3.0, 3.5) RESUSCITATION DRUGS AND FLUIDS: INJ. EPINEPHRINE INJ. NALOXONE NORMAL SALINE STERILE WATER

19. PHASES OF RESUSCITATION

20. INITIAL STEPS AT BIRTH AT 30 SEC AT 60 SEC TERM GESTATION? BREATHING OR CRYING? GOOD TONE YES ROUTINE CARE: PROVIDE WARMTH CLEAR AIRWAY DRY ONGOING EVALUATION WARM , CLEAR AIRWAY IF NECESSARY, DRY, STIMULATE

21. WARMTH AVOID HYPOTHERMIA DELIVERY TO BE DONE IN A WARM AND DRAFT FREE AREA BABY TO BE RECEIVED IN A PRE-WARMED TOWEL RAPIDLY DRY HEAD AND SKIN OF BABY AFTER BIRTH DISCARD WET TOWEL AND USE ANOTHER PRE-WARMED TOWEL TO WRAP THE NEONATE. PLACE IN RADIANT WARMER OR WITH MOTHER SKIN TO SKIN.

22. POSITIONING SUPINE WITH HEAD IN NEUTRAL OR SLIGHTLY EXTENDED POSITION WITH ROLLED TOWEL UNDER THE SHOULDER BLADES OF THE NEONATE.

23. CLEAR THE AIRWAY GENTLE SUCTION SOS FIRST MOUTH THEN NOSE TO PREVENT ASPIRATION OF THE MUCUS AND MECONIUM. EACH SUCTION IS ONLY FOR 2-3 SEC. SUCTION PRESSURE IS TO BE MAINTAINED AT < 100 mmHg AVOID DEEP SUCTIONING

24. STIMULATION FLICKING THE SOLE AND TOES TWICE RUBBING OF BACK COMPLETE ALL THIS IN 30 SECS IF NOT RESPONSIVE GO FOR BMV

25. EVALUATION REASSESS EVERY 30 SEC. CONSIDER INTUBATION, IF NEEDED EVALUATE HR,RR, COLOUR HR BY AUSCULTATION COUNT FOR 6 SEC THEN 10 SEC.

26. HR BELOW 100, GASPING? APNEA YES LABOURED BREATHING? PERSISTENT CYANOSIS ROUTINE CARE 30 Sec 60 Sec PPV, SPO2 MONITORING HR BELOW 100? CLEAR AIRWAY, SPO2 MONITORING CONSIDER CPAP YES POST-RESUSCITATION CARE YES TAKE VENTILATION CORRECTIVE STEPS HR BELOW 60 TAKE VENTILATION CORRECTIVE STEPS Intubate if chest does not rise CONSIDER HYPOVOLEMIA PNEUMOTHORAX YES NO NO NO

27. PROVIDE OXYGEN IF NORMAL BREATHING, HEART RATE BUT BLUE LIMBS FREE FLOW OXYGEN AT 5L/MIN BY AN OXYGEN MASK/TUBING MONITOR SPO STATUS.

28. BAG AND MASK VENTILATION INDICATIONS: APNEA OR GASPING HR <100 BEATS/MIN PERSISTENT CENTRAL CYANOSIS DESPITE 100% OXYGEN

29. PROCEDURE APPLY THE MASK OVER THE CHIN AND NOSE RESUSCITATOR SHOULD STAND AT THE HEAD END RATE 40-60/MIN IF CHEST COMPRESSIONS IS DONE THEN 30/MIN EVALAUTE EVERY 30 SEC UNTIL HR>100 BPM IF HR IS<60 BPM START CHEST COMPRESSIONS. IF STOMACH IS DISTENDED, DEFLATE IT.

30. CAUSES OF NON-INFLATION OF CHEST: BLOCKED AIRWAYS LEAK IN MOUTH SEAL INSUFFICIENT INFLATION OF BAG

31. YES CONSIDER INTUBATION CHEST COMPRESSIONS COORDINATE WITH PPV HR BELOW 60? IV EPINEPHRINE TARGET PREDUCTAL SPO2 1 MIN 60-65% 2 MIN 65-705 3 MIN 70-75% 4 MIN 75-80% 5 MINS 80-85% 10 MINS 85-90% 0.01=0.03 mg/kg 1:1000 (0.1 mg/ml)

32. CHEST COMPRESSIONS

33. TECHNIQUES 2 METHODS ARE FOLLOWED IN NEONATAL RESUSCITATION: 2 THUMB METHOD TWO FINGER METHOD

34. METHODS CONTINUED

35. RATE : 90/ MIN COMPRESSION : VENTILATION = 3:1 EVALUATE HR AFTER 3O SEC DISCONTINUE IF HR <60 BPM

36. INDICATIONS FOR ENDOTRACHEAL INTUBATION MECONIUM STAINED BABY MAS NO RESPONSE TO BMV CONGENITAL DIAPHRAGMATIC HERNIA WHEN CHEST COMPRESSION IS DONE SIMULTANEOUSLY FOR ADMINISTRATION OF DRUGS

37. WHEN TO DISCONTINUE NORMAL HR FOR >10 MINS. WHEN TO RESTRICT OR WITHHELD? GA < 23 WEEKS BIRTH WEIGHT < 400 GMS TRISOMY 13 OR 18 MECONIUM STAINED LIQUOR CONGENITAL DIAPHRAGMATIC HERNIA

38. DOCUMENTATION ASSESS AND RECORD THE APGAR SCORE. DESCRIPTION OF EVENTS AND TREATMENT PROTOCOLS WITH TIME TO BE RECORDED.

39. ANY DOUBTS?