Newborn Resuscitation

Delivery room management of normal newborn with introduction to neonatal resuscitation

1. Delivery Room Management & Newborn Resuscitation Dr.C.S.N.Vittal

2. The International Liaison Committee on Resuscitation (ILCOR)  reflected in their Consensus on Science and Treatment Recommendations ( CoSTR )  guidelines published in Oct 2015 and AAP launched 7 th edition of NRP in May 2016

3. Principles Birth asphyxia accounts for about 1/4 th of neonatal deaths occur each year worldwide 90% of newborns make smooth transition from intrauterine to extrauterine life requiring little assistance 10% of newborns need some assistance Only 1% require extensive resuscitation

4. How does a baby receive oxygen before birth? Fetal Circulation Transitional Circulation

5. Air replaces fluid in the alveoli

6. How does a baby receive oxygen before birth? All the oxygen used by a fetus diffuses across the placental membrane from the mother’s blood to the baby’s blood. Only a small fraction of fetal blood passes through the fetal lungs. Most of the blood from the right side of the heart cannot enter the lungs because of the increased resistance to flow in the constricted blood vessels in the fetal lungs

7. How does a baby receive oxygen before birth? Most of this blood takes the lower resistance path through the ductus arteriosus into the aorta

8. What happens normally at birth? fluid in the alveoli is absorbed into pulmonary lymphatics and replaced by air Umbilical arteries constrict and then the umbilical arteries and vein are closed when the umbilical cord is clamped. Blood vessels in the lung tissue relax, decreasing resistance to blood flow

9. What can go wrong? Compromise of uterine or placental blood flow > deceleration of FHR Weak cry > inadequate ventilation to push alveolar fluid In utero hypoxia > Meconium passage > may block airways Fetal blood loss (abruption) > Systemic hypotension Fetal hypoxia / ischemia > poor cardiac contractility and fetal bradycardia > systemic hypotension Pulmonary arterioles remain constricted > PPHN

10. Consequences Compromised baby Depression of respiratory drive - apnea, tachypnoea Poor muscle tone Bradycardia Low blood pressure Persistent cyanosis or low SpO 2 These outcomes can be improved with timely and effective resuscitation

11. How can you tell if a newborn had in utero or perinatal compromise? Perinatal stress results in an initial period of rapid breathing followed by a period of primary apnea (no breathing or gasping) During this period of primary apnea , stimulation, such as drying the newborn or slapping the feet, will cause a resumption of breathing.

12. How can you tell if a newborn had in utero or perinatal compromise? If cardiorespiratory compromise continues during primary apnea , the baby will have an additional brief period of gasping breaths and then will enter a period of secondary apnea During secondary apnea , stimulation will not restart the baby’s breathing. Assisted ventilation must be provided to reverse the process.

13. Sequence of Events Readiness for neonatal resuscitation requires: 1. Introduction 2. Anticipation of Resuscitation Need 3. Umbilical Cord Management 4. Initial Steps 5. Assessment of Heart Rate 6. Assessment of need / Administration of O2 7. Positive Pressure Ventilation (PPV) 8. Advanced Assisted Ventilation 9. Chest Compressions 10. Medications and Volume Administration

14. 1. Introduction answers to the following 3 questions: Term gestation? Good tone? Breathing or crying? If the answer to all 3 questions is “yes,” the newly born infant may stay with the mother for routine care. Routine care means the infant is dried, placed skin to skin with the mother, and covered with dry linen to maintain a normal temperature. Observation of breathing, activity, and color must be ongoing.

15.  Answers to the following 3 questions: Term gestation? Good tone? Breathing or crying? If the answer to any of the three assessment questions is “No,” the infant should be moved to a radiant warmer to receive one or more of the following 4 actions in sequence: Initial steps in stabilization (warm and maintain normal temperature, position, clear secretions only if copious and/or obstructing the airway, dry, stimulate) Ventilate and oxygenate Initiate chest compressions Administer epinephrine and/or volume. Approximately 60 seconds (“ the Golden Minute ”) are allotted for completing the initial steps, re-evaluating, and beginning ventilation if required

16. 2. Anticipation of resuscitation need Assessment of perinatal risk, A system to assemble the appropriate personnel based on perinatal risk, An organized method for ensuring immediate access to supplies and equipment, Standardization of behavioral skills that help assure effective teamwork and communication

17. 3. Umbilical cord management Delayed cord clamping for longer than 30 seconds is reasonable for both term and preterm infants who do not require resuscitation at birth. Routine use of cord milking for infants born at less than 29 weeks of gestation outside of a research setting, NOT RECOMMENDED

18. 4. Initial steps of newborn resuscitation Routine care Maintain normal temperature Position the infant in a “sniffing” position to open the airway Clear secretions if needed with a bulb syringe or suction catheter Dry the infant Ongoing evaluation Birth 30 sec 60 sec Term gestation? Breathing or crying? Good tone? Yes, stay with the mother

19. 4. Initial steps of newborn resuscitation Routine care Maintain normal temperature Position the infant in a “sniffing” position to open the airway Clear secretions if needed with a bulb syringe or suction catheter Dry the infant Stimulate Birth 30 sec 60 sec Term gestation? Breathing or crying? Good tone? Yes, stay with the mother No Clear secretions Dry the infant Stimulate

20. 4.1 Importance of maintaining normal temperature Hypothermia is associated with serious morbidities, such as increased risk of intraventricular hemorrhage , respiratory issues, hypoglycemia and late-onset sepsis. It is recommended that the temperature of newly born nonasphyxiated infants be maintained between 36.5°C and 37.5°C after birth through admission and stabilization. The goal is an axillary temperature between 36.5°C and 37.5°C. 

21. Interventions to Maintain Newborn Temperature in the Delivery Room The use of radiant warmers and plastic wrap with a cap has improved but not eliminated the risk of hypothermia in preterm infants in the delivery room. To prevent hypothermia in infants born at less than 32 weeks of gestation. Increased room temperature, Thermal mattresses, and Use of warmed humidified resuscitation gases. All resuscitation procedures, including endotracheal intubation, chest compression, and insertion of intravenous lines, can be performed with these temperature-controlling interventions in place Hyperthermia (greater than 38.0°C) should be avoided due to the potential associated risks.

22. Provide warmth Vigorous, term newborn . Initial steps are performed skin-to-skin with mother.

23. Maintaining Normothermia in Resource-Limited Settings In resource-limited settings, to maintain body temperature or prevent hypothermia during transition (birth until 1 to 2 hours of life) in well newborn infants, it may be reasonable to put them in a clean food- grade plastic bag up to the level of the neck and swaddle them after drying.  

24. Maintaining Normothermia in Resource-Limited Settings Another option that may be reasonable is to nurse such newborns with skin-to-skin contact or kangaroo mother care.  

25. Stimulate

26. 4.2 Clearing the airway When amniotic fluid is clear: Avoiding unnecessary suctioning helps prevent the risk of induced bradycardia that can be associated with suctioning of the nasopharynx.  It is recommended that suctioning immediately following birth (including suctioning with a bulb syringe) should be reserved for babies who have obvious obstruction to spontaneous breathing or who require positive-pressure ventilation (PPV)

27. Clearing the airway - When meconium is present: If the infant born through meconium-stained amniotic fluid presents with poor muscle tone and inadequate breathing efforts , the initial steps of resuscitation should be completed under the radiant warmer. PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed. Routine intubation for tracheal suction in this setting is not suggested Emphasis should be made on initiating ventilation within the first minute of life in nonbreathing or ineffectively breathing infants.

28. 5. Assessment of hart rate The use of 3-lead ECG for the rapid and accurate measurement of the newborn’s heart rate may be reasonable. Pulse oximeter tended to underestimate the newborn’s heart rate (potentially leading to unnecessary interventions)

29. 6. Assessment of oxygen need and adm Clinical assessment of skin color is a very poor indicator of oxyhemoglobin saturation during the immediate neonatal period and lack of cyanosis appears to be a very poor indicator of the state of oxygenation of an uncompromised baby following birth. There is evidence that either insufficient or excessive oxygenation can be harmful to the newborn infant.

30. 6.1 Use of Pulse Oximetry It is recommended that oximetry be used when resuscitation can be anticipated, when PPV is administered, when central cyanosis persists beyond the first 5 to 10 minutes of life, or when supplementary oxygen is administered. The probe should be attached to a preductal location ( ie , the right upper extremity, usually the wrist or medial surface of the palm).

31. 6.2 Administration of oxygen In term and late-preterm newborns (≥35 weeks of gestation) receiving respiratory support at birth, the initial use of 21% oxygen is reasonable. One hundred percent oxygen should not be used to initiate resuscitation because it is associated with excess mortality. Oxygen concentration should be titrated to achieve a preductal oxygen saturation approximating the interquartile range (see table) measured in healthy term babies following vaginal birth at sea level. Targeted Preductal SpO2 after birth 1 min 60-65% 2 min 65-70% 3 min 70-75% 4 min 75-80% 5 min 80-85% 10 min 85-95%

32. 6.2 Administration of oxygen In preterm newborns (<35 weeks of gestation) receiving respiratory support at birth, it may be reasonable to begin with 21% to 30% oxygen with subsequent oxygen titration based on pulse oximetry.   Oxygen concentration should be titrated to achieve a preductal oxygen saturation approximating the interquartile range (see table) measured in healthy term babies following vaginal birth at sea level.

33. 7. Positive Pressure Ventilation (PPV) If the infant remains apneic or gasping, or If the heart rate remains <100 per minute after performing the initial steps, begin positive pressure ventilation.

34. Different Types of Resuscitation Devices Flow inflating bags Fills only when oxygen from a compressed source flows in to it Self inflating bags Fills spontaneously after it is squeezed, pulling oxygen or air in to the bag T-piece resuscitator Also works when gas from compressed source flows into it. The gas is directed into the baby by occluding the opening on T-piece

35. Flow Inflating Bags

36. Self Inflating Bags

37. T-Piece Resuscitator

38. Frequency of PPV

39. 7.1 Initial Breaths An initial inflation pressure of 20 cm H 2 O may be effective, but ≥30 to 40 cm H 2 O may be required in some term babies without spontaneous ventilation The minimal inflation required to achieve an increase in heart rate should be used.  Assisted ventilation should be delivered at a rate of 40 to 60 breaths per minute to promptly achieve or maintain a heart rate >100 per minute.

40. 7.2 End-Expiratory pressure When positive pressure ventilation is administered to preterm newborns , approximately 5 cm H 2 O positive end-expiatory pressure is suggested. When self-inflating resuscitation bags are used, the addition of a positive end-expiratory pressure (PEEP) valve will be required.

41. Improving Efficacy of PPV

42. 8. Assisted ventilation Devices and Advanced Airways A laryngeal mask may be considered as an alternative to tracheal intubation I If face-mask ventilation is unsuccessful in achieving effective ventilation. IF tracheal intubation is unsuccessful or is not feasible.

43. 8.1 Assisted ventilation Devices and Advanced Airways Endotracheal intubation may be indicated when bag-mask ventilation is ineffective or prolonged, when chest compressions are performed, or for special circumstances such as congenital diaphragmatic hernia Confirmation of endotracheal tube placement in infants, including very low-birth-weight infants. Exhaled CO 2  detection Failure to detect exhaled CO 2  in neonates with adequate cardiac output strongly suggests esophageal intubation.

44. 8.1 Assisted ventilation Devices and Advanced Airways Other clinical indicators of correct endotracheal tube placement condensation in the endotracheal tube, chest movement, and presence of equal breath sounds bilaterally, CPAP Spontaneously breathing preterm infants with respiratory distress may be supported with CPAP initially rather than routine intubation for administering PPV.

45. Signs of Effective Positive-pressure Ventilation Rapid rise in heart rate Improvement in oxygenation Improving muscle tone Audible breath sound Chest movement

46. 9. Chest Compressions If the heart rate is less than 60/min despite adequate ventilation (via endotracheal tube if possible), chest compressions are indicated. Ensure that assisted ventilation is being delivered optimally before starting chest compressions. Compressions are delivered on the lower third of the sternum to a depth of approximately one third of the anterior-posterior diameter of the chest.

47. 9. Chest Compressions - Two techniques 2 thumbs with the fingers encircling the chest and supporting the back 2 fingers with a second hand supporting the back 2 thumb–encircling hands technique is suggested as the preferred method. 

48. 9. Chest Compressions The chest should be allowed to re-expand fully during relaxation [after each compression], but the rescuer’s thumbs should not leave the chest. A 3:1 ratio of compressions to ventilation , with 90 compressions and 30 breaths to achieve approximately 120 events per minute to maximize ventilation at an achievable rate is recommended.   3:1 compression-to-ventilation ratio is used for neonatal resuscitation where compromise of gas exchange is nearly always the primary cause of cardiovascular collapse, but rescuers may consider using higher ratios ( eg , 15:2) if the arrest is believed to be of cardiac origin Respirations, heart rate, and oxygenation should be reassessed periodically, and coordinated chest compressions and ventilations should continue until the spontaneous heart rate is ≥ 60 per minute.  

49. Rhythm of Chest Compression Coordinate with IPPR One ventilation interposed after every 3rd compression Total of 120 events (30 breaths + 90 compressions)

50. 10. Medications and Volume Administration Bradycardia in the newborn infant is usually the result of inadequate lung inflation or profound hypoxemia, and establishing adequate ventilation is the most important step to correct it. if the heart rate remains less than 60/min despite adequate ventilation with 100% oxygen (preferably through an endotracheal tube) and chest compressions, administration of epinephrine or volume, or both, is indicated.

51. 10.1 Epinephrine  IV administration of 0.01 to 0.03 mg/kg per dose is the preferred route [for epinephrine administration]. While access is being obtained, administration of a higher dose (0.05 to 0.1 mg/kg) through the endotracheal tube may be considered, but the safety and efficacy of this practice have not been evaluated. Concentration of epinephrine for either route should be 1:10 000 (0.1 mg/mL).

52. 10.2 Volume Expansion Considered when blood loss is known or suspected pale skin, poor perfusion, weak pulse and The infant’s heart rate has not responded adequately to other resuscitative measures. An isotonic crystalloid solution or blood may be considered for volume expansion in the delivery room. When resuscitating premature infants, care should be taken to avoid giving volume expanders rapidly, because rapid infusions of large volumes have been associated with intraventricular hemorrhage .  

53. Dr.C.S.N.Vittal Thank You