Resuscitation of the newborn

About 10% of all newborn require some assistance to begin breathing after birth, and 1% require extensive resuscitation efforts. Newborn resuscitation cannot always be anticipated in time to transfer the mother before delivery to a facility with specialized neonatal support. Therefore, every hospital with a delivery suite should have an organized, skilled resuscitation team and appropriate equipments available.

1. RESUSCITATION OF THE NEWBORN IMO (NICU) SYLHET WOMENS MEDICAL COLLEGE AND HOSPITAL.

2. Neonatal Resuscitation? Series of actions, used to assist, newborn babies who have difficulty with making the physiological ‘transition’ from the intrauterine to extrauterine life.

3. INTRODUCTION About 10% of all newborn require some assistance to begin breathing after birth, and 1% require extensive resuscitation efforts. Newborn resuscitation cannot always be anticipated in time to transfer the mother before delivery to a facility with specialized neonatal support. Therefore, every hospital with a delivery suite should have an organized, skilled resuscitation team and appropriate equipments available.

4. NORMAL PHYSIOLOGIC EVENTS AT BIRTH Normal transitional events at birth begin with initial lung expansion, generally requiring large negative intrathoracic pressures, followed by a cry. Umbilical cord clamping accompanied by a rise in systemic blood pressure and massive stimulation of the sympathetic nervous system. with onset of respiration and lung expansion, pulmonary vascular resistance decreases followed by gradual transition from fetal to adult circulation, with closure of the foramen ovale and ductus arteriosus .

5. ABNORMAL PHYSIOLOGIC EVENTS AT BIRTH The asphyxiated newborn undergoes an abnormal transition. Acutely with asphyxiation the fetus develops primary apnea, during which spontaneous respirations can be induced by appropriate sensory stimuli. If the asphyxial insult persist about another minute, the fetus develop deep gasping for 4-5 minutes, followed by a period of secondary apnea, during which spontaneous respiration cannot be induced by sensory stimulation.

6. CONT… Death occurs if secondary apnea is not reversed by vigorous ventilatory support within several minutes. Because one can never be certain whether an apnoeic newborn has primary or secondary apnea, resuscitative efforts should proceed as though secondary apnea is present.

7. PREPARATION FOR HIGH RISK DELIVERY Preparation for a high risk delivery is often the key to a successful outcome. Cooperation between the obstrtic , anesthesia and paediatric staff is important. Knowledge of potential high risk situations and appropriate interventions is essential. It is useful to have an estimation of weight and gestational age, so that drug doses can be calculated and appropriate endotracheal tube and umbelical catheter size can be chosen.

8. CONT… While waiting for the infant to arrive it is potential problems, steps that may be undertaken to correct them, and which member of the team will handle each step. Provided there is both time and opportunity, resuscitative measures should be discussed with the parents. This is particularly important when the fetus is at the limit of viability or when life threatening anomalies are anticipated.

9. STANDARD EQUIPMENTS SETUP Radiant warmer. Stethoscope. Pulse oximeter. Compressed air and oxygen source. Oxygen blender. Suction source, suction catheter, and meconium aspirators.

10. CONT… Nasogastric tubes Apparatus for bag and ventilation. Ventilation mask Laryngoscope Endotracheal tubes Epinephrine Volume expanders Clock Syringes Equipments for uvc Warm blankets

11. ASSESMENTS OF THE NEED FOR RESUSCITATION

12. ASSESMENTS OF THE NEED FOR RESUSCITATION BY APGAR SCORING The APGAR score is assigned at 1, 5 and occasionally, 10-20 min after delivery. It gives fairly a retrospective idea of how much resuscitation a term infant required at birth and the infants response to resuscitative efforts. During resuscitation , simultaneous assessment of respiratory activity and heart rate provides the quickest and most accurate evaluation of the need for continuing resuscitation.

13. APGAR SCORE Sign 1 2 Color (Appearance) Blue Pale Body pink, Extremities blue Completely pink Heart Rate (Pulse) Absent < 100/min > 100/min Reflex Irritability (Grimace) Absent Grimace Cough, Sneeze Muscle Tone (Activity) None Some flexion of extremities Active movement Respiratory Effort Absent Slow Good, crying

14. APGAR SCORE 8-10 Achieved by 90% of neonates, nothing is required, except Nasal and oral suctioning Drying of the skin Maintenance of normal body temperature.

15. APGAR Score 5-7 Suffered mild asphyxia just before birth. Respond to vigorous stimulation. Oxygen blown over the face.

16. APGAR Score 3-4 These Neonates are moderately depressed at birth. They are usually cyanotic and have poor respiratory efforts. But they usually respond to BMV, breath, and become pink.

17. APGAR SCORE 0-2 These neonates severely asphyxiated and require immediate resuscitation.

18. VENTILATORY RESUSCITATION The baby should be positioned on the back with the neck slightly extended in the neutral position. Clear air way-By suctioning oro -pharyngeal and nasal secretion by using suction catheter if there are sign of air way obstruction. Introduce the catheter about 5cm into the mouth and 3cm into the nose.

19. CONT… If liquor is meconium stained and baby is non vigorous give suction of oral cavity and tracheal suctioning after intubation before drying. While clearing airway in meconium stained the suction pressure should be at 100mmHg, suction should not be more than 10 seconds at a time.

20. CONT… In 1974 Gregory and associates were among the first to show that endotracheal suctioning at birth was beneficial. More recently the American Heart Association and American Academy of Paediatrics recommended endotracheal suctioning when meconium is present in amniotic fluid and infant is non vigorous. Clinical judgement is always Important in deciding whether or not aggressive endotrachel suctioning is necessary .

21. Certain actions of physical stimulation can harm the baby and should not be used . Harmful Action Slapping the back Squeezing the rib cage Holding upside down and shaking Consequences Bruising Fractures, pneumothorax , death. Intraventricular bleeding, brain damage .

22. POSITIVE PRESSURE VENTILATION Most infants can be adequately ventilated with a bag and mask provided that the mask is the correct size with a close seal around the mouth and nose and there is an appropriate flow of gas to the bag.

23. Steps to follow before beginning bag mask ventilation: Position of resuscitator should be at the baby’s side or head to use a resuscitation device effectively. Both positions leave the chest and abdomen unobstructed for visual monitoring of the baby, for chest compressions and for vascular access via umbilical cord. Position of the baby’s head : The baby’s neck should be slightly extended (but not over extended non flexed) into the “sniffing position” to maintain an open airway.

24. APPLYING AND SEALING MASK ON THE FACE Place the mask on the face so that it covers the nose and mouth and tip of the chin rests within the rim of the mask. Use four fingers to ensure sealing: Thumb and ring finger to encircle the upper stiff part of the mask to keep the mask firmly apposed on face, middle finger resting on the rim at chin and little finger at the jaw to maintain neutral position .

25. STARTING BAG MASK VENTILATION Once positioning and sealing are done start bagging and observe whether chest rises with each squeeze. Continue BMV at the rate of 30-40 breaths/min. Be sure that chest rises with each squeezing. If chest does not rise with squeezing : Repositioning Check the mouth, oro -pharynx and nose for secretions, suction the mouth and nose if necessary. Reapplying mask with mouth open and ensuring better seal.

26. CONT… Continue effective ventilation for one minute at the rate of 40 breaths/min. To help a rate of 40 breaths/min try saying to yourself as you ventilate the newborn.. One thousand… one… one thousand… two… (Squeeze) (Release) (Squeeze) (Release)

27. Assessment for sign of improvement after one min of effective ventilation. Improvement is indicated by the signs Improving color Breathing well Improving muscle tone. If spontaneous regular breathing established reduce rate of BMV and discontinue.

28. Check heart rate if not breathing well after one min of effective BMV. If heart rate <60 b/min, continue effective BMV till spontaneous regular breathing is established along with assessment for signs of improvement every 30 seconds. When the heart rate stabilizes above 100 b/minutes and no spontaneous regular respirations, reduce the rate and pressure of assisted ventilation until effective spontaneous respirations.

29. CONT… If heart rate remains below 60 b/min despite one min of effective ventilation, proceed to the next step of chest compressions. If physiologic improvements still cant be achieved, Endotracheal intubation may be done if possible.

30. If bag mask ventilation is to be continued for more than several times, following measures have to be taken : Insert an oro -gastric tube and left in place. The problems related to gastric/abdominal distention and aspirations of gastric contents can be reduced by inserting an oro -gastric tube, suctioning gastric contents and leaving the gastric tube in place and uncapped to act as a vent for stomach gas throughout the reminder of the resuscitation.

31. TARGETED PREDUCTAL OXYGEN SATURATION AFTER BIRTH The American Heart Association and American Academy of Paediatrics recommended that blended gas be used for positive pressure ventilation and oxygen concentration be adjusted to meet the preductal pulse oxymetry goals based on the age after birth.

32. CONT. Age SPO2 1 min 60-65% 2 min 65-70% 3 min 70-75% 4 min 75-80% 5 min 80-85% 10 min 85-95%

33. CARDIAC RESUSCITATION The chest compressions should be started when the heart rate is <60 b/min and baby is not breathing at all or Gasping after giving several cycles of effective bag mask ventilation . The person performing chest compressions must have access to the chest and be able to position his or her hands correctly. The person assisting ventilation will need to be positioned at the baby’s head to achieve an effective mask –face seal and watch for effective chest movement.

34. TECHNIQUES FOR PERFORMING CHEST COMPRESSIONS Two techniques : 1. The two thumb encircling hand technique : Two thumbs are used to depress the sternum, while the hands encircle the torso and the fingers support the spine. Hands should be positioned on the lower third of the sternum in the midline. The thumbs can be placed side by side or on small baby, one over the other. The thumbs should be fixed at the first joint and pressure applied vertically to compress the heart between the sternum and the spine.

35. CONT… 2.The two finger technique The tip of the middle finger and either the index finger or ring finger of one hand are used to compress the sternum, while the other hand is used to support the baby’s back. Position two fingers perpendicular to the chest and press with the finger tips. The 2 thumbs encircling hands technique is recommended for performing chest compression in newborn as it generates higher peak systolic and coronary perfusion pressure than two finger technique.

36. Two techniques for performing chest compression The required pressure to compress the chest: Use enough pressure to depress the sternum to a depth of approximately 1/3 rd of the anterior posterior diameter of the chest and then release the pressure to allow the heart to refill. One compression consist of the downward stroke plus the release. The actual distance compressed will depend on the size of the baby.

37. Coordination of chest compressions with ventilation During cardiopulmonary resuscitation ,chest compressions must always be accompanied by positive pressure ventilation, with one interposed after every third compression for a total of 30 breaths and 90 compressions per minute. One cycle of events(CPR Cycle) will consist of 3 compressions plus 1 ventilation(these 4 events should be administered in 2 seconds) If the heart rate <60 bpm after several cycles of CPR then consider the use of drugs.

38. DRUGS USED IN NEONATAL RESUSCITATION Before initiating drug treatment, one should check the following: Whether the air way is open Whether the chest inflates with each ventilation Whether chest compression given properly. If the newborn does not respond even after the airway is open the chest moves easily with ventilation,and effective chest compressions has been given, only then the drugs may help.

39. CONT… Intravenous adrenaline 1:1000;1ml mixed with 9ml of distilled water to make a 1:10000 dilution.0.1-0.3 ml/kg I/V and 0.5-1ml/kg can be given in ET Tube. Volume expander : when blood loss in known or suspected (Pale skin, weak pulse, poor perfusion and heart rate not responding adequately to the other resuscitative measures) an isotonic crystalloid solution or blood 10ml/kg is recommended which may need to be repeated.

40. Volume expanders should be infused very slowly to the premature babies. If infused rapidly that may cause hypertension & Intra ventricular hemorrhage. Intravenous glucose administration should be considered as soon as after resuscitation with the goal of avoiding hypoglycemia.

41. Sodium bicarbonate: Sodium bicarbonate is usually not useful during the acute phase of neonatal resuscitation. Without adequate ventilation and oxygenation it will not improve the blood pH and may worsen cerebral acidosis. After prolong resuscitation sodium bicarbonate may useful in correcting documented metabolic acidosis.

42. Atropine and Calcium: Although previously used during resuscitation of the asphyxiated newborn, atropine and calcium are no longer recommended by the American Academy of Paediatrics and American Health Association during the acute phase of neonatal resuscitation. These medications are used sometimes in special circumstances in resuscitation.

43. OTHER SUPPORTIVE MEASURES Temperature regulation : Regulation of temperature specially for preterm neonates, who have thin skin, decrease stores of body fat & increased body surface area. Heat loss may be prevented by the following measures- Dry the infant thoroughly immediately after delivery. Maintain a warm delivery room. Place the infant under pre warmed radiant warmer.

44. WHEN TO STOP RESUSCITATION Previous protocol of resuscitation by BSMMU was after 20minute of continuous and adequate efforts if there are no signs of life(no heart rate, no respirations),discontinue resuscitative efforts. Newer protocol by American Academy of Paediatrics and American Heart Association state that if there is no heart rate after 10minute of adequate resuscitation efforts, discontinuation of resuscitation may be adequate.

45. POST RESUSCITATION CARE Babies who require resuscitation are at risk for deterioration after their vital signs have returned to normal. Once adequate ventilation and circulation have been established, the infant should be maintained in, or transferred to an environment where close monitoring and anticipatory care can be provided.

46. Monitor the baby at least 6hrs for Oxygen saturation(SpO2) Heart rate Respiratory rate and pattern Blood glucose measurement Blood gas analysis Fluid balance and nutrition Blood pressure Temperature Neurological

47. COUNSELING AND ADVICE Talk with the parents about resuscitation, answer any question they may have. Counsel parents about hospital admission for post resuscitation care. Encourage mother to keep the baby warm. Explain that there are some risks of infection, feeding problem and convulsions. Advise them to come promptly if any medical problem arises.

48. KEY MESSAGE No respirations, no cry, gasping respirations with long pause in between pale or blue color, heart rate absent or <100 b/min- Go for resuscitation. Early diagnosis and early interventions results good outcome. Proper technique of resuscitation can give a good start of a newborn. Proper counseling and advice can aware parents about post resuscitative consequences . Early assessment and coordinated team work can minimize the neonatal death ratio.

49. REFERENCES Neonatology by Gomella Cunninghum Eyal (7 th edition) Text book of neonatal resuscitation (7 th edition) BSSMU Guidelines for neonatology American academy of paediatrics https://www.ncbi.nlm.nih.gov/pubmed/29373331