Neonatal resuscitation

Lecture by Andriy Berbets

Asphyxia – it’s a syndrome characterized by absence of breathing movements but with presence of heartbeat of fetus

Classification:1. Central (suppression of breathing centre)2. Peripheric3. May be caused by trauma, immaturity of fetus

nervous system, pharmacological depression etc.

4. May be cased by lungs, heart dysfunction or anemia

Apgar score

3 degrees of asphyxia Mild, moderate, severeApgar score 6-7 (1st min) – mildApgar score 5-4 (1st and 5th min) – moderateApgar less 3 – severe

Three stages of reanimation of the newborn1 ABC-reanimation2 Intensive therapy3 Reabilitation

АВС-stepsА- airwaysВ- breathingС-circulation

А-step1. To put the newborn in the correct position2. Free the nose, mouth and trachea (if needed)3. Intubation (if needed)

В-step4. Tactile stimulation to cause breathing 5. Artificial breathing (if needed)• Bag and mask ventilation• Trachea intubation (if needed)

C-step1. To support blood circulation2. Indirect heart massage3. Treatment by medication

Don’t forget about “heating chain”!

General methodfology

The necessity of further aid to the newborn during resuscitation is based on the simultaneous estimation of three clinical signs:

• presence and adequacy of independent breathing;

• frequency of heartbeat;• color of the skin and mucous membranes.

Every 30 seconds of resuscitation of newborn it is required:

– to estimate vital signs mentioned above;– using general algorithm of resuscitation to decide

what to do further,– to perform a corresponding action;– to estimate 3 important vital signs again; to

decide, what interference is required in this moment, and to perform it;

– to continue the cycle "estimation-decision-action" until resuscitation is completed.

Presence and adequacy of independent breathing

• The estimation of presence and adequacy of independent breathing is conducted:

• right after the birth of a baby – for taking the decision about beginning of resuscitation;

• at the end of the 1st and the 5th min (and further, in case of necessity) – for estimation by APGAR scale;

• during resuscitation actions;• during staying of a newborn in the delivery room

(regardless whether the primary resuscitation was conducted).

Signs of adequate breathing of a newborn

• The scream and/or satisfactory excursions of the thorax:

• The frequency and depth of respiratory movements must grow in a few seconds after birth (for instance, after the tactile stimulation);

• The normal frequency of breathing of a newborn is 30-60 movements per 1 minute.

• Besides of frequency and depth of breathing it is necessary to estimate symmetry of the respiratory movements, and also presence of other respiratory disorders: convulsive breathing, grunting breathing, considerable retractions.

Signs of inadequate breathing of a newborn

• Absence of breathing movements• Convulsive respiratory movements ("gasping" type of

breathing), or bradypnea < 30 breathings per 1 minute are ineffective.

• The appearance of expiratory grunting or other respiratory disorders – baby needs further post-resuscitational aid.

• If artificial respiration is conducted for baby, it has to be stopped approximately for 6 seconds to estimate presence and adequacy of independent breathing of the newborn.

Estimation of the heartbeat of a newborn

• Normal heartbeat frequency of a newborn is > 100 per 1 minute.

• Bradycardia < 100 heartbeats per 1 minute in newborn is always indication for initialing artificial respiration.

Methods of determination of heartbeat frequency of a newborn:

– Listening the palpitation using stethoscope on the left side of the thorax is the most reliable method.

– Palpation of pulsation on the basis of umbilical cord directly in the area of its connection to the frontal abdominal wall is useful to exclude bradycardia.

– Heartbeat frequency of a newborn is counted during 6 seconds. The result is multiplied on 10.

– While counting heartbeat frequency of a newborn artificial respiration and indirect cardiac massage have to be stopped.

Estimation of the color of the mucous membranes and skin

• Presence and changes of central cyanosis should be observed. It is determined as a dark blue color of mucous membranes, lips and skin of trunk of a newborn.

• Acrocyanosis (blue color of palms and feet of a newborn) without central cyanosis usually is not indicative of a low oxygen level in the blood of a newborn. However, it can testify to the presence of cold-provoked stress (hypothermia) of a newborn.

• Paleness or presence of a marble pattern of the newborn’s skin can be non-specific signs of decreased heartbeat volume, severe anaemia (including hemolytic), hypovolemia, hypothermia or acidosis of a newborn.

Maintenance of passability of the respiratory tract in case of clean amniotic fluid

To put the child in supine position (on the back) or lying on its side. The head should be slightly extended, a bolster should be placed under the shoulders. Conduct aspiration (sucking-out) procedure at first from the mouth, then – from the nose. General rules:

• to use a disposable rubber bulb for aspiration of secretion and mucus; in case of absence of disposable rubber bulbs sterile disposable catheters can be used;

• during aspiration do not insert a catheter or bulb too vigorously or too deeply (not deeper than 3 cm from the level of lips for a full-term newborn and 2 cm for a premature baby);

• to perform aspiration briefly and carefully. The bulb or catheter should be removed slowly. The duration of aspiration should not not exceed 5 seconds.

Meconium removal

Oxygen therapy

• Presence of central cyanosis in a baby is the indication to supply free stream of oxygen, regardless of adequate independent breathing and heartbeat frequency > 100 per minute.

• A newborn who gets an additional oxygen in delivery room (or in the operating-room) must be under the permanent supervision of medical personnel.

Oxygen therapy

• Give a free oxygen stream in the direction to the nose of a baby. Speed of free oxygen stream should not exceed 5 liters per minute, to prevent supercooling of a baby.

• Equipment for the oxygen therapy:- oxygenation tube;- breathing sack filled with oxygen stream, and

resuscitation mask;- oxygenation “tent”

Oxygen therapy

Artificial ventilation of lungs by sack and mask

Indications for artificial respiration by sack and mask:• Absent or inadequate independent breathing after initial steps

of resuscitation, conducted during 30 seconds after the child birth.

• The heartbeat frequency of a newborn < 100 per 1 minute regardless of presence and adequacy of independent breathing after initial steps of aid, conducted during 30 seconds after the child birth.

• Stable central cyanosis, in spite of presence of adequate independent breathing, heartbeat frequency of a newborn > 100 per 1 minute and supplement of free stream of 100 % oxygen during at least 5 minutes.

Bag and mask ventilation

Indications for artificial respiration by 100% oxygen

• Critical condition of a newborn: absence of independent breathing, muscle tonus, reaction to irritations, paleness of the skin in case of presence of heartbeating.

• Absence of positive changes of the state of a newborn within 90 seconds after delivery, in spite of effective lung ventilation by air:

• heartbeat frequency of a newborn < 100 per 1 minute after 30 seconds of ventilation;

• presence of indications for indirect cardiac massage.

Correct position of the baby

Assessment of efficacy of reanimation

Breath evaluation• If spontaneous breathing is present, we can

access the ECG• If no spontaneous breath movements are

present, we start artificial breathing with 90-100 % of oxygen

Heartbeat evaluation

Heartbeat (HB) is more then 100 per min:1. If there is spontaneous breathing, and HB is more then 100/min,

we stop artificial breathing (AB) and evaluate cyanosis of the skin

2. If there is no spontaneous breathing, we continue AB3. If there is less then 100 HB per min, AB has to be continued:• Heartbeat is 60-100 beats – continue AB• Heartbeat is less then 60 min – indirect heart massage

Indications for intubation:• Long-time AB• Aspiration by meconium• Diaphragmal hernia• No effect from bag/mask artificial breathingMedication for C-step• Adrenalin• Infusive solutions• Solution of soda (NaHCO3) for acidosis correction• Antagonists of narcotic drugs (naloxon 0.1 mg/kg)

i.v. or per os

Trachea intubation

Indirect cardiac massage

Frequency of pressure on the thorax is 90 for 1 minute.It is important to coordinate indirect massage of the heart

with artificial respiration, avoiding simultaneous implementation of both procedures:

• after each three pressures on the breastbone make a pause for realization of artificial ventilation of the lungs. After this the pressures are repeated;

• during every two seconds of resuscitation it is needed to press on the breastbone 3 times (90 presses per 1 min) and to conduct 1 ventilation action (30 actions per 1 min), altogether - 120 actions per 1 minute have to be performed.

Indirect cardiac massage

Criteria of efficiency of indirect cardiac massage

• the increase of frequency of the heartbeat of a newborn,

• the possibility to define pulsation on the humeral artery.

Stop indirect cardiac massage, if the heartbeat frequency of a newborn is more than 60 beats per minute.

After each 30 seconds of indirect cardiac massage repeatedly estimate the heartbeat and breathing of a newborn to decide what to do further.

Indications for adrenaline (epinephrine)

• HB < 60/min after 30 sec of AB 100% O2• Absence of heartbeatSolution 1:10000

Infusion therapyRinger’s solution (5-10 ml/kg) in umbilical veinBlood plasma (indications only!)0,9% NaCl

Resuscitation measures

Thank you!