Neonatal Resuscitation

Name:

Date:
Introduction

Birth asphyxia or perinatal asphyxia is a condition where a neonate fails to start and sustain
breathing at birth (WHO, 2012). In such a scenario, the neonate is compromised and therefore
needs neonatal resuscitation before it is too late. This assignment is going to focus on neonatal
resuscitation. Neonatal Resuscitation is a series of systematic procedures carried out to
establish and enhance circulation and breathing in a new born (Lockyer J. et. al, 2006).
According to WHO (2012), about one quarter of newborn deaths globally, are caused by
neonatal asphyxia. In 2008, about 40% of under-5 deaths occurred in the neonatal period and
approximately 9% of these were caused by neonatal asphyxia (WHO, 2011). According to
Versantvoort J. M. D., et al. (2020), the most important cause for neonatal mortality is
inadequate health professional skills and insufficient resources at the time of birth, that’s why
a simulation course on “Helping a Baby Breathe" was introduced. As per the National
Medical Council (NMC) 2018, guidelines on confidentiality, we shall use pseudonyms instead
of real names in the case study.

The study is about Mrs. Lilly, a 26 year old prim-gravida, who goes for antenatal care at
39weeks gestation, where the obstetrician diagnoses fetal distress and orders for emergency
vacuum evacuation. Upon delivery, baby Ariana is covered in meconium and gasps, her
Apgar scoring at one minute is 3 and is five at 5 minutes, she has bluish hands and legs, and
the midwife endeavors to resuscitate her. After about ten minutes of resuscitation, she gives a
weak cry, her Apgar score is six, and the midwife suspects a possibility of neonatal hypoxic
ischemic encephalopathy, (HIE), thus she is transferred to the neonatal intensive care unit
(NICU) for further management. I have not had a chance to provide care to a baby with birth
asphyxia, however, I picked interest in neonatal resuscitation after reading about Helping a
baby breathe initiative, and chose neonatal resuscitation as my topic so as to gain more
knowledge concerning the same.

Objectives

The aim of this article is to carry out a literature review on the factors causing hypoxic
ischemic encephalopathy (HIE), the effectiveness of evidence based practices used in
neonatal resuscitation, and the correlation between awareness of the health professionals of
these evidence based practices and decrease in neonatal morbidity and mortality due to birth
asphyxia. This review will also aim to help us understand the midwife’s role in neonatal
resuscitation.

Scenario

Mrs. Lilly is a 26 year old prim-gravida with 39 weeks gestation. During the antenatal visit,
fetal distress is diagnosed and an emergency vacuum extraction is done. Upon delivery, the
baby is covered by thick meconium and she gasps. The nurse suctions the mouth and pharynx,
the Apgar scoring at 1 minute is 3. The neonate presents with blue hands and feet, and doesn't
respond when dried. The neonate is given facial mask and oxygen and the 5 minute Apgar
score is 5. The nurse continues to resuscitate the baby using positive pressure ventilation and
after about ten minutes, the neonate gives a weak cry. The midwife suspects hypoxic ischemic
encephalopathy and the neonate is transferred to the NICU for further assessment and
management.

Methodology

Literature Review

According to Lee A. C. et al., (2013), an annual estimation of about 1.2 million still births and
700,000 full term neonatal deaths are due to intra- partum complications. Also, an
approximate of 1.2million infants develops neonatal encephalopathy later as they grow.

The literature review will focus on three main themes, which include, possible causative
factors of hypoxic ischemic encephalopathy in neonates and its management, evidence based
practices of neonatal resuscitation and how the degree of knowledge, expertise and team work
in health professionals, can drastically decrease the neonatal mortality and morbidity rates.

Causes of Neonatal Hypoxic Ischemic Encephalopathy (HIE)

Hypoxia is defined as diminished oxygen supply to the body tissues which impairs body
functions (Britanicca, T. Editors of Encyclopaedia 2020). The bluish discoloration of baby
Ariana’s hands and feet is an indication that she is hypoxic. Ischemia means diminished blood
supply and the word encephalopathy is used to mean a brain disorder. According to critical
care pediatric brain center, HIE is defined as an impairment in the brain function that occurs
due to diminished blood and oxygen supply to brain for a while. According to Allen K. A. and
Brandon D. H., (2012), the incidence of HIE in developed countries ranges from 1.5 to 2.5 per
1000 live births. Six articles have been scrutinized to review literature concerning the causes
of HIE. These include; Martinez-Biarge, M. et al (2013), Hayes B. C. et al (2013), and
Torbenson, V.E., et al. (2017), Dijxhoorn, M. J., et al. (1986), and Berkus, M. D., et al. (1994)

The research done by Martinez-Biarge, M. et al (2013), on a case-controlled study of infants

born after 36 weeks gestation, suggests one antepartum and seven intrapartum causes of
neonatal HIE, these are; thick meconium, failed vacuum, tight nuchal cord, an acute event,
shoulder dystocia, prolonged rapture of membranes, an abnormal cardiotocography and a
gestational age beyond forty weeks.

Furthermore, Hayes et al equally suggest thick meconium, a larger head circumference,

decreased fetal heart rate, maternal infections, fetal growth restriction, increased uterine
contractions and decreased amniotic fluid as the possible causes of HIE. The use of a case
controlled study and the inclusion of all existing cases of HIE, makes this research article
reliable. However, the study is limited by its retrospective nature.

The research by Vanessa was a case controlled study focused on the assessment of
intrapartum factors that are associated with neonatal HIE suggest that presence of thick
meconium in the amniotic fluid, a prolonged second stage of labor which is defined a second
stage of labor longer than 2 hours in multi-para women or greater than three hours in
primigravida mothers and decrease in fetal heart rate as the factors causing HIE. The use of a
well matched case-control method and having both their cases and controls emerge from the
same institution makes their research strongly reliable. Noteworthy, the use of a smaller
sample space and using diagnosis codes for case identification limited their study.

However, Meis P. J., et al. (1982) and Dijxhoorn, M. J., et al. (1986) seem to disagree with
the relation of the presence of thick meconium to hypoxia or low Apgar score. Furthermore,
Berkus, M. D., et al. (1994), suggest an association between the presence of meconium and
unsatisfactory outcomes. In conclusion, the causative factors of HIE are idiopathic but
presence of thick meconium, cord prolapse, shoulder dystocia, prolonged labor, fetal growth
restriction, decreased amniotic fluid, failed vacuum, fetal bradycardia, fetal cardiac
anomalies, among others are usually manifested in infants presenting with HIE.

Management of Neonatal HIE

This theme is going to explore the available literature on management of HIE. Six articles are
going to be scrutinized. These include; Shankaran, S., et al., (2005), So Hing-Yu, (2010),
Laptook, A. R., et al., (2017), Edwards A. D. et al., (2010), Allen K. A. and Brandon D. H.,
(2012) and Zhu, C., et al., (2009).

According to So Hing-Yu, (2010), Hypothermia is a core body temperature below 360C

whereas induced hypothermia is the deliberate reduction of a patient’s temperature to less
than 360C. Therapeutic hypothermia means induced hypothermia with the potentially
dangerous effects such as shivering regulated. The degrees of hypothermia vary with
temperatures between 340 C - 35.90C regarded as mild, moderate ranges from, 320C to 33.90C,
moderately deep ranges from 300 C to 31.90C and deep is less than 300C. In the treatment of
HIE, moderate therapeutic hypothermia is considered effective.

According to Shankaran, S., et al., (2005), who conducted a case-control study on whole body
hypothermia for neonates with HIE, their studies indicate that whole body therapeutic
hypothermia can reduce the mortality and disability of infants affected by severe to moderate
HIE. However, their study is limited by the fact that 44% of the case group died or got
moderate to severe disabilities, 24% of the case group died, and 19% got cerebral palsy, this
indicates that therapeutic hypothermia might not be 100% effective in the management of
HIE. The use of case control and a large sample space makes the study reliable.

Furthermore, in a randomized clinical trial, Laptook, A. R., et al., (2017), conducted a study
on the effect of therapeutic hypothermia initiated after six hours of age on newborns with
HIE, which suggests that hypothermia started in less than six hours after birth has a 76%
chance of reducing infant mortality and disability in cases of HIE. The study is strongly
reliable as it was conducted in a case control setting for a period of about eight years.

According to Edwards A. D. et al., (2010), during a study to determine the neurological

outcomes at eighteen months for perinatal HIE, using synthesis and meta-analysis of data, a
conclusion was made that indeed therapeutic hypothermia is effective in minimizing the
neurological impairment and infant mortality caused by HIE. However, the study discovered
that therapeutic hypothermia was not effective in the prevention of deafness.

According to Allen K. A. and Brandon D. H., (2012), Hypothermia intervention is

administered by either cooling the whole body or selective head cooling of the infant with an
aim of decreasing the neonate’s temperature to a range of about 330C to 36.50C, for a period
of about 48 to 72 hours, followed by a gradual rewarming to prevent complications, such as
hypotension.
All the articles concur that although moderate hypothermia seems improve on the chances of
positive out comes in neonates with HIE, it is not 100% reliable and despite the fact that it
reduces the infant mortality and disability rates due to HIE, 30% of the case studies still
experienced neurodevelopmental disabilities and whereas babies with moderate HIE had a
drastic decrease in disability and mortality rates at one and a half years of age, there was no
significant change in the disability and mortality rates of babies with severe HIE (Allen K. A.
and Brandon D. H., 2012). Therefore, Allen K. A. and Brandon D. H., (2012), conducted a
study on Hypoxic Ischemic Encephalopathy and enlisted the experimental treatments
emerging for the management of HIE, which included; the application of neuroprotective
agents and pre-conditioning of the cerebral tissues to demand low levels of oxygen, however,
this intervention is not yet understood and is not yet applicable to humans.

However, Zhu, C., et al., (2009), in their study on Erythropoietin improved neurological
outcomes in infants with HIE, continuous administration of recombinant human
erythropoietin in low doses demonstrated a reduction in the disability for babies with
moderate HIE and didn’t show any adverse effects.

In conclusion, the treatment of HIE is still under research and there isn’t any actual treatment
but management of symptoms and rehabilitation. However, moderate hypothermia and
Erythropoietin administration can help to reduce on the disability and mortality rates.

Evidence Based Practices on Neonatal Resuscitation

This theme is going to analyze the effectiveness of the available practices on neonatal
resuscitation, their feasibility, and how creating awareness among health professionals
concerning these practices can help to reduce neonatal morbidity and mortality due to
asphyxia. It will also help to assess how the effectiveness of teamwork among health
professionals during intranatal and postnatal period can help to reduce infant mortality.

The articles going to be analyzed include;

One of the practices in neonatal resuscitation is delayed cord clamping. Three randomized
studies (Mercer, J. S., et al., (2006); Baenziger, O., et al., (2007); Kugelman, A., et al, (2007)
that analyzed effect of delayed cord clamping on pre-term infant mortality were reviewed, and
they didn’t show any significant effect of delayed cord clamping to the mortality rates. The
risk of neonatal death in the delayed and early code clamping group was the same (RR 0.73,
95%, CI 0.30-1.81). Two studies (Ceriani Cernadas, J. M.,(2006); van Rheenen, P., et al,
(2007)) analyzed the effects of delayed cord clamping on the possibility of anemia at six
months of age on full term infants and there was no outstanding difference in the rate of
anemia in the early and delayed clamping clusters (RR 0.87, 95% CI0.69-1.10). Based on
these studies, there is minimum proof that delayed cord clamping is ineffective on infant
morbidity and mortality.

An animal study (Scarpelli, E. M., Condorelli, S., & Cosmi, E. V., 1977), on the outcome of
tactile stimulation on spontaneous breathing in fetal lambs indicated that spontaneous
respiration in apneic lambs was induced by cutaneous stimulation. There isn’t any human
studies concerning tactile stimulation, however, the available animal studies weakly suggest
that tactile stimulation can induce spontaneous respiration. Furthermore, WHO suggests that
drying the newborn is a form of stimulation and no further stimulation is needed.

Three studies, (Dunn, T. S., et al, (2001), Locus, P., Yeomans, E., & Crosby, U., (1990))
compared incidences of infants who had meconium aspiration syndrome and were suctioned
with a bulb syringe with those that were suctioned with a Delee catheter and no significant
observations were noted in the risk of meconium aspiration syndrome. However, one animal
study (Cohen-Addad, N., et al., 1987) suggested that using the Delee catheter in suctioning
was more successful in the removal of meconium from the trachea than using a bulb syringe.
Therefore suctioning of the neonate helps to reduce on the risk of meconium aspiration
syndrome, arrhythmias and mortality.

A retrospective study by Wall, S. N., et al., (2009), on cases of suspected birth-related

malpractices suggested that deaths in neonates whom positive pressure ventilation (PPV) had
been started within a minute upon birth was slightly lower than in the cases where PPV was
started at a later time. Therefore early initiation of PPV is strongly recommended as a means
to reduce on neonatal mortality and morbidity due to asphyxia. This study however was
limited by the small sample space, and the fact that most of the infants who underwent PPV in
the first minute upon birth were not resuscitated as per the guidelines in the next minutes
following delivery.

Two studies by (Bang, A., et al., (2020); Wall, S. N., et al, 2009) concur that routine training
of health professionals could reduce intrapartum-related mortality by 30%. Furthermore,
Gamtessa, L.C., et al., (2020), who carried out a study to analyze the success of the helping a
baby breathe initiative acknowledges that the degrees of satisfaction among the trainees was
high upon successful completion of the course and the techniques taught could be
implemented by the health professionals working from low income countries. In conclusion,
routine training of health professionals about neonatal resuscitation guidelines and techniques,
alongside teamwork are essential to reduce on mortality rates due to intrapartum
complications.

Role of the Midwife in Neonatal Resuscitation

It is the midwife’s role to be well versed with the hospital policy on baby friendly initiatives,
educate the expectant mother concerning the initiatives and help her implement them upon
delivery (Gomez-Pomar, E., and Blubaugh, R., 2018). Furthermore, it is the midwife’s role to
gain the expertise and knowledge concerning the neonatal resuscitation guidelines, and how to
effectively implement them (Hainstock, M. L., and Raval, G. L., 2020). The midwife must
endeavor to adhere to the recommended drug administration guidelines to ensure the safety of
both the mother and child (NMC, 2015). Therefore, the Nursing council and midwife
guidelines (NICE), recommend that the midwife should avail evidence based facts to the
patient, as well as a great deal of expertise whilst rendering care to the patient.

The midwife needs to maintain a care plan for both the mother and the neonate (NMC, 2015).
Moreover, it is the midwife’s role to courageously inform the mother and relatives concerning
the newborn’s condition and its management (NHS, 2013). The midwife should work in
harmony with other members of the health team for a positive outcome (NHS constitution,
2021).

Conclusion

Research shows that, of all the neonatal deaths, Neonatal Asphyxia accounts for 20.9%.
Indeed 90% of all new born babies do not need any form of interpolation to help them breathe
during the vital switch from intrauterine to extra uterine life. It is crucial to note that the 10%,
who require aid, are given the necessary help to begin breathing in the best way there is.
Neonatal resuscitation plays a major role in the provision of better care to new born babies.
The objective of neonatal resuscitation must always be clear, to avert morbidity and mortality
related with hypoxic ischemic tissue injury and also to re-start enough impulsive inhalation,
exhalation and cardiac yield. A great number of concerns under neonatal resuscitation still
needs to be researched more especially on the effect of endotracheal suction in a meconium-
stained, non-vigorous new born, the result of preterm babies treated with occlusive plastic
wrapping, the effect of inflation breaths with positive end-respiratory pressure on postnatal
adaptation for new born babies among other topics. In addition, new guidelines in Neonatal
Life Support Programs should be implemented; midwives and nurses trained more on the
same purposely to contribute to the enhancement of the care given to new born babies.
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