Transition to

extrauterine life
February, 2023
 Lecture content

• Transition to extrauterine life

• Neonatal resuscitation algorithm.
• The initial steps of resuscitation.
• Positive pressure ventilation.
• External cardiac massage.
• Intubation. Medication. Special situation. Ethical issues.
• Post resuscitation care and monitoring
Transition
• Transition represents a critical phase of physiological adaptation, impacting many organ systems,
most notably the heart and the lungs.

• Most neonates complete this transition without complications; however, dysregulation of normal
postnatal adaptation may lead to acute cardiopulmonary instability, necessitating advanced
intensive care support.

• In some situations, death or adverse neurosensory impairment may ensue

• A successful hemodynamic transition from fetal to extrauterine life is a complex process that
requires the interdependent sequential physiologic changes to take place in a timely manner
 Fetal circulation
• Low systemic vascular resistance
• High systemic blood flow
• High pulmonary vascular resistance
• Low pulmonary blood flow
• Two cardiac shunts: ductus arteriosus and foramen ovale
• One extra cardiac shunt: ductus venosus
• The combined cardiac output is in the range of 400-450
ml/kg/min
• Arterial oxygen saturation is different between the
upper and the lower part of the body
• The most oxygenated blood in the LA ensures supply of
adequate oxygen to the heart and the brain
 What happen at birth ?
• The removal of the low resistance placental circulation
• Increase level in catecholamines and other hormones increase the SVR
• PVR drops rapidly due to the act of breathing oxygenated air
• Secondary drop in the cerebral blood flow within minutes after birth in response
to the oxygen exposure
• ! The inability of the myocardium to pump against the suddenly increased SVR
might lead to a transient decrease in systemic blood flow ( i.e very preterm
infants)
Factors that foster
• Chemical factors
the onset of • Mechanical factors
breathing
 Circulatory system after birth
• Decreased PVR over the first 48-72 hours age
• Lung recruitment and increased alveolar paO2
• Increased in biventricular stroke volume
• The shunt flow becomes increasingly left to right and
eventually close
• First 12 hours of life, is a critical time period during which
the adaptative physiological changes are expected to be
greatest
 Early clamping of the umbilical cord

• Usually within 15-20 seconds

• The most frequently performed medical procedure since 1950
• Was introduced in obstetric care with no clinical trial and little
understanding of the physiological effects
• Was introduced as an attempt to reduce the risk of postpartum hemorrhage
• It is only in the past 5-10 years that the physiologic rationale of the potential
benefit of waiting before cord clamping have emerged
• Delay in clamping can reduce the mortality in preterm infants without harm
mother or baby
More about Transition to extrauterine life

• Before birth, the lungs are filled with liquid and gas exchange occurs across the placenta
• At birth, the airways must be cleared of liquid to allow the entry of air and the onset of
pulmonary ventilation
• Lung aeration triggers a large decrease in PVR
• RV output is redirected through lungs, causing a large increase in PBF
• PBF plays a vital role in sustaining cardiac output by replacing the venous return and
ventricular preload lost due to clamping the umbilical cord
• Clamping the umbilical cord before pulmonary blood flow increase is potentially problematic
causing a large reduction (up to 50%) in cardiac output
Cord Is the most common clinical intervention
clamping
It is often seen like a harmless act

Can became a harmful act, depends upon when occurs

during the progression through this physiologic sequence of
transition to extrauterine life

If it is occurred before the lung aeration and increased PBF

could lead to hypoxemia and the infants it is at increased
risk of ischemia
Cardio-pulmonary interaction
Lung fluid production:
• Actively secreted from alveolar type I and II cells at a
rate up to 50 ml/k/day at mid gestation to 120 ml/k/
day at term
• Essential to normal lung to growth
• Processes interfere with normal production:
oligoamnios cause RDS, pulmonary hypoplasia
Lung fluid clearance:
• increase in trans-thoracic pressure,
• increased circulating adrenaline level and
• trans- ephytelial hydrostatic pressure generated
during inspiration/inflation
Pulmonary blood flow
• increases 20 to 30 fold by the lung ventilation
Increased pulmonary
blood flow after birth
• Umbilical cord clamping after the onset of
ventilation alter the distribution of the
cardiac output
• Redirection of the entire RV output into the
lungs
• Rapid reversal of right to left into a large left
to right DA shunt
• As a result, both RV and LV contribute to the
increased PBF,
• Contribution of the LV to the PBF gradually
decrease as the DA closes
Respiratory function after birth
Resuscitation at birth
• 130-160 million infants born annually in the world
• 3-5% of term infants and 60% of preterm infants fail to aerate the
lungs spontaneously
• In most cases only establishment of adequate ventilation will fix the
transition
• Management of the infant care in the first minute after birth can
severely impact morbidities associated with prematurity
 Provide warm by Positioning the
placing the baby head in a sniffing
1
under a radiant position to open
heat source the airway
2

The initial steps

Clearing the airway
of neonatal if necessary, with a 3 Drying the baby
suction catheter
resuscitation
4

Making decision
Stimulate
5 about further steps
respiration
of resuscitation
 Overview of Resuscitation

• Initial stabilization

• Airway, breathing, circulation

• Chest compressions

• Administration of the epinephrine

and volume expansion
When Things Go Wrong…
• If apnoea or HR < 100, give positive pressure ventilation with a bag
and mask

• Clear secretions- suctioning, vigorous drying

• Position baby’s head and neck (sniffing position)-airway

permeability

• Correct size for the face mask

• CPAP is effective in helping the baby breathe

 • Apnea, Gasping respiration, HR less than 100

• Take care about PIP values !!!!

Positive • Effective ventilation is defined by the presence of bilateral

breath sounds, chest movement

pressure • Start with inspiratory pressure (PIP) of about 20 cm H2O and

PEEP 5 cm H2O at a rate of about 40-60 breath/minutes, avoid

ventilation excessive chest movement

• A pressure release valve is present on all PPV devices to avoid

excessive pressure
Positive pressure ventilation
Flow control, pressure limited device T
Self inflating bag piece resuscitator
 • Baby is floppy, not crying
• HR <100 bpm, gasping, apnea
• HR <100 inspite of PPV
• HR <60 bpm
• No adequate chest rise and no clinical
improvement
When to • If chest compression are needed, intubation
consider provides better coordination and efficiency of
PPV
intubation? • When aspiration of meconium and tracheal
suctioning required
• To administer drugs
• Special situations: Antenatal detected
diaphragmal hernia, ELBW
How to do Positive Pressure
Ventilation
• Initial ventilation pressure is 20 to 25 cm H2O.
• When PEEP issued, the recommended initial setting is 5 cm
H2O.
• If PPV is required for resuscitation of a preterm newborn, it
is preferable to use a device that can provide PEEP.
• Using PEEP (5 cm H2O) helps the baby’s lungs remain
inflated between positive pressure breaths.
• When PPV begins, the assistant listens for increasing heart
rate for the first 15 seconds of PPV.
 Indications:

Laryngeal Newborns with congenital anomalies

involving mouth, lipp, tongue, or neck
mask Small mandible or large tongue (e.g.,
airway Robin sequence, Trisomy 21)

When PPV ineffective and attempts at

intubation are unsuccessful
 Chest compression
• HR <60 bpm despite adequate vent with 100% O for
30 seconds

• 2 technique: 2 thumb, 2 finger

• Coordinate with PPV 3:1 ratio Compressions:

ventilation

• 1/3 of AP diameter

• Ensure that vent is being delivered optimally before

starting chest compression

• Be aware chest compression are likely to compete

with effective ventilation
Medication
• Medications are rarely needed in resuscitation of the newly born infant
because low heart rate usually results from a very low oxygen level in the
fetus or inadequate lung inflation after birth.

• Establishing ventilation is the most important step to correct low heart rate.

• However, if heart rate remains less than 60/min after ventilating with 100%
oxygen (preferably through an endotracheal tube) and chest compressions,
administration of epinephrine is indicated if HR remains <60 bpm
 Concentration : 1: 10 000 (Route IV/IO or ET)

Dose 0.1-0.3 ml/k iv, io

0.5-1 ml/kg endotracheal

Epinephrine Admin iv rapid push, endotracheal-follow with several

PPV breaths to distribute drug into lungs
Assess HR 1 minute after epinephrine administration

If HR remains < 60 bpm, increase dose and repeat at

3-5 minutes
• The chest compression will always be accompanied by ventilation Synopsis
• Rhythm is 3 chest compressions and one breath/ 2 seconds
• 90 chest compressions and 30 breaths per 60 seconds
• Need to remember these two numbers 100 bpm and 60 bpm
• All blocks are 30 seconds except C block is 45 seconds
• Intubation can be taken into consideration at any time during the algorithm
• Medication can be administered through ETT only into delivery room resuscitation
• Adrenaline is not indicated before a correct and efficient ventilation is established!
• Dose: 0.1-0.3 ml/kg rapidly of the 1/10000 dilution, intra-umbilically, repeated after
3-5 minutes
• Intra umbilical venous and intra pulmonary adrenaline dosage is different
 • Aspiration of meconium before delivery, during birth, or during
Special resuscitation can cause severe meconium aspiration syndrome (MAS).
situations • Elective and routine endotracheal intubation and direct suctioning of the
trachea were initially recommended for all meconium-stained newborns
• Recent studies suggest EI and suctioning of the tracheae only for those
newborns affected, severely hypotonic
• However, if attempted intubation is prolonged and unsuccessful, bag-
mask ventilation should be considered, particularly if there is persistent
bradycardia.
• The lack of response to resuscitation may be due to several factors:
extreme prematurity, pneumothorax, congenital pneumonia,
diaphragmatic hernia, pulmonary hypoplasia.
Special issues of RNP : other lung conditions and
pulmonary malformation
Post Resuscitation care
•Infants 36 weeks’ or greater estimated gestational age who receive advanced resuscitation should be examined for evidence of HIE

to determine if they meet criteria for therapeutic hypothermia.

•Newly born infants who receive prolonged PPV or advanced resuscitation (eg, intubation, chest compressions ± epinephrine)

should be closely monitored after stabilization in a neonatal intensive care unit

•Hypoglycemia These infants should be monitored for hypoglycemia and treated appropriately.

•Infants with unintentional hypothermia (temperature less than 36°C) immediately after stabilization should be rewarmed to avoid

complications associated with low body temperature (including increased mortality, brain injury, hypoglycemia, and respiratory

distress).
Ethical issues
• Some babies are so sick or immature at birth that survival is unlikely, even
if neonatal resuscitation and intensive care are provided.

• In addition, some conditions are so severe that the burdens of the illness
and treatment greatly outweigh the likelihood of survival or a healthy
outcome.

• If it is possible to identify such conditions at or before birth, it is reasonable

not to initiate resuscitative efforts.

• These situations benefit from expert consultation, parental involvement in

decision-making, and, if indicated, a palliative care plan
TOP 10 TAKE-HOME MESSAGES FOR NEONATAL LIFE SUPPORT

• Newborn resuscitation requires anticipation and preparation by providers who train individually
and as teams.
• Most newly born infants do not require immediate cord clamping or resuscitation and can be
evaluated and monitored during skin-to-skin contact with their mothers after birth.
• Inflation and ventilation of the lungs are the priority in newly born infants who need support after
birth.
• A rise in heart rate is the most important indicator of effective ventilation and response to
resuscitative interventions.
• Pulse oximetry is used to guide oxygen therapy and meet oxygen saturation goals.
Published in Pediatrics January 2021, 147 (Supplement 1) e2020038505E; DOI: https://doi.org/
10.1542/peds.2020-038505E
TOP 10 TAKE-HOME MESSAGES FOR NEONATAL
LIFE SUPPORT
• Chest compressions are provided if there is a poor heart rate response to ventilation after
appropriate ventilation corrective steps, which preferably include endotracheal intubation
• The heart rate response to chest compressions and medications should be monitored
electrocardiographically (EKG monitors)
• If the response to chest compressions is poor, it may be reasonable to provide epinephrine,
preferably via the intravenous route
• Failure to respond to epinephrine in a newborn with history or examination consistent with blood
loss may require volume expansion
• If all these steps of resuscitation are effectively completed and there is no heart rate response by
20 minutes, redirection of care should be discussed with the team and family
Published in Pediatrics January 2021, 147 (Supplement 1) e2020038505E; DOI: https://doi.org/
10.1542/peds.2020-038505E