NEONATAL RESUCITATION

DR LEIGHTON WYNTER M.B.B.S.,D.M.(ANAES)

INTRODUCTION
The successful transition from intrauterine to

extrauterine life is dependent upon significant physiologic changes that occur at birth
Approximately 10% of newborns require some

assistance to begin breathing at birth.

Less than 1% require extensive resuscitative measures

STAFFING REQUIREMENTS
Being prepared is the first and most important step in

delivering effective neonatal resuscitation The need for resuscitation is also not anticipated in the majority of infants who require resuscitation As a result, at every birthing location, personnel who are adequately trained in neonatal resuscitation should be readily available to perform neonatal resuscitation whether or not problems are anticipated.

TRAINING/ PREPARATION

The neonatal resuscitation program (NRP) was developed by the American Academy of Pediatrics (AAP) and American Heart Association (AHA) as a training program aimed at teaching the principles and skills of neonatal resuscitation

It is recommended all delivery-room personnel complete the NRP in an effort to improve their individual and group performance in neonatal resuscitation.

Factors associated with a high-risk delivery

Antepartum Maternal Conditions Age (>40 years, <16 years) Poor socio-economic status (poverty, malnutrition) Detrimental habits (smoking, drug and/or alcohol abuse) Medical conditions Diabetes mellitus Hypertension Chronic heart and/or lung diseases Kidney diseases/urinary tract infections Blood disorders (thrombocytopenia, anemia, blood group incompatibilities)

Factors associated with a high-risk delivery

Maternal Conditions Obstetric conditions Prior stillbirth/fetal loss/early neonatal death Prior birth of a high-risk infant Antepartum hemorrhage Premature rupture of membranes Serious infection during pregnancy Placental anomalies - praevia, polyhydramnios or oligohydramnios, pregnancyinduced hypertension, Group B streptococcus carrier

Factors associated with a high-risk delivery

Fetal conditions Prematurity Post-maturity Intrauterine growth retardation Macrosomia Multiple gestation Congenital anomalies Hydrops

Factors associated with a high-risk delivery

During Birth Complications of maternal medical disease Premature labor Prolapsed cord Utero-placental bleeding Abnormalities of presentation (transverse lie, breech, etc) Chorioamnionitis or systemic maternal infection Foul-smelling or meconium-stained amniotic fluid Abnormal fetal heart rate patterns Instrumented delivery (forceps, vacuum, or cesarean) Narcotic administered to mother within four hours of birth

Necessary equipment should be assembled prior to the birth of at-risk newborns as follows
The radiant warmer is turned on and is heating. The oxygen source is open with adequate flow through the tubing. The suctioning apparatus is tested and is functioning properly.The

laryngoscope is functional with a bright light. Testing of resuscitation bag and mask demonstrates an adequate seal and generation of pressure. In high-risk deliveries of multiple gestation, each infant will require a full complement of personnel and equipment

Preterm infants
Preterm infants pose a greater challenge than term infants, as they are more likely to require resuscitation and develop complications from the resuscitative process.
If a preterm birth can be anticipated and time permits, it is preferable to

transfer the mother prior to delivery to a perinatal center that has fully trained staff with expertise and experience in the care of these infants

Preterm Infants

The following factors make the preterm infant more likely to require resuscitation and to be more susceptible to sequelae Hypothermia Inadequate ventilation The greater the degree of prematurity, the more likely the infant will require intubation and positive pressure support. Infection Maternal infection is associated with premature delivery and offspring of infected mothers are at risk for antenatal infection. Premature infants also have immature immune systems, which increases the risk of acquiring postnatal infection. Organ damage Immature tissues and capillaries (eg, retina or germinal matrix) are more vulnerable to injury resulting in complications (eg, retinopathy of prematurity and intracranial hemorrhage, respectively Reduced antioxidant function Immature antioxidant defense systems may be unable to counteract the effects of free radicals. Free radicals and reactive oxygen species are speculated to contribute to many of the morbidities of prematurity (eg, bronchopulmonary dysplasia and necrotizing enterocolitis

Additional resources and personnel should be present when a preterm birth is anticipated. These include:
Equipment to keep the infant warm. In infants less than 28 weeks gestation, the use of

polyethylene bags and wraps have been used to maintain body temperature. Personnel skilled in intubation are especially important for the extremely low birth weight infant (birth weight <1000 g). In infants less than 30 weeks gestation who are more likely to be surfactant deficient, equipment and personnel should be available to deliver positive pressure to infants who fail to exhibit adequate spontaneous respiratory effort and to administer surfactant. Compressed air sources, oxygen blenders, and pulse oximeters should be available to allow delivery of less than 100 percent oxygen and allow monitoring of both the oxygen content of the air delivered and the oxygen saturation of the infant. This could reduce the potential oxidant injury that results from unnecessary exposure of supplemental oxygen Prewarmed transport incubator (with the capability to transport a ventilated infant), particularly if the delivery room is not in close proximity to the neonatal intensive care nursery.

Neonatal resuscitation supplies and equipment

Suction equipment Bulb syringe Mechanical suction, tubing, and catheters Meconium aspirator 8F feeding tube and 20 cc syringe Intubation equipment Laryngoscope with straight blades (Number 0 and 1 for preterm and term infants, respectively) Face masks (preterm and term infant sizes) Oxygen source with flowmeter

Neonatal resuscitation supplies and equipment

Medications Dextrose solution 10 percent Epinephrine (0.1 mg/mL) Isotonic solution Naloxone hydrochloride (0.4 mg/mL) Syringes & Needles Umbilical vessel catheterizations supplies Sterile gloves, scalpel, antiseptic prep solution, umbilical catheter, tape, three-way stopcock

SUPPLIES AND EQUIPMENT

Miscellaneous Radiant warmer Warm towels Cardiac monitor Pulse oximeter and probe Oropharyngeal airways Additional equipment for delivery of preterm infants Compressed air source Oxygen blender Plastic wrap Transport incubator

 In all instances, at least one healthcare provider is assigned primary

responsibility for the newborn infant. This person should have the necessary skills to evaluate the infant, and, if required, to initiate resuscitation procedures such as positive pressure ventilation and chest compressions.
In addition, either this person or another who is immediately available

should have the requisite knowledge and skills to carry out a complete neonatal resuscitation including endotracheal intubation and administration of medications.

ANTENATAL COUNSELING
Each birth institution should have a consistent approach based upon the best available evidence regarding clinical care and parental counseling in cases where the fetal outcome is a concern.
In particular, antenatal counseling should be provided to parents in the setting of an anticipated delivery of an extremely low birth weight infant (birth weight

<1000 g) as recommended by the American Academy of Pediatrics (AAP) Counseling should include information regarding prognosis.

COUNSELING AAP GUIDELINES

If there is no chance of survival, resuscitation should not be initiated.
When a good outcome is considered very unlikely, the parents should be given the choice of whether resuscitation should be initiated, and clinicians should respect their preference.

If a good outcome is considered reasonably likely, clinicians should initiate resuscitation and, together with the parents, continually reevaluate whether intensive care should be continued

OVERVIEW OF RESUSCITATIVE STEPS

The AHA/AAP/ILCOR 2010 guidelines recommend the following approach
Initial steps (provide warmth, position head, clear Airway, dry, and stimulate)
Breathing (ventilation) Chest compressions Drugs (administration of epinephrine and/or volume expansion)

Newborn Resuscitation Algorithm

Neonatal advanced life support (NALS)-neonatal resuscitation

INITIAL STEPS
Provide warmth

The following methods of warming infants are also used depending upon the condition of the neonate and the need for further resuscitative efforts:
Swaddling the infant after drying
"Skin to skin" contact with mother and covering the infant with a blanket Use of polyurethane bags or wraps Raise the environmental (room) temperature Warming pads

APGAR SCORE
Score Appearance Pulse (Heart Rate) Grimace (Reflex Irritability) Activity (Muscle Tone) Respiration 0 Blue or pale Absent Absent Limp Absent 1 Body pink; hands and feet blue Less than 100 beats per minute Grimace Some flexing of arms and legs Slow, irregular; weak cry 2 Completely pink More than 100 beats per minute Grimace and cough or sneeze Active motion Good; strong cry

INITIAL STEPS
Airway
The infant is positioned to open the airway by placing the infant on his/her back on a flat radiant warmer bed with the neck in a neutral to slightly

extended position; the neck should not be hyperextended or flexed. The proper position aligns the posterior pharynx, larynx, and trachea, and facilitates air entry. If needed, a rolled blanket or towel may be placed under the infant's shoulder to slightly extend the neck to maintain an open airway.

Head position for neonatal resuscitation

The top panel demonstrates the correct head position with the baby positioned on the back with the neck slightly extended resulting in alignment of the posterior pharynx, larynx, and trachea, which allows unrestricted air entry.

INITIAL STEPS
Meconium stained amniotic fluid(MSAF)

-In the presence of meconium stained amniotic fluid (MSAF), it had been common practice for obstetrical care providers to aspirate the upper airway of the infant on the perineum of the mother. This was thought to reduce the risk of meconium aspiration syndrome. However, subsequent data has demonstrated no benefit from this procedure.
After the infant with MSAF is delivered, the AHA/AAP/ILCOR guidelines also recommends no suctioning in the vigorous infant, defined as a neonate with strong respiratory effort, good muscle tone, and a heart rate above 100 beats per minute, because suctioning does not improve outcome and may cause complications Stimulation - Drying and suctioning the infant, which is performed as part of the initial steps, may provide adequate stimulation. Safe, appropriate ways of providing additional stimulation include briefly slapping or flicking the soles of the feet, and rubbing the infant's back.

BREATHING
No further resuscitative actions are required if the infant responds with adequate spontaneous respirations (eg, sustained regular respirations) that result in pink lips and trunk, and a heart rate above 100 beats per minute.
If central cyanosis (lips, tongue, and central trunk) is present in a newborn with adequate respiration and a heart rate above 100 beats per min, free-

flowing oxygen should be administered. When the infant turns pink, oxygen can be gradually withdrawn while ensuring that the newborn can still maintain a pink color. However, there is variability by clinicians on determining when an infant is pink

BREATHING
Positive-pressure ventilation (PPV) Positive-pressure ventilation is required in the following clinical settings:
If the infant is gasping, is apneic, or has ineffective respiration If the heart rate is <100/min, even if the infant has spontaneous

respiration. The heart rate can be checked either by auscultation or palpation of the pulse in the umbilical cord. If central cyanosis persists after free-flowing oxygen is administered

PPV
Positive-pressure can be administered to the newborn

infant by bag-mask ventilation (BMV) by three different devices: Self-inflating bag Flow-inflating bag T-piece resuscitator Laryngeal mask airway (LMA), which fit over the laryngeal inlet, has been found to be effective in ventilating late preterm and full-term newborn infants in instances when BMV or endotracheal intubation is unsuccessful, or endotracheal intubation is not possible

BMV- PROCEDURE
Position The infant should be positioned with the neck in a neutral to slightly extended position to ensure an open airway The clinician should stand at the head or side of the warmer to view the chest movement of the infant to assess whether ventilation is effectively delivered.
Suction The nose and mouth should be suctioned to clear any mucous to

prevent aspiration prior to delivery of assisted breaths. Seal An airtight seal between the rim of the mask and the face is essential to achieve the positive pressure required to inflate the lungs. An appropriately sized mask is selected and positioned to cover the chin, mouth, and nose, but not the eyes of the infant. Initial breaths The initial administered breaths often require pressures of 30 to 40 cm H2O to inflate the lungs of the newly born term infant. In most preterm infant, an initial inflation pressure of 20 to 25 cm H2O is usually adequate. Adequacy of ventilation is demonstrated by chest movement and/or air movement assessed by auscultation of the chest with each positive-pressure breath. The infant should be ventilated at a rate of 40 to 60 times per minute for 30 seconds

E-C clamp technique

The hand is positioned so that the little, ring, and index fingers are spread over the mandible from the angle of the jaw forward towards the chin in the configuration of the letter "E". The jaw is then lifted, pulling the face into the mask. The thumb and forefinger are placed over the mask in the shape of the letter "C". The mask is squeezed onto the face and a seal is formed between the mask and the face.

BREATHING
CPAP OR PEEP
Supplemental oxygen
AHA/AAP/ILCOR guidelines recommend the following
If room air is used when PPV is initiated, supplemental oxygen must be readily available. If there is no appreciable improvement in the infant's heart rate or color, supplemental oxygen should be added.
If supplemental oxygen is used when PPV is initiated, oxygen can be withdrawn when the infant appears pink or oxygen saturation reaches 92 percent by pulse

oximetry.

Endotracheal intubation
ET intubation may be indicated if:
Tracheal suctioning for meconium is required. BMV is ineffective or prolonged. Chest compressions are being performed.

CHEST COMPRESSIONS
Chest compressions are initiated if the infant's heart rate remains <60 beats per minute despite adequate ventilation for 30 seconds.
Chest compression applies pressure to the lower one-third of the sternum

visualized as an imaginary line between the nipples and the xiphoid process. Two methods are used to deliver neonatal chest compressions. -Thumb technique In this method, both hands encircle the infant's chest with the thumbs on the sternum and the fingers under the infant -Two-finger technique In this method, the tips of the first two fingers, or the middle and ring finger are placed in a perpendicular position over the sternum

Two-thumb technique

The thorax is encircled with the hands and cardiac compressions are performed with both thumbs. The compression site is approximately one finger's breadth below the intermammary line. The area over the xiphoid process should be avoided to prevent injury to the liver, spleen, or stomach.

Two fingers for chest compressions

Chest compressions for infants (under one year) may be performed with two fingers placed on the sternum just below the nipples.

 Chest compressions must always be accompanied by positive-pressure

ventilation (PPV). During neonatal resuscitation, the chest compression rate is 90 per minute accompanied by 30 ventilations per minute with one ventilation interposed after every third compression. Thus, the ventilation rate is reduced from the 40 to 60 breaths per minute used in the absence of chest compression to 30 breaths in the presence of chest compression.

DRUGS
Drugs are rarely required in neonatal resuscitation. Delivering adequate ventilation is the most important resuscitative step because the most common cause of bradycardia is inadequate lung inflation or profound hypoxemia. Epinephrine- dose of 0.01 to 0.03 mg/kg (0.1 to 0.3 ml/kg of a 1:10,000 solution Naloxone- may be considered if normal heart rate and color have been restored, but the infant remains apneic Sodium bicarbonate

FAILURE OF INITIAL RESUSCITATION

Rarely, infants will not respond to the initial resuscitative efforts. The clinical team needs to review that all the resuscitative steps were fully and properly administered.
If the infant fails properly executed resuscitation, the following clinical approach may help ascertain the cause:

Failure to respond to positive-pressure ventilation: Mechanical blockage (eg, meconium, mucus, choanal atresia, pharyngeal airway malformation

[Robin sequence], or laryngeal web)Impaired lung function (pneumothorax, pleural effusions, congenital diaphragmatic hernia, pulmonary hypoplasia, congenital pneumonia, or hyaline membrane disease)
Central cyanosis Congenital heart disease, Persistent bradycardia Heart block Apnea Brain injury (hypoxic-ischemic encephalopathy), congenital neuromuscular disorder,

or respiratory depression from maternally administered opioids

WITHHOLDING RESUSCITATION
The decision not to initiate intensive therapy is made together by the parents and the health

care team. Parents should be active participants in the decision-making process concerning the treatment of their child. Discussion, if possible, should occur prior to the birth of the infant. Noninitiation of resuscitation may be considered if early death is very likely and survival would be accompanied by unacceptably high morbidity. These clinical conditions include infants with gestational age <23 weeks or birth weight <400 g, anencephaly, or chromosomal abnormalities incompatible with life (eg, trisomy 13 or 18) [1]. Intensive care including neonatal resuscitation is always indicated when there is a high likelihood of survival and acceptable morbidity. In settings in which the prognosis of the infant is unclear but likely poor and survival may be associated with a diminished quality of life, parental wishes should determine management decisions. At delivery, if the appropriate course is uncertain, it is preferable to initiate resuscitation. After delivery, the health care team can review with the parents the clinical status and prognosis of their infant, and determine the parents' wishes. If additional data demonstrate that the outcome is almost certain early death or unacceptably high morbidity, support can be discontinued if agreed upon by the parents and health care team.

DISCONTINUING RESUSCITATION
Resuscitation efforts may be discontinued if the neonate has demonstrated no signs of life (no heart beat or respiratory effort) after 10 minutes of resuscitation because outcome is associated with high early mortality and unacceptably high morbidity among the rare survivors

POSTRESUSCITATION
Infants who required resuscitation are at risk of developing postresuscitative complications
These include:

Hypo- or hyperthermia Hypoglycemia Central nervous system (CNS) complications: apnea or seizures Pulmonary complications: Pulmonary hypertension, pneumonia, pulmonary air leaks, or transient tachypnea of the newborn Hypotension Electrolyte abnormalities: Hyponatremia or hypocalcemia Feeding difficulties: Ileus, gastrointestinal bleeding, or dysfunctional sucking or swallowing

SUMMARY AND RECOMMENDATIONS

Most infants successfully transfer from intrauterine to extrauterine life without any special assistance. However, about 10 percent of newborns will need some intervention, and 1 percent will require extensive resuscitative measures at birth.
Because the need for resuscitation is not anticipated in the majority of

neonates, personnel who are adequately trained should be readily available to perform neonatal resuscitation at every birthing location, whether or not problems are anticipated Infants who are more likely to require resuscitation can be identified by maternal and neonatal risk factors, and the presence of antepartum and delivery room complications. Care providers skilled in neonatal resuscitation should be present and equipment should be prepared prior to the birth of the high-risk infant.

SUMMARY AND RECOMMENDATIONS

Preterm infants are more likely to require resuscitation and develop complications from resuscitation than term infants. If a preterm birth can be anticipated and time permits, it is preferable to transfer the mother prior to delivery to a perinatal center.

Resuscitation steps
Neonatal resuscitation may be required in infants who are premature, do not have

clear amniotic fluid, or do not have good muscle tone, and is required in infants who are not adequately breathing. Initial care includes providing warmth to the infant, clearing his/her airway, and drying and stimulating the infant. If there is meconium stained amniotic fluid and the infant is not vigorous (absent or depressed respirations, decreased muscle tone, or a heart rate less than 100 beats/minute), suctioning of residual meconium should be performed. After the above initial steps are completed, positive-pressure ventilation (PPV) is required if the infant has an inadequate respiratory effort, central cyanosis (lips, tongue, or central trunk), or the heart rate <100 beats per minute. PPV is started with bag-mask ventilation (BMV) at a rate of 40 to 60 times per minute for 30 seconds, after which the heart rate is measured. Resuscitation may begin with either room air or supplemental oxygen (up to 100 percent oxygen). If resuscitation is started with room air, supplemental oxygen must be available and used if the infant does not show signs of improvement.

 Intubation is needed if tracheal suctioning for meconium is required, BMV is ineffective or prolonged, or chest compressions are being performed
Chest compressions are required if the infant's heart rate remains <60 beats per minute despite adequate ventilation for 30 seconds. Chest compressions must always be accompanied by PPV. Chest compression rate is 90 per minute

accompanied by 30 ventilations per minute with one ventilation interposed after every third compression. Drugs are rarely required in neonatal resuscitation. However, if the heart rate remains <60 beats per minute despite adequate ventilation and chest compressions, intravenous administration of epinephrine is indicated (table 4). Cannulation of the umbilical vein is the quickest means of obtaining intravenous access in the newborn

SUMMARY/RECOMMENDATIONS
Resuscitation can be withheld if it is legally acceptable and there is complete agreement among parents and care providers that the neonatal outcome is dismal
Resuscitation efforts may be discontinued if the neonate has demonstrated no

signs of life (no heart beat or respiratory effort) after 10 minutes of resuscitation.
Infants who required resuscitation are at risk of developing postresuscitative complications. After successful resuscitation, they require placement in a

setting in which close monitoring and ongoing appropriate care can be provided.