Neonatal Resuscitation

By Gizaw T. (MSc IN MATERNITY % NEONATOLOGY

 Introduction
 The successful transition from intrauterine to
extra uterine life is dependent upon significant
physiologic changes that occur at birth
 90% need no resuscitation
 10 percent of newborns require some degree of
active resuscitation to stimulate breathing.
 1 percent require extensive resuscitation
Four Categories
 Basic steps including rapid
assessments and initial
steps of stabilisation
 Ventilation, including bag-
mask or bag -tube
ventilation
 Chest compression
 Administration of
medications or fluids
 ABC’s of resuscitation
 Airways- Establish Clear Airway
 Breathing- Ventilation & Oxygenation
 Circulation- Adequate Cardiac Output.
 Introduction…
Neonates die mainly from three causes:
 Neonatal infection - 47%
 Birth Asphyxia - 23%
 Preterm delivery/ Low birth weight - 17%
 Response to hypoxia
 oxygen deprivation - transient period of rapid
breathing
 If such deprivation persists, however, breathing
stops and the infant enters a stage of primary
apnea
 This stage is accompanied by a fall in heart rate
and loss of neuromuscular tone
 Simple stimulation and exposure to oxygen will
usually reverse primary apnea
 Physiologic response cont…
 If oxygen deprivation and asphyxia persist,
however, the newborn will develop deep gasping
respirations, followed by secondary apnea
 This latter stage is associated with a further decline
in heart rate, falling blood pressure, and loss of
neuromuscular tone
 Neonates in secondary apnea will not respond to
stimulation and will not spontaneously resume
respiratory efforts. Unless ventilation is assisted,
death follows
Physiological changes associated with primary
and secondary apnea in the newborn
 Steps in neonatal resuscitation

 Anticipation of resuscitation- Antepartum and intrapartum

conditions that place the newly born infant at risk of perinatal
asphyxia
a. Antepartum risk factors
 Maternal medical conditions (thyroid, cardiac, renal,
pulmonary hypertensive disorders and diabetes mellitus)
 Rh disease
 APH, Oligo / polyhydramnios
 PROM
 Post term pregnancy
 Multiple gestations
 Maternal age < 16 or > 35
b. Intrapartum risk factors
 Emergency C/S
 Instrumental deliveries
 Breech/face deliveries
 Prolonged rupture of membranes (>/=8hrs before delivery)
 Prolonged labor (> 24hrs)
 Abruption placenta and placenta previa
 Chorioamnionitis
 Prolonged second stage (> 2hrs)
 Fetal distress
 Narcotics given in 4hrs of delivery
 Meconium Stained Amniotic Fluid (MSAF)
 Cord prolapse
Adequate preparation
a) Personnel- a team of 3 (1 for medication, 1 for
ventilation, 1 for chest compression) is highly
desirable
b) Equipment and supplements
 Suction equipment
 Intubation’s equipment
 Medications
 Umbilical vessel catheterization supplies
 Others: radiant warmer, firm padder resuscitation
surface, Clock (timer), warm sheets, Sthetscope,
Oropharyngeal airway
 Accurate evaluation
 Should begin immediately after birth, and proceed
throughout the resuscitation process
 Evaluation and intervention are simultaneous process

 The Apgar score is used to quantify and summarize the

response of the newly born infant to the extra uterine

environment and resuscitation

 The APGAR scores should not dictate appropriate

resuscitative actions
 APGAR score is not used to initiate or make decision
about resuscitative measures.
 It is useful for assessing the effectiveness of
resuscitation efforts.
 One minute Apgar score - is an index of intra-partum
asphyxia
 Normal Apgar score is >7 out of ten
 Beyond one minute, APGAR score reflects the
neonates changing condition and adequacy of the
resuscitative efforts.
 When 5 minute Apgar score is < 7 additional scores
should be obtained every 5 minutes up to 20 minutes
of age unless two successive scores are ≥ 8.
• A Appearance
• P Pulse Rate
• G Grimace
• A Activity
• R Respiration
 Evaluation cont…
 Evaluate rapidly the response of the newborn
infant to stimulation by extrauterine environment,
for meconium in the amniotic fluid or on the skin
 Look for congenital anomalies
 Assess gestational age by physical method
 After the basic steps of resuscitation further
assessment of the newly born infant is based on
the triad of respiration, heart rate and color .
 Steps
 Initial steps (provide warmth, position head,
clear Airway, dry, and stimulate)
 Breathing (ventilation)
 Chest compressions
 Drugs (administration of epinephrine and/or
volume expansion)
Initiation of resuscitation
 Resuscitation cont…
 the newborn is first placed in a warm environment to
minimize heat loss
 Next, the airway is cleared as necessary
 If the delivery is complicated by meconium and the infant
is not vigorous - tracheal intubation before further
resuscitative
 The infant is then dried and stimulated after which
respiratory effort, heart rate, and color are assessed
 In most instances, the newborn will take a breath within a
few seconds of birth and cry within half a minute
 If the infant is breathing, the heart rate is greater than 100
bpm, and the skin of the central portion of the body and
mucous membranes are pink, then routine supportive care
is provided
 Prevent heat loss

 Deliver the infant in warm and draft-free area

 Place under warmer
 Dry-off amniotic fluid
 Remove wet linen
 Wrap in prewar med towel or blanket
 Open airway
 Place the newborn on supine or on its side
with head in a neutral or slightly extended
position
 Clear secretions from the airway by wiping
from the nose and mouth with gauze or towel;
or by suctioning oropharynx first then the nose
 Resuscitation cont…

 Apply Tactile stimulation if drying and

suctioning doesn’t produce breathing
 Methods
 Slapping or flicking the soles of the feet
 Rubbing the infants back
 Tactile stimulation is attempted not more than
trice
 Avoid more vigorous methods.
 Positive-pressure ventilation

Indications: a) Apnea or gasping respiration

b) Heart rate < 100 bpm
c) Persistent central cyanosis despite 100%
oxygen
Ventilation rate - 30-60 breath/min
Signs of adequate ventilation: -
 Bilateral chest wall expansion
 good air entry
 Improvement in heart rate and color.
After 30 seconds of adequate ventilation with 100%
oxygen; check for spontaneous breathing and heart rate
Adequate spontaneous breathing and HR>
100/min: -
 Gradually reduce and discontinue ventilation
 Apply gentle tactile stimulation
 Administer free flow oxygen
Inadequate spontaneous respiration:-
– HR < 100 bpm:
• Continue ventilation with bag and mask or tracheal
tube
– HR < 60 bpm:
• Continue ventilation after endotracheal intubation
• Begin chest compression
E-C clamp technique
 Endotracheal intubation

Indications:
 When tracheal suctioning for meconium is
required
 If bag-mask ventilation is ineffective or prolonged
 When chest compressions are performed
 When congenital diaphragmatic hernia is
suspected
 Tracheal administration of medications
Size- 2.5-4.0mm Inside diameter
- depending on GA & birth wt
 Chest Compression
Indication:
 Heart rate < 60 bpm despite ventilation with 100% oxygen
for 30 sec.
Methods:
1) The two thumb encircling hands - Two thumbs on the

lower third of the sternum, hands encircling the rest of chest.

2) Two fingers (index and middle) on the lower third of the
sternum perpendicularly with the other hand
supporting the back
Depth of compression - approximately 1/3rd (a third) of the
A-P diameter of the chest to generate a palpable pulse.
– Have shorter compression phase than relaxation
– Co-ordinate compressions and ventilations at 3:1 ratio with 90
compressions and 30 breaths to achieve-120 events/min
Two-thumb technique
Two fingers for chest compressions
 Reassess the heart rate after 30 sec:
 If heart rate is > 60 bpm
 discontinue chest compressions and continue
ventilation till heart rate is > 100 bpm and good
respiratory effort is established
 If heart rate remains < 60 bpm
 continue chest compression and ventilations and
consider medications
 Medications
• Drugs are rarely indicated in resuscitation

• Indication:
– When heart rate remains < 6o despite adequate ventilation with 100% oxygen
and chest compression.

A- Adrenaline (epinephrine)
Indications:
– (a) Heart rate remains < 60 bpm after a minimum of 30 sec
of adequate ventilation and chest compression
– (b) presence of asystole.
– Dose- 0.1 - 0.3 ml/kg of 1:10,000 solution (0.01-0.03mg/kg)
– If given through the tracheal tube, higher doses are employed, up to 0.1 mg/kg,
that is, 1 mL/kg
– Repeat every 3-5 min as indicated
– Route - IV (Intravenous) or endotracheal (ET)
B. Volume Expanders
• Indication
– blood loss is suspected
– the infant appears to be in shock
– the response to resuscitative measures is inadequate
• Fluids - Isotonic crystalloids (Ringer’s lactate,
normal saline)
• O-Negative blood (red blood cells)
• Dose -10ml/kg IV over 5 to 10 min slowly. This is
delivered via a catheter placed into the umbilical
vein.
• Repeat same dose after assessment
 C. Bicarbonate
 Is not routinely recommended
 Indication - prolonged arrest unresponsive to other
therapy
 Corrects metabolic acidosis
 could adversely affect myocardial and cerebral function
 Should be given after establishing adequate ventilation
and circulation.
 Dose:- 1-2 meq/kg of a 0.5 meq/ml solution IV. Slowly
(at least 2 min)
D. Naloxone (Narcotic antagonist)
– Indication- reversal of respiratory depression in a
newborn due to narcotics given to mother within 4hrs of
delivery
– Not given to narcotic abusers for fear of with drawal
– Dose- 0.1mg/kg of a 0.4 mg/ml or 1.0mg/ml ampule
– Route- IV, ET. If perfusion is adequate, give IM or s/c.
E. Dextrose 10%
– Indication - hypoglycemia (blood glucose < 30mg%)
– Dose - 2ml/kg IV bolus, then 3-4 ml/kg/hr.
 Discontinuation of Resuscitation

 The International Liaison Committee on Resuscitation

(2006) concluded that discontinuation of resuscitative efforts
may be appropriate if there are no signs of life after 10
minutes of continuous and adequate resuscitative efforts.
 This is because continued resuscitation is associated with a
very high mortality rate or severe neurodevelopmental
disability
THANK
YOU