Neonatal resuscitation

• The successful transition from intrauterine to extrauterine life is dependent upon significant physiologic changes that occur at birth.

• In almost all infants (90 percent), these changes are successfully completed at delivery without requiring any special assistance.

• However, about 10 percent of infants will need some intervention.

• 1 percent will require extensive resuscitative measures at birth.

• Being prepared is the first and most important step in delivering effective neonatal resuscitation.

• Neonates requiring resuscitation are inevitably born in locations where most newborns are healthy and do not require additional special assistance.

• The need for resuscitation is also not anticipated in the majority of infants who require resuscitation.

• personnel who are adequately trained in neonatal resuscitation should be readily available

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

Medications • Dextrose solution 10 percent • Epinephrine (0.1 mg/mL) • Isotonic solution • Naloxone hydrochloride (0.4 mg/mL) • Needles • Syringes • Umbilical vessel catheterizations supplies • Sterile gloves, scalpel, antiseptic prep solution,

umbilical catheter, tape, three-way stopcock

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

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)

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, pregnancy-induced hypertension, Group B streptococcus carrier

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

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

• Hypothermia• Inadequate ventilation• Infection • Organ damage• Reduced antioxidant function

OVERVIEW OF RESUSCITATIVE STEPS

• The basic steps ("ABCDs") in resuscitation in any age group still apply in the newborn period.

• However, there are aspects of neonatal resuscitation that are unique and lead to differences in the initial resuscitative steps.

Neonatal advanced life support (NALS)-neonatal resuscitation

• Initial steps (dry, provide warmth, position head, clear airway, and stimulate)

• Breathing (ventilation) • Chest compressions • Drugs (administration of epinephrine and/or volume

expansion)• The decision to progress from one step to the next is

determined by the time-dependent response of the infant

• A time allocation of 30 seconds is given to apply the resuscitative procedure, evaluate, and decide whether to proceed to the next intervention

• Apgar scores are not used to guide resuscitation• They are useful as a measure of the newborn's overall

status and response to resuscitation.• When the 5-minute Apgar score is less than 7,

additional scores should be assigned every five minutes for up to 20 minutes.

• Apgar scores are not good predictors of outcome.• No further resuscitative actions are required if the

infant responds with adequate spontaneous respirations (eg, sustained regular respirations), heart rate above100 beats per minute, and pink color of the lips and central trunk.

INITIAL STEPSProvide warmth• Hypothermia in the delivery room or immediate newborn

period is independently associated with an increase in mortality

• Hypothermia in the newborn increases oxygen consumption and metabolic demands, which can impair subsequent resuscitative efforts, especially in the asphyxiated or extremely low birth weight infant.

• Low birth weight and preterm infants are particularly prone to rapid loss of body heat because of

• their large body surface area relative to their mass, • thin skin, and • decreased subcutaneous fat.

• To minimize heat loss, the delivered infant is first placed in a warmed towel or blanket and then under a pre-warmed radiant heat source, where he/she is dried with another warmed towel or blanket.

• The infant should remain uncovered to allow full visualization and permit the radiant heat to reach the patient.

• The radiant warmer also allows easy access to the infant for multiple members of the resuscitative team.

• The temperature control of the warmer should be regulated by servo-control to avoid hyperthermia; maintain the infant's temperature at 36.5⁰C

The following methods of warming infants are also used depending upon the condition of the neonate and the need for further resuscitative efforts: •Wrapping 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

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.

• Once the infant has been correctly positioned, the mouth and nose should be suctioned either with a bulb syringe or mechanical suction device.

• The mouth is suctioned first and then the nares to decrease the risk for aspiration. [the ‘M’ before the ‘N’ alphabetically]

• Suctioning of either the esophagus or stomach should be avoided if not indicated, as it can produce a vagal response, resulting in apnea and/or bradycardia.

Meconium stained amniotic fluid

• no suctioning in the vigorous newborn

• The AHA/AAP/ILCOR guidelines recommend that suctioning of residual meconium be performed in all infants with MSAF who have:– absent or depressed respirations, – decreased muscle tone, or – a heart rate less than 100 beats/minute

• These infants are placed under a radiant heater, and before drying, any meconium present in the oropharynx and hypopharynx should be suctioned.

• The TRACHEA is then suctioned under direct visualization. This is best accomplished by intubating the infant with an appropriately sized endotracheal tube

• Suctioning by passing a suction catheter through the endotracheal tube is not recommended because the catheter will be of a smaller size than the endotracheal tube and may not be able to remove particulate meconium.

• If the infant's heart rate is low or begins to fall, positive-pressure ventilation may have to be initiated before all the meconium can be removed from the trachea.

Stimulation• Except in the case of the "non-vigorous" infant who first requires

endotracheal intubation, tactile stimulation of the newborn should be initiated promptly after birth.

• Safe, appropriate ways of providing additional stimulation include briefly slapping or flicking the soles of the feet, and rubbing the infant's back.

• More vigorous stimulation is not helpful and may cause injury.• If, after one or two attempts of additional stimulation, the infant still

remains bradycardic or centrally cyanotic, positive-pressure ventilation should be initiated.

• Given that most infants will be stimulated from the moment of birth, efforts at stimulating the infant should not be prolonged.

• The time elapsed from the baby's birth to placing the baby under the warmer, positioning, suctioning, and providing additional stimulation should be no more than 30 seconds

Potentially hazardous forms of stimulation• Slapping the back• Squeezing the rib cage• Forcing thighs into abdomen• Dilating anal sphincter• Hot or cold compresses or baths• shaking

BREATHING:Free-flowing oxygen

• If central cyanosis (lips, tongue, and central trunk) is present in a newborn with adequate respiration and a heart rate above 100 bpm, 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.

• Positive-pressure ventilation is required in the infant who fails to adequately respond to the above initial steps.

Delivering free flow oxygen • Heated and humidified• Flow rate at approximately 5L/min• Enough oxygen for newborn to become pink

Positive-pressure ventilation • 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. – If central cyanosis persists after free-flowing

oxygen is administered

Procedure • Positive-pressure can be administered to the newborn infant by

bag-mask ventilation (BMV) • 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 • Initial breaths - often require pressures of 30 to 40 cm H2O to

inflate the lungs of the newly born term infant. • Next steps

Endotracheal intubation

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

• All necessary supplies should be readied for intubation, including appropriate size ET tubes (ETT)

Procedure• Two care providers are required - one to perform and the other

to assist and monitor • To minimize hypoxemia, time needed for intubation should be

limited to 20 seconds and free flowing oxygen is administered during the procedure.

The following steps are required for successful intubation of the neonate:

• Initial stabilization • Positioning • Insertion — The laryngoscope is held in the left hand of the

clinician between the thumb and the first two or three fingers, with the blade pointing away from the clinician. The right hand stabilizes the head of the infant.

• The laryngoscope blade is inserted over the right side of the tongue pushing the tongue to the left and is advanced until the blade lies in the vallecula, just beyond the base of the tongue.

• Assessment of successful intubation — Successful intubation following institution of PPV is associated with: – a prompt increase in heart rate, – auscultation of audible breath sounds over both lung fields, – vapor condensation inside the ETT during exhalation, and – symmetrical chest movement

CHEST COMPRESSIONS• Chest compressions are initiated if the infant's heart

rate remains <60 beats per minute despite adequate ventilation for 30 seconds.

• 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.

DRUGS

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 [Pierre-Robin syndrome], 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• With antenatal screening, it is now possible to identify

conditions associated with high neonatal mortality or poor outcome.

• In these settings, intensive therapy including neonatal resuscitation may result in prolongation of dying with significant pain and discomfort for the neonate or survival with unacceptable quality of life.

• Decisions regarding whether or not intervention should be initiated and to what degree are difficult and are made together by parents and care providers guided by their understanding of the child's best interests.

DISCONTINUING RESUSCITATION

• Resuscitation efforts may be discontinued if the neonate has demonstrated no signs of life after 10 minutes of resuscitation, because outcome is associated with high early mortality and unacceptably high morbidity among the rare survivors.

• support can be discontinued if agreed upon by the parents and health care team.

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

The longer and the greater the extent of resuscitation, the more likely that there will be subsequent and serious complications.