Neonatal Resuscitation

University of Duhok

Faculty of Medical Science

School of Nursing

prepared by:

Znar A. Tamar Ali Ahmad Ali Faris Ism’ail Ali

Objectives

• Definitions of neonatal resuscitations.• Identify of infants “at risk” for asphyxia• or ,what’s asphyxia.• Describe Resuscitation of newborn:

– Equipment– Bag and mask ventilation– Cardiac compressions– Post resuscitation care

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DefinitionNeonatal Resuscitation is intervention after a baby is born to help it breathe and to help its heart beat.

Before a baby is born, the placenta provides oxygen and nutrition to the blood and removes carbon dioxide.

After a baby is born, the lungs provide oxygen to the blood and remove carbon dioxide.

The transition from using the placenta to using the lungs for gas exchange begins when the umbilical cord is clamped or tied off, and the baby has its first breath.

Many babies go through this transition without needing intervention. Some babies need help with establishing their air flow, breathing, or

circulation.

Resuscitation is helping with Airway, Breathing, and Circulation, also known as the ABCs.

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What’s asphyxia?

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Asphyxia – it’s a syndrome characterized by absence of breathing movements but with presence of heartbeat of fetus.

Classification:1. Central (suppression of breathing centre)2. Peripheric3. May be caused by trauma, immaturity of fetus nervous

system, pharmacological depression etc.4. May be cased by lungs, heart dysfunction or anemia

Newborn resuscitation

130 million infants are born every year 10% require some kind of intervention 3% (~4 mill) develop birth asphyxia requiring

resuscitation 900,000 of these die each year ~1million develop sequela WHO 1998, AHA 2000 The need for resuscitation is higher in preterm than in term

infants

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Goals of resuscitation

Minimizing immediate heat loss.

Establishing normal respiration and lung expansion.

Increasing arterial po2 .

Supporting adequate cardiac output.

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INDICATIONS

Maternal Indication

Neonatal Indication

Labor & Delivery conditions

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MATERNAL CONDITION

Maternal fever Membranes ruptured for >24 h Foul smelling amniotic fluid History of sexually transmitted disease Precious delivery. Antenatal diagnosed congenital anamolies Oligohydromnia,polyhydromnias. Maternal illness

1.D.M.2.Rh or other isoimmunization without evidence of hydrops

fetalis. 3.hypertention. 4.Renal ,Endocrino, cardiac diseases. 5.Alcohol and other substance abuse.

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NEONATAL CONDITIONS

1.Maternal illness 8.Traumatic delivery

2.STD 9.Prolapsed cord

3.Malaria 10.Meconium stained liquor

4.Eclampsia. 11.Congenital anomaly

5.Maternal bleeding. 12.Prolonged labour

6.Maternal sedation. 13.Breech/abn. presentation

7.Fever during labour

15 low birth weight.

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OTHER CONDITIONS

Significant vaginal bleeding .

Pronged unusual or difficult labor

Abnormal fetal presentation.

Shoulder dystocia.

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Apnoea

Primary Apnoea Secondary Apnoea Because after delivery of an infant it is impossible to

differentiate between primary apnoea and secondary apnoea, assume the infant is in secondary apnoea and begin resuscitation immediately.

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WHO Guidelines

AnticipateBe prepared for every birth by having skill to

resuscitate and by knowing the institutions policy on resuscitation

Review the risk factors for birth asphyxiaClearly decide on the responsibilities of each

health care provider during resuscitationRemember that the mother is also at risk of

complications

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Neonatal 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

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NECESSARY EQUIPMENT

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Laryngoscop ET tubesTransport incubater

End tidal co2 moniter

Radiant warmer

Oxygen source Anesthesia bag with adjustable pop off valve (250 ml)

low presure suction maschine,doli’bulb suction

Infant feeding tube

Stethoscope

Preparation of Equipment

Ensure that radiant warmer on ,warm towel available,

Turn on oxygen source,

Test the anesthesia bag for pop off control &adequate flow.

Laryngoscope light and an appropriate blade.

Appropriate ET tube

Emergency drugs.

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DURING DELIVERY

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Initial Steps for Neonatal Resuscitation in Delivery Room

A. Warm & Dry infant

Place infant under radiant heat warmer bed and dry infant (tactile stimuli) .This helps prevent cold stress.

B. Initiate ABC

A= Establish airway: position head in neutral position and bulb sx mouth and nose.

B= Breathing : Bag & Mask Ventilation or Bag & Et tube always with 100% FI02.

C= Circulation: Assess heart rate by listening to Apical pulse with stethoscope, pulse in umbilicus, or brachial pulse.

C. Evaluate infant for:

• 1. Colour: central vs. acrocyanosis. If centrally cyanotic give infant facial oxygen.

2. Signs of Respiratory distress:

� a. Increased WOB b. Nasal flaring c. Tachypnoea d. Grunting01/11/14 17

Bag and Mask Ventilation in the Newborn� Indications for bag mask ventilation

a. Apnoea b. Heart rate less than 100

Pressure used

� a. Initial breath after delivery = 30-40 cm H20 b. Normal delivery = 15-20 cm H20 c. Diseased Lungs = 20-40 cm H20

5. Technique/Troubleshooting problems of Bag mask ventilation

� a. Check for a good seal b. Check for a patent airway c. Are you using enough pressure ?

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Chest Compressions

Indications: If after 15-30 seconds of positive pressure ventilation with 100% FI02 the heart rate is

� a. below 60 b. between 60-80 and not increasing

Technique: a. 1 fingers breadth below nipple line, using 2 fingers b. 1/2 to 3/4 compression depth c. accompanied by ventilations, ratio is 3:1

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Intubation of the Neonate

Indications for intubation

� a. Prolonged bag and mask ventilation b. Bag and mask is ineffective c. Tracheal suctioning

ET tube sizes and correct suction catheter sizes:

� Weight of Infant ET tube Size Suction catheter size

� < 1000 gms 2.5 Et tube 5-6 french suction catheter

� 1000-2000 gms 3.0 Et tube 6 french suction catheter

� 2000-3000 gms 3.5 Et tube 8 suction catheter

� >3000 gms 4.0 Et tube 8 french suction catheter

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Medications

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Naloxone Hydrochloride (Narcan) 0.4mg/ml: given if there is severe respiratory depression and a history of maternal narcotic administration within the past 4 hours.method iv push,im,sq, { 0.1-0.2mg/kg}

Sodium Bicarbonate 0.5: helps correct metabolic acidosis, indicated when there is a prolonged arrest that does no respond to other therapy. Because it is a hyperosmotic solution, give slowly in order to minimize the risk of intraventricular haemorrhage.method iv{2mEq/kg iv}

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Continue…

WHO Guidelines Resuscitation practises not effective or even

harmfulroutine aspiration of babies mouth and noseroutine aspiration of stomachstimulation by slapping or flicking the soles of its

feetpostural drainage or slapping the backsqueezing the chest to remove secretionsroutine giving sodium bicarbonate to newborns

who are not breathing01/11/14 23

WHO Guidelines

Care after successful resuscitation do not separate mother and newborn- skin-

to skin examine the newborn (body temp, count

breaths, observe indrawing and grunting, malformations, etc)

record the resuscitation and the problems.

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APGAR SCORE

SIGN 0 1 2

Heart rate ABSENT <100 bpm >100bpm

Respiratory effort ABSENT Slow irregular Good crying

Muscle Tone LIMP Some flexion extremities

Active motion

Reflex Irritability NO RESPONSE grimace Cough or sneeze

Color BLUE,PALE Pink body blue extremities

All pink

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Newborn ResuscitationAHA/AAP Guidelines

Meconium stained amniotic fluid: Endotracheal suctioning of the depressed - not the vigorous child.

Hyperthermia should be avoided.

Chest compression: Initiated if heart rate is absent or remains < 60 bpm despite adequate ventilation for 30 sec.

Medications: Epinephrine 0.01-0.03 mg/kg if heart rate < 60 bpm in spite of 30 seconds adequate ventilation and chest compression.

Volume: Isotonic crystalloid solution or 0-neg blood.

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Summary of changes from 1992

Reference

http:// www.pediatricnursing.org

http://www.nursingforall.org

http://www.slideshare.com

http://www.seattlechildrens.org

http://www.ncbi.nlm.nih.gov

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The End

Q. Below what heart rate are chest compressions appropriate?

A. If the heart rate is below 60 bpm, administer chest compressions.

Q. What are the four questions to ask about the newborn in your first assessment?

A. 1. Term gestation?2. Clear amniotic fluid?3. Breathing or crying?4. Good muscle tone?

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