Newborn Resuscitation: A way to protect newborn from asphyxia Neonatorum

Newborn Resuscitation: A way to protect newborn from asphyxia Neonatorum

 

Definition: 
Failure to establish spontaneous respiration immediately after complete delivery of the baby is called asphyxia neonatorum.

Normal Respiration:

• Normal newborn takes first respiration: within 6 seconds, majority within first 20 seconds,
• Rhythmic respiration: by 30 seconds, and majority by 90 seconds after birth
• Normal Rate is 40-60/ min

Prognosis / Consequence asphyxia neonatorum:

• Risk of cerebral palsyAuditory, Visual and language difficulty.
  • Quadriplegia
  • Diplegia
  • Hemiplegia
  • Choreoathetosis
• Intellectually handicapped

Causes of asphyxia neonatorum:

• Failure of respiratory center
  • prolonged hypoxia, birth trauma, maternal sedatives within 4 hours before delivery and preterm
• Failure of pulmonary expansion (atelectasis)
  • low alveolar surfactant and poor respiratory movements of preterm baby
  • Fetal hypoxia causes lung edema
• Obstructed air passageCirculatory collapse in neonatal shock
  • Inhaled mcous or meconium and choanal atresia
  • blood loss or cardiac abnormality

Signs and syndromes of asphyxia neonatorum:

• Baby does not cry or cries very weakly
• Baby does not breathe or breathes with difficulty, moaning or grunting
• Does not move, extremities limp
• Skin color is blue or pale
• Heart rate is slow or absent

APGAR score:

Signs	Score 0	Score 1	Score 2
Appearance	Blue or pale	Body pink, limbs blue	Pink all over
Pulse (heart rate)	Nil	<100/min	>100/min
Grimace	Nil	Feeble cry	Cough or sneezing
Activity and tone	Limp	Flexion of limbs	Active movements
Respiration	Nil	Slow, irregular	Good, crying

Normal = 8-10. Mild asphyxia = 6-8. Moderate asphyxia = 4-6. Severe asphyxia = 0-3

Immediate Care of the Newborn at Birth (for both normal or abnormal newborn)

• Step-1: Dry and stimuate
• Step-2: Assess breathing and color
• Step-3: Decide if resuscitation is needed
• Step-4: Keep warm
• Step-5: Tie and cut the cord
• Step-6: Start breastfeeding

ABCDS of resuscitation: if needed 
• AIRWAY – make sure the airway is open

Position the baby

Suction the mouth and nose ,and if there is meconium, the pharynx (back of throat) also include in suction.

• BREATHING- make sure the baby is breathing

Stimulate to initiate breathing

Use mouth to mouth or ambu bag breathing as necessary

Give oxygen, if available

• CARDIAC FUNCTION- make sure the heart is beating

Stimulate the baby.

Do chest compressions when necessary.

• Dry the mouth

Warm the baby with a blanket, a light, or the mother's skin.

• SHOCK

Make sure the baby is warm and dry.

MANAGEMENT: If resuscitation is needed.
A. Immediate management:

Steps of resuscitation:

• Dry & Wrap
• See Respiration/colour
• Decide for resuscitation
• Position, mouth to mouth respiration, ambu bag
• Cardiac massage
• Intubation
• Drug

Subsequent management:

• Fluid and nutrition should be maintained by IV 10% dextrose, NG tube feeding or oral feeding.
• To control seizure: Inj. Phenobarbitone 20mg/kg IV followed by maintenance dose of 5-6mg/kg per day.
• To control oedema: Fluid restriction 20-25% Mannitol may be used
• IV antibiotic.

Resuscitation Procedure 
A. Environment

• Maintenance of temperature
• radiant heater
• warm cloths

B. Positioning

• 1 inch roll of cloth below shoulder

 

C) Suctioning 
Should not be done always . When?

• Meconium in amniotic fluid
• Asphyxiated baby, first mouth then nose

D) Tactile Stimulation

• Drying
• Flicking of soles
• Rubbing the back

E) Assessment

• Color
• Respiratory effort.
• Heart rate
• Movements or Muscular activities

F) Ventilation

Indications:

• Apnea
• Heart rate < 100 beats
• Persistent central cyanosis

Process:

• Mouth to mouth
• Mouth to mask
• Umbu Bag
• Endotracheal intubation

Keep in mind:

• Rate of 40-60 breaths/min
• Tight face mask should be present
• Initial long inflation pressure-5 in number
• Equal bilateral breath sound should be found
• If good ventilation – count the Heart rate
• If>100 and increase in respiration –stop ventilation

G) Chest compressions

Indications:

• If heart rate is <60 beats/min or 60-80 beats/min and not rapidly increasing despite adequate ventilation with 100% O₂ for 30 seconds.
• Discontinuation: Heart rate > 80 b/min

H) Medications: when?

• Heart rate < 80 b/min despite adequate ventilation with O₂ and chest compression for 30 sec.
• Route:
  • Umbilical vein
  • Endotracheal tube

What are the drugs used?

• Adrenaline:
  • Dose: 1-3ml/kg of 1:10,000
• Volume Expanders:
  • Dose:10ml/kg 5% albumin-Saline or Ringers lactate
• Sodium Bicarbonate:
  • Prolonged arrest/or
  • profound metabolic acidosis-
  • Dose: 2meq/kg of 4.2%
• Naloxone:
  • Dose: 0.1mg/kg of 1mg/ml

 

Fig:Inverted pyramid showing relative frequencies of Neonatal resuscitative efforts

If there is no gasping or breathing at all after 20 minutes of ventilation: Stop ventilation

 

Time is life!

Preparation, skill and speed is essential!