Neonatal Resuscitation

1. Neonatal Resuscitation Lustily crying & Active Newborn Baby Is A Delight to the Mother Obstetrician Pediatrician

2. Neonatal Resuscitation Ventilation of the baby’s lungs is the most important and effective Action in Neonatal Resuscitation

3. Neonatal Resuscitation Give a Breath Save a Life !

4. Neonatal Resuscitation Objectives Lesson 1 • Changes in physiology that occur when a baby is born • Sequence of steps to follow during resuscitation • Risk factors that can help predict which babies require resuscitation • Equipment and personnel needed to resuscitate a newborn

5. Why Learn Resuscitation • Birth asphyxia - 19% ( 5 million) of all neonatal deaths every year (WHO 1995) • By appropriate resuscitation: Outcome of thousands of newborns may improve • 10% of all babies require resuscitation; 1% need extensive resuscitative measures

6. Neonatal Resuscitation Program • Asphyxia : as-fikse-ah a Greek word “ Stopping of Pulse ” “a condition due to lack of oxygen in respired air, resulting in impending or actual cessation of apparent life” • Asphyxia is the most likely complication which can occur at the time of birth

7. Neonatal Resuscitation Program resuscitate - Latin word - “ To arouse again ” “ Skillful resuscitation of the asphyxiated newborn can prevent brain damage and minimize subsequent Neonatal morbidity ”

8. ABCs of resuscitation • Temperature • Airway (position and clear) • Breathing (stimulate to breathe) • Circulation (assess heart rate and color) • Drugs (Medications)

9. Need For Resuscitation Assess baby’s risk for requiring resuscitation Provide Warmth Position, Clear airway, Dry, stimulate to breathe Always needed by newborns Needed less frequently Rarely needed by newborns Give Supplemental Oxygen, as necessary Assist ventilation with positive pressure Intubate the trachea Provide chest compressions Administer medications

10. Oxygenation before birth • Oxygen for fetus from mother’s blood • Small fraction of fetal blood passes through the lungs • Fetal alveoli filled with fluid and vessels constricted • Blood flows primarily through ductus arteriosus into the aorta

11. Fluid filled alveoli and constricted blood vessels in the lungs before birth Constricted vessels before birth Fluid in alveoli

12. Shunting of blood thru ductus away from Lungs before birth

13. What normally happens at birth Three major changes occur • The Fluid in the alveoli is absorbed • The umbilical arteries and vein constrict and are clamped • Removes low-resistance placental circuit • Increase systemic blood pressure • Blood vessels in the lung tissue relax • Decrease resistance to blood flow

14. Changes at birth Fluid in the alveoli absorbed and replaced by air

15. Dilated vessels after birth Constricted vessels before birth Oxygen in alveoli Fluid in alveoli Dilatation of Pulmonary Blood vessels at Birth

16. Oxygen-enriched blood in aorta Closing ductus arteriosus Pulmonary artery Lung Lung Cessation of Shunt thru Ductus after birth as blood preferentially flows through lungs

17. What can go wrong during Transition? • Breaths not forceful to remove alveolar fluid or • Foreign material blocks air entry oxygen not available • Excessive blood loss/poor cardiac contractility systemic hypotension • Hypoxia constriction of pulmonary arterioles tissue oxygen deprivation (PPHN)

18. Response of the baby to an interruption in normal transition • Poor muscle tone due to insufficient oxygen supply to brain, muscles and other organs • Depression of respiratory drive from insufficient oxygen supply to the brain • Bradycardia • Insufficient delivery of oxygen to heart, muscle or brain stem • Low Blood pressure • Poor myocardial contractility or blood loss • Tachypnea from failure to absorb lung fluid • Cyanosis from insufficient oxygen in blood

19. In utero or perinatal compromise • Respiration first to cease after oxygen deprivation • Primary apnea after initial period of rapid attempts to breathe – responds to stimulation • Secondary apnea, if oxygen deprivation continues; requires positive pressure ventilation

20. Physiology of asphyxia - Apnea Rapid breathing Irregular Gasps

21. Physiology of asphyxia - Apnea • Exposure to Oxygen and stimulation during period of primary apnea in most cases will induce respiration • With the onset of Secondary apnea • HR, BP and pO2 continue to fall farther & farther • Infant in this stage is unresponsive to stimulation and artificial respiration with oxygen must begin at once

22. Physiology of asphyxia - Apnea • In secondary apnea longer you delay starting of ventilation longer it takes for spontaneous respiration to develop • Fetus may go from primary to secondary apnea in-utero • Baby born apneic at birth - is assumed to be in SECONDARY APNEA

23. Sequence of Physiological Events in Animal Models

24. Airway Duration=30 sec

25. Breathing Duration=30 sec

26. Circulation Duration=30 sec

27. Drugs • Epinephrine • If HR remains < 60 bpm, continue chest compressions and PPV • When heart rate >60 bpm stop chest compression • When heart rate >100 bpm and baby breathing stop ventilation

28. Apgar score and resuscitation • Resuscitation initiated before score assigned • Not used to determine • Need for resuscitation • Steps to be taken and when to resuscitate • Three signs for evaluation (Evaluated simultaneously) • Respiration • Heart rate • Color

29. How to prioritize action

30. Preterm babies & resuscitation Some special characteristics in preterm babies • Surfactant deficiency: Lungs more difficult to ventilate • Thin skin/ large surface area to body mass ratio/ less subcutaneous fat – more likely to lose heat • More prone to infections • Increased risk of intracranial bleed during stress

31. Being Prepared for Resuscitation • Anticipation for need for resuscitation • Adequate preparation of both • Equipment • Personnel • Anticipation • May come as a surprise • Most episodes can be anticipated • Antepartum Factors • Intrapartum Factors

32. Being Prepared for Resuscitation • Adequate preparation • Trained Personnel : At least two • Equipment • A radiant warmer : Heated and ready to use • All resuscitation equipment immediately available and in working order

33. Personnel at delivery • At every delivery one person with skills to perform complete resuscitation must be present • High risk cases: Two or more persons required • Multiple births: Separate team for each baby

34. Birth • Term Gestation? • Clear of Meconium? • Breathing or crying? • Good Muscle Tone? • Routine Care • Provide warmth • Clear Airway if needed • Dry • Assess color T Yes A No 30 seconds • Provide warmth • Position clear airway • (as necessary) • Dry, stimulate, reposition Evaluate Resp, HR and Color Breathing, HR>100, Pink Breathing, HR>100, Cyanotic Pink 30 seconds 30 seconds B HR < 100 Apnea Persistent cyanosis Ventilating HR < 60 HR > 60 HR > 100 & Pink C HR < 60 D Observational Care Give Supplementary Oxygen • Provide positive pressure ventilation  Post resuscitation Care • Provide positive pressure ventilation  • Administer Chest Compressions  Endotracheal intubation may be considered at several steps Medications, continue PPV, CC

35. Equipment and supplies • Newborn resuscitation mannequin • Radiant warmer • Gloves • Bulb syringe or suction catheter • Stethoscope • Shoulder roll • Blanket or towel • Self or flow inflating bag

36. Equipment and supplies • Flow meter • Masks • Method to administer oxygen • Laryngoscope and blade • Suction catheter • Endotracheal tube • Meconium aspirator • Clock with second hand • Mechanical suction and tubing