NEW BORN

RESUSCITATION

DIVYA MUTHYALA
 CONTENT:

INTRODUCTION
PHYSIOLOGY OF BREATHING IN NEW
BORN
ASSESSING THE BABY-APGAR SCORE
STEPS IN RESUSCITATION
POST RESUSCITATIVE CARE
.
 INTRODUCTION:

The resuscitation of babies at birth differs from all

other age groups.
Knowledge of the relevant physiology is essential.
A clear airway and a warm environment are required
for most newborn babies.
However, 25% of all deliveries are at increased risk
of requiring resuscitation.
Any baby may have breathing difficulties at birth
therefore it is important to be prepared for
resuscitation in all deliveries.
 ANTEPARTUM INDICATIONS: MATERNAL

Diabetes
Severe hypertension &/ proteinuria
Previous Rh sensitization
Concomitant illnesses( renal, CVS, resp. etc)
Previous stillbirth
Bleeding in 2nd and 3rd trimesters
Infection
Drug abuse
ANTEPARTUM INDICATIONS: FETAL

Multiple pregnancy
Post term gestation
Size-date discrepancy
Polyhydramnios
Oligohydramnios
INTRAPARTUM INDICATORS: MATERNAL

C-section
Premature labour
Prolonged labour
General anaesthesia
Narcotic
INTRAPARTUM INDICATORS: IN UTERO

Abnormal presentation
PROM
Prolapsed cord
Forceps and ventouse delivery
Foetal distress, incl. low foetal pH
Thick meconium staining of amniotic fluid
 PHYSIOLOGY

Oxygen is important for every part of the human body,

without it, we die.
Before birth, the baby gets oxygen from the placenta.
After birth, the umbilical cord is clamped and cut; this
stops the delivery of oxygen from the placenta.
 continued...PHYSIOLOGY

If subjected to continued hypoxia, the baby will eventually lose

consciousness and stop trying to breathe
Due to lack of O2 neural centers controlling breathing cease to
function.
The baby then enters a period known as PRIMARY APNOEA.
Primary Apnoea:
During this period the baby’s heart rate remains
unchanged i.e. 120 – 150 bpm.
This however can decrease by half as the baby’s heart
reverts to anaerobic metabolism.
During this time CIRCULATION IS MAINTAINED!!!
If this continues shuddering and whole body gasps –
deep, spontaneous gasps – (at a rate of about 12/min)
are initiated by the primitive spinal centers
If these gasps fail to aerate the lungs they fade
and the fetus enters a period known as
SECONDARY OR TERMINAL APONEA.
As secondary apnoea progresses cardiac function
becomes impaired, the heart eventually fails and
without proper intervention the baby dies.
 So we can see that the baby can maintain proper
circulation in:
- primary apnoea
- gasping phase
- terminal apnoea
Therefore the most urgent requirement for any
hypoxic baby is that the lungs be effectively aerated.
Once there is efficient circulation, oxygenated blood
will be carried from the lungs to the heart.
The heart rate will increase and the brain will be
perfused with oxygenated blood and the neural centers
responsible for normal breathing will function once
again and the baby will recover.
 ASSESSING THE BABY

To do this we use the APGAR Score.

The intent of the APGAR score is to provide a
quick evaluation of a newborn and it assists in
determining if additional measures of
resuscitation are necessary.
A –appearance (color)
P – pulse
G – grimace (response to stimulation)
A – activity (muscle tone)
R – respiration
 APGAR Score
Apgar scores range from zero to 10.
The Apgar table comprises five (5) vital areas that
assess the newborn’s health.
These areas include:
- heart rate
- muscle tone
- respiratory effort
- the reflexive response to stimulation
- color
It quickly assess the health of an infant one minute and five
minutes after birth.
1-minute Apgar score:
measures how well the newborn tolerated the birthing process
5-minute Apgar score:
assesses how well the newborn is adapting to the environment.
A low APGAR identifies those babies who may require extra
attention and care.
Continual APGAR scores can be used to evaluate how effective
resuscitative efforts are.
In addition to the APGAR Score acute assessment is
made by the following parameters:
- Breathing – rate + quality
- Heart rate
- Colour
- Tone
Do not wait to assign APGAR scores prior to
starting resuscitation.
 First things first……

Immediately after delivery, any excess fluid should be

wiped off the baby.
The baby should then be wrapped in a warm, dry towel.
When pink and breathing regularly the baby should be
handed back to the mother.
Those babies not responding to being touched, for whatever
reason, should be transferred immediately to the resuscitation
area, under a radiant heater and a clock/timer started.
The baby should be placed flat or slightly head-down, with the
head in the neutral position.
Stimulate by flicking feet, rubbing trunk or extremities.
Clear the airway
 Key Steps in Resuscitation

Prevent heat loss by drying and covering the baby.

A-B-C-D
- Airway
- Breathing
- Circulation and
- Drugs
After assessment babies should fall into one of 3 categories:
1. Pink, with good tone and activity, pulse > 100 bpm.
2. Not breathing regularly, centrally cyanosed, heart rate > 100
bpm.
3. Not breathing OR has a heart rate < 100 bpm.
 Category 1
1)Pink, with good tone and activity, pulse > 100 bpm.
What to do?
Leave baby alone; Leave baby with mother if possible.
Dry the baby off, wrap in a warm towel, and give to the
mother.
Do not suction: This may result in vagal bradycardia and
laryngospasm (delaying onset of respiration)
 Keep the baby dry and warm
Ensure the cord is securely clamped
Dry the baby, remove the wet towels, and cover with dry ones.
For significantly preterm infants (GA < 30 weeks), drying the
infant, placing under a radiant source, and wrapping in food-
grade plastic wrap from head and body (excluding the face) is
the most effective way in keeping these babies warm during
resuscitation.
 Category 2
Not breathing regularly, centrally cyanosed, heart rate > 100 bpm.
What to do?
Dry the baby and place under a radiant heat source wrapped in a
warm, dry towel.
Drying often provides enough stimulation to induce breathing, but
gentle rubbing can also be used.
If there is no response begin active resuscitation using five
‘inflation breaths’ using a bag and mask and call for help/ assistance
 O2 and Assisted Ventilation

If the baby is breathing inadequately, oxygen should be given

immediately, initially just blown over the face.
If the breathing is persistently shallow or is absent or the
heart rate is less than 100, bag and mask ventilation should
be performed
Ventilation using Bag and Mask
Position the baby face up on a resuscitation
surface
Support the head in a neutral position to prevent
the tongue from obstructing the pharynx.
Gently suction the mouth and nose to remove
debris.
Then, apply facemask. It should cover the baby’s
mouth and nose, but not compress the eyes or
overhangs the chin
 Ventilation of the Baby
NEVER connect the baby directly to the hospital oxygen without using a pressure
limiting device. The bag should be attached to a manometer to prevent high
pressures being given to the newborn.
Babies only require pressures of about 30 cmH2O.
Adequacy of ventilation is measured by observing chest movements.
Start with 5 ventilation breaths, lasting for 1-2 seconds with the pressure set at
30-35 cmH2O for lung expansion.
Reduce the pressure to that which is sufficient for the chest to move – this is
usually 20 cmH2O.
Continue to give about 30 breaths per minute.
 Category 3
Not breathing OR has a heart rate < 100 bpm
What to do?
These babies require prompt resuscitation
Dry the baby quickly and place on a warm dry surface, in a warm dry towel and call
for help.
Initiate basic resuscitation with mask ventilation.
If the heart rate remains < 60 bpm begin chest compressions/cardiac massage.
If there is not a rapid response proceed to intubate when the person with the
necessary skill arrives.
Assist wherever possible
 External Chest Compressions (ECC)
*** Should not be started until effective ventilation has been established
This can either be with the tips of two fingers over the junction of the
middle and lower thirds of the sternum, or with the hands around the
chest, compressing the sternum with two thumbs at a rate of 100-120
bpm, to a depth of 2cm.
Depress the baby’s chest to approximately 1/3 the anterior-posterior
diameter of the chest.
Synchronize your compression with the ventilatory breaths aiming to give
90 compressions to 30 breaths per minute (3:1 ratio).
 Cut off Points
If there is no gasping or breathing at all after 20 minutes stop
ventilation.
If there was gasping but no spontaneous breathing after 30mins
stop ventilation.
Remember to always reassess the baby regularly
Every 30 seconds or so throughout the resuscitation process.
Especially the Heart Rate
the 1st sign of any improvement in the baby will be an increase in
HR.
Indications for Tracheal Intubation

Difficulty in ventilation by mask

Prolonged bag/mask ventilation
Continued bradycardia during bag/mask ventilation
During external chest compression (ECC)
Meconium aspiration [for suction vs. ventilation]
 Meconium

If meconium is present and baby is not vigorous:

Insert endotracheal tube (ETT)
Suction with ETT meconium aspiration device
Slowly withdraw tube
Repeat as necessary until little meconium is recovered
 Intubation

Intubation tubes can be either cuffed or uncuffed

During intubation the baby's head should be in the neutral
position, the laryngoscope blade (Cole’s/Straight-sided)
should be positioned either in the vallecula or posterior to the
epiglottis and the tracheal tube should be inserted with 2.0cm
beyond the cords
The chest should be examined for bilateral movement,
confirmed by listening with a stethoscope.
If there is only air entry on one side, the tube is probably in the
right main bronchus and should be withdrawn slowly until bilateral air
entry is heard.
If no air entry is heard and the baby remains blue and bradycardic,
the intubation will likely be oesophageal.
The baby should be extubated immediately and 100% oxygen
administered by bag and mask before re-intubation. If there is any
doubt about the position of the tracheal tube it should be removed.
Attempts at intubation should only take 20-30 seconds
The first few inflations may require higher pressures,
sustained for at least one second.
When the tracheal tube is in the correct position it
should be firmly secured.
If the tube is to remain in place following resuscitation,
its position should be confirmed, preferably by chest X-
Ray.
 DRUGS
Are rarely given during resuscitation
Used in babies not responsive to ventilation or when asystole is
present
IV adrenaline administered via an umbilical venous catheter,
peripheral vein
Additional medications
1. Sodium bicarbonate if acidosis is prolonged
2. Calcium gluconate if signs of hypocalcemia present
3. Naloxone if the CNS depression is thought to be due to
anaesthesia (meperidine) given to the mother
4. Glucose –last line as glycogen stores are depleted
5. Very rarely the baby may have significant blood loss and may
require isotonic crystalloid.
6. Surfactant
 Failure to Respond
Most babies respond readily to resuscitation
Before deciding whether to abandon efforts:
> Check the equipment
> Check the position and size of the endotracheal tube
> Give IV adrenaline twice and sodium bicarbonate and glucose
The possibility of pneumothorax, intrauterine infection or
unrecognized hypovolaemia should be considered.
Rarer causes of poor response include the presence of congenital
anomalies such as choanal atresia, diaphragmatic hernia or pulmonary
hypoplasia.
If there is a heartbeat but no
respiration then Intensive Care should
be considered
Resuscitation efforts should not be
continued beyond half an hour unless
the baby is making at least occasional
respiratory efforts.
 Post-resuscitative Care
Effective resuscitation does not stop when a baby is pink and
crying well
Parents may expect the worst and will require a full explanation
Consider (if the response to resuscitation is poor) a neonatal
room for observation, further investigations, or treatments
for possible sepsis.
Use all available information to guide your management:
cardiotocograph (CTG), cord pH, maternal history, and the
history of the labor
Discharge must be deferred for at least 12 hours and
the infant must be observed for signs of hypoxic-
ischaemic encephalopathy (seizures)
Fully document all events and procedures done
throughout the resuscitation
The circumstances surrounding a failed resuscitation
should be discussed and recorded
 Summary
Most babies require no resuscitation at birth and can be
handed directly to the mother.
Those that do require resuscitation, almost always require
only drying and being kept warm, suctioning, and facial
oxygen, or possibly bag and mask ventilation for a few
breaths.
Intubation and the administration of drugs are very rarely
required but should be readily available, especially for high
risk births.
THANK YOU FOR YOUR
PATIENCE ;)