Neonatal resuscitation

A. Principles
 It is estimated that 10% of newborns need assistance at birth to make the transition to extrauterine life.
 The purpose of resuscitation in the neonatal ward is to help the newborn to achieve the transition of
respiratory and circulatory functions through:
 expansion of the lungs;
 elimination of fetal pulmonary fluid;
 establishing an efficient respiratory gas exchange;
 closing the right-left circulatory shunt.
 These physiological changes occur during the first breaths, leading to an increase in the partial
pressure of oxygen (PO2) in the alveoli and in the arterial circulation from ~ 25 mm Hg (intrauterine) to
50-70 mm Hg, accompanied by:
 decreased pulmonary vascular resistance;
 increased venous return to the left atrium;
 increased left atrial pressure;
 closing the right-left shunt by oval foramen.
 Changes in tissue perfusion and oxygenation can lead to depression of cardiac function.
 In case of hypoxia, the fetus becomes apneic, its recovery being achieved by stimulation and
exposure to oxygen.
B. Objectives

 Minimization of heat loss by drying and heating the newborn, thus

increasing oxygen consumption by the newborn.
 Stabilize normal breathing and pulmonary expansion by cleaning
the upper airways.
 Increased arterial PO2 by adequate alveolar ventilation.
 Supporting adequate heart rate.
C. Perinatal circumstances with high risk
 Fetal status:  fetal hydrops;
 fetal heart rate abnormalities;  multiple pregnancy;
 pH of the scalp ≤7.20;  cardiac prolapse;
 fetal heart rate disorders.  abruptio placentae.

 Fetal disorders:  Labor and birth:

 Amniotic fluid stained by meconium or  significant vaginal bleeding;
other evidence of possible fetal  abnormal fetal presentation;
compromise;
 prolonged, difficult or unusual work;
 prematurity (˂36 weeks), postmaturity (>
42 weeks), anticipation of a small (<2  suspicion of humeral dystocia.
kg) or large (> 4.5 kg) birth weight;
 serious birth defects diagnosed
antenatally;
D. Equipment
 Thermal radiant
 Start and check before giving birth.
 Additional equipment for heating
newborns with very low birth weight
should be available.
 Source of oxygen (100%)
 Pulse oximeter and adjustable Neopuff
system for premature (<30-32 weeks)
 Anesthesia balloon
 Face masks of appropriate size
 Stethoscope
 Emergency kit equipped:
 laryngoscope with blades sizes 0 and 1;
 additional batteries;
 intubation probes (diameters of 2.5
mm, 3.0 mm and 3.5 mm);
 drugs, including adrenaline (1: 10,000),
sodium bicarbonate (0.50 mEq / ml),
naloxone and 0.9% NaCl;
 umbilical catheters;
 syringes (1, 3, 5, 10 and 20 ml) and
needles (caliber 18-25).
 Incubator with heat source on battery
and portable oxygen supply, if the birth
ward is not near the neonatology
section.
F. Procedure
 Place the newborn on the radiant table.
 Dry the newborn completely with gentle
movements and make sure it is warm.
 Extra heat sources may be needed in very
young children.
 Place the child with the head in the middle
position, with a slight extension of the neck.
 Complete suction of mouth, oropharynx and
nostrils with a probe.
 If the amniotic fluid is stained with meconium
and the newborn is not vigorous, aspirate the
oropharynx and trachea as quickly as
possible.
 The evaluation must determine whether:
 the newborn cries or breathes;
 muscle tone is good;
 the skin is pink;
 the child was born on time.
 If any of these situations are not present, the
initial resuscitation steps are started.
 First, evaluate whether the baby is breathing
spontaneously.
 Then determine if your heart rate is> 100 beats
per minute (bpm).
 Finally, check to see if the newborn has pink
complexions (acrocyanosis is normal).
 If any of these three characteristics is
abnormal, immediately correct the
deficiencies and reassess the child every 15-
30 seconds, until all the features are present
and stable. This approach will help avoid
complications.
1. Breathing
 The newborn breathes spontaneously, the heart rate is> 100 bpm
and the color of the skin becomes pink (Apgar score is 8-10).
 This situation is present in over 90% of all newborns at term, with an
average time until the first breath of about 10 seconds.
 After or during heating, drying, positioning and oropharyngeal
aspiration, the newborn should be evaluated.
 If the breathing, heart rate and color of the skin are normal, the
newborn is taken to the neonatology ward
 Some newborns do not breathe spontaneously immediately, but
respond quickly to tactile stimulation.
 If breathing is not resumed after two attempts at tactile stimulation,
the newborn is considered to have secondary apnea and
respiratory support is initiated.
 The newborn breathes spontaneously, the heart rate is> 100 bpm,
but it is cyanotic (Apgar score: 5-7).
 This condition is not uncommon and may follow primary apnea.
Newborn at term should be given oxygen (100%) at a rate of 5 l /
minute by face mask or free oxygen in the incubator.
 If the color improves, the oxygen must be stopped gradually and
the color re-evaluated.
 If cyanosis recurs, the oxygen source moves closer to the newborn.
 There is evidence that resuscitation with room air alone can be as
effective as supplemental oxygen, and the use of an oxygen-air
mixture can also be effective.
 For infants born less than 30-32 weeks, it is used for oxygen
resuscitation, while monitoring oxygen saturation in the blood (pulse
oximetry).
 It starts with an oxygen concentration of 60%, which is adjusted to
maintain oxygen saturation within the normal limits for premature,
85-93%.
 Newborn is apneic despite tactile stimulation or has a heart rate <100
bpm, despite respiratory effort (Apgar score: 3-4).
 Secondary apnea requires balloon and mask ventilation.
 Connect a flask with a volume of approximately 750 ml to oxygen
(100%) or to an air-oxygen mixture (depending on the gestational age),
administered at a rate of 5-8 l / minute, and to a suitable dimensions.
The mask should cover the chin and nose, leaving the eyes free.
 After positioning the newborn's head on the midline, with a slight
extension, the initiation of breathing should be performed at a pressure
adequate to produce a maximal thoracic excursion, which can be up
to 30-40 cm H2O at term birth. This will install the residual functional
capacity, and subsequent compressions will be efficient at lower
pressures.
 Support should be maintained until breathing is spontaneous and heart
rate> 100 bpm.
 The effectiveness of the procedure can also be appreciated by
improving the color of the skin and tone before installing spontaneous
breaths.
 The newborn is apneic and the heart rate is below 100 bpm, despite
the 30 seconds of assisted ventilation (Apgar score: 0-2).
 If the heart rate is> 60, positive pressure ventilation should be continued
and the heart rate should be checked within 30 seconds. It is advisable
to carefully evaluate the effectiveness of the support during this period
of time, by:
 observation of the movement of the ribcage and heart ascultation
 continued ventilation on the balloon and mask and reassessment in 15-30
seconds.
 If the heart rate does not increase and the color does not improve,
although the air is entering properly, intubation may be considered.
 Air leaks (eg pneumothorax) should be excluded.
 Intubation is an absolute indication only when a diaphragmatic hernia
or other similar anomaly exists or is suspected.
 Intubation should be performed quickly by a qualified person, limiting
each test to 20 seconds and continuing with ventilation on the balloon
and mask between two tests.
 The success of the intubation consists in the correct positioning of the
newborn and the laryngoscope and the knowledge of the anatomical
landmarks.
2. Circulation
 If the heart rate remains below 60 bpm, after  Determine the effectiveness of compression
intubation and 30 seconds of ventilation with
100% oxygen, cardiac massage is instituted.
The best technique is the following:
 The doctor stands at the feet of the newborn
and positions both police at the junction
between the middle and lower third of the
sternum, covering the chest with the other
fingers and supporting the back.
 Alternatively, the doctor may sit sideways
with the child and compress the lower third
of his sternum with the index finger and
middle finger of a hand.
 Regardless of the method used, compress
the sternum to approximately one third of the
diameter of the chest, at a frequency of 90
times per minute, performing three
compressions per breath.
 Ventilation with positive pressure should be
continued at a rate of 30 breaths per minute,
interspersed also at the third compression.
by palpating the femoral, brachial or
umbilical cord.
 After 30 seconds, suspend both ventilation
and compression for 6 seconds and evaluate
your heart rate.
 If the heart rate is> 60 bpm, chest
compression is interrupted and ventilation is
continued until breathing becomes
spontaneous.
 If no improvement is observed, the
compression and ventilation are continued
for successive periods of 30 seconds
alternating with periods of 6 seconds for
evaluation.
 Newborns requiring ventilatory and
circulatory support are significantly
depressed and require immediate vigorous
resuscitation. Resuscitation may require a
team of at least three trained people.
3. Medication
 If, despite adequate ventilation with 100% oxygen and chest compressions, a heart
rate> 60 bpm is not achieved within 1-2 minutes after birth, inotropic agents are
administered to support the myocardium, ensure water balance and, in some situations,
to correct acidosis.
 Medicines provide substrate and stimulation to the heart, to support the circulation of
oxygen and nutrients to the brain.
 The most accessible intravenous route for neonatal drug administration is umbilical vein
catheterization, which can be performed rapidly and aseptic.
 Drug therapy as an adjuvant to oxygen therapy has the role of supporting the
myocardium and correcting acidosis.
 Continuous bradycardia is an indication for adrenaline administration, after effective
ventilation has been achieved.
 An intravenous dose of 0.1-0.3 ml / kg (up to 1.0 ml) of 1: 10,000 epinephrine solution is
ideally administered through an umbilical venous catheter in the central circulation.
 This dose can be given repeatedly every 3-5 minutes, if necessary and if there is no
obvious benefit at higher doses.
 When access to the central circulation is difficult or delayed, adrenaline may be
administered on the intubation probe.
Filling the vascular bed.
 If the ventilation and oxygenation have been stabilized, but the
blood pressure is still low or the peripheral infusion is weak, filling the
circulatory bed can be done using physiological serum, 5% albumin,
erythrocyte mass or whole blood, starting with 10 ml / kg body.
 Additional indications for filling the vascular bed include signs of
acute bleeding or poor response to resuscitation efforts.
 Vascular bed filling should be performed with caution in newborns,
where hypotension may be caused by myocardial damage as a
result of suffocation.
 In most cases, there is no need for rapid acidosis correction as part
of the initial resuscitation. In the absence of epinephrine response
and volume expansion, documented or suspected acidosis should
be treated with 2 mEq of bicarbonate per kilogram body.
G. Special situation
1. Suction of meconium
 In the presence of meconium in the amniotic fluid, the obstetrician must rapidly
evaluate the newborn during birth, tracking the presence of secretions or
abundant amniotic fluid.
 Routine aspiration of all newborns in whom meconium is present is not
recommended, but in the presence of significant amounts of fluid or secretions,
the mouth and pharynx should be aspirated after the newborn's head exits and
before the first breath.
 The newborn should be evaluated immediately to determine if he is vigorous,
defined as strong breathing effort, good muscle tone and a heart rate> 100
bpm.
 Vigorous infants should be considered normal, despite the presence of meconium.
 Infants who are not clearly vigorous are rapidly intubated and aspirated into the
trachea meconium, preferably before the first breath.
 In many cases, even if the newborn breathed spontaneously, tracheal aspiration is
continued to prevent meconial aspiration pneumonia.
 The suction is made with adapters that allow the probe to be connected to the
catheter.
2. SHOCK
 Some newborns present with pallor and
shock in the birth room.
 The shock can be caused by:
 significant intrapartum blood loss due to
placenta separation;
 maternal-fetal hemorrhage;
 praevia placenta;
 incision through an anterior placenta during
caesarean section;
 transfusion between twins;
 rupture of an abdominal organ (liver or
spleen) during a difficult birth;
 vasodilation or loss of vascular tone due to
septicemia or hypoxemia and acidosis.
 Newborns in shock are pale, tachycardic (>
180 bpm), tachypnea and hypotensive,
with poor capillary filling and weak pulses.
 After initiation of respiratory support,
immediate transfusion with red blood mass
O may be required. Negative and albumin
5%, if the shock is caused by acute loss of
blood.
 20 ml / kg body can be administered through
an umbilical venous catheter.
 If no clinical improvement occurs, other
causes of blood loss should be sought, with
continued blood and colloid
administration.
 It is important to note that hematocrit can
be normal immediately after birth, if blood
loss was acute during the intrapartum
period.
 Except in cases of acute massive blood
loss, urgent replacement of the lost blood is
not required, and acute stabilization can
be performed with crystalloid solutions.
 Normal physiological serum is the first
choice for fluid replacement. Its
administration gives time to obtain
appropriate products from the blood bank,
in case the blood replacement is required
later.
3. Pneumothorax
 If a newborn does not respond to resuscitation, despite effective
ventilation, chest compression and medication, consider the
possibility of air loss syndromes.
 It must be excluded:
 pneumothorax (uni- saubilateral);
 pneumomediastinum.
4. Prematurity
 Premature infants require additional special care in the birth room,
including the use of air-oxygen mixtures and monitoring oximetry, as
well as precautions, such as wrapping in foils or plastic bags to
prevent heat loss from the thin skin and an increased ratio of body
surface area to weight.
 Apnea due to respiratory failure is more likely at young gestational
ages and newborns need support.
 Surfactant deficiency lungs are poorly compliant and may require
increased ventilatory pressures for first breaths.
 Depending on the reason for preterm birth, perinatal infection is
more likely in preterm infants, which increases the risk of perinatal
depression.
J. Maintaining or stopping resuscitation

 Resuscitation at birth is indicated in newborns with a high probability of

survival and a low risk of severe morbidity, including those with a
gestational age of 25 weeks or older.
 In situations where survival is unlikely or the associated morbidity is very
high, parents' desire to guide decisions regarding resuscitation initiation.
 If there is no sign of life after 10 minutes of aggressive resuscitation
efforts, in the absence of evidence of other causes of neonatal
compromise, resuscitation interruption may be considered.