NEONATAL RESUSCITATION

Ackni hartati
 ASPHYXIA

Mortality rate :
GLOBAL:
1 million newborns deaths each year
NATIONAL:
27.000 newborns deaths each year

Resuscitation:
10% of newborns require some assistance to
begin breathing
1% of newborns require extensive resuscitative
measures to survive
 ASPHYXIA

Asphyxia is reserved to describe a neonate

with all the following conditions:
1.Profound metabolic / mixed acidosis
(pH < 7.0)
2.APGAR score 5 minutes : 0-3
3.Neonatal neurologic manifestations
4.Multi-system organ dysfunction
 APGAR SCORES

Give informations about condition of the

baby and rescucitative efforts
It is not to determine whether the baby
needs rescucitation
 APGAR Scores
Sign Score = 0 Score = 1 Score = 2
----------------------------------------------------------------------------------------------------
APPEARANCE Blue all over, Acrocyanosis Pink all over
(color) or pale
PULSE Absent Below 100 Above 100
(heart rate)
GRIMACE No response Grimace or Good cry
(reflex irritability) weak cry
ACTIVITY Flaccid Some flexion of Well flexed, or active
(muscle tone) extremities movements of extremities
RESPIRATIONS Absent Weak, irregular, Good crying
or gasping
============================================
The APGAR score should be assigned at one minute and five minutes, finding the
total score (0-10) at each time by adding up points from the table above.
Continue to assign scores every five minutes thereafter as long as the APGAR
score is less than 7.
What normally happens at birth to allow a baby
to get oxygen from the lungs ?
RESPIRATORY SYSTEM TRANSITION
Fluid replaced by air in alveoli
Air
Fetal
lung
fluid

First Second Subsequent

breath breath breaths
The physiology of asphyxia

Primary Secondary
apnea apnea

Heart Rate

Blood pressure
 Prepare for resucsitation
 Personnel
- Every delivery has at least 1 personnel
- Extensive resuscitation
Skilled personel and more than > 1 personnel
 Equipment and the room for delivery
 Equipment and supplies
1. Laryngoscope with an extra
set of batteries and extra bulbs
2. Blade (No.00,0,1)
3. ET tubes (No. 2.5, 3, 3.5, & 4)
4. Stylet (optional)
5. CO2 monitor or detector
(optional)
6. Suction setup (No.>10F)
7. Roll of tape
8. scissors
9. Oral airway
10. Meconeum aspirator
11. Stethoscop
12. Resuscitation bag and mask,
manometer (optional), and
oxygen tube.
Endotracheal tube
The appropiated-sized tube

Tube size Weight Gestational

(mm) (g) age
(Inside diameter) (wks)
2,5 < 1000 < 28

3,0 1000 - 2000 28 - 34

3,5 2000 – 3000 34 – 38

3,5 – 4,0 > 3000 > 38

Non Re-breathing bag valve
Re-breathing bag valve
 Oxygen Reservoir

Reservoar

Ujung tertutup

Ujung terbuka
Pulse oxymeter Mutlak harus disediakan
ResusitasiNeonatus 2010
 RESUSITASINEONATUS 2010

Picture 3.14 Free flow oxygen given by flow-inflating bag (left) and by T-piece
resuscitator (right).
Note that mask is not held tightly on the face.
Administration of less than 100% oxygen will require compressed air and a
17
 Characteristics of resuscitation bag
used to ventilate newborns:

 Size of bag:  750 mL

 Newborn require : 15-25 mL tiap ventilasi (5-8
mL/kg)

 Capable delivering 90%-100% oxygen

 Without reservoar  O2 concentration to baby:
40%
 With reservoar  O2 concentration to baby: 90%-
100%

 Appropriate-sized masks
 Cover the chin, mouth and nose but not eyes
 MASK
 Size
 Rims
 Shaped

 
Giving Oxygen
1 2
Giving Oxygen
3
 Which babies require resuscitation

Always
needed by Assess baby’s response to birth
newborns
Initial Steps in resuscitation

Resuscitation Bag and mask

Needed
less
frequently Chest
compressions +
Bag and mask
Rarely
needed by Medications
newborns
 Target SPO2 Pre-
ductalSetelahLahir KESIMPULAN
1 menit 60-65%
2 menit 65-70%
Jangan terburu-
3 menit 70-75% buru
4 menit 75-80% memberikan O2
5 menit 80-85%
10 menit 85-95%
 PERSEPSI PERUBAHAN WARNA MERAH
SECARA KASAT MATA

Dalam sebuah studi

(27 staf medis memperhatikan perubahan warna kulit BBL)
SpO2 rata-rata ketika bayi terlihat merah

adalah 69%
Banyak staf tersebut merasa bayi tidak

berubah menjadi merah, bahkan saat SpO2> 92%

KESIMPULAN
Perlu memakai monitor SpO2 pulse oxymeter
ASSESSMENT (IN FEW SECONDS)
 assessed for these questions
Birth

1. Term gestation? Routine care

2. Breathing or crying? Yes  Provide warmth
 Clear air way
3. Good muscle tone?  Dry
 Evaluate color
 Determine if a baby needs
rescucitation in few seconds:
1. Term gestation?
2. Breathing or crying ?
 Assass whether the baby breathing spontaneously
 No efforts  intervension
 Gasping  intervension
 3. Muscle tone ?
Good muscle tone :flexed extremities and be active
 Variable assesment
No

30 seconds
i. Provide warmth
ii. Position;clear airway
(as necessary)
iii. Dry, stimulate,
reposition
i. PROVIDE WARMTH
 The baby should be placed under a radiant warmer
ii.POSITION;
CLEAR AIRWAY AS NECESSARY
 Position by slightly extending the neck
 Positioned on the back or side
 The neck slightly extended in the “sniffing” position
 Placed rolled blanket under the shoulders
iii. DRY_STIMULATION_REPOSITION

 Position & suctioning  stimulate

spontaneous breathing

 Tactile stimulation :
1. Flicking of the soles of the feet
2. Rubbing the back/chest/abdomen/extremity
 Bila ada mekonium :
 Bila Bayi tidak bugar : hisap dulu dari trakea
sebelum ke langkah berikut nya
 Bila bayi bugar : hisap hanya dari mulut dan
hidung,kemudian bayi dapat tetap bersama
ibunya untuk evaluasi dan perawatan rutin.
 Ada mekonium dan Bayi tidak
bugar
 Pasang laringoskop, hisap dgn kateter penghisap
no 12F/14F
 Masukkan pipa ET
 Sambung pipa ET ke alat penghisap
 Lakukan penghisapam sambil menarik keluar
pipa ET
 Ulangi bila perlu atau bila HR menunjukkan
resusitasi harus dilanjutkan
 Ada mekonium dan Bayi Bugar
 Jika : usaha nafas baik, Tonus otot baik, dan HR
> 100/mnt

 Gunakan balon pengisap atau kateter pengisap

untuk membersihkan mulut dan hidung

 Perwatan rutin dan evaluasi

 ResusitasiNeonatus 2010

Indikasi PPV :

Jika bayi tidak bernafas (apnea) atau gasping, HR < 100/mnt meskipun
bernafas, dan atau saturasi dibawah target walaupun sudah diberikan
free-flow oksigen sp 100 %, segera diberikan PPV
 ResusitasiNeonatus 2010

Peralatan Resusitasi untuk PPV

www.themegallery.com Company Logo

 How often should you squeeze the bag?

 40-60 breaths per

minute

Breathe Two….Three Breathe Two…..Three

(squeeze) (release…..) (squeeze) (release…….)
 ResusitasiNeonatus 2010

Hal Penting yang harus diperhatkan pada saat PPV , jika dada tidak
mengembang:

Pertimbangkan Akronim “MR SOPA” untuk koreksi :

Corrective Steps Actions

M Mask adjusment
R Reposition airway
S Suction mouth and nose
O Open mouth
P Pressure increase
A Airway alternative
Be sure there is a good seal of the mask on the
face
The head should be in the “sniffing” position
Check for secretions: suction if present
Ventilate with the baby’s mouth slightly open and
lift the jaw forward
Gradually increase the pressure every few breaths,
until there are bilateral breath sounds and visible
chest movement with each breath
Consider endotracheal intubation or laryngeal
 Pemberian CPAP
 Jika ada usaha nafas tetapi tampak sulit,
merintih, retrasi interkostal
 Sianosis menetap
 Hipoksemia
Assess for these questions:
1. Breathing ………….... Apnea / Breathing
2. Heart rate …….. > 100 beats/minutes ?
(in 6 seconds,multiply by 10)
3. Color…………….. pink ?
If you must continue bag and mask
ventilation for more than several minute:

Insert orogastric tube

 Gas forced into stomach disturbing
ventilation
 Gas in the stomach regurgitation of
gastric contents  aspiration
 Indications for beginning
chest compressions:
the heart rate remains <60 bpm despite
30 seconds of effective-pressure
ventilation
How many people are needed to
administer chest compression?

Needed two persons

- 1 person  chest compression
- 1 person  to continue ventilation
Two people are required when
chest compressions are given
 How do you position your hands on
the chest to begin chest compressions?

Two techniques:
1) Thumb technique
2) Two-finger technique
 The thumb technique
Two thumbs are used to depress the sternum
The hands encircle the torso and the fingers support
the spine
 The two-finger technique
The middle finger and either the index finger or ring
finger of one hand are used to compress the sternum
The Other hand is used to support the baby’s back
The thumb technique
advantage disadvantage
 Ussually less tiring  More convinient if the baby is
large or your hands are small
 It also make access to the
umbilical core more difficult when
medications become neccessary
 The two-finger technique
advantage
 can be used regardless of the size of the babay or the size of your hands
 it leaves the umbilicus more acceeible in case medication must be
administerd

disadvantage
 be more tired
 Position chest compressions
quickly locate the correct area sternum by running your finger along
the lower edge of the ribs until you locate the xyphoid.

then place your thumb or finger immediatelly above the xyphoid

Pressure use to compress the chest

 To a depth of approximately one third of the anterior-

posterior diameter of the chest
 Do not lift your thumb or finger off the chest between
compressions:
 Your waste time relocating the compression area.
 Your lose control over the depth of compression
 You may compress the wrong area, producing
trauma to the chest or underlying organs
Correct
Fingers remain in
contact with chest
on release

Incorrect
Finger lose
contact with
chest on release
 Complication
1. Broken ribs
2. Trauma/Laceration of the liver
3. Pneumotorax
 Frequency
 Ratio 3 : 1
 1 cycle (2 second)
  11/2 second : 3 compression
  1/2 second : 1 ventilation----- 90
compression + 30 ventilation on 1 minutes

one and two and Three and breathe

After 30 second chest compression +
ventilation  check heart rate

 Heart rate > 60 x/minutes

Discontinue chest compression, continue ventilation
 Heart rate > 100 x/minutes
Discontinue chest compression and the baby begins
to breathe spontaneously, you should slowly
withdraw positive-pressure ventilation.
 Heart rate < 60 x/minutes
Have Intubation (you most likely ) then you should
give epinephrine
Provide positive-pressure ventilation
Administer chest compressions

HR < 60

Administer epinephrine
 Indication to give epinephrine
Heart rate remains < 60 bpm after
given 30 seconds of assisted ventilation
and another 30 seconds of coordinated
chest compressions and ventilation

How should epinephrine be given?

The umbilical vein (recommended)
The endotracheal tube
 Give epinephrine
 Preparation : 1:10.000 solution in 1 ml
syringe
 Dose …… IV : 0,1-0,3 ml/kg larutan 1:10.000
ET : 0,3-1,0 ml/kg larutan 1:10.000
 Rate of administration : rapidly

If this does not happen

 you can repeat the dose every 3 to 5
minutes
If the babypale, there is evidence of blood loss and
or the baby is responding poorly to resuscitation

Administration of a volume expander may be

indicated
 The recommended solution for
acutely treating hypovolemia is
an isotonic crystalloid solution
 Acceptable solution include:
 Normal saline (recommended)
 Ringer’s lactate
 O – negative blood
 Dose : 10 ml / kg
 Route : umbilical vein
 Preparation : estimated volume drawn into large
syringe
 Rate administration: over 5-10 minutes
 If severe metabolic acidosis is suspected or
has been proven from blood gas analysis
 use sodium bicarbonate

Do not give sodium bicarbonat unless the

lungs are being adequately ventilated
 Indication For Endotracheal
intubation
 If there is meconeum and the baby has depressed
respirations
 If positive-pressure ventilation by bag and mask is nt
resulting in good chest rise
 Intubating may facilitate coordination of chest
compression and ventilation
 If epinephrine is required to stimulate the heart, one
common route to administer the epinephrine is directly
into the trachea.
 There are also some special :
- extreme prematurity, surfactant administration, and
suspected diaphragmatic hernia
 Hold laryngoscope
Turn on the laryngoscope light and hold the laryngoscope in your left
hand, between your thumb and first two or three fingers, by both right
and left-handed persons.
 Insert laryngoscope
1. stabilize the baby’s head
with your right hand

2. Slide laryngoscope blade over the

right side of tongue, pushing the
tongue to the left side of the
mouth, and advance the blade until
the tip lies in the vallecula.
 … Insert laryngoscope
3. Lift the blade slightly
 thus lifting the tongue out of the way to expose the
pharingeal area.

 
 … Insert laryngoscope

4. Look for landmarks

… Insert laryngoscope
Improving visualization with pressure applied to
larynx by intubator (left) or by an assistant
(right), applying downward pressure to the
cricoid (the cartilage that covers the larynx) may
help bring the glottis into view
 … Insert laryngoscope

5. Insert the tube

If the cords do not open within 20
seconds, stop and ventilate
with a bag and mask
 … Insert laryngoscope

6. Stabilize the tube with one hand,

and remove the laryngoscope
with the other

7. Removing stylet from

endotracheal tube
 Measurement of
endotracheal

tube marking at the lip

 4 cm
After intubation
investigation location ET tube:

Listening breath sound, be sure to use a small

stethoscope and place it laterally and high on the
chest wall (in the axilla) and stomach.

Observe for a rise in the chest with each ventilated

breath.

Take note of centimeter marking that appears at the

upper lip
The tip of the tube is in the right location
within the trachea
Noninitiation of resuscitation in the
delivery room is appropriated for
conditions such as

 Newborns with confirmed gestation

of less 23 minggu or BW <
400 g
 Anencephaly
 Babies with confirmed Trisomy 13
atau 18
 Stopped Resuscitation

 Current data support that resuscitation of

newborn after 10 minutes of asystole is very
unlikely to result in survival or survival
without severe disability.
 Parents clearly should have major role in
determining the care delivered to their
newborn.