Neonatal resuscitationNeonatal resuscitation

Primary cause of death: NNPD

18 %Other causes

09 %Malformation

29 %Perinatal hypoxia

17 %Infection

27 %Prematurity

Deaths(n = 1800)

Cause

4 million newborn deaths – Why?almost all are due to preventable conditions

Causes of neonatal death(n=258)

Not established

14.7%

Others10.7% Birth asphyxia

20.9%

Infection33.2%

Prematurity15.2%

Congenital malformation

5.4%

Others: Hypothermia, RD, Jn, Pulm. Haemorrhage, Seizure etc. ICMR 2006

Neonatal resuscitation

• Asphyxia accounts for 20-25% newborn deaths

• 10% neonates require some assistance at birth

• 1% neonates need extensive resuscitative measures

The most important and effective action is to ventilate ventilate

the baby’s lungs

Neonatal resuscitation

•AAirwayirway

•BBreathingreathing

•CCirculationirculation

Neonatal resuscitation

•AAirwayirway

•BBreathingreathing

•CCirculationirculation

Before birth

• Gas exchange in placenta

• Lung receives very little blood

• Alveoli are fluid filled

Very little flow to lungs

Alveoli are fluid filled

Blood vessels are constricted

Before birth

•Pulm arterioles constricted •Umbilical arteries feeding low pressure placenta circulation

•Low pressure in systemic circuit

•Very little pulmonary blood flow

•High pressure in pulmonary circuit

After birth•Fluid in the alveoli is absorbed

Alveoli

• EXPAND

• GET FILLED WITH AIR (O2)

1.

After birth

Umbilical arteries and veins are clamped

Sudden increase in systemic blood pressure

2.

Pulmonary vessels dilate, causing increased blood flow to lungs

3.

After birth

•Pulm arterioles dilate •Umbilical arteries and veins are clamped

•High pressure in systemic circuit

•Dramatic increase in pulmonary blood flow

•Low pressure in pulmonary circuit

Ductus arteriosus constricts

• Increased oxygen in blood

• Increased pulmonary blood flow

4.

Before After

What can go wrong

• Inadequate breathing hence lung fluid not absorbed

• Meconium may block airway• Blood loss may occur• Persistence of constricted pulmonary vessels • Myocardium may be depressed• Organ systems may be affected by

hypoxia/ischemia

Consequences of interrupted transition

1. Low muscle tone 2. Resp depression (apnea / gasping)3. Tachypnea4. Bradycardia5. Hypotension6. Cyanosis

Changes due to oxygen deprivation

Some dictums

If a baby does not breathe immediately after being stimulated >>> secondary apnea

Assume every apneic baby is in secondary apnea

Longer the duration of compromise, longer it takes for recovery

• The resuscitation flow diagram

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Evaluation-Decision-Action cycle

Evaluation

Action Decision

Evaluation: By 3 signs

1.1. Respiration Respiration • Breathing / crying Breathing / crying • ApneaApnea

2.2. Heart rateHeart rate• <100 or <100 or notnot• < 60 or < 60 or notnot

3.3. ColorColor• Central cyanosisCentral cyanosis• Peripheral cyanosis / pinkPeripheral cyanosis / pink

• The resuscitation flow diagram

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Evaluation

Evaluation

Evaluation

Assessment

Apgar score

Apgar score is great, but not for guiding resuscitation

• For resuscitation, not all items are For resuscitation, not all items are requiredrequired

• Resuscitation initiated before 1 min Resuscitation initiated before 1 min when Apgar is assignedwhen Apgar is assigned

• Classification differentClassification different

Requirements

• Personnel

– At least one trained person for all deliveries

– Two persons, if high risk; or for advanced

resuscitation

• Equipment

Risk factors of asphyxia

• Only 50% resuscitation needs are

identified prior to birth

Premature babies : concerns

1. May be surfactant deficient

2. Immature brain, poor resp drive

3. Weak muscles, not able to breathe

4. More prone to hypothermia

5. More likely to be infected

6. Prone to intraventricular hemorrhage

7. Small blood volume, prone to hypovolemia

8. Immature tissues, prone to oxygen toxicity

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Care after resuscitation

Prevent, prevent, prevent

Infection : asepsis

HIV : universal precautions