DR O.A EWEDEMIDR O.A EWEDEMIB.Sc; MBBSB.Sc; MBBS

Department of Obstetrics and Gynaecology,

LAUTECH Teaching Hospital,

Ogbomoso, NIGERIA

OBJECTIVES

Know The Physiologic Changes At Birth;

Be Aware of The Resuscitation Flow Diagram/Strategy;

Be Aware Of Equipment & Personnel Needed;

Be Able To Decide When To Resuscitate [High-Risk]; &

Understand the Sequelae of BA

INTRODUCTIONThe successful transition from intrauterine to extra-uterine life is dependent upon significant physiologic changes that occur at birth. 6-10% of 130 milliom newborns NEED some intervention at birth, 1% require extensive resuscitation 4 million die & similar number develop sequelae from BA: CP, Mental Retard, Microcephaly,Epilepsy, etc

PA Remains Very Common &

Serious Clinical Problem

Worldwideo 85/1000 Live births - Nigeria

o 58/1000 Live births – Libya

o 11.5/1000 Sweden

o 1.2/1000 Japan

FETAL CIRCULATIONIN THE FETUS

Placenta; lowest vascular

resistance – 40% fetal cardiac

output

Fetal lungs are filled with

fluid - resulting in a high

vascular resistance – 10%

cardiac output

2 right-to-left shunts occur in

the fetus

1. Foramen ovale

2. Ductus arteriosus

FETAL OXYGENATION Low intrauterine oxygen tension compared to extra-

uterine life. The highest oxygenated fetal

adequate tissue oxygenation:

* Fetal hemoglobin

* Decreased fetal oxygen consumption:

- no need for thermoregulation

- reduced physiologic functions

Differential blood flow

Liver - directly from the umbilical vein

Brain and heart — high degree of oxygen saturation; differential velocities of incoming venous blood streams and directing of oxygenated blood to the foramen ovale.

The low fetal oxygen tension maintains the architecture of the fetal circulation by causing pulmonary vascular constriction

TRANSITION AT DELIVERY

When the umbilical cord is

clamped at birth, the neonate

must rapidly make physiologic

changes in cardiopulmonary

function:

Alveolar fluid clearance

Lung expansion

Circulatory changes with

increases in pulmonary perfusion

and systemic pressure, and

closure of the right-to-left shunts

of the fetal circulation

TRANSITION AT DELIVERY Alveolar fluid clearance:

* Labor — increased catecholamine and oxygen tension= active resorption of sodium and liquid

* Initial breaths —high trans-pulmonary pressures; drives alveolar fluid from the air spaces into the interstitium and subsequently the pulmonary vasculature.

* Thoracic squeeze —pressure upon the chest wall

Lung expansion — 1st effective breath, intrathoracic pressure falls, air movement begins Increasing inspiratory pressure expands the alveolar air spaces and establishes functional residual capacity. Surfactant release stimulated, reduces alveolar surface tension, increases compliance, and stabilizes the FRC.

Circulatory changes — With the clamping of the umbilical cord, the placenta with its low vascular resistance is removed from the neonatal circulation, resulting in a rise in neonatal systemic blood pressure.

* closure of the ductus arteriosus.

* closure of the foramen ovale

DIFFICULTIES IN TRANSITION Lack of respiratory effort:

- suggests that the infant is neurologically depressed (usually brain asphyxia) or has impaired muscular function

Blockage of the airways:

- congenital airway malformation , presence of meconium or mucus in the airway

Impaired lung function:

- External causes —pneumothorax , pleural effusions

- Pulmonary hypoplasia — congenital diaphragmatic hernia, oligohydramnios

- Intrinsic lung disease —hyaline membrane disease, acquired pneumonia, transient tachypnea of the newborn

Persistent increased pulmonary vascular resistance (also referred to as persistent pulmonary hypertension or persistent fetal circulation)

Abnormal cardiac structure and/or function

SIGNS OF THE COMPROMISED NEWBORN Poor Muscle Tone/HypotoniaPoor Muscle Tone/Hypotonia

Depressed Respiratory DriveDepressed Respiratory Drive

BradycardiaBradycardia

Vascular Collapse/HypotensionVascular Collapse/Hypotension

TachypneaTachypnea

Color Change/CyanosisColor Change/Cyanosis

Poor Response To Stimulation; Depressed

Reflexes

Seizures & Other Neurological Problems Occur

within 1st 12hrs Of Significant Asphyxia

Overall Clinical Manifestations & Course Vary,

Depending On Occurrence Of/Severity Of

Hypoxic-Ischemic Encephalopathy (HIE)

IN UTERO OR PERINATAL COMPROMISE

Primary Apnea

When Fetus/Newborn 1st Becomes Deprived Of O2, An Initial Period Of Attempted Rapid Breathing Is Followed By Primary Apnea; PLUS Falling Heart Rate That Would Improve With Tactile Stimulation

Secondary Apnea

If O2 Deprivation continues, Secondary Apnea Ensues, Accompanied By Continued Fall In Heart Rate & BP

*Secondary Apnea Cannot Be Reversed With Stimulation;

Assisted Ventilation Is A Must.

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PATHOPHYSIOLOGYPATHOPHYSIOLOGY

0_________ 1__________ 2_____0_________ 1__________ 2_____

AAppearanceppearance Blue/Pale Blue/Pale Body Pink,Body Pink,Limbs BlueLimbs Blue All pink All pink Skin ColorSkin Color

PPulse Rateulse Rate 0 <100 0 <100 >100 >100 Pulse RatePulse Rate

GGrimacerimace 0 Slight 0 Slight Good Good Reflex IrritabilityReflex Irritability

AActivityctivity Limp Some Movement Active Limp Some Movement Active Movements/Movements/ Limbs Well Flexed Limbs Well Flexed MToneMTone

RRespirationespiration 0 Weak, Irregular Good 0 Weak, Irregular Good Reg Reg BreathingBreathing

RespiratnRespiratn

Apgar scores are not used to guide resuscitation but are useful as a measure of the newborn's overall status and response to resuscitation. When the five-minute Apgar score is less than seven, additional scores should be assigned every five minutes for up to 20 minutes. Apgar scores are not good predictors of outcome.

Virginia Apgar - 1953 [Anesthesiologist]

OVERVIEW OF RESUSCITATIVE STEPS

The 2010 AHA/AAP/ILCOR guidelines include a rapid assessment of the neonate's clinical status based on the following questions:

●Is the infant full-term?

●Is the infant breathing or crying?

●Does the infant have good muscle tone?

If the answer to all three questions is yes, the newborn does not need resuscitation, should not be separated from the mother, and is managed by routine neonatal care.

OVERVIEW OF RESUSCITATIVE STEPS

THE WHO Guidelines ANTICIPATE

Be Prepared For Every Birth By Having Skill To Resuscitate

Review The Risk Factors, If Any, For Perinatal Asphyxia

Clearly Decide On The Responsibilities Of Each Hlth Care

Provider During NR

Remember That The Mother Is Also At Risk Of Complications

The Following Questions Should Be Answered After Every Birth:

Is The Amniotic Fluid Clear Of Meconium?

Is The Newborn Baby Breathing Or Crying?

Is There A Good Muscle Tone?

Is The Color Pink?

Is The Newborn Baby Born At Term?

If Answer=No To Any Of These, Then Consider Resuscitation Immediately

ANTICIPATION OF NEED

Training: Neonatal resuscitation program; all healthcare providers who care for newborn infants

High risk delivery:

o Maternal conditions

o Fetal conditions

o Ante-partum complications

o Delivery complications

.

PREPARATION

Necessary equipment should be assembled prior to the birth of at-risk newborns:

●The radiant warmer is turned on and is heating.

●The oxygen source is open with adequate flow through the tubing.

●The suctioning apparatus is tested and is functioning properly.

●The laryngoscope is functional with a bright light.

●Testing of resuscitation bag and mask demonstrates an adequate seal and generation of pressure.

In high-risk deliveries of multiple gestations, each infant will require a full complement of personnel and equipment.

.

PREPARATION

Preterm infants: greater challenge than term infants

o Hypothermia

o Inadequate ventilation

o Infection

o Organ damage

o Reduced antioxidant function

.

PREPARATION

Additional resources and personnel should be present when a preterm birth is anticipated

●Equipment to keep the infant warm

●Personnel skilled in intubation

●Equipment and personnel should be available to deliver positive pressure and to consider administering surfactant.

●Compressed air sources, oxygen blenders, and pulse oximeters

●Pre-warmed transport incubator

.

PREPARATION

ANTENATAL COUNSELING — Each birth institution should have a consistent approach . Counseling should include information regarding prognosis.

American Academy of Pediatrics (AAP) guidelines:

●If there is no chance of survival, resuscitation should not be initiated.

●When a good outcome is considered very unlikely, the parents should be given the choice of whether resuscitation should be initiated, and clinicians should respect their preference.

●If a good outcome is considered reasonably likely, clinicians should initiate resuscitation and, together with the parents, continually reevaluate whether intensive care should be continued.

.

Basic("ABCDs") in resuscitation still apply in the newborn period.

unique and lead to differences in the initial resuscitative steps.

The 2010 AHA/AAP/ILCOR guidelines recommend the following approach:

●Initial steps (provide warmth, clear Airway if necessary, dry, and stimulate)

●Breathing (ventilation)

●Chest compressions

●Administration of Drugs, such as epinephrine and/or volume expansion

OVERVIEW OF RESUSCITATIVE STEPS

started within a few seconds of birth and should be applied throughout resuscitation.

Provide warmth — Prevent hypothermia; warm towel or blanket and pre-warmed radiant heat source maintain the infant's temperature at 36.5ºC

●Swaddling the infant after drying

●"Skin to skin" contact with mother and covering the infant with a blanket

●Use of polyurethane bags or wraps in infants with birth weights less than 1500 g

●Raise the environmental (room) temperature to 26˚C (78.8˚F)

●Warming pads

o In infants who require respiratory support, the use of humidified and heated air versus nonheated air decreases the rate of both mild (36 to 36.4ºC) and moderate hypothermia (<36ºC)

INITIAL STEPS

Airway — back positioned on a flat radiant warmer bed with the neck in a neutral to slightly extended position

neck should not be hyperextended or flexed

The proper position aligns the posterior pharynx, larynx, and trachea, and facilitates air entry.

If needed, a rolled blanket or towel may be placed under the infant's shoulder to slightly extend the neck to maintain an open airway.

Suctioning immediately after birth is reserved for babies with obvious obstruction due to secretions or who require positive pressure ventilation

Use bulb syringe or mechanical suction device

INITIAL STEPS

mouth and nose suctioned. mouth is suctioned first and then the nares to decrease the risk for aspiration.

Suctioning of either the esophagus or stomach should be avoided

Wiping the mouth and nose may be an alternative to suctioning for removal of secretions in infants who are greater than 35 weeks gestation.

Meconium stained amniotic fluid (MSAF)— aspiration of upper airway demonstrated no benefit

no longer recommend routine intrapartum suctioning for meconium-stained infants

However endotracheal suctioning of non-vigorous babies with MSAF still recommended.

INITIAL STEPS

Suction Of Mouth & Nose

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Stimulation - after birth, except in "nonvigorous" infant born with MSAF who first requires endotracheal intubation

Pulse oximetry — determine oxygen saturation (SpO2) in the following settings because oxyhemoglobin saturation may normally remain in the 70 to 80 percent range for several minutes following birth, which may result in the appearance of cyanosis, and the assessment of skin color is a poor indicator of oxyhemoglobin saturation during the immediate neonatal period:

●When resuscitation is anticipated

●Positive pressure ventilation is used for more than a few breaths

●Persistent cyanosis

●Use of supplementary oxygen

Placement at preductal location on the right upper extremity, usually the wrist or medial surface of the palm, as soon as possible.

INITIAL STEPS

Supplemental Oxygen – improved survival with resuscitation in room air rather than 100% oxygen

Positive pressure ventilation – Bag-mask Ventilation (BMV):

o Self-inflating bag – resource limited settings

o Flow-inflating bag

o T-piece resuscitator

o Laryngeal mask airway

Position

Suction

Air-tight seal: E-C technique

Initial breaths - Adequacy of ventilation is demonstrated by improvement in heart rate

NEXT STEPS

USE OF ROOM AIR USE OF ROOM AIR Vs Vs 100%100% OO2 2 IN P-P VENTILATIONIN P-P VENTILATION

Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group et al Pediatrics, Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group et al Pediatrics, 1998; 102:e11998; 102:e1

Bag & Mask Are The Most Vital Tool In Newborn Resuscitation Bag & Mask Are The Most Vital Tool In Newborn Resuscitation

Further resuscitative efforts are based upon the heart rate response of the infant after the initial 30 seconds of BMV.

If >100 beats per minute (bpm) and spontaneous effective respiration has begun, BMV can be discontinued and free-flowing oxygen administered as needed, based on the target oxygen saturations for minutes after birth.

If between 60 to 100 bpm, continue BMV ventilation and reevaluate after 30 seconds. Reevaluation includes the following sequence of M-Mask readjustment, R-Reposition the airway, S- Suction the mouth and nose, and O- Open the mouth slightly.

If <60 bpm, immediately begin chest compression and reassess that adequate positive pressure ventilation is being delivered.

NEXT STEPS

CPAP or PEEP — continuous positive airway (CPAP) or end-expiratory pressure (PEEP) may be beneficial for adequate lung recruitment and reduce subsequent lung injury

Data from observational studies and a single clinical trial appear to support the use of CPAP versus BMV in the initial resuscitation of preterm infants

Infants treated with single inflation/CPAP, when compared with those who received conventional BMV, were less likely to be intubated, receive more than one dose of surfactant, or develop bronchopulmonary dysplasia (BPD).

However, further studies to confirm these findings are needed before CPAP versus BMV can be recommended for neonatal resuscitation.

After BMV ventilation as the initial resuscitative intervention, CPAP rather than intubation and mechanical ventilation may be beneficial in the spontaneously vigorous preterm infants who require continued respiratory support or at risk for respiratory distress syndrome.

NEXT STEPS

Chest compressions are initiated if the infant's heart rate remains <60 beats per minute despite adequate ventilation for 30 seconds

Thumb technique – In this method, both hands encircle the infant's chest with the thumbs on the sternum and the fingers under the infant. This is the preferred method.

Two-finger technique – In this method, the tips of the first two fingers, or the middle and ring finger, are placed in a perpendicular position over the sternum

pressure is applied downward perpendicular to the chest wall sufficient to depress the sternum about one-third of the anteroposterior diameter of the chest, and then pressure is released to allow the heart to refill.

Avoid applying pressure directly over the xiphoid, as this may cause hepatic injury.

NEXT STEPS

Chest compressions must always be accompanied by positive pressure ventilation (PPV).

rate is 90 per minute accompanied by 30 ventilations per minute with one ventilation interposed after every third compression.

ventilation rate is reduced from the 40 to 60 breaths per minute used in the absence of chest compression to 30 breaths in the presence of chest compression.

After 30 seconds of chest compression and PPV, reassessment of the infant's heart rate, color, and respiratory rate should determine whether further interventions are required (eg, intubation or administration of medications).

NEXT STEPS

.

Endotracheal intubation; Two care providers are required, time needed for intubation should be limited to 20 seconds, and free flowing oxygen is administered during the procedure.

indicated in:

●Tracheal suctioning for meconium is required

●BMV is ineffective or prolonged

●Chest compressions are being performed

congenital diaphragmatic hernia, airway stabilization of the extremely low birth weight infant, and for administration of surfactant.

Initial stabilization – by BMV

Insertion of the laryngoscope

Assessment of successful intubation

Securing ETT

NEXT STEPS

DRUGS —rarely required in neonatal resuscitation. Delivering adequate ventilation is the most important resuscitative step because the most common cause of bradycardia is inadequate lung inflation or profound hypoxemia.

However, if the heart rate remains <60 beats per minute despite adequate ventilation and chest compressions, administration of epinephrine is indicated.

Rarely, volume expansion (normal saline, ringers lactate or O-ve blood) or a narcotic antagonist (eg, naloxone) may be useful.

NEXT STEPS

.

.

Heart rate related to 1 min Apgar score

0 1 2 3 4 550

70

90

110

130

150Apgar 1 min >6Apgar 1 min < 7Apgar 1 min < 4

Min after birth

hea

rt r

ate

bea

ts p

er m

in

Potentially Hazardous Forms Of Stimulation

Slapping Back Or ButtocksSlapping Back Or Buttocks

Squeezing Rib CageSqueezing Rib Cage

Forcing Thighs Onto AbdomenForcing Thighs Onto Abdomen

Dilating Anal SphincterDilating Anal Sphincter

Hot Or Cold Compresses Or BathsHot Or Cold Compresses Or Baths

ShakingShaking

DRUGS, e.g. Hydrocortisone, NaHCODRUGS, e.g. Hydrocortisone, NaHCO3 3 - Especially - Especially

With ApneaWith Apnea

Rarely, infants will not respond to the initial resuscitative efforts.

Ensure all the resuscitative steps were fully and properly administered.

If the infant fails to respond despite properly executed resuscitation, the following clinical approach may help ascertain the cause:

Resuscitation efforts may be discontinued if the neonate has demonstrated no signs of life (no heart beat or no respiratory effort for greater than 10 minutes) after 10 minutes of resuscitation

As previously discussed, if additional data obtained after resuscitation is started demonstrates that neonatal outcome is almost certain early death or unacceptably high morbidity, support can be discontinued if agreed upon by the parents and healthcare team.

FAILURE OF RESUSCITATION

With antenatal screening, it is now possible to identify conditions associated with high neonatal mortality or poor outcome.

●The decision not to initiate intensive therapy is made together by the parents and the healthcare team. Discussion, if possible, should occur prior to the birth of the infant.

●Non-initiation of resuscitation may be considered if early death is very likely and survival would be accompanied by unacceptably high morbidity. infants with gestational age <23 weeks or birth weight <400 g, anencephaly, or chromosomal abnormalities incompatible with life (eg, trisomy 13 or 18)

●Intensive care including neonatal resuscitation is always indicated when there is a high likelihood of survival and acceptable morbidity.

●In settings in which the prognosis of the infant is unclear but likely poor, and survival may be associated with a diminished quality of life, parental wishes should determine management decisions.

WITHOLDING RESUSCITATION

At delivery, if the appropriate course is uncertain, it is preferable to initiate resuscitation. If additional data demonstrate that the outcome is almost certain early death or unacceptably high morbidity, support can be discontinued if agreed upon by the parents and healthcare team.

Basic care that provides comfort to the infant must be given at all times, even when intensive therapy is not initiated.

When there is disagreement between the parents and healthcare team, continued discussion is recommended. Other resources in resolving disagreement include consultation with the hospital's ethics committee or finding healthcare providers that will provide care for the infant in the manner desired by the parents. At times, unresolved disagreement may result in the involvement of the court system.

At all times, the clinician must serve as an advocate of the infant and what he/she judges to be in the infant's best interest.

The clinician needs to know the relevant laws in his/her local area of practice.

WITHOLDING RESUSCITATION

Infants who required resuscitation are at risk of developing postresuscitative complications:

●Hypo- or hyperthermia

●Hypoglycemia (see "Neonatal hypoglycemia")

●Central nervous system (CNS) complications: apnea, seizures, or hypoxic ischemic encephalopathy

●Pulmonary complications: Pulmonary hypertension, pneumonia, pulmonary air leaks, or transient tachypnea of the newborn

●Hypotension

●Electrolyte abnormalities: Hyponatremia or hypocalcemia

●Feeding difficulties: Ileus, gastrointestinal bleeding, or dysfunctional sucking or swallowing

The longer and the greater the extent of resuscitation, the more likely that there will be subsequent and serious complications.

POSTRESUSCITATION

SUMMARY POINTS

Preparation & Teaching Is the bedrock of Successful NR

Ventilation Is The Primary Goal

Oxygenation can be achieved by Room Air

Chest Compression & Drugs Are Rarely Needed

Ethics Should Carefully Be Considered In Our Circumstances

Each Strategy/Step Should Be Assessed Scientifically - More

Research Is Required

SUMMARY POINTS

The Most Important & Effective Action In NR Is To Ventilate

Baby’s Lungs

Effective P-PV In Secondary Apnea Usually Results In Rapid HR

Improvement

If HR Does Not Increase, Ventilation Could Be Inadequate And/Or

Chest

Compressions & Epinephrine May Be Needed

HR <60 bpm → Additional Steps Needed

HR >60 bpm → Chest Compressions Can Be Stopped

HR >100 bpm & Breathing → P-PV Can Be Stopped

Time Line: If No Improvement After 30 Seconds, Proceed To

Next Strategy/Step

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Refs. For Further ReadingRefs. For Further Reading

1. 1. AHA/AAP: International Guidelines for Neonatal Resuscitation. (Pediatrics September 2000)AHA/AAP: International Guidelines for Neonatal Resuscitation. (Pediatrics September 2000)

2. Airede AI. Birth Asphyxia and Hypoxic-Ischemic Encephalopathy: Incidence and Severity. Ann 2. Airede AI. Birth Asphyxia and Hypoxic-Ischemic Encephalopathy: Incidence and Severity. Ann Trop Paediatr 1991; 11: 331-5. Trop Paediatr 1991; 11: 331-5.

3. Airede KI Neonatal Seizures and a two-year Neurologic Outcome. J Trop Pediatr 1991; 37: 3. Airede KI Neonatal Seizures and a two-year Neurologic Outcome. J Trop Pediatr 1991; 37: 313-17.313-17.

4. Airede A'KI. Should We Resuscitate? Ethical Dilemmas. Ann Trop Paediatr 1991; 11:169-74.4. Airede A'KI. Should We Resuscitate? Ethical Dilemmas. Ann Trop Paediatr 1991; 11:169-74.

5. 5. Apgar, V.: A Proposal for a New Method of Evaluation of the Newborn Infant. Curr Res Anesth Apgar, V.: A Proposal for a New Method of Evaluation of the Newborn Infant. Curr Res Anesth Analg 1953; 32 (4): 260–267.Analg 1953; 32 (4): 260–267.

6. Costello AM del. Perinatal Health in Developing Countries. Trans R Soc Trop Med Hyg 1993; 87: 6. Costello AM del. Perinatal Health in Developing Countries. Trans R Soc Trop Med Hyg 1993; 87: 1-2.1-2.

7. Idrisa A, Airede AI and Agida ET. Perinatal Mortality at the University of Maiduguri Teaching 7. Idrisa A, Airede AI and Agida ET. Perinatal Mortality at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. Nig J Surg Sci 1992; 2: 82-4.Hospital, Maiduguri, Nigeria. Nig J Surg Sci 1992; 2: 82-4.

8. 8. ILCOR: An Advisory Statement From the Pediatric Working Group of the International Liason ILCOR: An Advisory Statement From the Pediatric Working Group of the International Liason Committee on Resuscitation - Pediatrics, April 1999.Committee on Resuscitation - Pediatrics, April 1999.

9. Leviton A, Nelson KB. Problems with Definitions and Classifications of Newborn 9. Leviton A, Nelson KB. Problems with Definitions and Classifications of Newborn Encephalopathy.Encephalopathy.

Pediatr Neurol 1992; 8(2): 85-90. Pediatr Neurol 1992; 8(2): 85-90.

10. Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group, et al . Ventilation Using 10. Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group, et al . Ventilation Using 100% 100%

Oxygen and Room Air Oxygen. Pediatrics, 1998; 102:e1Oxygen and Room Air Oxygen. Pediatrics, 1998; 102:e1

11. 11. WHO: Basic Newborn ResuscitationWHO: Basic Newborn Resuscitation

(WHO, Geneva 1998)(WHO, Geneva 1998)

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