Neonatal Resuscitation ALSO(UK) wish to thank Dr S Richmond for this talk and fully acknowledge the use of material copyright the northern Neonatal Network, the Resuscitation Council (UK) and the Newborn Life Support course

Objectives Select and properly use equipment for neonatal resuscitation Perform rapid evaluation of the newborn Describe resuscitation schemes and algorithms Describe the management of meconium Describe the management of the early neonatal period and the most common complications

Stimuli for the first breath Cord obstruction Cold air Physical discomfort

First breaths Push fluid from airway & alveoli into pulmonary lymphatics Push fluid from airway & alveoli into pulmonary lymphatics Establishes resting lung volume Establishes resting lung volume

Sustained (2 second) Inflation Breaths First Breaths Arterioles Dilate and Blood Flow Increases Third Second Fetal Lung Fluid Air O 2 O 2 O 2

Resuscitation Equipment YOU CAN SUCCESSFULLY RESUSCITATE WITH THE FOLLOWING MINIMUM EQUIPMENT & SKILLS: Towels to dry and wrap Appropriate-sized face mask 500ml ventilation bag Firm, stable surface (possibly the floor) Ability to ventilate appropriately Ability to perform cardiac massage

‘Ideal’ Additional Equipment Clock Gas supply and blow off valve Guedel airways Laryngoscope & Endotracheal tubes Lighting Drugs - Sodium Bicarbonate - Adrenaline - Dextrose - (Volume) Wide-bore sucker Scissors and tape

Dry & cover the baby Assess the situation Airway Breathing - Inflation breaths Chest compressions (Drugs) Basic steps in resuscitation

Initial actions Start the clock Dry the baby Assess Do you need help ?

Initial assessment Colour Tone Breathing Heart rate

Condition – Group 1 Blue Pink Good tone Breathing regularly Fast heart rate

Dry and cover Give to Mum Dry and cover Give to Mum Blue Pink Good tone Breathing regularly Fast heart rate Management

Blue Moderate tone Breathing inadequately Slow heart rate Condition – Group 2

Blue Moderate tone Breathing inadequately Slow heart rate Management Dry and cover Open the airway Inflation breaths Dry and cover Open the airway Inflation breaths

Blue or white ‘Floppy’ Not breathing Slow or very slow heart rate Condition – Group 3

Blue or white ‘Floppy’ Not breathing Slow or very slow heart rate Management Dry and cover Open the airway Inflation breaths Re-assess Do you need help ? Dry and cover Open the airway Inflation breaths Re-assess Do you need help ?

Neonatal Position for Opening the Airway – ‘neutral position’ Incorrect: Neck Hyperextension Incorrect: Neck Under Extended Correct: Neck Slightly Extended

Head flexed by large occiput

Head in neutral or ‘sniffing’ position

Jaw falling back – obstructing airway

‘Jaw thrust’ applied – in neutral position

Open the airway - place the child in the neutral position If necessary, provide jaw thrust Give FIVE initial inflation breaths Airway Management

Inflation breaths Five breaths, each sustained for 2-3 seconds at 30 cms of water pressure Five breaths, each sustained for 2-3 seconds at 30 cms of water pressure

The heart rate will usually respond to lung inflation If there is no heart rate response check for chest movement Inflation breaths

Airway reassess Breathing reassess - is there a response ? Chest compressions reassess Drugs Further resuscitation

If the chest is not moving, it is not being inflated Check A & B Do not start chest compressions until the chest is being inflated Chest compressions

Reassess If the heart rate is slow and not improving Consider chest compressions

Chest (cardiac) compressions “Two-thumb” technique is usually preferred

Indicated when HR < 60bpm after 30 seconds of effective ventilation 3:1 compressions:breaths at HR approx 100bpm (Note: EFFECTIVENESS IS MORE IMPORTANT THAN RATE!!!) Re-evaluate HR every 30 seconds Continue cardiac compressions until HR rising and approx 100bpm (Note: HR USUALLY RESPONDS RAPIDLY) Chest (cardiac) compressions

You only need to move oxygenated blood from the lungs to the coronary arteries Its not that far and won’t take long!

Reassess Has the heart rate improved ? No Re-check airway Check chest movement Check compressions

Sodium bicarbonate Adrenaline Dextrose (Volume - rarely) Consider drugs

Preterm babies  care with inflation pressures Meconium  see next slide Congenital abnormality  eg diaphragmatic hernia - may make resuscitation extremely difficult Delivery outside labour ward  cold babies are more difficult to resuscitate Special Cases

Meconium Suction ONLY IF ‘SOLID’ MECONIUM causing physical block to ventilation F use catheter or endotracheal tube with wall suction Vigorous infant F tracheal suction NOT indicated Infant with absent/depressed respirations, HR < 100bpm or poor tone F if bag ventilation is inadequate, intubate with 10F catheter to clear SOLID meconium below cords

Dry & cover the baby Assess the situation Airway Breathing - Inflation breaths Chest compressions (Drugs) summary neonatal resuscitation

Neonatal mortality

Causes of neonatal mortality Preterm birth Asfyxia Neonatal sepsis 60-80% of neonatal deaths happen in low birth weight infants (<2000 gr.)

Preventing neonatal mortality All well-responding newborns should be given to their mother immediately after birth and start breastfeeding as soon as possible. Skin to skin contact with the mother is the best way of keeping the newborn warm. Breastfeeding helps inflate the lungs of the newborn (and prevents the mother from having PPH). Do not suction the ventricle

Managing preterm births If gestational age below 34 weeks the mother should have corticosteroids: Betametazone 12 mg IM twice 24 hours apart Reduces risk of perinatal death 68% Reduces risk of Respiratory distress syndrome 66% Reduces risk of intra-cerebral haemorrhage 54%

Managing preterm or low birth weight neonates Kangaroo Mother Care (KMC) Early, continuous and prolonged skin-to-skin contact between the mother and the baby Exclusive breastfeeding Initiated in hospital and can be continued at home

Kangaroo mother care

Breastfeeding: preferably mothers milk: if not directly then by cup

Kangaroo mother care Expressing breast milk:

Kangaroo mother care Expressing breast milk:

Kangaroo mother care Breastfeeding:

Asfyxia Early feeding Thermal regulation (KMC / SSC) Close observation (at risk for sepsis)

Neonatal sepsis Risk factors: Unhygienic procedures Prolonged rupture of membranes >24 hours PPROM Preterm birth Asfyxia

Neonatal sepsis Signs: Unable to breastfeed Lethargic or unconscious Fast breathing Severe chest indrawing Grunting Fever Hypothermia Umbilical discharge and redness of surrounding skin

Neonatal sepsis Treatment: Early feeding Antibiotics: Ampicillin (or penicillin) 25 mg/kg. IV each 6 hours Gentamycin 3 mg/kg IV each 12 hours Consider antimalarial treatment Close observation