1. RESUSCITATION OF A NEWBORN
PRESENTER: L NCHIMBA-HAMUYUNI
MODERATOR: DR S MACHONA

2. BIRTH ASPHYXIA
Perinatal asphyxia is an insult to the fetus or newborn due to a lack of O2 and/or lack of perfusion (ischemia) to various organs
Often assoc with tissue acidosis and hypercarbia
There is no universally acceped criteria; features include acidemia <7.0, persistence of apgars 0 to 3 beyond 5min
neurological manifestations:coma, seizures, hypotonia, HIE
pulmonary: pulm HTN, meconeum asp, surfactant disruption
Metabolic – m. acidosis, hypoglycemia, hypocalcemia, hyponatremia
Renal – oliguria, ARF
GI – Nec, hepatic dysfxn
Hematologic – DIC, thrombocytopenia

3. PHYSIOLOGY OF ASPHYXIA
Primary apnea – when an infant is deprived of O2, initially, rapid breathing occurs. If the asphyxia continues, the resp movmts cease, HR begins to fall, neuromuscular tone reduces
Tactile stimulation and exposure to O2 will induce resps
Secondary apnea- if asphyxia continues, baby devs deep gasping resps, HR continues to fall, BP begins to fall. The infant is now unresponsive to stimulation and will not spontaneously resume resps unless PPV is initiated

4. It is important to note that as a result of fetal hypoxia, infant may go thru the phase of primary and secondary apnea in utero and so an apneac neonate at birth may be in either; two situations may be virtually indistinguishable
Clinical significance: when one is faced with an apneac neonate, assume you are dealing with secondary apnea and be ready to undertake full resuscitation efficiently

5. PULMONARY CIRCULATION
An asphyxiated baby has hypoxemia and acidosis such that pulm arterioles remain constricted and ductus arteriosus remains patent; this results in persistent fetal circulation
In mild asphyxia, it may be possible to iincrease pulmonary blood flow by quickly restoring adequate ventilation
In severe forms, vent alone is not enough. Metabolic acidosis needs correction so that pulm vessels open and blood flow to the lungs improve

7. CARDIAC FUNCTION AND SYSTEMIC CIRCULATION
In asphyxia, there is redistribution of bloodflow to preserve blood supply to vital organs. There is vasoconstriction in the bowels, kidneys, muscles and skin; thus preserving blood flow to the heart and brain
As asphyxia prolongs, myocardial function and cardiac output deteriorate and blood flow to all organs is reduced – this sets the stage for progressive organ damage

8. INITIAL STEPS Provide warmth
Baby should be placed under radiant heat source during resuscitation
Positioning
On her back with neck slightly extended (place rolled blanket / towel under shoulders)
Clear airway
If no meconeum is present, suction mouth and nose (mouth first) using suction catheter. For meconeum asp., under direct vision using laryngoscope, clear residual meconeum in mouth/pharynx and intubate and suction the trachea and lower airways

9. EVALUATION Based on 3 or 4 signs Respirations Heart rate Colour CRT
Low HR is the most important sign for proceeding to next step

10. If the baby has good breathing (RR 40 to 60/min) and HR > 120and has pink color, no further intervention is needed
If the baby is breathing well, good HR but has central cyanosis, administration of supplemental O2 is indicated
If the baby is not breathing well, gasping or apneac or HR is < 100, ambubag (PPV)

11. Technique for ambubagging….. Contraindication to ambubagging….
Follow up action after ambubagging:
HR > 100: discontinue ventilation gradually; O2 per nasal catheter
HR 60 to 100: continue ventilating
HR <60: cont ventilating, start chest compressions

12. CHEST COMPRESSIONS Indicated if HR < 60, even after ambubagging
Two techniques
Thumb technique
Two finger technique
Rate: it is important to ventilate between chest compressions – a vent breath should follow every 3 compressions
Procedure…..

15. ENDOTRACHEAL INTUBATION
Requires frequent practice to master
Indications:
When tracheal suction is needed: MSL babies born flat
When prolonged bag and mask ventilation is required or is ineffective
When diaphragmatic hernia is suspected

17. Newborn Resuscitation Algorithm
Kattwinkel, J. et al. Circulation 2010;122:S909-S919
Copyright ©2010 American Heart Association

19. MEDICATIONS
The majority of neonates needing resuscitation will respond to ventilation but a few will need medications
Epinephrine
If HR remains below 60. 1:10000 at 0.3ml/kg IV or via endotracheal route
Volume expanders
Normal saline bolus of 10ml/kg in CRT>3secs to increase tissue perfusion
Naloxone
In resp depression with h/o narcotic administration 4hrs before delivery
Sodium bicarbonate
For prolonged asphyxia, documented acidosis even after the use of epinephrine and vol. expanders. Bicarbonate therapy must be preceded and accompanied by ventilation

20. MEDICATIONS
Other medications used to improve perfusion of the organs include PLASMA and DOPAMINE.
There is no role for dexamethasone, calcium gluconate, mannitol, atropine

21. Postresuscitation Care
  Babies who require resuscitation are at risk for deterioration after their vital signs have returned to normal. Once adequate ventilation and circulation have been established, the infant should be maintained in, or transferred to an environment where close monitoring and anticipatory care can be provided.
Naloxone
Glucose
Induced Therapeutic Hypothermia