Initial Stabilisation and Resuscitation of the Newborn Infant
Learning OutcomesInitial Stabilisation and Resuscitation of the Newborn Infant1. Prevention1.1 Identify the factors that predispose to the development of perinatal hypoxia.1.2 Propose how perinatal hypoxia can be prevented.2. Principles of Diagnosis2.1 Describe the pathophysiological changes that occur in hypoxia.2.2 Recognise an asphyxiated newborn2.3 Classify an asphyxiated newborn based on the predicted adverse outcomes (Sarnat staging)3. Principles of Management3.1 Resuscitate a newborn who is not adapting to the extra-uterine transition.3.2 Describe the principles involved in the management of mild to moderate asphyxiated newborn.
Perinatal Hypoxia-Ischemia Birth asphyxia - Failure to initiate and sustain breathing at birth Causes5. Fetal and Antepartum (90%)7. Birth process (10%)
Fetal and Antepartum Pathologies1. Inadequate oxygenation of maternal blood - anesthesia, cyanotic heart disease, respiratory failure3. Inadequate flow of maternal blood (ischemia/hypotension) – spinal anesthesia, compression of IVC or aorta by uterus5. Abruptio placentae7. Uterine vasoconstriction (cocaine)
Recognition of an Asphyxiated Baby Oxygen supply to the fetus is reduced, resulting in Apnea at birth 2. Low Apgar scores (severe if <5 at five minutes) 3. Neurologic sequelae (hypoxic-ischaemic encephalopathy) 4. Metabolic acidosis
Apgar Scores 0 1 2Heart rate 0 <100 >100Respiration Absent Slow, Good, irregular cryingMuscle Limp Some Activetone flexionResponse No Grimace Cough,to catheter response sneezein nostrilColour Blue Body pink, All pink extremities blue
Apnea 10 Apnea: When asphyxiated, the infant responds initially with tachypnea. If insult continues, the infant becomes apneic and bradycardic. The infant will respond to stimulation and 02 therapy with spontaneous respirations. 20 apnea: When insult continues after 10 apnea, the infant responds with a period a gasping respirations, bradycardia, and falling BP. The infant takes a last breath and then enters the 20 apnea period. The infant will not respond to stimulation and death will occur unless resuscitation begins immediately. It is impossible to differentiate between 10 apnea and 20 apnea at delivery, assume the infant is in 20 apnea and begin resuscitation immediately.
Pathophysiological changes in Asphyxia Stimulation Resuscitation
Neopuff® Positive Pressure Device T-piece resuscitator Capable of providing peak inspiratory pressure (PIP) & positive end expiratory pressure (PEEP) for manual ventilation, Can also be used to provide continuous positive airway pressure (CPAP) Needs a constant gas flow to work (air or oxygen) Can be used with the Resuscitaire ® set-up & gas supply
Neopuff® Positive Pressure Device Oxygen/air (gas)supply tubing/ inlet Gas outlet (to Neopuff®) and tubing (to patient)
EVALUATION Respiration Breathing or Apneic? Heart rate >100 or <100 (auscultate / palpate base of umbilical cord) Colour Pink or centrally blue?
POSITIVE PRESSURE VENTILATION Indications: apnea / gasping, HR<100, persistent cyanosis Bag and mask (self-inflating) with 100% O2 Adequate chest rise (rather than a particular manometer reading) Rate – 40 to 60 breaths per minute Successful – improving HR and colour The key to successful neonatal resuscitation is establishment of adequate ventilation
Face MaskPositive Pressure Ventilation - Correct Position & Size of Face Mask
CHEST COMPRESSIONS If after 30 seconds of adequate PPV with 100% O2 and HR<60, start chest compressions Ratio of 3 compressions : 1 breath, to give 90 compressions and 30 breaths per minute (120 events per minute) Depth of compression – 1/3 the depth of the chest Preferred technique – Two thumb-encircling hands Compressions delivered on the lower third of the sternum
Using the Neopuff® to give PPVWhen giving PPV, occluding the PEEP valve gives PIP and uncovering it maintains PEEP.
Giving CPAP Using the NeopuffDo not occlude the PEEP valve when using for CPAP.
Medications1. Adrenaline – Concentration 1 : 10 000 solution – Dose 0.1 – 0.3 ml/kg – Route ETT or intravenous – Indication if HR < 60 bpm after 30 sec of effective PPV and chest compressions• Naloxone – Dose 0.1 mg/kg, repeat dose if necessary – Route intramuscular, intravenous, ETT – For respiratory depression with maternal pethidine in last 4 hours3. Volume expanders (normal saline) 10 ml/kg over 10 minutes5. Sodium bicarbonate
Hypoxic-Ischemic EncephalopathySarnat Stages of HIE Stage One: Mild irritability and hyper-alert Stage Two: Seizure Stage Three: StuporOutcomeDeath or severe neurological sequelae Stage 1 (mild) 0% Stage 2 (moderate) 30 -50% Stage 3 (severe) 90 - 100%
Management of the Asphyxiated Infant• Optimise perfusion• Optimise oxygenation, CO2• Restrict fluid• Normal blood sugar, calcium, acid-base balance• Treat seizures• Therapeutic hypothermia• Cord stem cell infusion?
Case 1 You are asked to attend an emergency LSCS delivery of a 41-weeks gestation infant with non- reassuring fetal cardio-tocogram (CTG). Mother is a 33 year old gravida one Chinese lady. She was admitted to hospital two days ago. Her labor was induced. She had good prenatal care and her pregnancy has been uncomplicated. She suddenly felt sharp pain in lower abdomen. CTG, which was normal before that showed bradycardia.
Case 1 What are the possible conditions that you can think of in the mother causing the problem? Whatresuscitation equipments would you prepare for delivery? Wouldyou involve any other medical personnel?
Case 1 Atdelivery, you receive a floppy and blue male infant. His heart rate was 40/minutes and there is no spontaneous respiration. Baby does not respond to stimulation. Whatis the initial Apgar score in this baby? What are the initial steps you would
Case 1 You bring him to the radiant warmer, quickly positioned, dried, stimulated the baby and give free-flow oxygen. At 30 seconds of life, he remains apneic and cyanotic. His heart rate is still 40 per minute. What would be the next step in resuscitation?
Case 1 You administer bag and mask ventilation with 100% FiO2. There is good chest expansion. After one minute of bag and mask ventilation baby remained apneic. His heart rate is 60 per minute. What would be your next step? What are the other possible
Case 1 Youstart chest compressions and decide to intubate the baby. How would you ensure proper positioning of ETT? How would monitor your resuscitation?
Case 1 You check for equal air entry and expansion of lung field. Baby’s heart rate after two minutes of ventilation is 100/minutes. The color is still pale and pulse volume is low. What could the possible reason for low volume pulse? What intervention would you like to consider at this point?
Case 1 You decide to give normal saline bolus 10-15 ml/kg. How can you secure an intravenous access quickly? How fast do you want to administer the normal saline bolus? What are other types of fluid you can use?
Case 1 You cannulate the umbilical vein and administer the normal saline over five minutes. Baby’s heart rate improve to 150/minute and color and perfusion are better now. You have decided to transfer the baby to intensive care nursery. Whatare the laboratory test you want to order?
Case 1 ABG shows following parameter – pH 7.03 – PCO2 52 mm of Hg – PO2 85 mm of Hg – Base excess –15 – HCO3 12 – How would you interpret the ABG?
Case 1 What are possible consequences in this baby? – Clue: Organ systems – Clue: Short term and long term How would you monitor the baby? – Symptoms – Laboratory test How would you counsel the parents regarding prognosis of the baby?
Case 2 You are requested to ‘stand-by’ for delivery of a term neonate. The mother is 32-year- old. This is her first pregnancy. Her antenatal follow-up was irregular. She was admitted to hospital with labor 6 hours ago. The CTG shows persistent heart rate of 170/minutes. Amniotic membrane was ruptured spontaneously and it is heavily stained with meconium.
Case 2 Name few conditions that may give rise to the problem described. Whatare the resuscitation equipments you would need? Ideally, how many medical personnel you would need during resuscitation?
Case 2 The baby is delivered vaginally. The baby was found to covered with thick meconium. There is no spontaneous cry. The heart rate is 120/minute and the baby has some activity. What would the role of obstetrician? What would be your first step in resuscitation? What are the consequences of meconium aspiration?
Conditions That Requires Different Resuscitation Approach Thickmeconium stained liquor Congenital diaphragmatic hernia Feto-maternal or feto-placental hemorrhage
Reference and Further Readings1. Neonatal resuscitation guidelines. Circulation 2005;112:118– 95.• Volpe J. Neurology of the Newborn. 5 ed. Philadelphia:W. B. Saunders Company; 2008 (Chapter on Neonatal Encephalopathy)• Nelson Textbook of Pediatrics 18th ed. 2007 Chapter 99.5: Hypoxia-Ischemia