Lecture by Andriy Berbets
Asphyxia – it’s a syndrome characterized by
absence of breathing movements but with
presence of heartbeat of fetus
1. Central (suppression of breathing centre)
3. May be caused by trauma, immaturity of fetus
nervous system, pharmacological depression
4. May be cased by lungs, heart dysfunction or
3 degrees of asphyxia
Mild, moderate, severe
Apgar score 6-7 (1st min) – mild
Apgar score 5-4 (1st and 5th min) – moderate
Apgar less 3 – severe
Three stages of reanimation of the newborn
2 Intensive therapy
To put the newborn in the correct position
Free the nose, mouth and trachea (if needed)
Intubation (if needed)
Tactile stimulation to cause breathing
Artificial breathing (if needed)
Bag and mask ventilation
Trachea intubation (if needed)
To support blood circulation
Indirect heart massage
Treatment by medication
Don’t forget about “heating chain”!
The necessity of further aid to the newborn
during resuscitation is based on the
simultaneous estimation of three clinical
• presence and adequacy of independent
• frequency of heartbeat;
• color of the skin and mucous membranes.
Every 30 seconds of resuscitation of
newborn it is required:
– to estimate vital signs mentioned above;
– using general algorithm of resuscitation to decide
what to do further,
– to perform a corresponding action;
– to estimate 3 important vital signs again; to
decide, what interference is required in this
moment, and to perform it;
– to continue the cycle "estimation-decisionaction" until resuscitation is completed.
Presence and adequacy of
• The estimation of presence and adequacy of
independent breathing is conducted:
• right after the birth of a baby – for taking the
decision about beginning of resuscitation;
• at the end of the 1st and the 5th min (and further,
in case of necessity) – for estimation by APGAR
• during resuscitation actions;
• during staying of a newborn in the delivery room
(regardless whether the primary resuscitation
Signs of adequate breathing of a
• The scream and/or satisfactory excursions of
• The frequency and depth of respiratory movements
must grow in a few seconds after birth (for instance,
after the tactile stimulation);
• The normal frequency of breathing of a newborn is 3060 movements per 1 minute.
• Besides of frequency and depth of breathing it is
necessary to estimate symmetry of the respiratory
movements, and also presence of other respiratory
disorders: convulsive breathing, grunting breathing,
Signs of inadequate breathing of a
• Absence of breathing movements
• Convulsive respiratory movements ("gasping"
type of breathing), or bradypnea < 30 breathings
per 1 minute are ineffective.
• The appearance of expiratory grunting or other
respiratory disorders – baby needs further postresuscitational aid.
• If artificial respiration is conducted for baby, it has
to be stopped approximately for 6 seconds to
estimate presence and adequacy of independent
breathing of the newborn.
Estimation of the heartbeat of a
• Normal heartbeat frequency of a newborn is >
100 per 1 minute.
• Bradycardia < 100 heartbeats per 1 minute in
newborn is always indication for initialing
Methods of determination of
heartbeat frequency of a newborn:
– Listening the palpitation using stethoscope on the left
side of the thorax is the most reliable method.
– Palpation of pulsation on the basis of umbilical cord
directly in the area of its connection to the frontal
abdominal wall is useful to exclude bradycardia.
– Heartbeat frequency of a newborn is counted during 6
seconds. The result is multiplied on 10.
– While counting heartbeat frequency of a newborn
artificial respiration and indirect cardiac massage have
to be stopped.
Estimation of the color of the mucous
membranes and skin
• Presence and changes of central cyanosis should be
observed. It is determined as a dark blue color of mucous
membranes, lips and skin of trunk of a newborn.
• Acrocyanosis (blue color of palms and feet of a newborn)
without central cyanosis usually is not indicative of a low
oxygen level in the blood of a newborn. However, it can
testify to the presence of cold-provoked stress
(hypothermia) of a newborn.
• Paleness or presence of a marble pattern of the newborn’s
skin can be non-specific signs of decreased heartbeat
volume, severe anaemia (including hemolytic),
hypovolemia, hypothermia or acidosis of a newborn.
Maintenance of passability of the
respiratory tract in case of clean
To put the child in supine position (on the back) or lying on its side. The
head should be slightly extended, a bolster should be placed under
the shoulders. Conduct aspiration (sucking-out) procedure at first
from the mouth, then – from the nose. General rules:
• to use a disposable rubber bulb for aspiration of secretion and
mucus; in case of absence of disposable rubber bulbs sterile
disposable catheters can be used;
• during aspiration do not insert a catheter or bulb too vigorously or
too deeply (not deeper than 3 cm from the level of lips for a fullterm newborn and 2 cm for a premature baby);
• to perform aspiration briefly and carefully. The bulb or catheter
should be removed slowly. The duration of aspiration should not
not exceed 5 seconds.
• Presence of central cyanosis in a baby is the
indication to supply free stream of oxygen,
regardless of adequate independent breathing
and heartbeat frequency > 100 per minute.
• A newborn who gets an additional oxygen in
delivery room (or in the operating-room) must
be under the permanent supervision of
• Give a free oxygen stream in the direction to
the nose of a baby. Speed of free oxygen
stream should not exceed 5 liters per minute,
to prevent supercooling of a baby.
• Equipment for the oxygen therapy:
- oxygenation tube;
- breathing sack filled with oxygen stream, and
- oxygenation “tent”
Artificial ventilation of lungs by sack
Indications for artificial respiration by sack and mask:
• Absent or inadequate independent breathing after initial steps
of resuscitation, conducted during 30 seconds after the child
• The heartbeat frequency of a newborn < 100 per 1 minute
regardless of presence and adequacy of independent
breathing after initial steps of aid, conducted during 30
seconds after the child birth.
• Stable central cyanosis, in spite of presence of adequate
independent breathing, heartbeat frequency of a newborn >
100 per 1 minute and supplement of free stream of 100 %
oxygen during at least 5 minutes.
Indications for artificial respiration by
• Critical condition of a newborn: absence of
independent breathing, muscle tonus, reaction to
irritations, paleness of the skin in case of
presence of heartbeating.
• Absence of positive changes of the state of a
newborn within 90 seconds after delivery, in spite
of effective lung ventilation by air:
• heartbeat frequency of a newborn < 100 per 1
minute after 30 seconds of ventilation;
• presence of indications for indirect cardiac
Assessment of efficacy of reanimation
• If spontaneous breathing is present, we can
access the ECG
• If no spontaneous breath movements are
present, we start artificial breathing with
90-100 % of oxygen
Heartbeat (HB) is more then 100 per min:
1. If there is spontaneous breathing, and HB is more then 100/min,
we stop artificial breathing (AB) and evaluate cyanosis of the
2. If there is no spontaneous breathing, we continue AB
3. If there is less then 100 HB per min, AB has to be continued:
Heartbeat is 60-100 beats – continue AB
Heartbeat is less then 60 min – indirect heart massage
Indications for intubation:
Aspiration by meconium
No effect from bag/mask artificial breathing
Medication for C-step
Solution of soda (NaHCO3) for acidosis correction
Antagonists of narcotic drugs (naloxon 0.1 mg/kg)
i.v. or per os
Indirect cardiac massage
Frequency of pressure on the thorax is 90 for 1 minute.
It is important to coordinate indirect massage of the
heart with artificial respiration, avoiding simultaneous
implementation of both procedures:
• after each three pressures on the breastbone make a
pause for realization of artificial ventilation of the
lungs. After this the pressures are repeated;
• during every two seconds of resuscitation it is needed
to press on the breastbone 3 times (90 presses per 1
min) and to conduct 1 ventilation action (30 actions
per 1 min), altogether - 120 actions per 1 minute have
to be performed.
Criteria of efficiency of indirect cardiac
• the increase of frequency of the heartbeat of a
• the possibility to define pulsation on the humeral
Stop indirect cardiac massage, if the heartbeat
frequency of a newborn is more than 60 beats
After each 30 seconds of indirect cardiac massage
repeatedly estimate the heartbeat and breathing
of a newborn to decide what to do further.
Indications for adrenaline
• HB < 60/min after 30 sec of AB 100% O2
• Absence of heartbeat
Ringer’s solution (5-10 ml/kg) in umbilical vein
Blood plasma (indications only!)