Neonatal resuscitation is important in Pakistan which has a high rate of newborn deaths, many occurring within the first day of life. About 10% of newborns require assistance breathing at birth and 1% will need extensive resuscitation to survive. The transition to breathing after birth involves hormonal and physical changes that prepare the lungs. If breathing does not start at birth, providing ventilation through positive pressure is crucial to revive the respiratory and cardiac functions until spontaneous breathing begins. Proper resuscitation techniques can significantly improve outcomes for newborns.

1. NEONATAL RESUSCITATION
(INTRODUCTION)

3.  Pakistan has the world’s third highest number of newborn
deaths .
 Neonatal deaths, account for around half (47 %) of under-five
deaths in Pakistan.
 three-quarters (74 %) of deaths occur in the first week of life.
 More than one quarter of deaths occur in first 24 hrs of life.

4.  Birth asphyxia
“ failure to initiate and sustain breathing at birth.”
 Brain damage, it causes is the major concern.
 Cause of arrest/ collapse--- primarily respiratory arrest.
 Upto 50% babies who require resuscitation have no
identifiable risk factors before birth.
 Resuscitation must be anticipated at every birth.

5.  The transition from intrauterine to extrauterine life occurs
without incident in approximately 90% of all births.
 10% of newborns will require some assistance with
breathing at birth.
 1% will need extensive resuscitative measures in order
to survive.
 The outcome of newborns can be improved by the use of
effective neonatal resuscitative measures.

7.  At term, the fetal lung is filled with approximately 20 ml of
fluid
 This lung fluid maintains lung volume at about the functional
residual capacity (FRC) and is a determinant of normal lung
growth.
 80-90% of FRC is established within the first hour of birth in
term neonates with spontaneous respirations.

8. At the onset of labour,
i. HORMONAL SURGE from the mother and baby cause
the secreting cells within baby’s lung to switch from
secretion to absorption.
ii. THORACIC SQUEEZE during birth process(25-33%).
 Babies are thus prepared by labour for this step.
 Babies born via caesarean section, before labour are
more likely to have respiratory problems in the first few
hours after birth.

9. New born initiates breathing in response to
i. Cord obstruction
ii. Physical discomfort
iii. Cold air
FIRST BREATHS ----push out fluid in the airways
resting lung volume
CONCERN IF i) only partially achieved
ii) not achieved at all

10.  Fetal "breathing" (ie, chest wall and diaphragmatic movement)
begins at approximately 11 weeks of gestation and increase in
strength and frequency throughout gestation.
 low PaO2 in utero --- the mechanism that inhibits continuous
breathing.

11.  The centre responsible for NORMAL breathing (higher
centre) has two functions,
i. To initiate and maintain normal regular breathing
ii. To suppress the more primitive spinal centre (lower
centre) responsible for gasping.
 When the higher respiratory centre is put out of action, the
lower respiratory centre ,initiates the gasping.
 Still if no oxygen is delivered to the lower respiratory centre
then this primitive form of breathing cannot be maintained
and it stops (terminal apnea).

12.  fetus undergoing asphyxia exhibit an altered respiratory
pattern.
 Breathing movements gradually becoming more desperate
 With continuing low PaO2 ---- breathing stops (PRIMARY
APNEA)
 After few minutes of apnea fetus tries to breathe again---
GASPING BREATHS gradually increasing frequency &
vigor & then decrease
 Continuing low /falling PaO2 ---- stops gasping (TERMINAL
APNEA).


13.  The PaCO2 is increasing throughout, when PaO2 is falling.
 The heart rate increases under the stress of initial insult in
first minute or so, but then suddenly drops to about half its
normal rate after about 4 minutes.
 The baby’s heart has adequate glycogen stores & thus able to
revert to anaerobic respiration, during low PaO2 .
 During the effective uterine contractions there is very little
effective gas exchange occuring at the placenta and the baby
is likely “holding breath” & the heart is managing to
maintain a reasonable rate by means of anaerobic
respiration.

14.  The price of reverting to anaerobic respiration is that
this will produce lactic acid in large quantities.
 Contributes to falling pH.

15. • Blood pressure, though gradually falling, is well maintained
for some time despite the low heart rate.
• By shutting down circulation to non-essential areas and thus
maintain a reasonable circulation to the most important
organs.
• Thus, there is sufficient functioning circulation during
this period.

17.  After a pause of a minute or two the baby will start gasping.
 If the airway is open, air is drawn into the lungs & as the circulation
is still functioning, the blood will become oxygenated .
 As soon as the oxygenated blood reaches the coronary arteries the
heart will revert to aerobic metabolism (energy efficient), and
the heart rate will rapidly rise.
 After a few gasps, oxygenated blood will have reached the higher
respiratory centre in the brain resulting in recovery of its function
thus initiate normal breathing as well.
 The result is a self resuscitating baby.

18.  The baby will gasp and provided the airway is clear the baby
will again recover itself.
 However, because this baby has had a longer period of
asphyxia it may take longer for the brain to recover i.e. the
period of gasping may be longer and normal breathing
may be interspersed with gasping for a bit longer.

19. • The baby will make no breathing efforts, the heart rate and
blood pressure will gradually fall .
• No spontaneous breathing effort of any sort will arise from
the baby.
• By this point, there is no reserve left and though the
circulation may still be just functioning , it is rapidly
failing.
• In the absence of some external intervention this
baby will die.

20. • A baby delivered in terminal apnea, needs help i.e.
resuscitation.
• If we inflate the lungs, baby’s heart may still be functioning
sufficiently to maintain circulation.
• Thus some blood still flowing though the lungs, will become
oxygenated & perfuse the heart .
• The heart will then revert to aerobic metabolism and will
almost immediately increase its rate.
• Increase in heart rate is an indicator that the lungs have
been inflated effectively.

21.  If delivery occurs a little later in terminal apnea, lung inflation
is not followed by an improvement in heart rate.
 The heart has deteriorated so much that it cannot maintain
circulation and thus requires chest compressions to
establish it again.
 A brief period of chest compressions manages to bring some
oxygenated blood back to the heart rate while waiting for the
baby to recover.
 After a period the baby will start to gasp. Once oxygenated
blood has reached the higher respiratory centre it will also
respond and normal breaths will begin.

22.  PRIMARY APNEA, responds to stimulation with
reinstitution of breathing.
 SECONDARY / TERMINAL APNEA
 does not respond to tactile or noxious stimulation
 require positive-pressure ventilation (PPV) to restore
ventilation
 Primary and secondary apnea cannot be clinically
distinguished.
 Therefore, if an infant does not readily respond to
stimulation, PPV should be initiated .

24.  Babies can withstand asphyxial process of normal
delivery.
 Circulation can continue reasonably well despite about
20 mins of anoxia.
 If baby is not breathing at birth
THE MOST IMPORTANT TASK IS TO
AERATE THE BABY’S LUNGS
 In few cases, babies who have further asphyxial insult,
lung aeration & a brief period of chest
compressions is required for recovery.

25. Neonatal resuscitation primarily focuses on
revival of RESPIRATORY FUNCTION