Neo Transition

1. Pengurus Pusat IDAI & UKK Neonatologi IDAI
berkolaborasi dengan
American Academy of Pediatrics (AAP)
Training of The Trainers
Neonatal Resuscitation
Jakarta, 9 - 11 Desember 2013
NEONATAL TRANSITION

2. Objectives
 Identify physiologic changes during transition to
extra-uterine life.
 Identify primary features of fetal and newborn
pulmonary and circulation.
 Identify signs and symptoms of common problems
during transition period.
 Identify routine care considerations for a
newborn during the transition period.

3. Neonatal Transition
Transition is a process of physiologic change in the
newborn infant that begins in utero as the infant
prepares for transition from intrauterine placental
support to extra-uterine self-maintenance.
When the cord is CUT  the newborn must switch
rapidly from intrauterine mechanisms to adult
physiology.

4. Physiological changes at birth
Changes
 Breathing
 Blood flow
 Glucose homeostasis
 Temperature control
 Renal
 GI tract
Time
Seconds
Seconds
Minutes
Minutes
Hours – days
Hours - days

5. Events Happening at Birth
 First breath
 70-110 cmH2O vs. 5-10 cmH2O for normal breathing
 Removal of fluid from the lungs
 Closure of ductus arteriosus
 Functional and later anatomic closure
 Initialy systemic and pulmonary pressures are equal

6. Pulmonary transition

7. Intrauterine lung condition

8. Pulmonary transition at birth
Fluid filled Air-filled

9. Pulmonary transition
Basic requirements for gas exchange
 Ventilation
 Fluid clearance
 Establishing an air-filled FRC
 Spontaneous breathing
 Perfusion
 Rapid reduction in PVR
 Adequate cardiac output with pulmonary perfusion

10. Pulmonary transition
Clearance of lung fluid

11. Pulmonary transition
The first spontaneous breath

12. Pulmonary transition
PVR changes at birth

13. As a result of the gaseous distention and increased oxygen in the alveoli,
the blood vessels in the lung tissue relax

14. Pulmonary transition – summary
In case of uncomplicated (physiological) delivery at term
pulmonary transition is a spontaneous unasissted event!!

15. Circulatory Adaptation

16. Fetal circulation
 Fetus
 From 8 weeks until birth
 Organs mature to support external life
 Circulation
 Umbilical-placental circuit via umbilical cord
 Circulatory shunts bypass
 Liver
 Ductus venosus to inferior vena cava
 Lungs
 Foramen ovale, between right & left atria
 Ductus arteriosus connects pulmonary artery to aorta

18. Circulatory shunts bypass
By pass 1 : DUCTUS VENOSUS By pass 2 : Foramen ovale

19. Circulatory shunts bypass
By pass 3 : DUCTUS ARTERIOSUS

20. Circulatory Adaptation
FETAL CIRCULATION
High pulmonary resistance
Low resistance in systemic blood flow
RIGHT to LEFT shunt
Foramen Ovale
(Left atrial pressure low because returned lung blood is low and right atrial
pressure high due to large volume of blood from placenta)
Ductus arteriosus
(High pulmonary resistance, Low fetal systemic blood and prostaglandin
function)

21. Circulatory Adaptation
FETAL
CIRCULATION
NEONATAL
CIRCULATION

22. Circulatory Adaptation
NEONATAL CIRCULATION
• Profound changes of circulation at birth
• Increased pulmonary blood flow due to the drop of pulmonary resistance
 lung expansion.
• Venous return from lung increase.
• Left atrial press. is raised; Right atrial press. decrease  foramen ovale
closed.
• Systemic resistance higher than pulmonary resistance (24 hours) 
Prostaglandin function  Ductus arteriosus close
• Umbilical arteries constrict and placental blood flow stops.

23. Transition to Extra-uterine Life
begins when the cord is CUT.
 Placenta no longer works as lungs
 Lungs begin to exchange gases
 First breath inflates lungs and causes circulatory
changes
 Lungs inflate -  resistance to blood flow through
lungs &  blood flow from pulmonary arteries
 This results in Newborn Circulation.

24. Barrier in Transitional Period
The baby may not breath sufficiently to force fluid
from the alveoli
The lungs will not be filled with air
Oxygen will not be available for circulating blood through the lungs

25. Excessive blood loss or hypoxia/ischemia resulting poor cardiac
contractility and bradycardia
Failure in increasing systemic blood pressure
Systemic hypotension
Barrier in Transitional Period

26. Low oxygen concentration
Sustained constriction of the pulmonary arterioles
Persistent pulmonary hypertension
Barrier in Transitional Period

27. Consequences of interrupted transition
1. Tachypnea
2. Cyanosis
3. Resp depression (apnea / gasping)
4. Bradycardia
5. Hypotension
6. Low muscle tone

28. The Global Need for neonatal Resuscitation, FIGO, Wall et al

29. Breathing/crying?
Good tone?
Routine Care
Yes
No
Initial Steps
Observe breathing, HR and tone
Apnea/gasping, and or HR < 100 bpm Spontaneously breathing
PPV and SpO2 monitoring Respiratory Distress Persistent Central Cyanosis
CPAP Consider supplemental O2
HR < 100 bpm?
CPAP Failure, consider intubation
Adequate chest explansion?
Yes No
HR < 100 bpm
PPV (O2 100%) +
chest
compression
Consider
intubation
Evaluate head
position, airway
obstruction,
leakage,
adequate PIP?
HR < 60 bpm? Consider drugs and fluid administration
Time from
Birth
Preductal
Target O2
Saturations
1 minutes 60-70%
2 minutes 65-85%
3 minutes 70-90%
4 minutes 75-90%
5 minutes 80-90%
10 minutes 85-90%
Information:
If HR > 100 bpm and target oxygen
saturation is successfully achieved:
• Without equipment support 
observational care
• With equipment support  post-
resuscitation care

30. Evaluation-Decision-Action cycle
Evaluation
Action Decision

31. Summary
 Changes in respiratory and circulation is the
key component of transitional period in
newborn.
 Barrier of transitional period in newborn
include delayed removal of lung liquid,
failure of systemic blood pressure increase,
and failure of lung arterioles dilatation

32. Thank you