Anticipate
Adequate preparation
Timely recognition
Quick and correct action
Prerequisite
Trained in neonatal rescitation
Prepare appropriate equipments
close communication between obstetrician and paediatricinan to identify high risk women before labour if possible or high risk newborn during delivery
High risk delivery
Maternal
Antenatal:
Pre-eclampsia, Maternal diabetes, PPROM, Preterm, maternal substance abuse, lack of ANC, Multiple pregnancy, anemia in pregnancy
Rh isoimmunisation
Oligo and polyhydramios
cchronic maternal illness
Teenage pregnancy <18,
Elderly primi >35
Post term pregnancy
Intrapartum
Prolonged labour
Prolonged rupture of membrane delivery interval
Precipitous labour
Cord prolapse
Placental abruption or praevia
Instrumental delivery
Emergency C section
Fetal bradycardia-- hypoxia, acidosis, local anaesthetics, epidural, pethidine to mother, propanolol, MgSo4, fetal heart conduction defect
Meconium stained liquour
Narcotics to mother 4 hours before delivery
General anaesthesia
Chorioamnionitis
Fetal
IUGR
Prematurity
Postmaturity
Congenital anomalies
Multiple pregnancy
Delivery complications
Transverse lie or breech presentation
Chorioamnionitis
foul smelling or meconium stained liqour
antenatal asphyxia with abnormal fetal heart rate pattern, maternal administration of a narcotic within four hours of birth or delivery instrumentation eg forceps vacuum or caesarean
Asphyxia in a neonate can be due to to types of apnoea
Primary: Blue, heart rate increase, rescuscitate easily
Secondary: white floppy, heart rate decreased, BP decrease, require active rescuscitation like intermittent positive pressure ventilation.
APGAR score
Appearance - Blue or pale Pink centrally blue extremities completely pink
Pulse Absent <100bpm >100bpm
Grimace No response grimace on painful stimulus cry, cough, sneeze
Activity Limp some flexion active movement
Respiration absent slow irregular cry vigorous cry
Apgar score 1 minute signanls need for immediate resuscitation
5 minute apgar score indicates response to resuscitation rough prognostic indicator
If <7 at 5 min, repeat every 5 minutes up to 20 minutes to note progress
APGAR score at 20min is a good prognostic indicator for neurological outcome
Physiology of the newborn
There is basically a transition from fetal to Extrauterine life
Initial respiration inflates the lings and fluid in the lungs is absorbed
Clamping of umbilical arteries and veins removes low resistance placenta circulation and increase systemic BP
Lung expands and increases oxygenation so decreasing pulmonary vascular resistanc and increase pulmonary blood flow
Ductuus arteriosus and foramen ovale closes
MANAGEMENT OF NEWBORN
Birth
Term gestation?
Meconium stained liquour? Yes Routine care:
Breathing or crying? Provide warmth,
Good muscle tone? Dry: remove wet towel, replace with dry
Colour pink? Clear aiway- suck nose and mouth
Position
NO
Provide warmth
Neutral position
Clear airway if necessary
Dry stimulate reposition
Give oxygen if necessary
Evaluate breathing heart rate colour and tone
Apnoeic or HR <100bpm- assess heart rate with stethoscope
Give PPV ( mask ventilation, O2 5L/min
Intubate when mask ventilation inadequate to oxygenate or ventilate
HR <60bpm (count by palpate the umbilicus)
PPV plus chest compression
HR less than 60bpm
Consider epinephrine with or without volume
administered through umbilical vein
If heart rate does not increase and adequate lung inflation not achieved consider DOPE
D- displaced tube (esophagus or right bronchus)
O- Obstructed tube (meconium)
P- patient--- lung disorder eg pneumothorax, shock, birth asphyxia, upper airway obstruction
E- equipment failure- exhausted gas supply
1 minute- 60-65%
2min- 65-70%
3min- 70-75%
4min - 75-80
5min- 80-85%
10min- 85-95
Breathing (ventilation): PPV by bag and mask ventilation required: infant gasping or apnoeic
HR <100
ET intubation if:
Tracheal suctioning for meconium is required
BMV is ineffective or prolonged
Chest compressions are being performed
Chest compressionsa re initiated if the infants heart rate remains <60 beats per minute despite adequate ventilation for 30 seconds
Administration of drugs such as epinephrine and or volume expansion
If the heart rate remains less than 60 beats per minute despite adequate ventilation and chest compressions administration of epinephrine is indicated
Rarely volume expansion or a narcotic antagonist eg naloxone may be useful
THe decision to progress from one step to the nect is determined by the time dependent response of the infant to the applied resuscitiative effort based upon his or her respiration and heart rate
A time allocation of 30 seconds is given to apply the resuscitative procedure evaluate and decide whether to proceed to the nect intervention
Monitoring of oxygen satyration by using pulse oximetry should be performed in infants who are gasoing apnoeic have laboured breathing persistent cyanosis or a heart rate less than 100 beats per minute. No further rescuscitative efforts are needed if he responds with spontaneous respirations and a heart rate of above 100 beats per miute
Equipment
Radiant warmer
Warm towel and blankets kept in the warmer
2 infant masks normal size and small size
A suction device- mucus extractor
Resuscitation bag and mask- self inflating bag
Oxygen source and tubing
suction source and tubing
drugs and fluid
syringes, needles, cannula and IV lines
Endotracheal tubes
Laryngoscopes
Stethoscope
- Place child in radiant warmer- prevent cold stress
- In neutral position- nose to the ceiling, towel under the neck to support. Maintains airway open.
- Clear airway by suction of FIRST MOUTH the nose.
- Wipe baby dry
- Stimulate the baby by gentle tap on the foot flick in heel or rubbing back briefly
- Repositioned and heart rate is evaluated along with respiration and colour.
- Oxygen if necessary-
- A- head in neutral position and bulb suction in mouth and nose.
- B- tactile stimulation. BMVPosition mask so no air can escape, give 5 inflation breaths to inflate the lungs . Squeeze bag, count 1 2 3, observe for chest wall rising. If it doesnt adjust baby position and repeat 5 inflation breaths
- Then ET tube connected to 100% O2
- C- circulation-- heart rate by listening to apical pulse wih steth, pulse in umbilius or brachial pulse
- Compressions if- cyanotic, increased work of breathing, nasal flaring, tachypnoea, grunting
- D- drugs- depends. Can be Epinephrine, sodium bicarbonate or dextrose. Even O neg blood
- E- environmental temperature by switching on radiant warmer and using warm blankets/ bunny rugs for premature baby
Apnoea- BMV and proper postioning. Ventilate for 30 seconds at a rate of 40-50 times/min
Bradycardia- less than 60bpm or Less than 6 beats in 6 seconds but chest is rising.--
chest compression with 100% oxygen CPAP
Firm support for baby back
Compression on lower 1/3rd sternum.
Use fingertips of middle and index fingers or use distal portion of both thumbs
Compress sternum approx 1/3 AP diameter of chest to count cadence of "one and two and three and breath and "
Reassess baby after 30 seconds
Baby pink, HR>100- adequately resuscitated
Baby cyanosed on ventilation and chest compression, HR 60-100- ET and ventilation with chest compression
If cyanosed on ventilation and chest compression and HR <60 continue ventilation and chest compression along with epinephrine 1:10 000 for inotropic support, 0.01-0.03mg/kg if heart rate is less than 60
Ventilation breaths vs Inflation breaths
Much shorter
Mimic baby's pattern of breathing
35-40 per minute
Reassess after 30 seconds
Complications
Chest compressions
broken rib
laceration of liver
pneumothorax
Intubation
Pneumothorax
contusion of the airway
When to discontinue resuscitation
If neonate has demonstrate no signs of life after 10 minutes of resuscitation becomes outcome is associated with high early mortality and unacceptabl high morbidity among the rare survivors
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