Resuscitation of the Newborn

Introduction

A team effort—at least two persons who possess skills of resuscitation must be available and their sole responsibility must be resuscitating asphyxiated neonate. One of the two must be skilled in endotracheal intubation and administration of medicines.

• Requires a uniform method and therefore the protocol may have areas which may sound dogmatic—must be repeatedly practiced by the team so that quick and uniform decisions are made easily and action taken without delay.
• It is a prompt and effective procedure, if perinatal asphyxia can be anticipated and necessary equipment kept adequately prepared and ready for urgent use at all time.
• Does not depend on APGAR score for decision-making. This objective assessment is used only for evaluating the effectiveness of resuscitation every fifth minute or till two successive scores of eight or greater are obtained.
• Decision-making during resuscitation depends on three parameters—respiration, heart rate and colour, in that order.
• Chest movements, immediately after birth, cannot be used as sole indicator of effective respiration.

Initial Steps

The steps taken, as soon as the baby is delivered, to prevent asphyxia neonatorum, are called the INITIAL STEPS. 90 per cent of babies do not need any resuscitation if these initial steps are properly instituted. To prevent heat loss:

a. Switch off the A/C in the O.T./or remove from A/C room

b. Receive baby in a prewarmed sheet

c. Place baby under a spot light/radiant warmer or surface warmer with bottles

d. Quickly dry the baby with the first sheet and then discard this sheet

e. Baby now lies on two other sheets already laid on the table and baby is again mopped completely dry with the upper of these two sheets. To ensure open airway a. Positioning: Placed on back or side in slight Trendelenburg position with neck slightly extended. b. Suctioning: Mouth first and then nose using a bulb syringe or a Delee mucus sucker/trap with catheter. If thick particulate meconium is present, obstetrician must suction mouth, oropharynx and hypopharynx as soon as baby’s head is delivered—prior to delivery of shoulders. After delivery, especially if baby is not breathing adequately, visualize vocal cords by direct laryngoscopy and if meconium is present at the cords, intubate and remove residual meconium from the trachea by applying continuous suction through the endotracheal tube as it is being withdrawn. To initiate breathing Tactile stimulation—slapping or flicking of soles of the feet or rubbing of the back.

Evaluation

After the initial steps, evaluate.

1. Check respiration:

• If normal: Check heart rate next
• If not normal: Start positive pressure ventilation

​2. Check heart rate: (Count for 6 and multiply by 10)

• If > 100/min: Check color next
• If < 100/min: Positive pressure ventilation
• If < 80/min: Positive pressure ventilation and chest compression

​3. Check colour: If respiration is normal and heart rate is >100/min and still there is cyanosis—administer free flow oxygen till the color improves. Free-flow oxygen is given by blowing 100 per cent oxygen at five L/min through the oxygen tube or through a mask over mouth and nose at a rate just enough to keep baby pink.

Oxygen concentration chart

O2 Conc. Tubing from nose Mask

Approx 80% ½” Mask firmly held on face

Approx 60% 1

Approx 40% 2 Mask held loosely on face

A self-inflating resuscitating bag and mask attached to O2 source should not be used to deliver free-flow O2 .

Chest Compression

• Two-finger method: Using either middle and index or middle and ring finger—requires firm support for back— firm board or hand at the back.
• Thumb method: With both thumb—palm encircling the torso—the lower third of sternum is compressed at 120/ min (squeeze – one – two – three – squeeze – the 1, 2, 3 being chest compressions). After 30 sec of ventilation with chest compressions, reevaluate:
• If HR < 80/min: Continue ventilation and compression.
• If HR > 80/min: Discontinue compression/continue ventilation.
• If HR > 100/min: With spontaneous respiration—stop resuscitation. Remember: Even if HR is zero, compression and ventilation should continue till a medical decision is reached to discontinue—30 minutes is the minimum time.

Medications

Indications

• For stimulating heart
• To restore acid-base balance
• To increase tissue perfusion.

1. If HR is 0 or < 80/min after 30 seconds of ventilation and chest compression, give 1:10,000 solution of Adrenaline at 0.1–0.3 ml/kg IV or intratracheally, rapidly. May be repeated every five minutes if required.
2. If HR still less than 100/min, there is documented metabolic acidosis, or APGAR is two at five minutes, give 7.5 percent soda bicarb at two ml/kg or two mEq/kg IV slowly over 5 to 10 minutes. Give soda bicarb only if infant is adequately ventilated.
3. If there is acute bleeding or hypovolaemia,

give volume expanders—normal saline, plasma, albumin at 10 ml/kg over 5-10 minutes.

​4. If there is evidence of continuing shock, give Dopamine.

​5. Naloxone hydrochloride—indicated if there is severe respiratory depression with history of maternal narcotic administration within preceding 4 hours. Dose: 0.1 mg/kg IV/IT given rapidly. The entire process to this point should not take more than 30 sec. If at this stage (baby already under warmer/ dried/positioned/suctioned and provided tactile stimulation) infant is not breathing or HR is <100/min, it is essential to establish respiration with positive pressure ventilation.

Bag and Mask

Always check for proper functioning. Block mask outlet by making an air tight seal with the palm. Then squeeze and check if there is pressure felt against the palm, and whether pressure release valve and valve assembly are functioning. Make sure that rim of the cushioned or noncushioned anatomical masks do not have cracks or defects. The size of mask should be such that it covers mouth and the nose but not the eyes. Place mask tight over the mouth and nose, check seal and squeeze (squeeze – two – three – squeeze and look for rise of chest and confirm air entry by auscultation. Use fingertips to squeeze). The only contraindications to bag and mask are: 1. Diaphragmatic hernia 2. Meconium aspiration. After 30 seconds of ventilation, re-evaluate:

• HR > 100/min–spontaneous respiration: Check colour– if normal–tactile stimulation and observe. Free-flow O2 required if colour is blue.
• HR 80-100/min and increasing, continue ventilation

HR < 80/min and not increasing, ventilation (check adequacy of ventilation) and chest compressions.

• If positive pressure ventilation and chest compressions do not lead to improvement, medication.
• If a bag and mask is used for >5 minutes, orogastric tube is inserted as air vent to relieve abdominal distension.
• Oral airway is used if bilateral choanal atresia or Pierre Robin syndrome is present or if the baby needs ventilation with open mouth.