What are the main components of neonatal resuscitation?

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• Resuscitation of neonates

• Effective ventilation is the key to successful resuscitation.
• The need for neonatal resuscitation at birth cannot always be anticipated or predicted.
• At every birth, no matter how ‘low risk’, suitable equipment and staff must be available and prepared to resuscitate the newborn infant.
• 10% of newborns require resuscitation.
• Newborn resuscitation is a critical skill that requires constant practice.

Page contents: Preparation | Management | Ongoing care | Stopping resuscitation | Areas of uncertainty in clinical practice | PEEP | More information

Approximately 10% of newborns delivered in hospital require resuscitation assistance to breathe at birth. Less than 1% will require extensive resuscitation.

The aim of neonatal resuscitation is to prevent neonatal death and adverse longterm neurodevelopmental sequelae associated with perinatal asphyxia.

Substantial physiologic changes occur in the transition from fetal to extrauterine life including:

• The role of the placenta in gas exchange is taken over by the lungs.
• Changes from fluid-filled to air filled lungs.
• Dramatic increase in blood flow to the lungs with reversal, then closure of intra and extra cardiac shunts.

Failure or disruption of these changes may result in further difficulties with resuscitation in the newborn infant. For example, failure to increase alveolar oxygen and reduce pulmonary vascular resistance may lead to persistence of fetal circulation or persistent pulmonary hypertension (PPHN).

The need for resuscitation of the newborn infant at birth cannot always be anticipated or predicted. Therefore, at every birth, no matter how ‘low risk’, suitable equipment and staff must be available and prepared to resuscitate the newborn infant.

Preparation

Personnel

At least two trained people are required for adequate resuscitation involving positive pressure ventilation and chest compressions. Therefore, always call for help. Issues to note:

• The most senior person available needs to coordinate resuscitation.
• Each person must have a dedicated job, for example with three people, one should be solely responsible for airway, one solely responsible for chest compressions and the third person should coordinate the resuscitation and administer medication as necessary.
• If possible have another person record events including time of administration of drugs, and the infant's response to interventions.

Check equipment

Checking equipment is essential. Issues to note:

• Resuscitation equipment should be checked at least daily and after each usage.
• When use is anticipated at a birth recheck equipment including medical air and oxygen supply, suction, positive pressure devices, resuscitation equipment, largyngoscope, and endotracheal tubes.
• If an infant is expected to be in poor condition have medication readily available (eg O negative red blood cells and 0.9% normal saline in the presence of massive antepartum haemorrhage).

Communication

Communication is vital to smooth resuscitation. Ensure clear communication with:

• Anaesthetic and obstetric staff regarding maternal condition, fetal condition, maternal therapies.
• The family meet with them before the birth if there is time.

Environment

Pay careful attention to the environment including:

• Prevention of heat loss
• Where possible deliver infant into a warm draft free environment.
• The ambient temperature of the room should be at least 26oC for very preterm infants.

Assessment

The steps of evaluation and intervention during neonatal resuscitation are often simultaneous processes.

Evaluation begins immediately after birth with assessment of tone, breathing, and heart rate and continues throughout the resuscitation process until vital signs have normalised.

Key features in ongoing evaluation are:

• Breathing the newly born infant should establish regular respirations in order to maintain HR > 100 bpm;
• Heart rate determined from auscultation over the apex with a stethoscope or direct palpation of cord or with stethoscope. Peripheral pulses are often difficult to feel. If no pulsation is felt on palpation of the cord do not assume there is no heartbeat but auscultate the chest. The HR should be > 100 bpm in a well newly born infant
• Colour during labour the uncompromised infant has oxygen saturations of about 60% which after birth usually take 5-10 minutes to reach 90%. The well newborn infant should then be able to maintain a central pink colour in room air.  Assessment of colour is a poor proxy for oxygenation. Assessment of oxygenation  can be aided by use of a pulse oximeter with neonatal probe attached to the infant's right hand

Management

Temperature control

A warm draft free environment should be available. Drying the infant with prewarmed towels will help minimise heat loss in addition to use of a radiant warmer.

Infants less than 28 weeks gestation should be placed immediately after birth in a polyethylene bag or wrap (appropriate size, food grade, heat resistant) with their head out and the body completely covered. 

Drying the infant's body prior to covering is not recommended. Aim for normothermia (36.5o to 37.5oC) in all newborn infants and avoid iatrogenic hyperthermia 

Stimulation

Drying with a soft towel will stimulate most newborns to breathe.

If meconium is present in a non-vigorous infant, immediate suction below the vocal cords under direct vision may be appropriate. Delay tactile stimulation to avoid gasping in the infant with an oropharynx full of particulate meconium. Repeated suctioning of the trachea is not recommended and may unnecessarily delay commencement of active resuscitation.

Airway

The head should be in a neutral or slightly extended 'sniffing' position.

Suction is rarely required and should not exceed -100 mmHg. It should be limited in depth to 5 cm below the lips.

Breathing

Guidelines for breathing include:

• Attend to adequate inflation and ventilation before oxygenation
• The rate for assisted ventilation is 60 inflations per minute.
• Positive pressure ventilation should be commenced in air (21% oxygen) initially.
• Supplemental oxygen administration should be guided by pulse oximetry.
• Hyperoxia should be avoided as even brief exposure to excessive oxygenation can be harmful to the newborn during and after resuscitation.
• Regardless of gestation, aim for oxygen saturations of 91-95%.
• Wean supplemental oxygen once the saturations reach 90%.

Target saturations

Effective ventilation is confirmed by observing these three signs: 

• Increase in the heart rate to about 100/min.
• A slight rise in the chest and upper abdomen with each positive pressure inflation.
• Oxygenation improves.

Few infants require immediate intubation. The majority of infants can be managed with positive pressure ventilation via a face mask. With improvement in the infant's condition, the inflation pressures and breath rate can be progressively reduced.

See intubation for technical details.

Circulation

In the majority of infants establishment of adequate ventilation will restore circulation.

Begin chest compressions for;

• HR < 60 despite effective positive pressure ventilation for at least 30 seconds.

Aim for approximately a ratio of 90 chest compressions to 30 breaths per minute (3:1). (120 events per minute) count one-and-two-and-three-and-breath etc.

Supplemental oxygen should be increased to 100% when compressions are commenced and titrated with guidance of pulse oximetry.

The ‘two thumb’ technique is preferred. Both thumbs meet over the sternum with fingers around the chest wall. The sternum should be compressed to one third of the antero-posterior chest dimension.

Medications

Route of delivery

Routes of delivery for medications include:

• umbilical venous catheter preferred route
• ET for adrenaline only
• peripheral intravenous line difficult to cannulate in the collapsed infant
• intraosseous needle for failed or unsuccessful umbilical venous catheterisation
• umbilical arterial catheter should not be used for drug administration during resuscitation

Adrenaline

For HR < 60 for > 30 sec despite compressions and positive pressure ventilation.

Dosage:

• 0.3 ml/kg of 1:10,000 as a quick push IV repeated at 3-5 minute intervals. It should be followed by a small saline flush.
• 0.5 - 1.0ml/kg of 1:10,000 ET (if no IV access).

Volume (preload)

10 - 15 ml/kg normal saline repeated 2 or 3 times.

This may need to be followed with O negative red blood cells in the setting of massive blood loss, especially in babies who are not responding to resuscitation interventions.

Naloxone

Naloxone does not form part of the initial resuscitation of newborns with respiratory depression in the delivery room.

Dosage - 0.1mg/kg of 0.4mg/ml solution

Contra-indication  Naloxone may result in rapid withdrawal with seizures if given to infants of narcotic dependent women.

Bicarbonate

Bicarbonate is not indicated for routine use:

• Argument for correction of acidosis includes theoretical concerns about hypoxia and elevated pulmonary vascular bed pressure and poor cardiac contractility with acidosis.
  
• Argument against correction includes concerns regarding hyperosmolarity and CO2 generation with intracellular acidosis from alkali infusion.

Ongoing care

Infants require careful observation and management in a special or intensive care nursery following active resuscitation. Attention to management of temperature, cardio-respiratory status (oxygenation, heart rate, respiratory pattern, blood gas analysis), blood glucose sugars and infection risk are required.

Term infants at risk of hypoxic ischemic encephalopathy should be considered for therapeutic hypothermia therapy (‘cooling’).

Prompt discussion with PIPER is recommended as cooling must be initiated within 6 hours of birth.

Stopping resuscitation

Issues to note about stopping resuscitation:

• It is difficult to accurately define a time beyond which active support worsens brain injury.
• It is reasonable to consider stopping treatment if the infant has not responded with a spontaneous circulation by 10 minutes of age.
• It is helpful to be able to review events during resuscitation and this is made easier when events are recorded during resuscitation.

Areas of uncertainty in clinical practice

Areas of uncertainty include:

• Resuscitation for term infants should be commenced using medical air.
• Many preterm infants less than 32 weeks gestation will not achieve target saturations in air. Resuscitation should be commenced in 30% oxygen in these babies and should be guided by pulse oximetry.
• Hyperoxia and hypoxia should be avoided.  
• If a blend of medical air and oxygen is not available, resuscitation should be initiated with air (using a self-inflating bag and room air).
• In all cases, the priority is to ensure adequate inflation of the lungs, followed by increasing the oxygen concentration.  (ARC and NZRC, 2010, Guideline 13.4).

PEEP

Positive end-expiratory pressure issues to note:

• PEEP has been shown to be very effective for establishing and maintaining lung volume and improving oxygenation, especially in preterm babies.
• If suitable equipment is available, PEEP of at least 5cm H2O should be used during resuscitation.
• It is possible to provide PEEP either by use of:
  • A T-piece device (eg Neopuff or similar). This technique can be easily applied but the device requires a flow of gas to operate.
  • An anaesthetic bag and mask. Considerable practice is required to develop competence with this technique.  

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