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47. Neonatal Resuscitation
47.1 Introduction
To resuscitate means to revive from unconsciousness or apparent death. Neonatal resuscitation is an attempt to facilitate the dynamic transition from foetal to extrauterine physiology. Perinatal hypoxia is one of the leading causes of perinatal mortality in developing countries, and birth asphyxia is an important cause of static developmental, neurologic handicap in later life. Ninety percent newly born babies need little or no assistance to begin breathing at birth. Others will need some assistance, and <1% would require more extensive resuscitative measures [1].
47.2 Anticipation and Preparedness
It is possible to anticipate birth asphyxia in a setting of high-risk deliveries [2] (List 47.1). But some unforeseen events may take place, and a depressed baby at birth may come as a surprise. So each and every delivery must be considered a potential emergency, and at each delivery, there should be at least one trained person whose primary responsibility is to take care of the baby and is capable of resuscitation or to initiate resuscitation and call for more skilled available help if required. In case of multiple births, equal number of such trained personnel should be available. All the equipment essential for neonatal resuscitation, in functional order, should be available at all delivery points [1] (List 47.2).
List 47.1: Predisposing Risk Factors for Birth Asphyxia
- 1.
Maternal Factors
- (a)
Antepartum
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Elderly mothers (>35 years)
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Short stature
-
Systemic medical illness
-
Bad obstetrical history
-
Diabetes mellitus
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Hypertension, eclampsia
-
Oligo-/polyhydramnios
-
Post-term/multiple gestation/abnormal presentation
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Maternal medication/substance abuse
-
Rh isoimmunization
-
Unsupervised pregnancy
-
- (b)
Intrapartum
-
Difficult/traumatic/operative delivery
-
Meconium-stained amniotic fluid (MSAF)
-
Prolonged labour/rupture of membranes (24hrs)
-
Precipitate/premature labour
-
Use of narcotics/GA
-
Significant intrapartum bleeding
-
- (a)
- 2.
Foetal Factors
-
Intrauterine growth retardation (IUGR)
-
Foetal distress
-
Foetal hydrops
-
Foetal malformations
-
Macrosomia
-
List 47.2: Essential Resuscitation Equipment and Material
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Resuscitation trolley with baby mattress, overhead heat source and timer (Fig. 47.1)
Resuscitation trolley
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Mechanical suction machine with pressure gauge
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Mucus aspirator (standby)
-
Meconium aspirator
-
Suction catheters 5, 6, 8, 10, 12 and 14F
-
Nasogastric tubes
-
Self-inflating resuscitation bag 200, 500 and 750 cc
-
Oxygen reservoir
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Flow-inflating bag
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T-piece resuscitator
-
Oxygen source
-
Compressed gas source
-
Oxygen blender
-
Cushioned rim face masks of different sizes
-
Pulse oximeter with neonatal probe
-
Laryngoscope with straight blades ‘0’ and ‘1’ sizes
-
Endotracheal tubes 2.5, 3.0, 3.5, and 4.0 mm
-
Stylet, scissors
-
Laryngeal mask airway (LMA)
-
Surgical blades
-
Umbilical vein catheters 3.5 and 5F
-
Three-way stopcock
-
Epinephrine
-
Volume expanders—normal saline, Ringer’s lactate
-
Sterile water
-
Sodium bicarbonate, naloxone hydrochloride
-
Hand sanitizer, antiseptic solution
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Syringes of different sizes
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Gloves, clean warm linen, micropore sticking tape
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Cardiac monitor with electrodes
-
Stethoscope
-
Transport incubator
Sequence of resuscitation: Steps and sequence of resuscitation are based on cycle of assessment, decision and action.
Assessment Before Birth
Look for any of high-risk conditions predisposing for birth asphyxia as per List 47.1. Specially note gestational age, amniotic fluid clear or meconium-stained amniotic fluid (MSAF) and singleton or multiple gestation [2].
Assessment After Birth
Answer three questions by looking at the baby:
Gestation—Is it full term?
Respiration—Breathing or crying?
Muscle tone/Activity—Is it good?
If the answer to all three questions is ‘yes’, the baby stays with mother for routine care, ongoing evaluation and stabilization.
-
Provide warmth—place the baby skin to skin on mother’s abdomen covered with warm clean linen.
-
Clear airway if indicated.
-
Wipe the baby dry with warm clean linen.
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Initiate breast feeding.
-
Ongoing observation of breathing, colour and activity.
- A.
Airway and stabilization—Initial steps
- B.
Breathing—Ventilation of lungs
- C.
Circulation—Chest compressions
- D.
Drug administration—Epinephrine and volume expanders
At each category of intervention, three signs, respiration, HR and state of oxygenation (colour or preferably Spo2 with pulse oximetry), are evaluated frequently. HR is the most important of the three.
47.2.1 Initial Steps
-
Provide warmth.
-
Position and clear the secretions to establish the open airway.
-
Dry, remove wet linen and reposition.
-
Stimulate breathing if needed.
Baby is born wet, has to be kept uncovered if resuscitation is required and hence is predisposed to hypothermia. So baby should be kept under heat source to maintain body temperature. At the same time, take precautions to avoid hyperthermia. To keep the airway open, baby is put supine with neck in ‘sniffing’ position, i.e. slightly extended to align posterior pharynx, larynx and trachea in line to allow unrestricted air entry. It is best achieved by putting a rolled towel under the shoulders with an elevation of 2–2.5 cm off the mattress. Airway should be cleared by suction if there is obvious obstruction or there is need for positive pressure ventilation (PPV).
Clear fluid/secretions can be cleaned by wiping the mouth with clean gauze/cloth or suction with bulb syringe or suction catheter. With mechanical suction, the negative pressure should not exceed 80–100 mmHg. Suction mouth before nose to ensure that there is nothing in the mouth for the newborn to aspirate if she/he gasps, while the nose is being suctioned first. It can easily be remembered by thinking ‘M’ comes before ‘N’ in alphabets. If the baby is born through MSAF or meconium is present on baby’s skin or in the upper airway, assess whether the baby is vigorous or nonvigorous by observing breathing, HR and muscle tone. Baby is nonvigorous if breathing is depressed or HR is <100 bpm or muscle tone is weak. In vigorous baby the airway is cleaned as described above. In a nonvigorous baby in addition to upper airway, clearing of trachea by endotracheal suction is required to prevent complications of meconium aspiration. Endotracheal suction in these babies is still practised even though limited data has not established its significant benefit.
Tracheal suction: Clear the mouth and posterior pharynx to visualize the glottis, intubate with appropriate-size endotracheal tube (ET tube), and apply direct suction to the ET tube for 3–5 s as you withdraw the tube. Repeat the procedure as necessary until little or no meconium is recovered or baby’s HR indicates that resuscitation with PPV must proceed without delay.
Once the airway is clear, quickly dry the head and body with clean, warm linen to prevent evaporative heat loss. Discard wet linen; rewrap in dry, warm, clean linen; and reposition head in sniffing position. Clearing the airway and drying will provide stimulation for most babies to initiate breathing. If normal breathing is not established at this stage, additional tactile stimulation may be provided once or twice by flicking the soles or gently rubbing the back, trunk or extremities. If the newborn is still not breathing normally, assume the baby to be in terminal apnoea where no amount of further stimulation will work, and proceed to the next step.
Evaluation After Completion of Initial Steps
On completion of initial steps within about 30 s, evaluate respiration, HR and colour or preferably Spo2.
Respiration: Look for cry or normal breathing or laboured breathing or apnoea.
HR: Palpate and count pulse rate at the base of umbilical cord, or listen to heart beat with stethoscope over precordium; count for 6 s, and multiply it with 10 to give quick estimate of HR per minute.
-
To confirm perception of cyanosis
-
Presence of central cyanosis
-
Administration of oxygen to a newborn
-
Anticipated resuscitation beyond initial steps
-
PPV required longer than few breaths
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