Initial Stabilisation and Initial Stabilisation and Resuscitation of the Resuscitation of the

Newborn InfantNewborn Infant

Learning OutcomesLearning OutcomesInitial Stabilisation and Resuscitation of the Newborn InfantInitial Stabilisation and Resuscitation of the Newborn Infant

1.1. PreventionPrevention

1.11.1 Identify the factors that predispose to the development of Identify the factors that predispose to the development of perinatal hypoxia.perinatal hypoxia.

1.21.2 Propose how perinatal hypoxia can be prevented. Propose how perinatal hypoxia can be prevented.

2. Principles of Diagnosis2. Principles of Diagnosis

2.12.1 Describe the pathophysiological changes that occur in Describe the pathophysiological changes that occur in hypoxia.hypoxia.

2.22.2 Recognise an asphyxiated newbornRecognise an asphyxiated newborn

2.32.3 Classify an asphyxiated newborn based on the predicted Classify an asphyxiated newborn based on the predicted adverse outcomes (Sarnat staging)adverse outcomes (Sarnat staging)

3.3. Principles of ManagementPrinciples of Management

3.13.1 Resuscitate a newborn who is not adapting to the extra-Resuscitate a newborn who is not adapting to the extra-uterine transition. uterine transition.

3.23.2 Describe the principles involved in the management of mild Describe the principles involved in the management of mild to moderate asphyxiated newborn.to moderate asphyxiated newborn.

Perinatal Hypoxia-IschemiaPerinatal Hypoxia-Ischemia

Birth asphyxia - Failure to initiate Birth asphyxia - Failure to initiate and sustain breathing at birth and sustain breathing at birth

CausesCauses

1.1. Fetal and Antepartum (90%)Fetal and Antepartum (90%)

2.2. Birth process (10%)Birth process (10%)

Fetal and Antepartum PathologiesFetal and Antepartum Pathologies

1.1. Inadequate oxygenation of maternal blood - Inadequate oxygenation of maternal blood - anesthesia, cyanotic heart disease, respiratory anesthesia, cyanotic heart disease, respiratory failurefailure

2.2. Inadequate flow of maternal blood Inadequate flow of maternal blood (ischemia/hypotension) – spinal anesthesia, (ischemia/hypotension) – spinal anesthesia, compression of IVC or aorta by uteruscompression of IVC or aorta by uterus

3.3. Abruptio placentaeAbruptio placentae

4.4. Uterine vasoconstriction (cocaine)Uterine vasoconstriction (cocaine)

5.5. Placental insufficiency (pre-eclampsia, Placental insufficiency (pre-eclampsia, postmaturity)postmaturity)

Birth ProcessBirth Process

1.1. BreechBreech

2.2. Shoulder dystociaShoulder dystocia

3.3. Cephalopelvic disproportionCephalopelvic disproportion

4.4. Cord compression, knottingCord compression, knotting

5.5. Uterine tetany (too much oxytocin)Uterine tetany (too much oxytocin)

6.6. Uterine ruptureUterine rupture

Recognition of an Asphyxiated BabyRecognition of an Asphyxiated Baby

Oxygen supply to the fetus is reduced, Oxygen supply to the fetus is reduced, resulting inresulting in

  Apnea at birthApnea at birth

1.1. Low Apgar scores (severe if <5 at five minutes)Low Apgar scores (severe if <5 at five minutes)

2.2. Neurologic sequelae (hypoxic-ischaemic Neurologic sequelae (hypoxic-ischaemic encephalopathy) encephalopathy)

3.3. Metabolic acidosisMetabolic acidosis

4.4. Multi-organ failure: cardiovascular, gastrointestinal, Multi-organ failure: cardiovascular, gastrointestinal, hematologic, pulmonary, renalhematologic, pulmonary, renal

Apgar ScoresApgar Scores

00 11 22

Heart rateHeart rate 00 <100<100 >100>100

RespirationRespiration AbsentAbsent Slow, Slow, irregularirregular

Good, Good, cryingcrying

Muscle Muscle tonetone

LimpLimp Some Some flexionflexion

ActiveActive

Response Response to catheter to catheter in nostrilin nostril

No No responseresponse

GrimaceGrimace Cough, Cough, sneezesneeze

ColourColour BlueBlue Body pink, Body pink, extremities extremities blueblue

All pinkAll pink

ApneaApnea

1100 Apnea Apnea: When asphyxiated, the infant responds initially : When asphyxiated, the infant responds initially with tachypnea. If insult continues, the infant becomes with tachypnea. If insult continues, the infant becomes apneic and bradycardic. The infant will respond to apneic and bradycardic. The infant will respond to stimulation and 0stimulation and 02 2 therapy with spontaneous respirations. therapy with spontaneous respirations.

2200 apnea apnea: When insult continues after 1: When insult continues after 100 apnea, the infant apnea, the infant responds with a period a gasping respirations, bradycardia, responds with a period a gasping respirations, bradycardia,

and falling BP. The infant takes a last breath and then and falling BP. The infant takes a last breath and then enters the 2enters the 200 apnea period. The infant will not respond to apnea period. The infant will not respond to stimulation and death will occur unless resuscitation begins stimulation and death will occur unless resuscitation begins immediately. immediately.

It is impossible to differentiate between 1It is impossible to differentiate between 100 apnea and 2 apnea and 200 apnea at delivery, assume the infant is in 2apnea at delivery, assume the infant is in 200 apnea and apnea and begin resuscitation immediately.begin resuscitation immediately.

Pathophysiological changes in Pathophysiological changes in AsphyxiaAsphyxia

Stimulation Resuscitation

Neonatal ResuscitationNeonatal Resuscitation

STEPS IN NEONATAL RESUSCITATIONSTEPS IN NEONATAL RESUSCITATION

Warm, dry, stimulateWarm, dry, stimulate

A – airway (positioning, suctioning)A – airway (positioning, suctioning)

B – breathing (spontaneous / B – breathing (spontaneous / assisted ventilation)assisted ventilation)

C – external cardiac massage/ C – external cardiac massage/ medicationsmedications

Drying, Warming, Positioning, Suction, Tactile Stimulation

Oxygen

Bag& Mask Ventilation

Chest

Intubation

Medi-cations

Compressions

Operating Theatre Operating Theatre AnteroomAnteroom

Operating Theatre Newborn Resuscitation Operating Theatre Newborn Resuscitation BedBed

Thermoregulation: Turn Warmer Thermoregulation: Turn Warmer OnOn

Heating element glows red

ON Button

Preparation:Preparation:Turn on the Overhead Warmer to Manual Turn on the Overhead Warmer to Manual ModeMode

Turning on the Overhead Warmer: Turning on the Overhead Warmer: Push up warmer output to maximumPush up warmer output to maximum

Thermoregulation: Warm up the linensThermoregulation: Warm up the linens

Thermoregulation: Final Set-Thermoregulation: Final Set-UpUp

Warmer on

Warmed towels & blankets

ready

SaO2

monitor ready

EQUIPMENT FOR NEWBORN RESUSCITATION

WALL SUCTION CATHETER

Neopuff® Positive Pressure Device

T-piece resuscitator

Capable of providing peak inspiratory pressure (PIP) & positive end expiratory pressure (PEEP) for manual ventilation,

Can also be used to provide continuous positive airway pressure (CPAP)

Needs a constant gas flow to work (air or oxygen)

Can be used with the Resuscitaire ® set-up & gas supply

NeopuffNeopuff®® Positive Pressure Positive Pressure DeviceDevice

Oxygen/air (gas)

supply tubing/ inlet

(to Neopuff®)

Gas outlet

and tubing

(to patient)

NeopuffNeopuff®® Positive Pressure Positive Pressure DeviceDevice

Circuit Pressure Dial (Pressure Gauge)

Gas Inlet MaximumPressure Release Knob Gas Outlet PIP Knob

Neopuff® and Resuscitaire® Positive Pressure Devices

BASIC STEPSBASIC STEPS

WarmthWarmth – radiant warmer, dry skin, remove wet – radiant warmer, dry skin, remove wet linen, wrap in pre-warmed blanketslinen, wrap in pre-warmed blankets

PositioningPositioning – supine, head neutral or slightly – supine, head neutral or slightly extended (open airway)extended (open airway)

SuctioningSuctioning – healthy, vigorous infants do not need – healthy, vigorous infants do not need suctioning (clear airway)suctioning (clear airway)

Tactile stimulationTactile stimulation – flick the soles – flick the soles

Neck hyperextended

Neck slightly extended

Neck flexed

Airways - PositioningAirways - Positioning

EVALUATIONEVALUATION

Respiration Respiration Breathing or Apneic?Breathing or Apneic? Heart rate Heart rate >100 or <100 (auscultate / palpate base of >100 or <100 (auscultate / palpate base of

umbilical umbilical cord)cord) Colour Colour Pink or centrally blue?Pink or centrally blue?

POSITIVE PRESSURE VENTILATIONPOSITIVE PRESSURE VENTILATION

Indications: apnea / gasping, HR<100, persistent Indications: apnea / gasping, HR<100, persistent cyanosiscyanosis

Bag and mask (self-inflating) with 100% OBag and mask (self-inflating) with 100% O22

Adequate chest rise (rather than a particular Adequate chest rise (rather than a particular manometer reading)manometer reading)

Rate – 40 to 60 breaths per minuteRate – 40 to 60 breaths per minute Successful – improving HR and colour Successful – improving HR and colour

The key to successful neonatal resuscitation is The key to successful neonatal resuscitation is establishment of adequate ventilationestablishment of adequate ventilation

Face MaskFace Mask

Positive Pressure Ventilation - Correct Positive Pressure Ventilation - Correct Position & Size of Face MaskPosition & Size of Face Mask

CHEST COMPRESSIONSCHEST COMPRESSIONS

If after 30 seconds of adequate PPV with 100% OIf after 30 seconds of adequate PPV with 100% O22 and and HR<60, start chest compressions HR<60, start chest compressions

Ratio of 3 compressions : 1 breath, to give 90 compressions Ratio of 3 compressions : 1 breath, to give 90 compressions and 30 breaths per minute (120 events per minute)and 30 breaths per minute (120 events per minute)

Depth of compression – 1/3 the depth of the chestDepth of compression – 1/3 the depth of the chest

Preferred technique – Two thumb-encircling handsPreferred technique – Two thumb-encircling hands

Compressions delivered on the lower third of the sternum Compressions delivered on the lower third of the sternum

Using the Neopuff® to give PPVUsing the Neopuff® to give PPV

When giving PPV, occluding the PEEP valve gives PIP and uncovering it maintains PEEP.

Giving CPAP Using the Giving CPAP Using the NeopuffNeopuff

Do not occlude the PEEP valve when using for CPAP.

MedicationsMedications1.1. AdrenalineAdrenaline

– Concentration 1 : 10 000 solutionConcentration 1 : 10 000 solution– Dose 0.1 – 0.3 ml/kg Dose 0.1 – 0.3 ml/kg – Route ETT or intravenousRoute ETT or intravenous– Indication if HR < 60 bpm after 30 sec of effective PPV Indication if HR < 60 bpm after 30 sec of effective PPV

and chest compressionsand chest compressions

2.2. NaloxoneNaloxone– Dose 0.1 mg/kg, repeat dose if necessaryDose 0.1 mg/kg, repeat dose if necessary– Route intramuscular, intravenous, ETTRoute intramuscular, intravenous, ETT– For respiratory depression with maternal pethidine in For respiratory depression with maternal pethidine in

last 4 hourslast 4 hours

3.3. Volume expanders (normal saline) 10 ml/kg over 10 Volume expanders (normal saline) 10 ml/kg over 10 minutesminutes

4.4. Sodium bicarbonateSodium bicarbonate

Dept of NeonatologyDept of Neonatology

Multi-organ InjuryMulti-organ Injury

Hypoxia may leads to multi-organ involvement:Hypoxia may leads to multi-organ involvement:– Brain injury: hypoxic-ischemic Brain injury: hypoxic-ischemic

encephalopathy (HIE)encephalopathy (HIE)– Cardiac: hypotension Cardiac: hypotension – Lung: respiratory distress, persistent Lung: respiratory distress, persistent

fetal circulationfetal circulation– Renal: oliguriaRenal: oliguria– Adrenal: adrenal hemorrhage Adrenal: adrenal hemorrhage – Hematological: DIVCHematological: DIVC– Liver: abnormal liver functionLiver: abnormal liver function

Hypoxic-Ischemic EncephalopathyHypoxic-Ischemic Encephalopathy

Sarnat Stages of HIESarnat Stages of HIE Stage One: Mild irritability and hyper-alert Stage One: Mild irritability and hyper-alert Stage Two: Seizure Stage Two: Seizure Stage Three: Stupor Stage Three: Stupor OutcomeOutcomeDeath or severe neurological sequelaeDeath or severe neurological sequelae Stage 1 (mild)Stage 1 (mild) 0%0% Stage 2 (moderate)Stage 2 (moderate) 30 -50%30 -50% Stage 3 (severe)Stage 3 (severe) 90 - 100%90 - 100%

Management of the Asphyxiated InfantManagement of the Asphyxiated Infant

1.1. Optimise perfusionOptimise perfusion

2.2. Optimise oxygenation, COOptimise oxygenation, CO22

3.3. Restrict fluidRestrict fluid

4.4. Normal blood sugar, calcium, acid-base balanceNormal blood sugar, calcium, acid-base balance

5.5. Treat seizuresTreat seizures

6.6. Therapeutic hypothermiaTherapeutic hypothermia

7.7. Cord stem cell infusion?Cord stem cell infusion?

Case 1Case 1

You are asked to attend an emergency LSCS You are asked to attend an emergency LSCS delivery of a 41-weeks gestation infant with non-delivery of a 41-weeks gestation infant with non-reassuring fetal cardio-tocogram (CTG). Mother is reassuring fetal cardio-tocogram (CTG). Mother is a 33 year old gravida one Chinese lady. She was a 33 year old gravida one Chinese lady. She was admitted to hospital two days ago. Her labor was admitted to hospital two days ago. Her labor was induced. She had good prenatal care and her induced. She had good prenatal care and her pregnancy has been uncomplicated. She pregnancy has been uncomplicated. She suddenly felt sharp pain in lower abdomen. CTG, suddenly felt sharp pain in lower abdomen. CTG, which was normal before that showed which was normal before that showed bradycardia. bradycardia.

Case 1Case 1

What are the possible conditions that What are the possible conditions that you can think of in the mother causing you can think of in the mother causing the problem?the problem?

What resuscitation equipments would What resuscitation equipments would you prepare for delivery? you prepare for delivery?

Would you involve any other medical Would you involve any other medical personnel? personnel?

Case 1Case 1

At delivery, you receive a floppy and blue At delivery, you receive a floppy and blue male infant. His heart rate was 40/minutes male infant. His heart rate was 40/minutes and there is no spontaneous respiration. and there is no spontaneous respiration. Baby does not respond to stimulation.Baby does not respond to stimulation.

What is the initial Apgar score in this What is the initial Apgar score in this baby? baby?

What are the initial steps you would What are the initial steps you would perform? perform?

Case 1Case 1

You bring him to the radiant warmer, quickly You bring him to the radiant warmer, quickly positioned, dried, stimulated the baby and positioned, dried, stimulated the baby and give free-flow oxygen. At 30 seconds of life, give free-flow oxygen. At 30 seconds of life, he remains apneic and cyanotic. His heart he remains apneic and cyanotic. His heart rate is still 40 per minute.rate is still 40 per minute.

What would be the next step in resuscitation?What would be the next step in resuscitation?

How would you monitor the resuscitation? How would you monitor the resuscitation?

Case 1Case 1

You administer bag and mask ventilation You administer bag and mask ventilation with 100% FiO2. There is good chest with 100% FiO2. There is good chest expansion. After one minute of bag and expansion. After one minute of bag and mask ventilation baby remained apneic. His mask ventilation baby remained apneic. His heart rate is 60 per minute. heart rate is 60 per minute.

What would be your next step?What would be your next step?

What are the other possible interventions What are the other possible interventions you can think of at this point? you can think of at this point?

Case 1Case 1

You start chest compressions and You start chest compressions and decide to intubate the baby. decide to intubate the baby.

How would you ensure proper How would you ensure proper positioning of ETT? positioning of ETT?

How would monitor your How would monitor your resuscitation? resuscitation?

Case 1Case 1

You check for equal air entry and expansion of You check for equal air entry and expansion of lung field. Baby’s heart rate after two minutes of lung field. Baby’s heart rate after two minutes of ventilation is 100/minutes. The color is still pale ventilation is 100/minutes. The color is still pale and pulse volume is low. and pulse volume is low.

What could the possible reason for low volume What could the possible reason for low volume pulse? pulse?

What intervention would you like to consider at What intervention would you like to consider at this point? this point?

Case 1Case 1

You decide to give normal saline bolus 10-15 You decide to give normal saline bolus 10-15 ml/kg. ml/kg.

How can you secure an intravenous access How can you secure an intravenous access quickly? quickly?

How fast do you want to administer the normal How fast do you want to administer the normal saline bolus? saline bolus?

What are other types of fluid you can use? What are other types of fluid you can use?

Case 1Case 1

You cannulate the umbilical vein and You cannulate the umbilical vein and administer the normal saline over five administer the normal saline over five minutes. Baby’s heart rate improve to minutes. Baby’s heart rate improve to 150/minute and color and perfusion are 150/minute and color and perfusion are better now. You have decided to transfer better now. You have decided to transfer the baby to intensive care nursery. the baby to intensive care nursery.

What are the laboratory test you want to What are the laboratory test you want to order? order?

Case 1Case 1

ABG shows following parameterABG shows following parameter

– pH 7.03 pH 7.03

– PCOPCO22 52 mm of Hg 52 mm of Hg

– POPO22 85 mm of Hg 85 mm of Hg

– Base excess –15 Base excess –15

– HCOHCO33 12 12

– How would you interpret the ABG? How would you interpret the ABG?

Case 1Case 1

What are possible consequences in this baby?What are possible consequences in this baby?

– Clue: Organ systemsClue: Organ systems– Clue: Short term and long termClue: Short term and long term

How would you monitor the baby? How would you monitor the baby? – SymptomsSymptoms– Laboratory testLaboratory test

How would you counsel the parents regarding prognosis of How would you counsel the parents regarding prognosis of the baby? the baby?

Case 2Case 2

You are requested to ‘stand-by’ for delivery of a You are requested to ‘stand-by’ for delivery of a term neonate. The mother is 32-year- old. This is term neonate. The mother is 32-year- old. This is her first pregnancy. Her antenatal follow-up was her first pregnancy. Her antenatal follow-up was irregular. She was admitted to hospital with labor irregular. She was admitted to hospital with labor 6 hours ago. The CTG shows persistent heart rate 6 hours ago. The CTG shows persistent heart rate of 170/minutes. Amniotic membrane was of 170/minutes. Amniotic membrane was ruptured spontaneously and it is heavily stained ruptured spontaneously and it is heavily stained with meconium. with meconium.

Case 2Case 2

Name few conditions that may give Name few conditions that may give rise to the problem described. rise to the problem described.

What are the resuscitation What are the resuscitation equipments you would need? equipments you would need?

Ideally, how many medical personnel Ideally, how many medical personnel you would need during resuscitation? you would need during resuscitation?

Case 2Case 2

The baby is delivered vaginally. The baby The baby is delivered vaginally. The baby was found to covered with thick meconium. was found to covered with thick meconium. There is no spontaneous cry. The heart rate There is no spontaneous cry. The heart rate is 120/minute and the baby has some is 120/minute and the baby has some activity. activity.

What would the role of obstetrician? What would the role of obstetrician? What would be your first step in What would be your first step in

resuscitation?resuscitation? What are the consequences of meconium What are the consequences of meconium

aspiration? aspiration?

Conditions That Requires Conditions That Requires DifferentDifferent Resuscitation ApproachResuscitation Approach

Thick meconium stained liquorThick meconium stained liquor Congenital diaphragmatic herniaCongenital diaphragmatic hernia Feto-maternal or feto-placental Feto-maternal or feto-placental

hemorrhagehemorrhage

Reference and Further ReadingsReference and Further Readings

1.1. Neonatal resuscitation guidelines. Circulation Neonatal resuscitation guidelines. Circulation 2005;112:118– 95.2005;112:118– 95.

2.2. Volpe J. Neurology of the Newborn. 5 ed. Volpe J. Neurology of the Newborn. 5 ed. Philadelphia:W. B. Saunders Company; 2008 Philadelphia:W. B. Saunders Company; 2008 (Chapter on Neonatal Encephalopathy)(Chapter on Neonatal Encephalopathy)

3.3. Nelson Textbook of Pediatrics 18Nelson Textbook of Pediatrics 18thth ed. 2007 ed. 2007 Chapter 99.5: Hypoxia-IschemiaChapter 99.5: Hypoxia-Ischemia

Thank YouThank You

Sarnat Stage 1Sarnat Stage 1

Mildest stageMildest stage Hyperalert and irritableHyperalert and irritable Normal toneNormal tone Mild over-reactive tendon reflexesMild over-reactive tendon reflexes Weak sucking reflex and exaggerated Weak sucking reflex and exaggerated

Moro’sMoro’s No seizuresNo seizures EEG - normalEEG - normal

Sarnat Stage 2Sarnat Stage 2

Moderately severe encephalopathyModerately severe encephalopathy Lethargic and obtundedLethargic and obtunded Mild hypotoniaMild hypotonia Over-reactive tendon reflexesOver-reactive tendon reflexes Weak or absent suckWeak or absent suck Focal or multi-focal seizuresFocal or multi-focal seizures EEG – low-voltage, seizuresEEG – low-voltage, seizures

Sarnat Stage 3Sarnat Stage 3

Severe encephalopathySevere encephalopathy StuporousStuporous Tone is diminished and flaccidTone is diminished and flaccid Reflexes absentReflexes absent Seizures uncommonSeizures uncommon EEG – burst suppression or isoelectricEEG – burst suppression or isoelectric