Neonatal resuscitation

::::::::::::::: Neonatal Resuscitation::::::::::::: -The goals of neonatal resuscitation are to prevent the morbidity and mortality associated with hypoxic-ischaemic tissue (brain, heart, kidney) injury and also to re-establish adequate spontaneous respiration and cardiac output.

-A rapid assessment of newly born infants who do not require resuscitation can generally be identified by the following four characteristics: 1. Was the infant born after a full-term gestation? 2. Is the amniotic fluid clear of meconium and evidence of infection? 3. Is the infant breathing or crying? 4. Does the infant have good muscle tone? -If the answer to all four of these questions is ‘yes,’ the infant does not need resuscitation and should not be separated from the mother. The infant can be dried, placed directly on the mother’s chest and covered with dry linen, to maintain temperature. Observation of breathing, activity and colour should be ongoing. -If the answer to any of these assessment questions is ‘no,’ there is a general agreement that the infant should receive one or more of the following four categories of action in sequence:– 1. Initial steps in stabilisation (provide warmth, position, clear airway, dry, stimulate, re-position) 2. Ventilation 3. Chest compressions 4. Administration of epinephrine and / or volume expansion -The decision to progress from one category to the next is determined by the simultaneous assessment of three vital signs: respiration, heart rate and colour. – The most sensitive indicator of a successful response to each step is an increase in heart rate. -The initial steps of resuscitation are to provide warmth by placing the infant under a radiant heat source, position the head in a ‘sniffing’ position to open the airway, clear the airway with a bulb syringe or suction catheter, dry the infant and stimulate breathing. – Evaluation of the neonate for respiration, heart rate and colour at every 30-second interval must be done. -During delivery, if the amniotic fluid is meconium stained:- a.If the baby is vigorous (strong respiratory effort i.e., cry, good muscle tone, heart rate > 100 bpm) at birth, clear the airway by suctioning mouth first and then the nose with a bulb syringe or suction catheter. If bradycardia occurs during suctioning then stop suctioning and re-evaluate the heart rate. No intubation suctioning is required. b.If the baby is not vigorous (depressed respiration, depressed muscle tone and heart rate < 100 bpm), the newborn requires tracheal suctioning. First insert a laryngoscope and clear the mouth and posterior pharynx by using a suction catheter under direct vision, then insert the endotracheal tube into the trachea. Attach a suction device to the endotracheal tube. Apply suction as the tube is slowly withdrawn. Repeat if necessary till the meconium is recovered or until the heart rate indicates < 60 bpm, after which resuscitation must proceed without delay. A gentle but firm stimulation is given; gently flick the soles and rub the back. c.If heart rate is low, that is, < 100 bpm, positive pressure ventilation (PPV) with oxygen should be provided without suctioning of the trachea. d.After about 30 seconds of ventilation and / or supplemental oxygen, evaluation is done again. e.If the newborn starts breathing, becomes pink and has a heart rate of > 100 bpm, post resuscitation care must be given. f.If the heart rate is < 60 bpm, then support of the circulation by chest compression and positive pressure ventilation must be done. After about 30 seconds, evaluation is done again. g.If the heart rate is still < 60 bpm then epinephrine is administered along with continued PPV and chest compression. If the heart rate remains < 60 bpm, chest compression, positive pressure ventilation, and epinephrine can be repeated every three to five minutes. h.In case of placental abrupt, placenta previa or blood loss from the umbilical cord, the baby may not improve despite effective ventilation, chest compression and epinephrine. The baby will look pale, have delayed capillary refill, weak pulse and a low heart rate. The baby may be in hypovolemic shock and will need volume support. -In Diaphramatic hernia, positive pressure ventilation (PPV) is contraindicated. – Endotracheal intubation may be indicated at several points during neonatal resuscitation: a.When tracheal suctioning for meconium is required b.If bag-mask ventilation is ineffective or prolonged c.When chest compressions are performed d.When endotracheal administration of medications is desired e.For special resuscitation circumstances, such as congenital diaphragmatic hernia or extremely low birth weight. -Compressions and ventilations should be coordinated to avoid simultaneous delivery. -The chest should be permitted to fully re-expand during relaxation, but the rescuer’s thumbs should not leave the chest. -There should be a 3:1 ratio of compressions to ventilations with 90 compressions and 30 breaths to achieve120 events per minute, to maximize ventilation at an achievable rate.