Power point presentation on the topic of New born resuscitation.

1. DR. NELSONDR. NELSON
KILIMO,KILIMO,MBCHB.MBCHB.
Department of Paediatrics,
Busia County Teaching & Referral Hospital,
Busia, Kenya.
9/2/20169/2/2016

2. OBJECTIVES
Have an overview of the Basic Physiologic Changes At Birth
Understand the Resuscitation Flow Diagram/Strategy;
 Know the equipment & Personnel Needed;
 Be Able To Decide When To Resuscitate [High-Risk]
 Understand the Sequelae of birth asphyxia

3. Prologue
• Birth asphyxia kills 0.7 to 1.6 million newborns a
year globally
• 99% of deaths in developing countries.
• Effective newborn resuscitation could reduce this
burden of disease
• But the training of health-care providers in low
income settings is often outdated.
(Opiyo, Were et al,2008)

4. FETAL CIRCULATION
IN THE FETUS:
 Placenta; lowest vascular
resistance – 40% fetal cardiac
output
 Fetal lungs are filled with fluid -
resulting in a high vascular
resistance – 10% cardiac output
 2 right-to-left shunts occur in the
fetus 1. Foramen ovale
2. Ductus arteriosus

5. TRANSITION AT DELIVERY
When the umbilical cord is clamped at
birth, the neonate must rapidly make
physiologic changes in cardiopulmonary
function:
 Alveolar fluid clearance
 Lung expansion
 Circulatory changes with increases in
pulmonary perfusion and systemic
pressure, and closure of the right-to-left
shunts of the fetal circulation

6. TRANSITION AT DELIVERY
 Alveolar fluid clearance:
* Labor — increased catecholamine and oxygen tension= active resorption
of sodium and liquid
* Initial breaths —high trans-pulmonary pressures; drives alveolar fluid
from the air spaces into the interstitium and subsequently the pulmonary
vasculature.
* Thoracic squeeze —pressure upon the chest wall
 Lung expansion — 1st
effective breath, intrathoracic pressure falls, air
movement begins Increasing inspiratory pressure expands the alveolar air
spaces and establishes functional residual capacity. Surfactant release
stimulated, reduces alveolar surface tension, increases compliance, and
stabilizes the FRC.
 Circulatory changes — With the clamping of the umbilical cord, the
placenta with its low vascular resistance is removed from the neonatal
circulation, resulting in a rise in neonatal systemic blood pressure.
* closure of the ductus arteriosus.
* closure of the foramen ovale

7. DIFFICULTIES IN TRANSITION
 Lack of respiratory effort:
- suggests that the infant is neurologically depressed (usually brain
asphyxia) or has impaired muscular function
 Blockage of the airways:
- congenital airway malformation , presence of meconium or mucus in
the airway
 Impaired lung function:
- External causes —pneumothorax , pleural effusions
- Pulmonary hypoplasia — congenital diaphragmatic hernia,
oligohydramnios
- Intrinsic lung disease —hyaline membrane disease, acquired
pneumonia, transient tachypnea of the newborn
 Persistent increased pulmonary vascular resistance (also referred to as
persistent pulmonary hypertension or persistent fetal circulation)
 Abnormal cardiac structure and/or function

8. SIGNS OF THE COMPROMISED NEWBORN
 Poor Muscle Tone/HypotoniaPoor Muscle Tone/Hypotonia
 Depressed Respiratory DriveDepressed Respiratory Drive
 BradycardiaBradycardia
 Vascular Collapse/HypotensionVascular Collapse/Hypotension
 TachypneaTachypnea
 Color Change/CyanosisColor Change/Cyanosis
 Poor Response To Stimulation; Depressed Reflexes
 Seizures & Other Neurological Problems Occur
within 1st
12hrs Of Significant Asphyxia
 Overall Clinical Manifestations & Course Vary,
Depending On Occurrence Of/Severity Of Hypoxic-
Ischemic Encephalopathy (HIE)

9. IN UTERO OR PERINATAL COMPROMISE
Primary Apnea
When Fetus/Newborn 1st
Becomes Deprived Of O2
, An
Initial Period Of Attempted Rapid Breathing Is
Followed By Primary Apnea; PLUS Falling Heart Rate
That Would Improve With Tactile Stimulation
 Secondary Apnea
If O2
Deprivation continues, Secondary Apnea Ensues,
Accompanied By Continued Fall In Heart Rate & BP
*Secondary Apnea Cannot Be Reversed With
Stimulation;
Assisted Ventilation Is A Must.

10. PATHOPHYSIOLOGYPATHOPHYSIOLOGY

11. 0_________ 1__________ 2_____0_________ 1__________ 2_____
AAppearanceppearance Blue/Blue/PalePale Body PinkBody Pink,,Limbs BlueLimbs Blue All pinkAll pink Skin ColorSkin Color
PPulse Rateulse Rate 0 <100 >1000 <100 >100 Pulse RatePulse Rate
GGrimacerimace 0 Slight Good0 Slight Good Reflex IrritabilityReflex Irritability
AActivityctivity Limp Some Movement Active Movements/Limp Some Movement Active Movements/
Limbs Well FlexedLimbs Well Flexed MToneMTone
RRespirationespiration 0 Weak, Irregular Good Reg0 Weak, Irregular Good Reg BreathingBreathing
RespiratnRespiratn
Apgar scores are not used to guide resuscitation but are useful as a
measure of the newborn's overall status and response to
resuscitation.
When the five-minute Apgar score is less than seven, additional
scores should be assigned every five minutes for up to 20 minutes.
Apgar scores are not good predictors of outcome.
Virginia Apgar - 1953
OVERVIEW OF RESUSCITATIVE STEPS

12. THE WHO Guidelines
ANTICIPATE
• Be Prepared For Every Birth By Having Skill To Resuscitate
• Review The Risk Factors, If Any, For Perinatal Asphyxia
• Clearly Decide On The Responsibilities Of Each Hlth Care Provider During NR
• Remember That The Mother Is Also At Risk Of Complications
 The Following Questions Should Be Answered After Every Birth:
• Is The Amniotic Fluid Clear Of Meconium?
• Is The Newborn Baby Breathing Or Crying?
• Is There A Good Muscle Tone?
• Is The Color Pink?
• Is The Newborn Baby Born At Term?
 If Answer=No To Any Of These, Then Consider Resuscitation Immediately

13. ANTICIPATION OF NEED
• Training: Neonatal resuscitation
program; all healthcare providers
who care for newborn infants
• High risk delivery:
Maternal conditions
Fetal conditions
Ante-partum complications
Delivery complications
.

14. PREPARATION
Necessary equipment should be assembled prior to the
birth of at-risk newborns:
●The radiant warmer is turned on and is heating.
●The oxygen source is open with adequate flow through the
tubing.
●The suctioning apparatus is tested and is functioning
properly.
●The laryngoscope is functional with a bright light.
●Testing of resuscitation bag and mask demonstrates an
adequate seal and generation of pressure.
* In high-risk deliveries of multiple gestations, each infant
will require a full complement of personnel and equipment.
.

15. PREPARATION
Preterm infants: greater challenge than term
infants
• Hypothermia
• Inadequate ventilation
• Infection
• Organ damage
• Reduced antioxidant function
.

16. PREPARATION
Additional resources and personnel should be
present when a preterm birth is anticipated
●Equipment to keep the infant warm
●Personnel skilled in intubation
●Equipment and personnel should be available to
deliver positive pressure and to consider
administering surfactant.
●Compressed air sources, oxygen blenders, and
pulse oximeters
●Pre-warmed transport incubator
.

17. PREPARATION
ANTENATAL COUNSELING — Each birth institution should
have a consistent approach . Counseling should include
information regarding prognosis.
American Academy of Pediatrics (AAP) guidelines:
●If there is no chance of survival, resuscitation should not be
initiated.
●When a good outcome is considered very unlikely, the parents
should be given the choice of whether resuscitation should be
initiated, and clinicians should respect their preference.
●If a good outcome is considered reasonably likely, clinicians
should initiate resuscitation and, together with the parents,
continually reevaluate whether intensive care should be
continued.
.

19. OVERVIEW OF RESUSCITATIVE STEPS
 Basic("ABCDs") in resuscitation still apply in the newborn
period.
 Unique and lead to differences in the initial resuscitative
steps.
 The 2010 AHA/AAP/International Liaison Committee on
Resuscitation (ILCOR) guidelines recommend the following
approach:
●Initial steps (provide warmth, clear Airway if necessary, dry, and
stimulate)
●Breathing (ventilation)
●Chest compressions
●Administration of Drugs, such as epinephrine and/or volume
expansion

20. INITIAL STEPS
 Started within a few seconds of birth and should be applied
throughout resuscitation.
 Provide warmth — Prevent hypothermia; warm towel or blanket and
pre-warmed radiant heat source maintain the infant's temperature at
36.5ºC
●Swaddling the infant after drying
●"Skin to skin" contact with mother and covering the infant
with a blanket
●Use of polyurethane bags or wraps in infants with birth
weights less than 1500 g
●Raise the environmental (room) temperature to 26˚C (78.8˚F)
●Warming pads
o In infants who require respiratory support, the use of
humidified and heated air versus nonheated air decreases
the rate of both mild (36 to 36.4ºC) and moderate
hypothermia (<36ºC)

21. INITIAL STEPS
• Airway — back positioned on a flat radiant
warmer bed with the neck in a neutral to
slightly extended position
• neck should not be hyperextended or
flexed
• The proper position aligns the posterior
pharynx, larynx, and trachea, and
facilitates air entry.
• If needed, a rolled blanket or towel may be
placed under the infant's shoulder to
slightly extend the neck to maintain an
open airway.
• Suctioning immediately after birth is
reserved for babies with obvious
obstruction due to secretions or who
require positive pressure ventilation
• Use bulb syringe or mechanical suction
device

22. INITIAL STEPS
• Mouth and nose suctioned. Mouth is suctioned first and then the
nares to decrease the risk for aspiration.
• Suctioning of either the esophagus or stomach should be avoided
• Wiping the mouth and nose may be an alternative to suctioning for
removal of secretions in infants who are greater than 35 weeks
gestation.
• Meconium stained amniotic fluid (msaf)— aspiration of upper airway
demonstrated no benefit
• No longer recommend routine intrapartum suctioning for meconium-
stained infants
• However endotracheal suctioning of non-vigorous babies with MSAF
still recommended.

23. INITIAL STEPS
 Stimulation - after birth, except in "nonvigorous" infant born with
MSAF who first requires endotracheal intubation
 Pulse oximetry — determine oxygen saturation (SpO2) in the following
settings because oxyhemoglobin saturation may normally remain in the
70 to 80 percent range for several minutes following birth, which may
result in the appearance of cyanosis, and the assessment of skin color is a
poor indicator of oxyhemoglobin saturation during the immediate
neonatal period:
●When resuscitation is anticipated
●Positive pressure ventilation is used for more than a few breaths
●Persistent cyanosis
●Use of supplementary oxygen
 Placement at preductal location on the right upper extremity, usually the
wrist or medial surface of the palm, as soon as possible.

24. NEXT STEPS
• Supplemental Oxygen – improved survival with
resuscitation in room air rather than 100% oxygen
• Positive pressure ventilation – Bag-mask Ventilation (BMV):
Self-inflating bag – resource limited settings
Flow-inflating bag
T-piece resuscitator
Laryngeal mask airway
• Position
• Suction
• Air-tight seal: E-C technique
• Initial breaths - Adequacy of ventilation is demonstrated by
improvement in heart rate

25. USE OF ROOM AIRUSE OF ROOM AIR VsVs 100%100% OO22
IN P-P VENTILATIONIN P-P VENTILATION
Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group et al Pediatrics,Saugstad, Rootwelt, Aalen on behalf of the Resair 2 Study Group et al Pediatrics,

26. Bag & Mask Are The Most Vital Tool In Newborn ResuscitationBag & Mask Are The Most Vital Tool In Newborn Resuscitation

27. NEXT STEPS
Further resuscitative efforts are based upon the heart rate
response of the infant after the initial 30 seconds of BMV.
If >100 beats per minute (bpm) and spontaneous effective
respiration has begun, BMV can be discontinued and free-
flowing oxygen administered as needed, based on the target
oxygen saturations for minutes after birth.
If between 60 to 100 bpm, continue BMV ventilation and
reevaluate after 30 seconds. Reevaluation includes the
following sequence of M-Mask readjustment, R-Reposition
the airway, S- Suction the mouth and nose, and O- Open the
mouth slightly.
If <60 bpm, immediately begin chest compression and
reassess that adequate positive pressure ventilation is being
delivered.

28. NEXT STEPS
 CPAP or PEEP — continuous positive airway (CPAP) or end-expiratory
pressure (PEEP) may be beneficial for adequate lung recruitment and
reduce subsequent lung injury
 Data from observational studies and a single clinical trial appear to
support the use of CPAP versus BMV in the initial resuscitation of
preterm infants
 Infants treated with single inflation/CPAP, when compared with those
who received conventional BMV, were less likely to be intubated, receive
more than one dose of surfactant, or develop bronchopulmonary
dysplasia (BPD).
 However, further studies to confirm these findings are needed before
CPAP versus BMV can be recommended for neonatal resuscitation.
 After BMV ventilation as the initial resuscitative intervention, CPAP
rather than intubation and mechanical ventilation may be beneficial in
the spontaneously vigorous preterm infants who require continued
respiratory support or at risk for respiratory distress syndrome.

29. NEXT STEPS
 Chest compressions are initiated if the infant's heart rate
remains <60 beats per minute despite adequate ventilation for
30 seconds
 Thumb technique – In this method, both hands encircle the
infant's chest with the thumbs on the sternum and the fingers
under the infant. This is the preferred method.
 Two-finger technique – In this method, the tips of the first
two fingers, or the middle and ring finger, are placed in a
perpendicular position over the sternum
 pressure is applied downward perpendicular to the chest wall
sufficient to depress the sternum about one-third of the
anteroposterior diameter of the chest, and then pressure is
released to allow the heart to refill.
 Avoid applying pressure directly over the xiphoid, as this may
cause hepatic injury.

30. NEXT STEPS
 Chest compressions must always be accompanied by positive
pressure ventilation (PPV).
 rate is 90 per minute accompanied by 30 ventilations per
minute with one ventilation interposed after every third
compression.
 ventilation rate is reduced from the 40 to 60 breaths per
minute used in the absence of chest compression to 30
breaths in the presence of chest compression.
 After 30 seconds of chest compression and PPV, reassessment
of the infant's heart rate, color, and respiratory rate should
determine whether further interventions are required (eg,
intubation or administration of medications).

31. .

32. NEXT STEPS
 Endotracheal intubation; Two care providers are required,
time needed for intubation should be limited to 20 seconds,
and free flowing oxygen is administered during the
procedure.
 indicated in:
●Tracheal suctioning for meconium is required
●BMV is ineffective or prolonged
●Chest compressions are being performed
 congenital diaphragmatic hernia, airway stabilization of the
extremely low birth weight infant, and for administration of
surfactant.
 Initial stabilization – by BMV
 Insertion of the laryngoscope
 Assessment of successful intubation
 Securing ETT

33. NEXT STEPS
 DRUGS —rarely required in neonatal resuscitation. Delivering adequate
ventilation is the most important resuscitative step because the most common
cause of bradycardia is inadequate lung inflation or profound hypoxemia.
 However, if the heart rate remains <60 beats per minute despite adequate
ventilation and chest compressions, administration of epinephrine is
indicated.
 Rarely, volume expansion (normal saline, ringers lactate or O-ve blood) or a
narcotic antagonist (eg, naloxone) may be useful.

34. .
• .

35. Potentially Hazardous Forms Of Stimulation
 Slapping Back Or ButtocksSlapping Back Or Buttocks
 Squeezing Rib CageSqueezing Rib Cage
 Forcing Thighs Onto AbdomenForcing Thighs Onto Abdomen
 Dilating Anal SphincterDilating Anal Sphincter
 Hot Or Cold Compresses Or BathsHot Or Cold Compresses Or Baths
 ShakingShaking
 DRUGS, e.g. Hydrocortisone, NaHCODRUGS, e.g. Hydrocortisone, NaHCO33 - Especially With Apnea- Especially With Apnea

36. FAILURE OF RESUSCITATION
 Rarely, infants will not respond to the initial resuscitative
efforts.
 Ensure all the resuscitative steps were fully and properly
administered.
 If the infant fails to respond despite properly executed
resuscitation, the following clinical approach may help ascertain
the cause:
 Resuscitation efforts may be discontinued if the neonate has
demonstrated no signs of life (no heart beat or no respiratory
effort for greater than 10 minutes) after 10 minutes of
resuscitation
 As previously discussed, if additional data obtained after
resuscitation is started demonstrates that neonatal outcome is
almost certain early death or unacceptably high morbidity,
support can be discontinued if agreed upon by the parents and
healthcare team.

37. WITHOLDING RESUSCITATION
 With antenatal screening, it is now possible to identify conditions
associated with high neonatal mortality or poor outcome.
●The decision not to initiate intensive therapy is made together by the
parents and the healthcare team. Discussion, if possible, should
occur prior to the birth of the infant.
●Non-initiation of resuscitation may be considered if early death is very
likely and survival would be accompanied by unacceptably high
morbidity. infants with gestational age <23 weeks or birth weight
<400 g, anencephaly, or chromosomal abnormalities incompatible
with life (eg, trisomy 13 or 18)
●Intensive care including neonatal resuscitation is always indicated
when there is a high likelihood of survival and acceptable morbidity.
●In settings in which the prognosis of the infant is unclear but likely
poor, and survival may be associated with a diminished quality of
life, parental wishes should determine management decisions.

38. WITHOLDING RESUSCITATION
 At delivery, if the appropriate course is uncertain, it is
preferable to initiate resuscitation. If additional data
demonstrate that the outcome is almost certain early death or
unacceptably high morbidity, support can be discontinued if
agreed upon by the parents and healthcare team.
 Basic care that provides comfort to the infant must be given at
all times, even when intensive therapy is not initiated.
 When there is disagreement between the parents and healthcare
team, continued discussion is recommended. Other resources in
resolving disagreement include consultation with the hospital's
ethics committee or finding healthcare providers that will
provide care for the infant in the manner desired by the parents.
At times, unresolved disagreement may result in the
involvement of the court system.
 At all times, the clinician must serve as an advocate of the infant
and what he/she judges to be in the infant's best interest.
 The clinician needs to know the relevant laws in his/her local
area of practice.

39. POSTRESUSCITATION
 Infants who required resuscitation are at risk of developing
postresuscitative complications:
●Hypo- or hyperthermia
●Hypoglycemia (see "Neonatal hypoglycemia")
●Central nervous system (CNS) complications: apnea, seizures, or
hypoxic ischemic encephalopathy
●Pulmonary complications: Pulmonary hypertension, pneumonia,
pulmonary air leaks, or transient tachypnea of the newborn
●Hypotension
●Electrolyte abnormalities: Hyponatremia or hypocalcemia
●Feeding difficulties: Ileus, gastrointestinal bleeding, or
dysfunctional sucking or swallowing
 The longer and the greater the extent of resuscitation, the more
likely that there will be subsequent and serious complications.

40. SUMMARY POINTS
Preparation & Teaching Is the bedrock of Successful NR
Ventilation Is The Primary Goal
Oxygenation can be achieved by Room Air
Chest Compression & Drugs Are Rarely Needed
Ethics Should Carefully Be Considered In Our Circumstances
Each Strategy/Step Should Be Assessed Scientifically - More
Research Is Required

41. SUMMARY POINTS
 The Most Important & Effective Action In NR Is To Ventilate Baby’s Lungs
 Effective P-PV In Secondary Apnea Usually Results In Rapid HR Improvement
 If HR Does Not Increase, Ventilation Could Be Inadequate And/Or Chest
 Compressions & Epinephrine May Be Needed
 HR <60 bpm → Additional Steps Needed
 HR >60 bpm → Chest Compressions Can Be Stopped
 HR >100 bpm & Breathing → P-PV Can Be Stopped
 Time Line: If No Improvement After 30 Seconds, Proceed To Next Strategy/Step

42. References
1. Opiyo E, English M . Newborn resuscitation: defining best practice for low-
income settings. Trans R Soc Trop Med Hyg. 2006 October ; 100(10): 899–908.
2. English M, Esamai F, Wasunna A, Were F, Ogutu B, Wamae A, Snow RW, Peshu
N. Delivery of Paediatric Care at the first-referral level in Kenya. Lancet
2004;364:1622–1629
3. 2015 Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care of the Neonate, AHA,AAP,ILCOR
4. Guidelines on basic newborn resuscitation. WHO,2012 at
http://www.who.int/maternal_child_adolescent/documents/basic_newborn_resuscitation
Accessed on 8th
February 2016,9:40PM

43. END.
Now let us watch a short
video on resuscitation of a
new born.
THANK YOU.