Newborn resuscitation

Birth Asphyxia
Definition
When the baby does not initiate and sustain adequate
breathing at birth is called birth asphyxia.
Magnitude

Of the deaths 3.3 million neonatal deaths that occur

worldwide, 23% death occur due to birth asphyxia
alone (WHO and Save the Children 2011).
Fetal Hypoxia
Concentration of oxygen that is less than normal in
fetus causing lack of oxygen for bodys cell and
organs to perform normal function is called fetal
hypoxia.

Factors associated with birth asphyxia

1. Fetal distress
Meconium stain
Abnormal presentation
2. Prolonged or obstructed labor
3. Medical disease of mother
3. Complicated, traumatic or instrumental delivery
4. Severe maternal infections
5. Maternal sedation, analgesia or anesthesia
6. Antenatal or Intrapartam hemorrhage
7. Pre-term or post-term birth
8. Congenital anomalies

Who will need resuscitation?

80 - 90% of newborns require no assistance to
initiate breathing at birth.
10% require some assistance to begin breathing.
1% out of 10% requires extensive resuscitative
measures to survive.
Sometimes the need for resuscitation can be
predicted, but often it cannot, so... PREPARE FOR
RESUSCITATION AT EVERY BIRTH

Neonatal Resuscitation
Introduction:
We cannot tell which babies will have asphyxia at
birth. Therefore we must prepared to do newborn
resuscitation at all births. If a few minute pass
before the starts to breath, baby can suffer from
brain damage or die. Preparing for resuscitation
include, warming the resuscitation area, preparing
clean surface for the resuscitation and collecting
the equipments and supply.

Principles of Newborn Resuscitation

According to Pediatric working Group of the
International Liaison Committee on Resuscitation
(ILCOR) the principles of newborn resuscitation are as
follows:
Personal capable of initiating resuscitation should attend
every delivery to establish a vigorous cry or regular
respiration, to maintain a heart rate >100 beats per
minute and achieve good color and tone.

Preparation of newborn resuscitation

We cannot predict which baby will have asphyxia
at birth. Therefore, we must be prepared to do
newborn resuscitation at all births. When certain
preparations are not done the time will be lost.
Preparations for newborn resuscitation include:
Preparation of the resuscitation area
Preparation of personnel
Preparation of resuscitation equipment and
supplies.

Preparation of resuscitation area

Room warm and free from wind.
At home: do the resuscitation near a fire or other
heat source.
In health facility use a heater or light bulb above
the baby of 100-150 watts, 45 cm from baby. Turn
on before delivery so warm by delivery time. Use a
flat place that is clean, warm dry and covered with
a warm cloth.
Heat should avoided near the resuscitation area if
possible
Use a warm cloth to wrap the baby.

Preparation of personnel
Ideally at every delivery one person whose primary
responsibility is the baby and who is capable of doing
resuscitation.
Anticipated high risk birth-at least 2 person with
varying degree of resuscitation skills.
If only one person to care for both mother and baby:
if baby needs resuscitation , do resuscitation in a
place where you can observe the mothers perineum
for bleeding or ask a family member to look for
bleeding.

Preparation of resuscitation equipments and supplies

1. Suction equipment :- Mucus extractor-Dee Lees or gauze
electrical or manual suction with suction catheters
2. Ventilation equipment :. Self inflating ambu bag with reservoir
. Face mask size 1 for normal weight newborn baby and
size 0 for low birth weight i.e. <2.5 kg baby.
. Oxygen with flow meter and tubing if available
3. Gloves (do not need to be sterile)
4. Firm or flat surface radiant warmer
5. Stethoscope

6. Two pieces of gauze or clean cloth: one to dry

the babys mouth and one to use as protective
barrier if doing mouth to mouth and nose
resuscitation.
7. Pre warmed linen 4 pieces of clothes
8. A cap to cover the babys head.
9. A clock or watch with second hand
Be prepared to cut the cord immediately if the
baby needs resuscitation.

STEPS FOR RESUSCITATION

I. Evaluation
II. Decision
III. Action

STEPS IN NEONATAL RESUSCITATION

Step I: On Initial Assessment ask the
following:
At birth ask or look:
Meconium not present?
Breathing or crying?
Good muscle tone?
Color pink?
Term gestation?
If the answer to each question is yes, proceed
with routine immediate newborn care, If the
answer to any one question is no, then go to the
next step.

Step II: Initial Steps of Resuscitation

Initial assessment, initial steps and first evaluation should be completed
within 30 seconds
I. Dry, stimulate, warm
Immediately after delivery, put the baby on the mothers abdomen. Rub
the babys whole body firmly with the covering cloth (dry and stimulate
at the same time). This first step often helps the baby to start breathing
regularly.
If it is clear the baby needs resuscitation, cut cord quickly and wrap baby
with warm cloth take baby to resuscitation place.
Near a heat source, have 2 warm cloths or towels ready on the flat surface
you will use for resuscitation.
Quickly wrap the baby in the clean, dry, warm cloth.
Do not cover the face and chest so you can evaluate the babys breathing,
color and heart rate.

II. Position , clear airway (as necessary)

Put the wrapped baby on its back with slightly extended the head.
Suction baby. If no suction device is available, wipe out babys
mouth with a cloth/gauze.
Always suction the mouth first (5cm) and then the nose (3cm).
If suction tube is used, suction only while pulling tube out, Not
while putting it in.
Do not suction deep in the throat as it may cause the babys heart
to slow or the baby may stop breathing. In case of meconiumstained amniotic fluid.
Suction babys mouth and pharynx first then the nose, after the
head is delivered before birth of the bady.
After birth, if the baby is not vigorous, do not stimulate. Quickly
dry, position and suction baby (mouth and pharynx first then nose)
in preparation to ventilate.

III. Reposition
If the baby still not crying or breathing reposition the baby with
slightly extended the head. Some time the head may be flexed
which may difficult for breathing.
IV. Stimulate for breathing*
If the baby is not breathing, stimulation can be provided by
flicking the bottom of the foot or rubbing up and down the back
with your hand over the cloth while the other persons proceed
with resuscitation and assessment.
V. Give O2 (as necessary)
*Important: If meconium present, baby not vigorous - do not
stimulate until after clearing airway.

Evaluate
Respiration
Heart rate
Color
Decide action based on evaluation
Give supportive care: if the baby breathing, heart rate is above
100, the baby is pink and has good tone baby may be given to
mother for warmth, breast feeding and love. This baby will need
frequent assessment of color, tone and vial signs for the first six
hours. It should be done within first 30 seconds.
Keep warm, stimulate and give oxygen (if available): If the
baby is breathing, heart rate is above 100 but baby has cyanosis.
This baby will need frequent assessment of color, tone and vital
signs for the first six hours.
If the baby is not breathing or is gasping or the heart rate <100,
Start Ventilation to the baby.

STEP III: Ventilate the baby

Explain to the mother and family that the baby needs help and
that you will give that help.
I. Make sure baby has neck slightly extended
II. Put the mask on the baby. Cover the babys mouth and nose
(If using bag and mask).
III. Ventilate the baby 2 times and look for a gentle rise and fall
of the babys chest.
If the chest does not rise:
Position the head
Re-position the mask to correct seal.
Suction the mouth and nose if fluid or secretion are present.
Squeeze harder.

IV. Ventilation the baby 20-30 times in 30 seconds.

Evaluate chest rise with each breath.
When the baby begins to breathe normally, stop ventilating
V. Re assess the babys breathing, heart rate and color after each
30 seconds of ventilation.
If the baby breaths spontaneously and his heart rate is >100 stop
resuscitation and continue to give supportive care.
If the baby is not breathing or is gasping or the heart rate is <100,
continue to ventilate 20-30 times in 30 seconds and then re-evaluate.
VI. If the baby does not breathe spontaneously after 2-3 minutes
of resuscitation:
Refer the baby with continue ventilation (if it is possible ask the
family to get ready for referral)

In the health post or home setting or facility level id the baby still
is not breathing after 20 minutes of resuscitation, stop
resuscitation.
STEP IV. Provide positive pressure ventilation with chest
compression
If heart rate < 60 bpm despite adequate ventilation:
Support circulation by starting chest compressions while
continuing ventilation. Then, evaluate again
Chest Compression:
Almost all babies needing help at birth will respond to successful
lung inflation with an increase in heart rate followed quickly by
normal breathing. However, in some cases chest compression is
necessary.
in babies, the most efficient method of delivering chest
compression is to grip the chest in both hands in such a way that
the two thumbs can press on the lower third of the sternum,

just below an imaginary line joining the nipples with the

fingers over the spine at the back.
Compress the chest quickly and firmly, reducing the anteroposterior diameter of the chest by about one third.
The ratio of compressions to inflations in newborn
resuscitation is 3:1.
Techniques
I. Positioning of thumb and fingers for chest compression
Apply pressure to lower third of sternum
Avoid xiphoid process

II. Thumb technique

Pressure must remain on sternum
III. Two finger technique
Tips of middle finger and index or ring finger of one hand compress
sternum
Other hand supports back.
Chest compressions to move oxygenated blood from the lungs back
to the heart. Allow enough time during the relaxation phase of each
compression cycle for the heart to refill with blood . Ensure that the
chest is inflating with each breath.
In a very few babies (less than one in every thousands births)
inflation of the lungs and effective chest compression will not be
sufficient to produce an effective circulation. In these circumstances
drugs may be helpful.

Drugs
Drugs are needed rarely and only if there is no significant cardiac
output despite effective lung inflation and chest compression.
The drugs used include adrenaline (1:10,000), occasionally sodium
bicarbonate (ideally 4.2%) and dextrose (10%). They are best delivered
via an umbilical venous catheter.
The recommended intravenous dose for adrenaline is 10 mcg kg-1
(0.1ml kg-1 of 1:10,000 solution). If this is not effective, a dose of up to
30 mcg kg-1(0.3 ml kg-1 if 1:10,000 solution) may be tried.
If the tracheal route is used, it must not interfere with ventilation or
delay acquisition of intravenous access. The tracheal dose is thought to
be between 50-100mcg kg-1.
The dose for sodium bicarbonate is between 1 and 2 mmol of
bicarbonate kg-1 (2 to 4 ml of 4.2% bicarbonate solution).
The dose of dextrose recommended is 250 mg kg-1 (2.5 kg -1 of 10%
dextrose).

Clear the airway

Open the airway by

 If the newborn is breathing but

central cyanosis is present, give
oxygen

Positioning the bag and mask on

face

 Stimulation for breathing

Care After Successful Resuscitation

Counsel/advice mother and family
Talk with them and answer questions
Teach mother to check for breathing and warmth
Encourage breast feeding
Recognition of danger signs and how to seek help
Given Care
Check newborn hourly for the next hours at least (color,
breathing, feeding, temperature)
Observe baby for possible problems (respiratory distress
syndrome,
pneumonia,
aspiration,
hypothermia,
hypoglycemia, poor feeding/feeding intolerance)
Give normal care for a newborn

Care after resuscitation with referral

Counsel/advice mother and family
Talk with them and answer questions.
Explain the need for special care of baby and that referral is
recommended. Ask them if they will go.
Advise mother to accompany baby if referred
Explain need to keep baby warm.
If baby can (depending on babys condition), encourage
breastfeeding during transport.
Give care
- Continue to stimulate/resuscitate the baby
- Continue to monitor breathing, color and keep
warm
- Arrange referral (follow referral guidelines
- If possible, the health worker should accompany during referral

 Records
- Prepare a referral note
- Prepare records for health facility and for family to take home
Do follow -up
Care after unsuccessful resuscitation
Counsel/advice mother and family
- Talk with them about the babys death and answer their questions
- Ask the mother and family if they want to see and hold the baby
- Explain to the mother and family about the mothers care
- Rest, support and good diet
- Management of engorged breasts
Records
- Recording and notification of babys birth and death
- Completion of required medical records for the delivery
Do follow-up care of the mother