Mohammad Al maghayreh

Princess Rahma Teaching Hospital

Helping Babies Breathe
A healthy first cry represents a baby
with unlimited potential
Golden minute
At no other time in ones life will necessary
critical concepts in resuscitation have a potential
lifelong impact
A babys first cry is one of the most anticipated
and welcome sounds in all the world

Appropriate interventions can make the
difference between life or death, or normal
life vs. life of disability


Inverted Pyramid
of Neonatal Resuscitation
Medications
Chest
Compressions
Positive-Pressure
Ventilation
Initial Steps: Drying, Warmth,
Clearing the Airway,
Stimulation
Assessment at Birth and Simple
Newborn Care
All infants
Some infants
Few infants
Wall, Lee, Niermeyer et al. IJGO 2009
136 million
babies born
Approx 10
million babies
Approx 6
million babies
< 1.4 million
babies
What Can Go Wrong During
Transition
Inadequate ventilation; oxygen may not reach
blood in lungs
Systemic hypotension from excess blood loss
or neonatal hypoxia and ischemia
Pulmonary arterioles may remain constricted
after birth (PPHN)
Lack of perfusion and oxygenation may cause
brain damage or death

Signs of a Compromised Newborn
Depressed respiratory
drive
Poor muscle tone
Bradycardia
Tachypnea
Persistent cyanosis
Low blood pressure

Good
tone with
cyanosis
Bad tone
with
cyanosis
Perinatal Compromise
Primary Apnea
Oxygen deprivation
Period of attempted rapid breathing
Primary apnea and dropping HR
Will improve with tactile stimulation



Secondary Apnea
Continued oxygen
deprivation leads to
secondary apnea
Heart rate and blood
pressure fall
Secondary apnea cannot
be reversed with
stimulation
Assisted ventilation must
be provided

The Theme of Neonatal
resuscitation
Circle of
Evaluation
Decision
Action
Timely manner
Team work

TABCs
Temperature
Airway
Suction secretions, assess for anomalies
Breathing
Stimulate respiratory effort
Tactile
Bag-mask positive pressure ventilation (PPV)
Circulation
Assess heart rate
Chest compressions if PPV ineffective at restoring heart rate
Term gestation

Breathing or
crying?

Good tone?
YES
ROUTINE CARE

Stays with mother
Provide Warmth
Clear Airway
Dry
Ongoing evaluation

Initial steps
NO
Evaluate HR
Respirations
Warmth
Open Airway
Dry
Stimulate

NRP algorithm (2010)
HR below 100,
gasping, or apnea?
PPV, Spo2
monitoring
HR below
100?
Take ventilation
corrective steps
Labored
breathing or
persistent
cyanosis?
Clear airway,
Spo2 monitoring,
Consider CPAP
Post Resuscitation
Care
YES
NO
NO
Yes
Ineffective
PPV (MR
SOPA)
HR below 100?
Take ventilation
corrective steps
HR below 60 ?
Consider intubation
Chest compressions
Coordinate with PPV
HR below 60 ?
i.v. epinephrine
Take ventilation
corrective steps
Intubate if no chest
rise!
Consider
-Hypovolemia
- Pneumothorax
yes
Yes
Yes No
No
Yes
Mask Adjustment
Reposition head
Suction upper airway
Open mouth and lift Jaw
Pressure increase
Airway alternative
Plan and prepare for birth
Equipment check
before birth , you should ask
Gestational age
Clear fluid
How many babies
Other risk factor

Need additional equipment
Need more people
Quick pre resuscitation checklist
Warm, dry
Suction
Auscultate
Oxygenate
Ventilate
Intubate
Medicate
Thermoregulate
Plastic wrap in < 28 wks
Polythene wrap or bag up to their necks without
drying.
Infants should be kept wrapped until admission and
temperature check.
Management of Meconium
2010
???
Bag & mask ventilation in MSAF??
If attempted intubation is
prolonged and unsuccessfull .

& if there is persistent
bradycardia.
Indications for PPV
Apnea
Gasping respirations
Heart rate < 100
Positive Pressure Ventilation
When done appropriately, PPV should result in
improvement in heart rate and color
Appropriate size mask and bag
Self-inflating vs. flow-inflating bag
Forming a good seal with mask
Achieve adequate chest rise
40-60 breaths per minute


Positive Pressure Ventilation
inflation pressure?
initial inflation pressure of
20 cm H2O
30 to 40 cm H2O may be required in some term babies
without spontaneous ventilation




Effective Ventilation
Bilateral breath sounds
Chest movement (HR may rise without visible
chest movement, especially with preterm baby)
Most important indicator of successful PPV is
improving heart rate
Use lowest inflation pressure to maintain HR
above 100

Ineffective PPV (MR SOPA)
Mask Adjustment
Reposition head
Suction upper airway
Open mouth and lift Jaw
Pressure increase
Airway alternative
When to use
PULSE OXIMETRY

- Anticipated resuscitation
positive pressure respiration is administered
- When cyanosis is persistent
- When supplemental oxygen is administered

Oximetry and Oxygen Supply
For all compromising babies pulse oximetry should
be used to detect the preductal saturation and heart
rate

28
OXYGEN ASSESSMENT


Insufficient Excessive
oxygenation oxygenation


Harmful to neonate


Chest Compressions
Compression of sternum 1/3 depth of AP
diameter of chest
Increase O2 to 100%
Chest Compressions
Begin chest compressions
when HR is below 60 despite
at
least 30 seconds of effective
PPV
Coordinate with ppv at 1 :3


Two thumb method is
preferred
Provides more consistent
pressure
Better control of compression
depth
2-Finger Technique
Better for small hands
Provides access to umbilicus for
medications

Depress sternum to approximately one
third of the anterior-posterior diameter
of the chest
100% oxygen should be given with
chest compressions
Continue chest compressions for 45-60
seconds before stopping to evaluate the
HR
Intubation is highly recommended
with chest compressions
Endotracheal Intubation
Endotracheal Intubation: Indications
To suction trachea in presence of meconium when
the baby is not vigorous
To improve efficacy of ventilation after several
minutes of bag-and-mask ventilation
To facilitate coordination of chest compressions
and ventilation
To administer epinephrine while IV access is
being established
Limit attempt to 30 seconds
Endotracheal Intubation:
Radiographic Confirmation
Correct Incorrect
Indications for Epinephrine
Heart rate persists < 60 after
Initial steps [30 seconds]
PPV [30 seconds]
Chest compressions [45-60 seconds]

Dosage given IV (UVC preferred), or
endotracheal (higher dose given)
Epinephrine Administration
Dilute 1:1000 concentration of epinephrine to
1:10,000
Recommended concentration: 1:10,000
Recommended route: Intravenously
Recommended dose: 0.1 to 0.3 mL/kg
Recommended preparation: 1:10,000 solution in 1 mL syringe

Recommended rate of administration: Rapidly

Consider endotracheal route ONLY while IV access being obtained
Recommended dose: 0.5 to 1mL/kg
Prepare 1:10,000 solution in 3 mL syringe

Epinephrine: Poor Response
(Heart Rate < 60 bpm)
Recheck effectiveness of:
Ventilation
Chest compressions
Endotracheal intubation
Epinephrine delivery
Consider possibility of hypovolemia
Indications for Volume Administration
No response to above resuscitation measures
History of blood loss at delivery suggesting
hypovolemia
Infant appears to be in shock (pallor, poor
perfusion, failure to respond appropriately to
resuscitation efforts)

IV, 10-20 mL/kg, Normal saline, Ringers lactate,
or O- blood


Withhold / discontinue resuscitation?

Age of viability in your institution.
Parental informed decision
In a newly born baby with no detectable heart rate, it
is appropriate to consider stopping resuscitation if the
heart rate remains undetectable for 10 minutes
Key Points
Resuscitation requires a rapid series of
assessments, interventions, and reassessments

Prompt initiation of respiratory support with
positive pressure ventilation by bag-mask is the
key to successful resuscitation of most infants

Always consider corrective steps in ventilation
and hypovolemia and pneumothorax (other
causes)
Recommendation
Routine intrapartum oropharyngeal and nasopharyngeal
suctioning for infants born with clear and/or meconium-
stained amniotic fluid is not recommended.
If attempted intubation is prolonged or unsuccessful,
mask ventilation should be implemented, particularly if
there is persistent bradycardia.
The LMA should be considered during resuscitation of
the newborn if face mask ventilation is unsuccessful
and tracheal intubation is unsuccessful or not feasible.

Endotracheal Intubation
Tracheal suctioning for non-vigorous
meconium-stained newborn
Effective PPV with bag and mask and no clinical
improvement
PPV lasting more than a few minutes
When chest compressions are needed
Special indications (diaphragmatic hernia, etc)
Use of Oxygen
Resuscitation of term newborns should begin
with 21% oxygen
Resuscitation of preterm newborns may begin
with slightly higher oxygen
It may take up to 10 minutes for a healthy
newborn
to become well oxygenated on room air
Place oximeter (if available) and increase oxygen
gradually to meet target saturations

Umbilical cord clamping
For healthy term infants delaying cord clamping
for at least one minute or until the cord stops
pulsating following delivery improves iron status
through early infancy.
For preterm babies in good condition at delivery,
delaying cord clamping for up to 3 min results in
increased blood pressure during stabilisation, a
lower incidence of intraventricular haemorrhage
and fewer blood transfusions
Most infants successfully transfer from intrauterine to extrauterine life
without any special assistance.
10 percent of newborns will need some intervention.
1 percent will require extensive resuscitative measures at birth.
personnel who are adequately trained should be readily available to
perform neonatal resuscitation at every birthing location
Infants who are more likely to require resuscitation can be identified by
maternal and neonatal risk factors
Care providers skilled in neonatal resuscitation should be present and
equipment should be prepared prior to the birth of the high-risk infant.
Preterm infants are more likely to require resuscitation and develop
complications from resuscitation than term infants
Please take good care of me!
Im the Future!