Neonatal Resuscitation Flashcards
Why are neonates at risk of hypoxia?
Hypoxia is central to neonatal resuscitation. Normal labour and birth leads to hypoxia. When contractions happen, the placenta is unable to carry out normal gaseous exchange, leading to hypoxia. Extended hypoxia will lead to anaerobic respiration and a subsequent drop in the fetal heart rate (bradycardia). Further hypoxia will lead to reduced consciousness and a drop in respiratory effort, in turn worsening hypoxia. Extended hypoxia to the brain leads to hypoxic-ischaemic encephalopathy (HIE), with potentially life-long consequences in the form of cerebral palsy.
What issues arise during neonatal resuscitation?
- Babies have a large surface area to weight ratio, and get cold very easily
- Babies are born wet, so they loose heat rapidly
- Babies that are born through meconium may have this in their mouth or airway
What are the principles of neonatal resucitation?
- Warm the baby
- Calculate the APGAR Score
- Stimulate breathing
- Inflation breaths
- Chest compressions
What is the role of ‘warming the baby’ in neonatal resusctitation?
- Get the baby dry as quickly as possible
- Vigorous drying also helps stimulate breathing
- Keep the baby warm with warm delivery rooms and management under a heat lamp
- Babies under 28 weeks are placed in a plastic bag while still wet and managed under a heat lamp
What is the role of ‘APGAR’ score in neonatal resuscitation?
- This is done at 1, 5 and 10 minutes whilst resuscitation continues
- This is used as an indicator of the progress over the first minutes after birth
- It helps guide neonatal resuscitation efforts
What is the role of ‘stimulating breathing’ in neonatal resuscitation?
- Simulate the baby to prompt breathing, for example by drying vigorously with a towel
- Place the baby’s head in a neutral position to keep airway open
- A towel under the shoulders can help keep it neutral.
- If gasping or unable to breath, check for airway obstruction (i.e. meconium) and consider aspiration under direct visualisation
What is the role of ‘inflation breaths’ in neonatal resuscitation?
Inflation breaths are given when the neonate is gasping or not breathing despite adequate initial simulation.
- Two cycles of five inflation breaths (lasting 3 seconds each) can be given to stimulate breathing and heart rate
- If there is no response and the heart rate is low, 30 seconds of ventilation breaths can be used
- If there is still no response, chest compressions can be used, coordinated with the ventilation breaths
Technique is very important in delivering effective inflation breaths. Get someone experienced to show you how to perform them. It is essential to maintain a neutral head position and get a good seal around the mouth and nose. Look for a rise and fall in the chest.
When performing inflation breaths, air should be used in term or near term babies, and a mix of air and oxygen should be used in pre-term babies. Oxygen saturations can be monitored throughout resuscitation if there are concerns about the breathing. Aim for a gradual rise in oxygen saturations, not exceeding 95%.
What is the role of ‘chest compressions’ in neonatal resuscitation?
- Start chest compressions if heart rate remains below 60 bpm despite resuscitation and inflation breaths
- Chest compressions are performed at a 3:1 ratio with ventilation breaths
What are the treatment options in severe situations?
For example: hypoxic-ischaemic encephalopathy (HIE)
Time is precious during neonatal resuscitation. Prolonged hypoxia increases the risk of hypoxic-ischaemic encephalopathy (HIE). In severe situations, IV drugs and intubation should be considered. Babies near or at term that have possible HIE may benefit from therapeutic hypothermia with active cooling.
What are the risk factors for requiring help with stabilisation or resuscitation of a neonate?
Fetal:
- Intrauterine growth restriction
- < 37 weeks gestation
- Multiple pregnancy
- Serious congenital abnormality
- Oligo or polyhydramnios
Maternal:
- Infection
- Gestational diabetes
- Pregnancy-induced hypertension
- Pre-eclampsia
- High BMI
- Short stature
- Preterm lack of antenatal steroids
Intrapartum:
- Evidence of fetal compromise (non-reassuring CTG, etc.)
- Meconium stained amniotic fluid
- Delivering vaginally by breech
- Forceps or vacuum delivery
- Significant bleeding
- Caesarean-section before 39 weeks
- Emergency Caesarean-section
- General anaesthesia
What % of oxygen concentration is given in neonatal resuscitation?
Note: ≥ 32 weeks, 28-32 weeks and < 28 weeks
Initial delivered oxygen concentration depends upon gestation:
- ≥ 32 weeks gestation - 21% oxygen
- 28-32 weeks- 21-30% oxygen
- < 28 weeks- 30% oxygen
Briefly describe the use of the APGAR score
Apgar is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score determines how well the baby tolerated the birthing process. The 5-minute score tells the health care provider how well the baby is doing outside the mother’s womb. In rare cases, the test will be done 10 minutes after birth.
The APGAR score is measured out of 10. The lowest score is 0 and the highest is 10.
What is the role of umbilical clamping in neonatal resuscitation?
After birth there is still a significant volume of fetal blood in the placenta. Delayed clamping of the umbilical cord provides time for this blood to enter the circulation of the baby. This is known as placental transfusion. Recent evidence indicates that in healthy babies, delaying cord clamping leads to improved haemoglobin, iron stores and blood pressure and a reduction in intraventricular haemorrhage and necrotising enterocolitis. The only apparent negative effect is an increase in neonatal jaundice, potentially requiring more phototherapy.
Current guidelines from the resuscitation council UK state that uncompromised neonates should have a delay of at least one minute in the clamping of the umbilical cord following birth.
Neonates that require neonatal resuscitation should have their umbilical cord clamped sooner to prevent delays in getting the baby to the resuscitation team. The priority will be resuscitation rather than delayed clamping.
What dose of adrenaline is given to neonates if CPR fails?
Both initial and subsequent IV/IO adrenaline doses are 20 micrograms kg-1 (0.2 mL kg-1 of 1:10,000 adrenaline (1000 micrograms in 10 mL)), in the absence of a response to CPR give repeat doses every 3-5 minutes.
