Neonatal Resuscitation Flashcards
What is hypoxia?
Oxygen deficiency
What is anoxia?
Severe hypoxia; absence of oxygen
What is apnoea?
Absent respiratory effort
What is asphyxia?
Suffocation
Give 10 events that lead to hypoxia
- Hypoxia in uterus
- Foetus attempts to breathe
- Foetus loses consciousness
- Neural centres in brainstem that control breathing efforts cease to function
- Primary apnoea
- HR decreases by half as myocardium reverts to anaerobic metabolism
- Lactic acid released, adding to respiratory acidosis from accumulation of carbon dioxide
- Shuddering agonal gasps initiated by primitive spinal reflexes
- Failure to aerate lungs results in secondary/ terminal apnoea
- Worsening acidosis, reducing substrate for anaerobic metabolism and on-going anoxia lead to impaired cardiac function and then heart failure
What is the most effective way to keep the foetus alive?
Lung aeration
What are the potential causes of neonatal respiratory distress related to the mother?
- Heavy sedation
- Chronic illness
- Drug addiction
- Diabetes mellitus - surfactant production if premature
- Severe pregnancy induced hypertension or pre-eclampsia
- Antepartum haemorrhage
What are the potential causes of neonatal respiratory distress related to the foetus?
- Preterm <34/40
- Post term >42/40
- Multiple pregnancy
- Intrauterine infection
- Growth restriction
- Polyhydramnios
- Oligohydramnios
- Rhesus isoimmunisation
- Reduced foetal movement
- Abnormal presentation
What is polyhydramnios and oligohydramnios?
Polyhydramnios = excess amniotic fluid Oligohydramnios = deficiency of amniotic fluid
What are the potential causes of neonatal respiratory distress related to delivery?
- Suspected foetal compromise
- Prolonged rupture of membranes
- Intrapartum haemorrhage
- Assisted deliveries
- Emergency LSCS
- Prolapsed cord
- Prolonged/ difficult labour
- Thick meconium stained liquor
What must be prepared for all births?
- Equipment (familiar, available, working, turned on)
- Warm room and towels
- Check history (any risk factors?)
What must be prepared for high risk births?
- Inform labour ward coordinator
- Paediatrician
- Consider second midwife for delivery (may be mandatory in some units)
- If high risk, inform SCBU/NNICU
What is the sequence of actions following apnoea?
- Keep infant warm and assess
- Airway
- Breathing
- Chest compressions
- Drugs
How should significantly preterm infants be placed after birth?
In polyethene wrapping under a radiant heater, without drying
What must the temperature be after birth?
36.5 - 37.5 degrees C
What should be done if the baby is breathing well after birth?
Put skin to skin with mother and encourage BF
What does a healthy infant look like?
- Blue with good tone
- Will cry within a few seconds of delivery
- Good HR within a few mins (120-150min-1)
What does a less healthy infant look like?
- Blue with poor tone
- Slow HR (<100min-1)
- May not establish breathing by 90-120 seconds
What does an unwell infant look like?
- Born pale and floppy
- Not breathing with a very slow/ undetectable HR
How should the baby be assessed following birth?
- Cover infant with dry towels and a hat
- Assess infant’s breathing and HR (and colour and tone)
- Reassess breathing and HR every 30 secs during resuscitation; increasing HR is most important
- Use stethoscope to read HR and pulse oximeter where possible
What should be done about the airways?
- Open airway (place infant on back with head in neutral position)
- If infant is floppy, may need jaw thrust
- Airway suction necessary for airway obstruction with direct visualisation
- Tracheal obstruction requires intubation and suction during withdrawal of the endotracheal tube
How many inflation breaths should be given?
- 5 inflation breaths
- 30cm water for 2-3 secs or 20-25cm water in preterm infants
If heart rate increases after inflation breaths, what can be assumed?
Lungs have been successfully aerated
What should be done if heart rate increases but infant is not breathing?
Continue ventilations 30-40min-1 until infant starts breathing
What should be considered if the lungs are not aerated?
- Check infant’s head is in neutral position
- Check if there’s a face mask leak
- Jaw thrust/ 2 person approach needed?
- Longer inflation time needed?
- Obstruction in oropharynx?
- Will an oropharyngeal airway assist?
- Is there a tracheal obstruction?
What can be assumed if the lungs do not move with inflation breaths?
There is an airway obstruction
When should chest compressions be started?
If HR remains slow after 5 effective breaths and 30 seconds of effective ventilation
What do infants require if they are showing signs of respiratory distress?
CPAP of 5cm water
What do preterm infants that are not breathing adequately require?
PEEP with inflation breaths to prevent the lungs collapsing
Describe how to do chest compressions
- Chest compression should only be started when you are sure that the lungs have been aerated successfully
- Grip chest in both hands so that 2 thumbs can press on lower third of sternum
- Compression:Inflations = 3:1
Why would drugs be required?
If there is no significant cardiac output despite effective lung inflation and chest compression
How is adrenaline administered?
- Recommended IV dose of 10mcg/kg-1 but can use 30mcg/kg-1 if this is not effective
- Can be given via tracheal route at 50-100mcg/kg-1
How is sodium bicarbonate administered?
- Used during prolonged arrests unresponsive to other therapy
- Between 1 and 2 mmol/kg-1
How is glucose administered?
- Used if there is no response to other drugs delivered through a central venous catheter
- 2.5mL/kg-1
What is the effect of dextrose?
Corrects low blood sugar
What is isotonic crystalloid used for?
Emergency volume replacement if HR cannot increase due to significant blood loss
Describe when and how air should be used for resuscitation
- For term infants
- If pO2 levels are low despite adequate ventilation, the addition of oxygen to the air should be considered
- Babies <32 weeks may need blended air/ oxygen mixture should be carefully used and guided by pulse oximetry
How does meconium affect oxygen intake?
- Meconium rarely inhaled unless baby is gasping for oxygen
- Suction not recommended at perineum, should only be done if no gasps from baby
- Paediatrician should inspect with laryngoscope and suction under direct visualisation - intubate if no paediatrician present
- Only suction as far as you can see and then continue resuscitation
What are some reasons that may cause baby to be unresponsive?
- Narcotics and other drugs causing respiratory depression
- Material blocking airway
- Hypovolaemia
- Hydrops fetalis
- Extreme prematurity
- Intracranial haemorrhage
When should resuscitation be stopped?
- No detectable cardiac activity for 10 minutes
- Efforts beyond 10 minutes depend on availability of therapeutic hypothermia and intensive care facilities, gestation, presence of complications and parent’s previous expressed feeling about acceptable risk of morbidity
How is therapeutic hypothermia used as post-resuscitation care?
- Used to treat infants with evolving moderate to severe hypoxic-ischaemic encephalopathy (brain injury caused by asphyxia)
- Involves either whole body cooling or selective head cooling
- Treatment should be consistent with protocols of RCTs (e.g. commence cooling within 6 hrs, continue for 72hrs before re-warming infant over at least 4 hrs)
How is glucose used as post-resuscitation care?
- Preterm infants/ requiring significant resus should be monitored and treated to maintain blood glucose in normal range
- Hypoglycaemia must be avoided
- An infusion of 10% glucose rather than repeated boluses is usually best at treating low blood glucose
What is hypoglycaemia?
Low blood glucose levels
What is different about a pool birth?
- Baby takes longer to cry due to less temperature difference
- Baby’s head must be kept above water after it surfaces to ensure it doesn’t inhale water
Why can’t reversal drugs be given for pethidine?
Reverses effects of drugs mother may have taken (e.g. cannabis) which could cause withdrawal for mother and baby
Why should premature babies not be rubbed with a towel?
- Could damage organs
- Should wrap them in plastic to keep them warm
When should APGAR scores be taken?
1, 5 and 9 minutes
What is the average circulating blood volume?
100ml/kg
