Neonatology - Resuscitation Flashcards
Pathophysiology
Natural labour and birth leads to hypoxia.
- When contractions happen, the placenta unable to carry out normal gaseous exchange -> hypoxia.
- Extended hypoxia leads to anaerobic respiration and 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 brain -> hypoxic ischaemic encephalopathy (HIE) = potentially life-long consequences = cerebral palsy
Other issues in neonatal resuscitations
- Babies have large surface area to weight ration = get very cold very easily
- Babies born wet = so loose heat easily
- Babes that are born through meconium may have this in their mouth or airway
Principles of neonatal resuscitation (treatment)
Warm the baby
- Dry ASAP = vigorous drying also helps stimulate breathing
- Warm delivery rooms + management under heat lamp
- Babies under 28 weeks = placed in plastic bag while still wet and managed under a heat lamp
Stimulate Breathing
- Drying vigorously with a towel
- Place 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 breathe = check for airway obstruction (i.e. meconium) and consider aspiration under direct visualisation
Intervention when neonate is gasping or not breathing despite adequate initial simulation
- 2 cycles of 5 inflation breaths (lasting 3 seconds long each) = help stimulate breathing and heart rate
- If there is no response and the HR = low = 30 seconds of ventilation breaths
- If theres still no response = chest compression’s = co-ordinated with ventilation breaths
- Important to maintain neutral head position and get a good seal around the mouth and nose = look for a rise and fall of the chest *
Term/near term babies = air
Pre-term babies = air and oxygen mixed
O2 SATS should be monitored throughout the resuscitation if there’s concerns avout breathing. Aim = gradual rise in O2 sats not exceeding 95%
When to start chest compressions
- Start chest compressions if heart rate remains below 60 bpm despite resuscitation and inflation breaths (see protocol)
- Chest compressions are performed at a 3:1 ratio with ventilation breaths
Severe situations = last resort treatment
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.
APGAR Score (0 = BAD - 10 = GOOD)
Appearance (skin colour)
- 0 = Blue/pale centrally
- 1 = Blue extremities
- 2 = Pink
Pulse
- 0 = Absent
- 1 < 100
- 2 > 100
Grimmace (response to stimulation)
- 0 = No responce
- 1 = Little response
- 2 = Good response
Activity (muscle tone)
- 0 = Floppy
- 1 = Flexed arms and legs
- 2 = Active
Respiration
- 0 = Absent
- 1 = Slow/irregular
- 2 = Strong/crying
Delayed umbilical cord clamping
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.
