about 5-10% of newborns need active resuscitation to prevent birth asphyxia
high-risk babies should anticipated by the history of the pregnancy , labor , delivery , diabetic mother , old age , and signs of fetal distress , also some babies with normal mother hx may have birth asphyxia (unpredictable)
ABC rule in neonatal resuscitation :
A:airway , anticipate and establish patent airway by suction of secretion , may need endotracheal tube if necessary
B:breathing by tactile stimulation or initiate breathing by positive pressure ventilation with bag-mask (ambu bag)
C: circulation , by cardiopulmonary resuscitation (chest compression ) and medications ( like adrenaline )
apgar score help in determine if this newborn need resuscitation , 1min apgar score may signal the need for immediate resuscitation , 5-10-15-20 min apgar score indicate probability of successfully resuscitating the infant or not ( the outcome )
as its name apgar , a=aapearance , p=pulse(heart rate) , g=grimace(response to catheter in nostril (suction tube /ng tube)) , a=activity(muscle tone) , r = respiratory effort
A 0=blue ,pale 1=body pink but extremities blue , 2=completely pink
P 0=absent 1=<100 bpm 2=>100 bpm
G 0=no response , 1=grimace response , 2=cough or sneeze
A 0=limp , 1=some flexion of extremities , 2=active motion
R 0=absent 1=slow , irregular , 2=good , crying
how to resuscitate : after delivery of the newborn , immediate drying , warming and simulation of all
term infants who have apgar score >7 ,
those need only this routine care if gentle drying , warming and suctioning (clear the airway) if necessary with ng tube , the length of ng tube that introduced into baby nose or mouth to suction , not more than 4-5 cm in depth
in infant with apgar score <7 , active resuscitation should start :
1-in 30 seconds , place newborn under radiant heater (not prevent hypothermia) , give supplemental o2 , head down with slight extension , clear airway by suctioning , gentle tactile stimulation (rubbing the back , thigh , slapping the feet ,gentle chest stimulation )
then reassess apgar score , if become higher stop the active resuscitation , if still low , go to next step
2-in 30 seconds , use ambu bag to provide positive pressure ventilation , with continuous o2 monitoring by spo2 pulse oximeter , then reassess if apgar become higher , consider cpap if available or nasal o2 with incubator , if apgar still low , go to 3
3-provide positive pressure ventilation through endotracheal tube , the size and depth of ET should be according to birth weight
kg size mm depth cm
<1 2.5 6.5-7
1-2 3 7-8
2-3 3-3.5 8-9
>3 3.5-4 >9
after insertion , air entry in both lungs should checked by auscultation of lateral and posterior chest (not anterior aspect due to presence of heart) , if air entry more in right side , ETT may passed into right main bronchi (more likely because right main bronchi in continuity with trachea more than left ), so try slightly to withdraw the ETT and recheck
if heart rate <60bpm , initiate chest compression over lower third of sternum at rate of 90compression per minute , with 30 ventilation per minute with o2 100% (compression/ventilation 3:1 )for 1 minute , then do apgar score , if become higher consider cpap with continuous o2 monitoring until complete recovery , whereas if still low , go to 4
*poor response to ventilation may due of loosely fitter mask , poor positioning of ETT , intraesophageal intubation , airway obstruction , insufficient pressure , pleural effusion , pneumothorax , excessive air in stomach , asystole , hypovolemia , diaphragmatic hernia or prolonged intrauterine asphyxia
4- use adrenaline injection into umbilical vein or ETT if placed , dose 0.1-0.3ml/kg IV of 1:1000 or 0.5-1ml kg of 1:10,000 , can repeated every 3-5min if no response ,
when to stop resuscitation ? if adequate resuscitation continues for 10 min without detectable heart rate , it is reasonable to stop effort , but you can try longer
also in other cases such as acute hemorrhage , you can give blood by umbilical vein catheterization , also iv fluid , dopamine for severe asphyxia with cardiogenic shock , NA bicarbonate for metabolic acidosis after prolonged resuscitation (ensure adequate ventilation before give ) , naloxone if the mother received analgesic narcotic drugs 4hours prior to delivery
when resuscitation successful , after long resuscitation , now search for all manifestation of multiorgan hypoxic ischemic injury especially brain (hypoxic-ischemic encephalopathy )
what's the difference between resuscitation of term and preterm ?
1-preterm can be initiated with slightly higher o2 concentration (21-30%)
2-preterm should warmed in delivery room by plastic bag or wrap rather than drying
3-delayed cord clamping 1-3 minute can performed in both term and preterm , but especially recommended for preterm , benefit of delayed cord clamping higher hemoglobin level , better iron store for first several months , for preterm , additional benefit are improve hemodynamic stability , decrease need for inotropic support , decrease need for transfusion , decrease risk of necrotizing enterocolitis and intraventricular hemorrhage
ref: american journal (advances in pediatric and neonatal care )