Neonatal Resuscitation & Birth Asphyxia

• Objectives for neonatal resuscitation include understanding the goals, risk factors, guidelines, proper techniques, and situations for non-initiation/discontinuation, as well as changes in the new (8th ed) NRP guidelines.
• Neonatal resuscitation requires lung expansion, effective air exchange, and establishing neonatal circulation with termination of fetal circulation.

Birth Asphyxia

• Birth asphyxia means a newborn fails to initiate and sustain respiration after birth
• Usually defined as a complex combination of hypoxemia, hypercapnia, and tissue ischemia
• If birth asphyxia is not corrected, it will lead to multiple organ death
• ACOG defines birth asphyxia results from intrapartum hypoxia that causes neurological damage
• This neurological damage is characterized by:
  • Umbilical artery pH <7.00
  • A 5-minute Apgar score ≤3
  • Moderate or severe neonatal encephalopathy
  • Multi-organ dysfunction, e.g., CVS, renal and/or pulmonary system

Causes of Asphyxia

• Maternal factors include inadequate placental perfusion, severe pre-eclampsia/eclampsia, postdate pregnancy, and placenta abruption.
• Fetal factors include IUGR, prematurity, congenital abnormalities (rare) like tracheal atresia or lung hypoplasia, and meconium aspiration.
• Complications during labor include hypertonic uterine action, delayed delivery of after-coming head of breech, shoulder dystocia, and cord prolapse/compression.
• Cerebral trauma from difficult labor (precipitate/prolonged/traumatic delivery) and maternal drug use (suppressing respiratory activity like Diazepam, Narcotic drugs) are causes of asphyxia.

4 Phases of Asphyxia

• Hyperventilation (Tachypnea) is the first phase of asphyxia
• Primary apnea occurs during asphyxia
• Gasping is the third phase of asphyxia
• Secondary (Terminal) apnea is the last phase of asphyxia
• If primary apnoea is managed adequately, secondary apnoea will not occur
• In severe asphyxia, the secondary phase may manifest at birth if the primary phase occurred in utero or during delivery.

Primary Apnea

• Primary Apnoea occurs 1-2 minutes after birth
• Primary Apnoea is usually caused by an airway obstruction
• Initially involves rapid breathing followed by cessation, decreased heart rate and neuromuscular tone; blood pressure usually maintained until secondary apnoea onset
• Newborn should respond well to stimulation & supplemental oxygen with proper airway clearance

Secondary Apnea

• Secondary Apnoea may occur 4-6 minutes after birth.
• Secondary Apnoea results from continuous hypoxemic stress
• It involves deep, irregular gasping, then breathing stops which causes heart rate, blood pressure, and PaO2 to fall profoundly
• Spontaneous breathing will not resume; only assisted ventilation can correct the hypoxemic state.

Apgar Score

• Apgar score is quantitative
• Apgar score may reflect baby's response to resuscitation, it is not used to determine need for resuscitation
• Heart rate
  • 0 points: Absent
  • 1 point: Slow<100bpm
  • 2 points: ≥100bpm
• Respiratory effort
  • 0 points: Absent
  • 1 point: Slow, irregular
  • 2 points: Good, crying
• Muscle tone
  • 0 points: Limp
  • 1 point: Some flexion of extremities
  • 2 points: Active motion, well flexed
• Reflex response
  • 0 points: No response
  • 1 point: Grimace, feeble cry
  • 2 points: Cough or sneeze
• Color
  • 0 points: Blue or pale
  • 1 point: Body pink, extremities blue
  • 2 points: Completely pink

Degree of Birth Asphyxia

• Apgar Score >7 indicates no asphyxia
• Apgar Score 4-7 indicates Mild /Moderate asphyxia
• Apgar Score ≤3 indicates Severe asphyxia

Umbilical Cord Blood Analysis

• Umbilical blood gas value is related to intrapartum FHR data to acid-base status & neonatal condition at birth.
• Umbilical blood gas helps reflect the state of fetal oxygenation & degree of fetal acidosis
• Umbilical blood gas data can confirm normal acid-base status
  • 98% were vigorous newborns
  • Nearly 80% of infants were judged depressed at birth
• Umbilical cord blood analysis is recommended to be done after all deliveries

Complications of Asphyxia

• Asphyxia results in low O2 content of blood (hypoxaemia) with a resulting fall in pH (acidosis) & the ischemic effect and will lead to damage to CNS & multiple organ systems.
• Organ involvement rates in asphyxia:
  • CNS: 72%.
  • Kidney: 62%
  • Heart: 29%
  • Intestine: 29%
  • Liver: 26%
• Injury to most organs (except CNS) is not permanent, and complete recovery can be expected in most survivors

Neonatal Resuscitation

• It helps newborns in accomplishing the necessary physiological changes in transition from fetal to neonatal
• Approximately 10% of newborns require some assistance to begin breathing at birth
• Less than 1% need extensive resuscitative measures to survive
• Over 90% make the transition from intra to extra-uterine life without difficulty (AHA 2010)
• Some newborns without the risk factors may still require resuscitation

Goals for Neonatal Resuscitation

• Establish & maintain a patent airway, ventilation, and oxygenation.
• Ensure effective circulation
• Correct respiratory & metabolic acidosis
• Prevent hypothermia, hypoglycaemia & haemorrhage

Steps for Neonatal Resuscitation

• Preparation
• Assessment
• Management
• Post-resuscitation Care

Preparation

• Early recognition and prompt anticipation
• Provide ready and well functioning resuscitaire & utensils
• Trained persons stand-by (pediatrician)
• Conduct antenatal counseling, team briefing and assemble personnel (assigned leader & delegate tasks)
• NNU Care and anticipate resuscitation needs by assessing perinatal risks.

4 Pre-Birth Questions

• Gestation Age?
• Amniotic fluid clear?
• How many babies?
• Additional risk factors?

Assess Baby's Risk for Requiring Resuscitation

• Provide warmth
• Position the baby and clear the airway, if required Provide warmth Position, clear airway, if required
• Dry and stimulate to breathe

Ready Resuscitaire

• Preheated warmer
• Warm towels or blankets
• Temperature sensor and sensor cover for prolonged resuscitation
• Hat
• Plastic bag or plastic wrap (for <32 weeks' gestation)
• Thermal mattress (for <32 weeks' gestation)
• Bulb syringe
• 10F or 12F suction catheter attached to wall suction, set at 80 to 100 mm Hg
• Meconium aspirator
• Stethoscope
• Flowmeter set to 10 L/min
• Oxygen blender set to 21% (21%-30% if <35 weeks' gestation)
• Positive-pressure ventilation (PPV) device
• Term- and preterm-sized masks
• 8F feeding tube and large syringe
• Equipment to give free-flow oxygen
• Pulse oximeter with sensor and cover
• Target oxygen saturation table
• Laryngoscope with size-0 and size-1 straight blades (size 00, optional)
• Stylet (optional)
• Endotracheal tubes (sizes 2.5, 3.0, 3.5)
• Carbon dioxide (CO2) detector
• Measuring tape and/or endotracheal tube insertion depth table
• Waterproof tape or tube-securing device
• Scissors
• Laryngeal mask (size 1) and 5-ml syringe
• Epinephrine 1:10,000 (0.1 mg/mL)
• Normal saline
• Supplies for use in placing emergency umbilical venous catheter and administering medications
• Electronic cardiac (ECG) monitor leads and ECG monitor

Antepartum Risk Factors

• Gestational age less than 36 0/7 weeks
• Gestational age greater than or equal to 41 0/7 weeks
• Preeclampsia or eclampsia
• Maternal hypertension
• Multiple gestation
• Fetal anemia
• Polyhydramnios
• Oligohydramnios
• Fetal hydrops
• Fetal macrosomia
• Intrauterine growth restriction
• Significant fetal malformations or anomalies
• No prenatal care

Intrapartum Risk Factors

• Emergency cesarean delivery
• Forceps or vacuum-assisted delivery
• Breech or other abnormal presentation
• Category II or III fetal heart rate pattern*
• Maternal general anesthesia
• Maternal magnesium therapy
• Placental abruption
• Intrapartum bleeding
• Chorioamnionitis
• Opioids administered to mother within 4 hours of delivery
• Shoulder dystocia
• Meconium-stained amniotic fluid
• Prolapsed umbilical cord

Delay Cord Clamping at Birth

• For babies ≥ 34 weeks' gestation who don't need resuscitation, delayed cord clamping can be beneficial.
• For babies 28-34 weeks' gestation who don't require resuscitation and cannot undergo DCC: intact cord milking may be reasonable
• Intact cord milking is NOT recommended for babies * < 28 weeks* gestation.

Assessment (After Birth)

• Ask 3 questions:
  • Term gestation
  • Good tone
  • Breathing or crying

Management:

• If the answer is YES to all 3 questions (Term gestation, Good tone, Breathing or crying?): Baby stays with the mother for initial steps, routine care & ongoing evaluation
• The initial steps and routine care include maintaining warmth through Skin to Skin Contact or warm towel, gently drying the baby, stimulation and position to ensure airway is open
• Gentle suction to clear secretion if needed
• Ongoing evaluation after initial steps includes breathing, tone, HR, color & body temp.

If ANY ONE questions is NO

• If the answer is NO to any of the three questions (Term gestation, Good tone, Breathing or crying?), take the following 4 steps in sequence: initial steps, ventilation and oxygenation, initiate chest compression, and administer drugs or volume expander

Step 1: Inital Steps of Stabilization

• Step 1 addresses: (Warm & maintain normal temp., dry, stimulate, position, clear secretions if needed)
• During stabilization, bring baby to resuscitatire & start timer !
• Resuscitaire care keeps the body temperature between 36.5 and 37.5°C
• Hypothermia is associated with intraventricular haemorrhage (IVH), hypoglycaemia, respiratory issue & late onset sepsis
• Under radiant warmer/ provide thermal mattress after removing wet linen, dry & wrap with warm towel and plastic wrapping with cap (for very LBW baby or <32wks).
• Tactile stimulation via gentle rubbing of back/ truck, slapping sole
• Position airway via correct neck alignment for clear secretions

Suction After Birth

• Do not do routine suction for baby born with clear liquor
• Vigorous suction → cause bradycardia & apnoea
• Gentle suction reserve for baby when:
  • There is obvious airway obstruction
  • positive pressure ventilation is required
• Clear secretion from MOUTH FIRST THEN NOSE by bulb syringe or suction catheter at with suction pressure (80-100mm Hg), and 3-5 sec/attempt

MSL After Birth

• Routine tracheal suction immediately after birth no longer recommended to prevent from meconium aspiration syndrome (MAS)
• Intubation or tracheal suctioning may be indicated if PPV does not inflate the lungs & suspect airway obstruction
• Vigorous newborn with MSL means baby has good respiratory effort & muscle tone, so stay with mother & perform initial steps
• Non-vigorous newborn with MSL means Baby has depressed respiration or poor muscle tone, so follow step 1: initial steps in stablization

Step 2: Ventilation and Oxygenation

• After completing basic stabilization on Step 1, evaluate the baby's Heart rate & Respiratory rate
• Initial HR is auscultated by stethoscope and along left side of baby's chest, or count in 6s & multiplying by 10
• Pulsations felt at umbilical cord base is less accurate & may underestimate the true HR
• Connect pulse oximeter or cardiac monitor (by 3-lead ECG) if baby is not vigorous

SpO2 Monitoring

• Oximeter measure the blood oxygen saturation (SpO2) in terms of percentage
• Oximeter can display an accurate HR
• Oximeter's Limitation is it takes 1-2 mins to measure the SpO2
• Oximeter does not work when peripheral circulation is collapsed
• Attach the Oximeter probe to baby's right wrists/palm to accurately the pre-ductal saturation
• Adjust the percentage of inspired O2 to achieve the target value for saturation .

Supplemental Oxygen

• If the baby is breathing spontaneously but O2 saturation is not within the target range, give free-flow oxygen that uses medical air (21%) and 100%Oxygen that is built into the wall or portable tanks and also uses compressed gases connected to a blender to adjust gas mixtue between 21-100%
• Adjust flows between 0-20L/min
• Free-flow oxygen should be: adjusted to a flowmeter to 10L/min, begin with the blender (set to 30% oxygen), adjust the concentration of oxygen (FiO2) to achieve oxygen saturation target.
• If a blender is not available, then adjust oxygen concentration by moving the tubing or mask closer to or farther from baby's face

Consider CPAP

• Consider CPAP if baby has labored breathing / persistently decreased oxygen saturation despite of 100% oxygen
• Continuous positive airway pressure (CPAP) is only when baby is breathing with a HR ≥ 100bpm
• The process uses a low gas pressure to keep spontaneously breathing baby's lungs open

If Baby is Not Breathing

• If baby is not breathing (apneic), OR gasping, OR HR <100bpm use a call in the help team to begin Step 2
• After contacting the help team, initiate PPV (Positive Pressure Ventilation), SpO2 monitor, and consider cardiac monitor
• The first 60s after birth is "Golden Minute" to establish effective ventilation, so start PPV within the period if needed

Cardiac Monitoring

• Assess the newborn's HR by 3-lead ECG
  • Place RA (white) electrode under patient's left clavicle within the mid-clavicular line of the rib cage frame
  • Place LA (black) electrode right sternal border, four intercostal space within the rib cage frame
  • Place LL (red) electrode on the patient's lower left abdomen within the rib cage frame

Initiate PPV

• Be sure airway is clear by inflating bag and ensure proper position of baby's head and neck in sniffing position
• Position yourself at the Resuscitaire where:
  • At baby's head: be responsible for positioning airway & providing PPV
  • At baby's side: assess chest movements, HR & breathe sounds, assist with pulse oximeter & cardiac monitor placement

Ventilation rate & Preesure

• Positive Pressure Ventilation should be 40-60 breaths per minute
• Set the inflation pressure betwen 20-25cm H2O (not >40cm H2O)

Effective Ventilation

• Rising HR (best indicator) should be:
  • Within 15 seconds of starting PPV
  • Should be >100bpm within 30s of starting PPV
• Audible for bilateral breath sounds
• Visible chest movements
• Rising oxygen saturation

Evaluate Using ECG

• When PPV begins, consider using an ECG for accurate HR measurement using 3-leads
• the use of ECG does not replace the need for pulse oximetry to evaluate the newborn's oxygenation
• After 15 seconds of PPV, evaluate the newborns heart rate to determine if the treatment is effective
• Announce "Heart rate is increasing" and continue PPV if Heart rate is increaing and then perform second HR assessment 15 seconds after PPV However, if after this time chest is moving but not increasing heartrate then announce “Heart rate NOT increasing, chest IS moving." and continue PPV that moves the chest and perform a second HR assessment 15 seconds after PPV but if instead chest is NOT moving: then announce "Heart rate NOT increasing, chest is NOT moving." and provide Ventilation corrective steps until chest movement with PPV before considering intubate or laryngeal mask if necessary and announce when chest is moving before continuing PPV that moves the chest
• Second HR assessment after 30 seconds of PPV that moves the chest

Second Assessment

• Evaluate HR after 30s of effective PPV to determine if the heartrate is at least 100 beats per minute (bpm)
• Continue PPV 40-60 breaths/min until spontaneous if At least 100 beats per minute (bpm)
• If 60-99 bpm then Reassess ventilation and provide Ventilation corrective steps if necessary
• If under 60BPM then perform Reassess ventilation, Ventilation corrective steps if necessary and Insert an alternative airway and if no improvement, 100% oxygen and chest compressions.

Correct Ventilation Using MR SOPA:

• Mask adjustment
• Reposition airway (head & neck)
• Suction mouth & nose
• Open mouth
• Pressure increase
• Airway alternatives with Endotracheal intubation and Laryngeal mask airway

Endotracheal intubation

• PPV with face mask does not result in clinical improvement
• PPV is prolonged
• Before starting chest compressions
  • ensure adequate ventilation & may prevent the need to proceed chest compressions
  • Aids coordination of ventilation & compressions
• In special circumstances like:
  • trachea
  • Surfectant needs to be administered
  • stabilize newborn with diaphragmatic hernia The ET tube should ahve unifor diamether with centimer markings along the tube but cuffed ttubves should not be used. The size of the tube varies based on the gestational weeks.

Inserting ET Tube

• Use a 2.5mm tube for newbrons with gestational weeks under 28 and weight under 1000g and insert to depth of 5.5-6.5 cm
• 3.0mm tube for newbrons with gestational weeks of 28-34 and weight of 1000-2000g and insert to depth of 6.5-7.5 cm
• 3.5mm tube for newbrons with gestational weeks over 3.5 and weight over 2000g and insert to depth of 8-9 cm
• An accurate determination can be used to estimate insertion depth (cm) using the Nasal-tragus length (NTL) + 1cm
• Ensure ET tube is stable by:
  • Monitoring increased heartrate
  • Checking for the presence of CO2 in the tube using a CO2 detector
• Watch for: D - Displaced O - Obstructed P – Pneumothorax E - Equipment failure" which are all indicators of tube failure

Laryngeal Mask Airway

• Laryngeal Mask Airway should be used if intubation is not successful or not feasible - Insert into baby's mouth & advanced into the throat until it makes a seal over the glottis - Use size 1 mask - Inflate cuff with 5ml air - +/- insert gastric tube to relieve stomach gas

Chest Compressions

• If baby's HR is <60bpm (despite effective PPV of at least 30s) proceed by
• If not done do Intubation and compressions with Coordinate with PPV 100% O2, ECG monitor, and Consider emergency UVC

Chest compressions

• Rhythmic compression of the sternum
• Compresses the heart against the spine
• Increases intrathoracic pressure
• Helps circulate blood to the vital organs of the body Requires Two person required to administer effective chest compression (compress chest & continue ventilate)
• the postion of the baby should be firmed wth back and neck slight extended and lower third of sternum at 1/3 the AP diameter of chest with at ration 3:1 with 30 cycles (120 events) per min

Types of Chest Compressions

• 2-thumb technique (preferred) where : two thumbs depress the sternum, while the hands encircle the torso & fingers support the spine which provides Better control of the depth of compressions with more consistent pressure and is Superior in generating peak systolic & coronary arterial pressure vs

• 2- finger technique where tips of middle finger & index finger of one hand are used to compress the sternum, while the other hand support the baby's. This allows Easier access to umbilicus for umbilical catheter insertion

• If 2-thumb is used then use the from the bottom or top approach but if it is use on from small chests, with thumbs overlapped

• It is helpful if the compressor stands at head of bed when performing the procedure

• A cycle of compression then ventilation is 2 seconds and Should be 120 events per 1 min (90 compressions plus 30 breaths)

Check HR after 60 seconds from starting chest compression & PPV HR ≥100bpm, Stop compression and also Stop PPV if newborn is breathing well HR 60 -99bpm, Stop compressions but Continue ventilation (40-60 breaths/ min) HR <60bpm, Continue ventilation with compressions (and ensure quality) Consider Intubation (if not done) Proceed to Step 4

4. Administer Epinephrine

Step 4 addresses: volume expanders Drugs used in acute phase of resuscitation Epinephrine, volume expanders (NS) can be used . with adminstration through Both Intravenous or intraosseous route (preferred) followed by and NS flush or with an Et Route

• *if the first dose is given by the ET route & response is not satisfactory, a repeat dose should be given as soon as emergency umbilical venous catheter (UVC) or intraosseous access is obtained (do not wait 3-5mins after ET tube)

Once admininstered, evaluate every 60 with: HR ≥100bpm, : Stopp compression then Stopp PPV if newborn is breathing well HR 60-99bpm, Stop compression and then Continue ventilation (40-60 breaths/ min) HR <60bpm, Continue ventilation with compressions and Intubation (if not done)

Post-Resuscitative Care

• Observe and document
• Transfer to NICU care
• Monitor temperature control and vitals signs for potential complications and or resuscitation injuries
• support parents and family
• Promote mother-newborn bonding
• Document
  • Baby condition including onset , compression time, staff arrival, use of duirs, and the outcome

What are ethics to review after the procedures?

• Observe and document
• Transfer to NICU care
• Monitor temperature control and vitals signs for potential complications and or resuscitation injuries
• support parents and family
• Promote mother-newborn bonding
• Document baby condition including onset , compression time, staff arrival, use of duirs, and the outcome