Neonatal Resuscitation

21/04/2020 1

21/04/2020 2

Neonatal Resuscitation/ Helping Babies Breathe

(HBB)

21/04/2020 3

Neonatal Resuscitation

• Of the 130 million babies born each year, about 4 million die in the first 4 weeks of life. A quarter of these deaths are due to asphyxia.

• It is estimated that an additional million develop problems such as cerebral palsy and other disabilities.

World Health Report 200521/04/2020 4

21/04/2020 5

Inverted Pyramid

of Neonatal Resuscitation

Medications

Chest

Compressions

Positive-Pressure

Ventilation

Initial Steps: Drying,

Warmth, Clearing the

Airway, Stimulation

Assessment at Birth and

Simple Newborn Care

All infants

Some infants

Few infants

Wall, Lee, Niermeyer et al. IJGO 2009

136 million

babies born

Approx 10

million babies

Approx 6

million babies

< 1.4 million

babies

21/04/2020 6

Old resuscitation methods

21/04/2020

7

Since the second quarter of the twentieth century, the basis for resuscitation of the newborn has changed. With increased knowledge, many earlier methods which depended on uncomfortable stimuli to initiate the onset of breathing like

intermittent traction on the tongue,

spanking the feet or buttocks,

dilation of the anal sphincter

alternate immersion of the infant in hot and cold water have been found to be injurious and wasteful of precious time which can be used more effectively.2,7-9

Bloxsom positive pressure oxygen-air lock,

Historical aspects

21/04/2020

8

Body rocking Brain injury, intracranial bleed

Intragastric oxygen gastric distension, splinting

of diaphragm

Hyperbaric oxygen: oxygen toxicity

Analeptic drugs severe hypotension, CBF

Electrical stimulation of the phrenic nerve

Hypothermia which were once thought to be effective

have also been discarded when controlled animal

experiments were undertaken.

Some Recommendations for

Resuscitation (1850-1950)

•Rectal stimulation

(stretching of the

rectum with

a corn cob)

•Tobacco smoke

blown into the rectum

•Immersion into cold water(+ alternating

with warm water)21/04/2020 9

Some Recommendations for

Resuscitation (1850-1950)

•Intragastric oxygen

•Rhythmic traction of the tongue

•Rubbing, slapping, and pinching

•Raising and lowering of the arms, while an assistant compresses the chest

O2

O2

O2

21/04/2020 10

Current observed dangerous neonatal resuscitation practices1

Methylated spirit

Intramuscular Vitamin K

Intramuscular Aminophylline

Intramuscular Steroids (Hydrocortisone)

Analeptics (Doxapram, Nikethamide{Couramine})

Hot water stimulations

Cold water immersion

21/04/2020 11

1. Adebami et al. Neonatal resuscitation at the Nigerian Primary and Secondary Health institutions: An

evaluation of ongoing practices.Nig J Paediatr 2007;34:8-13

Methylated Spirit Instilled into the nostrils, rubbed on the skin for tactile stimulation or instilled

into a swab placed under the nostrils of the baby. is a denatured absolute ethyl alcohol commonly used in the hospital for

preparation of the skin, wound dressing and as a cleaning agent. It consists of 2 percent methanol, less than 6.2 percent water and over 90

percent of ethanol It is known to be irritant to the eyes, mucous membranes, upper respiratory

tract and skin. It causes :

central nervous system depression, convulsions, ataxia and coma. pulmonary damage, alteration in gastric secretion, nausea, vomiting and other gastrointestinal

changes.

However, no known study has documented the direct immediate and long term effect of its use on newborns.

WASTE TIME FOR EFFECTIVE ACTION AND CAUSES DAMAGE

21/04/2020 12

Parenteral Aminophyline Aminophylline is a combination of theophylline with

ethylenediamine.

It is a xanthine derivative.

It improves contraction of the diaphragm

Theophylline is a CNS stimulant therefore dangerous to an ischaemic or hypoxic brain

Can precipitate convulsions, bleeding

Gastric bleeding.

WASTE TIME AND VERY DANGEROUS!!!

21/04/2020 13

Parenteral Steroids Steroids have not been shown to be of any benefit

in birth asphyxia,

Predispose the baby to abnormal bleeding, increased intracranial pressure, pseudotumour cerbri and increased mortality. Animal studies have also shown increased mortality and lack of any improvement in the extent of neurological injury just as has been similarly found in human adult patients with head trauma, stroke and hypoxic ischaemic encephalopathy (HIE).2

21/04/2020 14

2. Levene-MI; Sands-C; Grindulis-H; Moore-JR. Comparison of two methods of predicting

outcome in perinatal asphyxia. Lancet 1986; 11: 67-9.

Hypothermia Hypothermia regulated to between 33oC and 34oC in

Full Term babies if initiated as soon as possible after delivery has been observed to reduce mortality and disability in babies with hypoxic ischaemic encephalopathy.2

However, extreme cooling and hypothermia are known to induce neonatal cold injury and result in grave consequences.3,4

21/04/2020 15

Respiratory Analeptics Drugs that stimulate CNS and respiration centre

Developed to treat CNS and respiratory depression

Reduces cerebral blood flow

Increased cerebral oxygen requirements

Reduces blood pressure and causes hypotension

Examples: Nikethamide (Couramine), Doxapram

21/04/2020 16

Consequences of Poor

Neonatal Resuscitation

• Increased Death

• Increased Disability

• Emotional & Financial Burden

• Family crises

• Poor utilization and confidence

in health facilities utilization

• Direct Community Costs

• Loss of Productivity21/04/2020 17

21/04/2020 18

21/04/2020 19

Global Causes of Neonatal Death

UNICEF 2007Lee, Wall, Cousens et al. Int J Epidemiol (in press)

21/04/2020 20

Big Target of Helping Babies Breathe

Lawn JE et al. IJGO 2009; 107:S5

1 million “stillbirths” due to asphyxia

830,000 neonatal deaths due to asphyxia

Helping Babies Breathe®

21/04/2020 21

21/04/2020 22

Helping Babies Breathe

Sustainability

• Simple and evidence-

based

• Low-cost and effective

• Easy to integrate with

other essential parts of

NB care

21/04/2020 23

21/04/2020 24

21/04/2020 25

Dawes Foetal and Neonatal Physiology. Year Book Medical Publishers Inc; 1968.

Pathophysiologic Cardio-Pulmonary

Consequences of Asphyxia

21/04/2020 26

21/04/2020 27

21/04/2020 28

21/04/2020 29

21/04/2020 30

Helping Babies Breathe®

21/04/2020 31

HBB: Action Plan

21/04/2020 32

Identify a helper and review the emergency plan

Prepare the area of delivery: Clean, Warm and well-lighted

Wash hands with Soap and water

Prepare an area for ventilation and check equipment:- +Gloves; +Sunction device;+ Ventilation (Bag and mask); +Cloths x2;

+Stethoscope; +Timer (Clock/Watch);

+Scissors; +Tiles; +Cap (Head covering;

21/04/2020 33

If meconium, sunction Mouth, then Nostrils (M before N)!

Then DRY THOROUGHLY!!!

Change wet cloth to dry

21/04/2020 34

Do Routine care◦ Keep Warm Skin to Skin on mother

◦ Cover baby with warm, dry cloth and a cap

◦ Postpone bathing baby and weighing

Check breathing

Cut cord

Encourage breastfeeding

21/04/2020 35

21/04/2020 36

Routine Care• Clearing the airway if

meconium present

• Drying infant

• Recognize crying

• Keeping warm

• Cutting the umbilical cord

• Encouraging breastfeeding

21/04/2020 37

Clear Airways and Stimulate breathing◦ Keep warm by position skin-to-skin and cover with

cloth

◦ Position the head- extend the head slightly

◦ Clear the airway by removing secretions from mouth, then nose (M before N)

◦ Stimulate breathing_ rub the back once or twice

21/04/2020 38

Keep baby warm

Position the head

Clear the airway

Stimulate breathing

21/04/2020 39

Do Routine care◦ Keep Warm Skin to Skin on mother

◦ Cover baby with warm, dry cloth and a cap

◦ Postpone bathing baby and weighing

Check breathing

Encourage breastfeeding

21/04/2020 40

21/04/2020 41

Cut the Cord immediately

BABY MUST BE VENTILATED IN THE FIRST MINUTE CALLED: “THE GOLDEN MINUTE”

A baby not breathing well means◦ Gasping with shallow, irregular, slow breathing

◦ Not breathing at all.

21/04/2020 42

The Golden Minute®

• Recognizing infant not

crying

• Positioning head

• Clearing the airway

• Stimulating

• Recognizing breathing

• Initiating ventilation by

1 minute21/04/2020 43

To Ventilate Place the baby on a clean, warm, dry area with good light. Stand at the baby’s head. Select the correct mask that covers the chin, mouth, and nose, but

not the eyes. Attach the mask to the ventilation bag. Position the head slightly extended, with the nose higher than the

forehead or chin. Support the chin with the middle finger. Move the jaw upward and

forward. Position the rim of the mask on the chin, and then place the mask

over the mouth and nose. Make a firm seal between the mask and face by pressing on the top

of the mask with the thumb and index finger while gently holding the chin up toward the mask.

Squeeze the bag to produce a gentle movement of the chest. Give 40 breaths per minute

21/04/2020 44

21/04/2020 45

21/04/2020 46

21/04/2020 47

21/04/2020 48

21/04/2020 49

Baby Still NOT BREATHING OR CRYING! ie NOT GETTING RESULT!

Check your method!

If Baby still not breathing well: Use MR SOPA! M = Adjust Face mask R = Reposition head S = Suction mouth and nostrils O = Open mouth P = Increase the ventilating Pressure by squeezing the bag

more and a little faster A = Use Alternate airways: Laryngeal mask or

Endotracheal intubation CALL FOR HELP AND USE THE EMERGENCY PLAN

21/04/2020 50

21/04/2020 51

Evaluate the Heart rate Feel the pulse in the umbilical cord where it attaches

to the baby’s abdomen.

If you cannot feel a pulse, listen over the left chest with a stethoscope and count the heartbeat.

Pause ventilation for several seconds in order to hear the heartbeat.

21/04/2020 52

A Baby still not breathing Refer for Advanced Care!

Maintain ventilation during transfer

21/04/2020 53

Welcome to :

ADVANCED CARE

This takes place in the hospital with

basic facilities for resuscitation

Maintain ventilation during transfer to the hospital for advanced care

21/04/2020 54

NRP Now

Textbook of Neonatal Resuscitation, 6th Edition, 201121/04/2020 55

21/04/2020 56

21/04/2020 57

21/04/2020 58

21/04/2020 59

21/04/2020 60

21/04/2020 61

21/04/2020 62

21/04/2020 63

21/04/2020 64

21/04/2020 65

21/04/2020 66

21/04/2020 67

21/04/2020 68

21/04/2020 69

21/04/2020 70

21/04/2020 71

21/04/2020 72

21/04/2020 73

21/04/2020 74

When bag and mask is not effective enough to improve oxygenation or SPO2◦ No clinical improvement

◦ No adequate Chest rise with bag and mask

◦ If Chest compression is needed, intubation provides better coordination with bag and mask ventilation

◦ To administer drug like Adrenaline, Sulfactant

When other Special conditions are present

21/04/2020 75

21/04/2020 76

21/04/2020 77

21/04/2020 78

21/04/2020 79

21/04/2020 80

21/04/2020 81

21/04/2020 82

21/04/2020 83

21/04/2020 84

21/04/2020 85

21/04/2020 86

21/04/2020 87

21/04/2020 88

21/04/2020 89

21/04/2020 90

21/04/2020 91

21/04/2020 92

Adrenaline

Normal Saline or Ringers lactate

10% Dextrose in water

8.4% Sodium bicarbonate

10% Calcium gluconate

Ionotropes like Dopamine

21/04/2020 93

21/04/2020 94

21/04/2020 95

21/04/2020 96

21/04/2020 97

21/04/2020 98

21/04/2020 99

Every Baby CountsSo

Count Every Baby

THANK YOU

21/04/2020 100