Newborn resuscitation programme(NRP)

Renu Singh

Burden of the problem

• Birth asphyxia• 23% of the 1 million neonatal deaths in India• Long term neurological complications• Death• NNR (Neonatal resuscitation) :simple,

inexpensive, cost effective method• Problem: NNR often not initiated, incorrect

use of methods

The Golden minute

• The “first minute after birth”• Anxiety for parents, health providers• Period of transition from intrauterine to extra

uterine life• Major: No/minimal assistance• 10%: assistance to begin breathing at birth• 1%: extensive resuscitative measures• First Golden Minute Project: skill based training

Successful NNR: factors

• Anticipation: call a skilled personnel• Adequate preparation• Accurate evaluation, algorithm based• Prompt initiation of support

Resuscitation: initial steps

• Provide warmth• Head position “ sniffing position”• Clearing the airway• Drying the baby• Tactile stimulation for breathing

Sniffing position

Extension of neck with help shoulder roll:: to open the airway

Newly born infant

• Specifically the Infant at time of birth

• (A)Do not require resuscitation• (B)Require resuscitation • Rapid assessment of 3 characters– Term gestation?– Crying or breathing?– Good muscle tone?

Newly born infantTerm gestation?Crying or breathing?Good muscle tone?

YES :Do not require resuscitation– Dry– Skin to skin contact– Covered with dry linen to maintain

temperature– Ongoing observation: breathing, color, activity

Newly born infantTerm gestation?Crying or breathing?Good muscle tone?

NO :require resuscitation; One/more of the following actions in sequence– Initial steps in stabilization(warmth, clear

airway, dry, stimulate)– Ventilation– Chest compressions– Administration of epinephrine& /or volume

expansion

AAP Algorithm

IAP Algorithm

The golden minute

• <30 seconds: complete initial steps• Warmth• Drying• Clear airway if necessary• Stimulate

• 30-60 seconds: assess 2 vital characteristics• Respiration (apnea/gasping/labored/unlabored)• Heart rate (<100/>100bpm)

<60 seconds of birth• If gasping/apnea If heart rate<100 beats per minute

PPV( positive pressure ventilation) Spo2 monitoring by pulse oximeter• Simultaneous evaluation of 3 vitals

• Heart Rate, • Respiration, • oxygenation status

Targeted SPO2 after birth

1 minute 60-65%

2 minutes 65-70%

3 minutes 70-75%

4 minutes 75-80%

5 minutes 80-85%

10 minutes 85-90%

Increase in heart rate is the most sensitive indicator of a successful response to each step practiced

PPV: Positive pressure ventilation

• Form of assisted ventilation• Needed when there is no improvement in HR• Also assess chest wall movements• Should be delivered at rate of 40-60

breaths /min, maintain HR>100 /min• Devices: BMV, ET (endotracheal

tube),LMA(laryngeal mask airway)

Bag & mask ventilation

Endotracheal tube

• Initial endotracheal suctioning of non vigorous meconium stained newborn

• If BMV is ineffective/prolonged• When chest compressions are performed

Endotracheal tube

LMA(Laryngeal mask airway)

• Fits over laryngeal inlet• Done when BMV is unsuccessful• When tracheal intubation is unsuccessful or

not feasible

LMA(Laryngeal mask airway)

Chest compressions

• Started when HR<60 per minute despite adequate ventilation with 100% oxygen for 30 sec

• Delivered at lower third of sternum, to depth 1/3 of AP diameter of chest

• 2 techniques: – 2 thumb-encircling hands technique– Compression with 2 fingers ,second hand

supporting the back– 3:1 ratio::[ 90 comp:30 ventilations]

Chest compressions

medications

• Rarely indicated• Most important step to treat bradycardia is

establishing adequate ventilation• HR remains <60bpm,despite adequate

ventilation(ET) with 100% Oxygen & chest compressions

• Epinephrine or volume expansion or both

Epinephrine

• Route of administration: intravenous(IV),ideal• Recommended dose: 0.01-0.03 mg/kg per

dose• Desired concentration: 1:10,000 0.1 mg/ml

Volume expansion

• Suspected or known blood loss• Isotonic crystalloid solution• Blood• Dose calculation: 10 ml/kg

Post resuscitation care

• Needed for those who required PPV• At risk of deterioration• Need monitoring ,evaluation• NICU may be necessary

NNR : not indicated

• Conditions with certainly early death• Extreme prematurity(GA<23 weeks)• Birth weight<400g• Anencephaly• Chromosomal abnormality: Trisomy 13

NNR: nearly always indicated

• High rate of survival• Acceptable morbidity• GA≥ 25 weeks• Those with most congenital malformations

NNR?

• Conditions associated with uncertain prognosis

• Survival borderline

• Parental desires concerning initiation of resuscitation should be supported

Discontinuing resuscitative efforts

• Newly born baby with no detectable heart rate, consider stopping NNR if the heart rate remains undetectable for 10 minutes

MCQ1

For successful neonatal resuscitation following is/are needed except:

1.Anticipation2.Adequate preparation3.Skilled personnel4.Delayed initiation of support

MCQ1

• For successful neonatal resuscitation following is/are needed except:

1.Anticipation2.Adequate preparation3.Skilled personnel4.Delayed initiation of support

MCQ2

• Following are true in relation to initial steps of neonatal resuscitation except

1.Provide warmth2.Tactile stimulation3.Clear airway and intubation4.Drying the baby

MCQ2

• Following are true in relation to initial steps of neonatal resuscitation except

1.Provide warmth2.Tactile stimulation3.Clear airway and intubation4.Drying the baby

MCQ3

• The following is the primary measure of adequate ventilation

1.Chest wall movement2.Improvement in heart rate3.Pink extremities4.Spo2 of 80%

MCQ3

• The following is the primary measure of adequate ventilation

1.Chest wall movement2.Improvement in heart rate3.Pink extremities4.Spo2 of 80%

MCQ4

• Endotracheal intubation may be indicated at several points during neonatal resuscitation except

1. If BMV is ineffective2. When chest compressions are performed3. Endotracheal suctioning of vigorous meconium

stained newborns4. For special resuscitation circumstances like

extremely LBW

MCQ4

• Endotracheal intubation may be indicated at several points during neonatal resuscitation except

1. If BMV is ineffective2. When chest compressions are performed3. Endotracheal suctioning of vigorous meconium

stained newborns4. For special resuscitation circumstances like

extremely LBW

MCQ5

• The recommended compression to ventilation ratio in neonatal resuscitation is

1.2:12.3:13.4:14.5:1

MCQ5

• The recommended compression to ventilation ratio in neonatal resuscitation is

1.2:12.3:13.4:14.5:1

MCQ6

• The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation

1.0.01-0.03,IV2.0.01-0.03,IM3.0.03-0.05,1V4.0.05-0.1,IV

MCQ6

• The recommended dose(mg/kg per dose) and route of epinephrine in neonatal resuscitation is

1.0.01-0.03,IV2.0.01-0.03,IM3.0.03-0.05,1V4.0.05-0.1,IV

MCQ7

• Recommended method/clinical indicator of confirming ET placement is

1.Condensation in ET2.Chest movement3.Equal breath sounds on auscultation4.Exhaled C02 Detection

MCQ7

• Recommended method/clinical indicator of confirming ET placement is

1.Condensation in ET2.Chest movement3.Equal breath sounds on auscultation4.Exhaled C02 Detection