Primary neonatal resuscitation Order № 312 from 06.08.2007

Доц. Багній Н.І.

Preparation of delivery room to resuscitation

Two sets of equipment and materials on delivery - for primary and complete resuscitation.

Set for initial resuscitation always should be in every delivery room. In anticipation of the birth of the child at high risk, resuscitation equipment for full resuscitation (both sets) should be ready for immediate use.

Resuscitation bag and mask, laryngoscope blade and suction meconium should be sterile, and the rubber pear, catheters, probes, endotracheal tubes - disposable.

For initial resuscitation of newbornsEquipment for suction1. Rubber pear (only individual) 2. Electrical / mechanical suction system with tube3. Suction catheters 5F or 6F, 8F, 10F or 12F 4. Stomach pump 8F and 20-ml syringe5. Meconium aspirator

Equipment for mechanical ventilation and oxygen therapy1. Bag for neonatal resuscitation with pressure limiting valve or pressure gauge (bag

should provide 90-100% of oxygen feeder) 2. Facial masks in two sizes with soft edges (for full-term infants and premature

babies)3. Oxygen tubes set

Other1. Gloves and appropriate personal protective equipment2. Warmed napkins, clothing (caps, socks)3. Cushion under the shoulders4. Neonatal stethoscope5. Plasters 1-1,5 sm6. Scissors

Optional set for resuscitationEquipment for intubation1. Laryngoscope with straight blades, № 0 (for premature) and № 1 (for term babies)2. Spare bulbs and batteries for laryngoscope3. Disposable endotracheal tube with an internal diameter2,5; 3,0; 3,5; 4,0 mm4. Stiletto (conductor)

Medicines1. Adrenalin 1:10000 (0,1 mg/ml)2. Saline solution- 100 or 250 ml3. Sodium bicarbonate 4,2 % (5 mEq/10 ml)4. Naloxone hydrochloride 0,4 mg/ml - 1-ml ampoules or 1,0 mg/ml - 2 ml ampoules

Set for umbilical vein catheterization1. Sterile gloves2. Sterile scalpel or scissors3. A solution of iodine alcohol4. Umbilical ligature5. Umbilical catheters 3,5F; 5F6. Syringes 1, 3, 5, 10 and 20 ml7. Needles 25, 21 і 18 G 8. Three-way stopcock (if possible)

Other -1. Special transparent food plastic bags.

Oropharynx ducts (sizes 0, 00 and 000 or length 30, 40 and 50 mm)

Responsible personnel of delivery room before every birth should:

prepare well-lighted place for possible neonatal resuscitation

with a clean, dry and warm surface check the temperature of indoor air (not below 25 С) and

ensure there is no draft switch on a radiant heat source in advance to heat the

surface of the table and diaper before the baby's birth; check two sets of equipment, materials and medicines;

cushion under the shoulders; connect oxygen tubing to the oxygen source and check its

availability in the tank; check the contents of the set for initial resuscitation and

functioning resuscitation bag and equipment for suction (bag checks carried out under sterile gloves to avoid contamination of equipment)

Further assistance during newborn resuscitation based on the simultaneous evaluation of three clinical signs:

availability and adequacy of of independent breathing

heart rate

color of skin and mucous membranes

After every 30 seconds of intensive care of newborn

necessarily : evaluate three signs using a common algorithm

resuscitation decide what to do next

perform the appropriate action

re-evaluate the three features; decide what intervention is necessary at this point, and act

continue the cycle "evaluation-decision-action" until the end of resuscitation.

Availability and adequacy of independent breathing - the main feature that determines the need of providing of neonatal resuscitation

Assessment of the availability and adequacy of independent breathing is conducted: immediately after birth to

decide to start resuscitation actions; end of 1 and 5 minutes

(and later, if necessary) to assess Apgar;

during resuscitation actions;

during the stay of the newborn in the delivery room

Signs of adequate breathing baby - scream and / or satisfactory excursions chest: frequency and depth of

respiratory movements should grow a few seconds after birth

normal newborn respiratory rate is 30-60 for 1 min.

If a child undergoes artificial ventilation then the process should be stopped for 6 seconds to assess the availability and adequacy of independent breathing

convulsive respiratory movements (“gasping"), or bradypnea breathing <30 breaths in 1 minute are ineffective and their presence is an indication for the immediate start of mechanical ventilation of newborn;

appearance of expiratory groan or other respiratory disorders during resuscitation indicates that the baby needs further post-reanimation care.

HR Assessment - heart rate is counted within 6 seconds to get the figure for 1 minute, the result is multiplied by 10

Methods for heart rate determining : listening of heartbeat

by stethoscope over the left side of the chest

Palpation of pulse at umbilical cord directly into the area of its accession to the anterior abdominal wall

Normal heart rate of just born child ≥ 100 for 1 minute.

Bradycardia heart rate <100 for 1 minute of a newborn is always an indication for starting of mechanical ventilation.

Evaluation of mucous membranes and skin colour

Persistent central cyanosis (hypoxemia) requires intervention: first - oxygen therapy, and in case of its failure - ALV

Acrocyanosis (blue hands and feet) without central cyanosis, usually does not indicate a low level of oxygen in the blood of the child, but may indicate the cold stress (hypothermia) of newborn.

Pale skin or marble pattern may be nonspecific signs of reduced cardiac output, severe anemia, hypovolemia, hypothermia or acidosis.

Initial help steps

Providing of proper positioning of the child on the surface under radiant heat source and releasing of airways, especially in the case of meconium aspiration threat.

Final drying of the newborn and repeated providing of proper head position.

Reevaluation of the newborn.

A – airways

Firstly, you should suck from the mouth, then from the nose with a disposable rubber pear or sterile disposable catheter; input-depth should be

no deeper than 3 cm from the lips of term infants and 2 cm in premature babies

A – airways

suck briefly, carefully, slowly removing the catheter or rubber pear out;

length of suction should not exceed 5 seconds.

A – airways

During aggressive suctioning stimulation of the posterior pharyngeal wall is possible, which can cause a vagal reaction (severe bradycardia or apnea) and delay independent breathing.

If during the suction bradycardia of newborn appeared, necessary to stop manipulation and re-evaluate HR.

In the case of a significant accumulation of secretions, blood, mucus advisable during suctioning turn the child's head to the side and repeat the procedure.

While using suction negative pressure should not exceed 100 mm Hg. (13.3 kPa or 136 cm aq.).

Special initial help steps are necessary for a child who was born after the outpouring of amniotic fluid contaminated with meconium

At the absence of independent breathing or breathing type “gasping" or bradypnea (RR <30 for 1 minute), or clearly decreased muscle tone (no active movements, hanging limbs), or heart rate <100 for 1 minute:

avoiding tactile stimulation as soon as possible under the control of direct laryngoscopy suck the contents of the lower pharynx, then intubate trachea and carry on sucking it.

Ensure airway

Provide child supine or side position with moderate straighten back head with the caution beneath shoulders

Check whether skin and hair of newborn are completely dried; conduct additional drying if needed.

Remove wet diaper and then provide the correct position of the baby.

Re-evaluate the child's condition

B - breathing

If there is central cyanosis it’s necessary to set oxygen therapy despite appropriate independent breathing and heart rate> 100 for 1 minute

B - breathing

The aim of oxygen therapy - to ensure proper oxygen levels in the blood of newborn

Saturation of blood - less than 95% (according to pulsoxymetrie).

Equipment for oxygen therapy:

oxygen tube and palm composed in the form of a funnel resuscitation bag, that is filled by stream (anesthetical) and

resuscitation mask: mask loosely placed upon the face of the child

free flow of oxygen can’t be served by mask attached to a bag that is filled independently

oxygen mask and oxygen tube

B - breathing

If there is still central cyanosis despite oxygen therapy for at least 5 minutes it’s necessary to begin ventilation by resuscitation bag and mask

Indications for mechanical ventilation by resuscitation bag and mask

Absence / inadequate independent breathing, heart rate <100 for 1 minute

Absence or inadequate independent breathing after the initial steps of care conducted within 30 seconds after birth

HR <100 per 1 minute regardless of the availability and adequacy of independent breathing after the initial steps of care conducted within 30 seconds after birth.

Persistent central cyanosis, despite the presence of adequate independent breathing, heart rate> 100 for 1 minute and feed the free flow of 100% oxygen for at least 5 minutes.

Technique of the primary ventilation during neonatal resuscitation

The correct position of the child

To stay in front of the head

Apply mask of appropriate size, attached to resuscitation bag hermetically

To fix the head position.

INTUBATION

APPLICATION OF MASKS

Monitoring the ventilation effectiveness

rapid increasing of heart rate, what must be checked immediately after the ventilation

movements of the chest during compression of the sack should be subtle and symmetrical.

additional signs of effective ventilation: symmetric breathing is auscultated over the lungs; appearance of independent breathing; Improving of skin colour (reduction or disappearance of

central cyanosis); Improving of newborn muscle tone.

In the case of absence of effective ventilation evidence by bag and mask it’s necessary to:

check the fit of the mask to the face (re-apply mask);

check the airway (change head position, suctioning of the upper airway, ventilate by opening child’s mouth);

increase ventilation pressure : compress the resuscitation bag stronger by more fingers or the whole hand, but avoid too sharp and vigorous compression;

predict the necessity of trachea intubation.

Indications for trachea intubation

Absolute indications: the necessity of meconium suction from the

trachea; presence of child diaphragmatic hernia.

Відносні показання : bag and mask ventilation is ineffective or long-

term; necessity of endotracheal entering of medicine; birth of a child with extremely low birth weight

(<1000 g);

Indirect cardiac massageC - circulation

Indications Heart rate < 60 for 1 minute after 30 seconds of

effective ventilation. 2 techniques of indirect cardiac massage are used

thumbs method - press the breast by pads of two thumbs, while the rest of the fingers of both hands support the child back (this method is preferred)

two fingers method - press the breasts by tips of two fingers of one hand: the second and third or third and fourth, during this second hand supports the child back. This method is used if access to the vessel umbilical cord is needed.

C - circulation The frequency of pressing on the

chest is 90 per 1 minute. after every three presses on the

chest a pause is made for ventilation, then pressing should be repeated. You should press on the chest

3 times for 2 seconds (90 for 1 minute) and do 1 ventilation (30 in 1 minute) - together - 120 action for 1 minute.

heart rate increasing indirect heart massage

should be stopped, if the heart rate is ≥ 60 beats per minute.

After every 30 seconds of indirect massage you should re-evaluate heart rate and breathing to decide what to do next

The use of medicine

Despite adequate ventilation by 100% oxygen and indirect cardiac massage for 30 seconds, the heart rate remains < 60 for 1 minute.

Epinephrine. Means that normalize vascular volume - saline. Sodium bicarbonate. Naloxonum.

Indications

Heart rate < 60 for 1 minute after at least 30 seconds of indirect cardiac massage and artificial ventilation by 100% oxygen

No cardiac activity of newborn at any moment of resuscitation (necessary ventilation, indirect cardiac massage and injection of epinephrine).

Prepare a 0.01% solution of epinephrine[1:10000]: To 1 ml of 0.1% solution of epinephrine hydrochloride or 0.18%

solution of epinephrine gidrotartrata must be added 9 ml of 0.9% sodium chloride.

Gaining in a 1-5 ml syringe prepared solution [1:10000]. Dosage:

intravenous dose– 0,1-0,3 ml/kg (0,01-0,03 mg/kg); endotracheal dose– 0,3-1,0 ml/kg (0,03-0,1 mg/kg).

Do not use larger doses of intravenous epinephrine during neonatal resuscitation, as their input can cause brain and heart damage of a child. Smaller endotracheal doses are ineffective

If no effect, and there are indications injection of epinephrine are repeated every 3-5 minutes. Repeated injection of epinephrine is performed only intravenously.

During mechanical ventilation check the heart rate and the presence of independent breathing every 30 seconds until the heart rate does not exceed 100 for 1 minute and is established adequate independent breathing.

Neonatal resuscitation can be terminated if, in spite of timely, proper and full implementation of all its activities, the cardiac activity of child is absent for at least 10 minutes