Updates in Neonatal iris Out-of-hospital deliveries 2014 ... 05 13 Prise en charge du... · Umbilical Cord Milking (UCM) Effect of umbilical cord milking in term and near term infants:

Updates in Neonatal

Resuscitation:

Out-of-hospital deliveries 2014

E. Preka, S. Redant, D. Biarent

Service des Urgences Pediatriques HUDERFsemina

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Overview

• Introduction

• Physiology of birth

• Considerations in every delivery

– Cord clamping (time, sterile procedure)

– Temperature management

– Pulse oxymetry : Air VS 100%Oxygen

• Basic NLS instructions

• Particular cases (meconium, therapeutic hypothermia)semina

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Introduction

• Out-of-hospital Delivery (OHD) : Planned or unplanned deliveries

(home, road, out-of-bloc arrival in the hospital)

• Is it often?

0,6% in USA, 0,5% in France, 0,8% in italy,

0,15% in Finland

Peoples’ needs change….

30% in Netherlands, 3% in UK, 1% in USA

• Who’s more at risk ?

• Is it more dangerous ?

K. Viisainen, Acta Obstet Gynecol Scand 1999

Lancet 2010

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• France : retrospective case-

control study 2007-2009

• Inclusion criteria : a live birth

and no planned home birth

• Exclusion criteria : GA < 22w

and BW < 500gr

• 4 independent risk factors :

- multiparity

- unemployement

- lack/poor antenatal care

- a travel time > 45 min

Background characteristics of OHD (2)

I. Renesme, Acta Pediatrica 2013

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• Finland : 1958-1973 and 1991-1995

More often in women : living in rural areas, older > 35yrs, not married,

mutliparous, not good antenatal follow-up, smoking

Background characteristics of OHD (1)

K. Viisainen, Acta Obstet Gynecol Scand 1999

A de Jonge et al, National Cohort for planned home deliveries in Netherlands BJOG 2009

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Risks for the neonate in OHD (1)

• Most frequent complication :

hypothermia (Temp < 36,50C)

• 11/76 admissions to NICU :

- 3 : prematurity

- 2 : RDS

- 1 : severe hypothermia <29,50C

- 2 : neonatal infections

- 3 : social reasons


No planned Home Births

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• Prematurity :

• Low-birth-weight : 151 OHD / 151 hospital deliveries

P< 0.001 for weight < 2500 grams

Declercq et al,

Obstet Gynecol 2010

A.Hadar et al, J Reprod Med 2005,

Acta Obstet Gynecol Scand 2002

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• Hypothermia : in 14 cases over a 3-year-period > 50% hypothermia >

14% (2/7) NICU

• Risk of death ; OHD 317

Hospital births 325339


U. ESEN, Irish Medical journal 2005

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Results……

Perinatal Mortality> no significant differences

Admission to the NICU> less for the group ‘’Planned Home Birth’’


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Overview• Introduction

• Physiology of birth

• Considerations in every delivery

– Cord clamping (time, sterile procedure)

– Temperature management

– Pulse oxymetry : Air VS 100%Oxygen

• Basic NLS instructions

• Particular cases (meconium, therapeutic hypothermia)semina

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Fetal-to-neonatal physiology

Consequences for the Neonate semina

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Considerations

• Cord clamping

• Temperature control

• Air or 100% oxygen

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Definition: Early Cord Clamping = 5-15 sec

Delayed Cord Clamping = 1-3 minutes

Method: Vaginal Delivery 40cm lower than placenta level for 1 min.

Prema: 20-30 cm lower than uterus during ?

45-60s.

Cord clamping : A ‘’wait a minute’’ policy

Cernadas et al, Pediatrics 2006

Menget et al, Interêt du clampage retardé du cordon

ombilical chez le NN, Elsevier, 2013

Benefits:

1.Reduces neonatal anemia

2.Greater mean Hct

3.Safe (Without adverse effects)

Remember to do it

sterile !!

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Cord clamping : A ‘’wait a minute’’ policy

gives at least a 6-month protection !!

Lancet 2006

Methods: 476 mother-infant pairs in Mexico, randomly assigned to

Delayed (2 min) VS Early clamping (around 10 sec after deivery)

Benefits:

1. Sufficient iron stock for 6m. at least

2. Hypochromic anemia 3-7%

3. MAP 3x in preterm infants

4. Less intraventricular hemorrhagy

5. Less late-onset-infections

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Umbilical Cord Milking (UCM)

Effect of umbilical cord milking in term and near term infants: RCT

Am J Obstet Gynecol 2013

Cord milking group VS Control group

Hb(g/dL) 11,9 VS 10,8 (p<0,05)

Ferritin at 6 weeks(μg/L) 355.9 VS 177,5 (p< 0,05)

Higher Hb = need for RBC transfusion and mean BP

Rabe at al, Obstet Gynecol 2011

UCM vs DCC: comparable increase in Hb,

-//- mean BP at NICU,

duration of O2-dependence FiO2>30%

UCM in preterms> better neurodevelopmental

outcome at 2 yrs

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Importance of Temperature in babies

post-delivery

Hypothermia in neonates is

associated with increased

morbidity and mortality

- increase metabolic rate

- increase O2 consumption

Results…. : acidosis, hypoglycemia

hypoxia, DR

Dry immediately, pre-warmed towels, pre-warmed incubators, Kangaroo care,

monitor baby’s Temp, Delivery’s room temp ≥260C

For babies < 1000gr / < 28w. : PLASTIC BAG

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Temperature Control after delivery

Use of polyethylene bag: a way to improve the thermal environment of the premature +

LBW newborn in the delivery room

Pediatrics 2013: 104 infants, 1000-2500gr , GA 26-36 6/7w., 1:1 parallel design to standard

thermoregulation (blanket or radiant warmer to standard thermoregulation plus plastic bag at birth.

Primary outcome: axillary Temp. (36,5-37,50C) at 1h after birth

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Air or 100% Oxygen

Successful REA at delivery = rapid establishment of pulmonary gas exchange

• Oxygen Paradox : oxidative stress !!

• RCT in asphyxiated newborn babies: Air = 100% O2

Air more effective in short term and less deleterious effects on immature

human brain

• Put Sat.O2 (wait 2 min…)

• Don’t trust the color

ERC 2010: 2 min : 60%

3 min : 70%

4 min : 80%

5 min : 85%

10 min : 90%

Koch et al, Cereb Blood Flow Metab 2008

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Air or 100% Oxygen

Recommendation ERC 2010 :

Term infants: Start with Air (FiO2 21%)

if despite effective ventilation, no increase in HR/O2 ->>>> Air+Oxygen

Premature babies < 32weeks: Start with Oxygen (FiO2 21-30%)

and then adjust depending on the Sat.O2

Method: 5 first inflations

Pression: start with +/- 20 cm H2O

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Intubate or not? Indications

• Meconium Aspiration Syndrome

• If bag-mask ventilation is ineffective or prolonged

• When Chest Compressions are performed

• Special circumstance: Congenital Diaphragmatic Hernia,

BW < 1000gr

ERC for babies at birth, 2010

Depends on the

experience of the person

responsible…

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European Resuscitation Council

Resuscitation of babies at birth 2010

1. Preparation

1. Planned Home Deliveries

1. Equipment and environment PREPARATION !!!!

1. Temperature control

1. Initial assessment (FC, FR/Satu, Colour, Tone)

Acta Paediatr 1992, Methods of resuscitation in low-Apgar-

score newborn infants--a national survey in Sweden

of 100,000 babies in 1yr, only 1% needed resuscitation at

delivery and only 0,2% needed IT

( limitations, awareness of mother, at least 2

persons: one fully trained in mask ventilation and

chest compressions)

(exposure of the newborn to cold stress -> lower

SatO2%, metabolic acidosis!)

APGAR does not identify babies that

need resuscitation !!!!!!

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Initial assessment :

- Breathing : rate, depth, symmetry, gasp?, grunting?

- Heart rate : USE your stethoscope !

- Colour : poor means of judjing oxygenation

- Tone



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Classification according to initial assessment :

1. Vigorous breathing/crying

Good tone

HR > 100bpm

2. Breathing inadequaly or apnoeic

Normal or reduced tone

HR < 100 bpm

3. Breathing inadequaly or apnoeic

Floppy, often pale (poor perfusion)

Low/ indetectable HR



Dry only, wrap

Skin-to-skin

Dry-wrap

Mask inflation

+/- chest compressions

Dry-wrap

Airway control (air inflation and ventilation)

+/- chest compressions

+/- drugssemina

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Resuscitation : Airway (A)

Neutral Position

Suction ONLY if obstruction is present

Use a 12-14 FG suction catheter, not exceed 100mmHg

ERC, 2010

START if : Abnormal breathing or HR < 100 bpm

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Resuscitation : Breathing (B)

START if : breathing efforts are absent or inadequate, after initial steps

Lung aeration: normally HR, assess chest wall if not

5 first inflation breaths -> if not breathing reponse in 30 sec -> VENTILATION 30/min

Passive ventilation if HR > 100 bpm

Confirm lung aeration before proceed to C

Term babies: start with air ERC, 2010

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Resuscitation : Circulation (C)

START if : HR < 60 bpm despite adequate ventilation

Most effective technique: with 2 thumbs, encircling the torso

3:1 (90 compressions:30 ventilations /min)

Check HR after 30 sec and every 30’’

ERC, 2010

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• STOP Resuscitation if :

- HR not detectable for 10 minutes

- desicion is often much more complex…

• Communication with the parents

Resuscitation : Until when ?

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Resuscitation : Drugs (D)

START if : RARELY NEEDED

Umbilical venous catheter : quick and effective (try to stay sterile)

- Adrenaline10-30γ/kg IV (or if no other choice…. 50-100 γ/kg IT)

- Bicarbonate (during prolonged arrests unresponsive to other therapy: 1-2mmol/kg)

- Fluids (RARE : if blood loss, baby in shock 10cc/kg)

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PARTICULAR CASES

Meconium

Induced hypothermia.

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Meconium

• 12-15% of all newborn infants : 3-10% of those develop MAS

• Since mid-1970s (and for 25 years): Intubation in order to suction out the trachea

• Wiswell TE et al, Pediatrics 2002

RCT with 2000 infants: Intubation+trachea suctioning OR expectant management

Vigorous immediately (HR >100bpm, good respiratory effort, normal tone)

No differences in outcome

• ERC 2010

If feasible: direct oropharyngeal + tracheal aspiration of non-vigorous babies.

If intubation prolonged/unsuccessful : mask ventilation !!!!

TRUTH : Not enough data (RCT studies…clinical arguments…)

Wiswell ET, Respiratory Care 2011

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Induced Hypothermia

Definition: Induced hypothermia (33,5-34,50C) of babies >36weeks with moderate-to

severe hypoxic-ishcemic encephalopathy

Outcomes: death and neuro-developmental disability at 18m

Method: start <6h of life (continue 72), whole body/ selective head cooling

Follow NICU scores/protocols

If eligible: Eteindre table chauffante

Pas de bonnet, ne pas couvir

Retrocontrôle Temp à 36-370C

Isolette non chauffée

NO cooling during the transfer

Edwards et al, MLJ 2010

Azzopardi et al, NEJM 2009

Luxembourg, NLS instructions 2014

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Take Home Message

• An out-of-hospital delivery becomes the more and more usual in our

societies

- Safe for low-risk-pregnancies

- Unsafe for all the rest…

• Remind regurarly your NLS skills

• Remember:

- A ‘wait-a-minute’’ policy for cord clamping

- Keep the baby’s temperature 36,5-37,50C

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Merci pour votre attention…

Questions ?semina

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Documents

Updates in Neonatal iris Out-of-hospital deliveries 2014 ... 05 13 Prise en charge du... · Umbilical Cord Milking (UCM) Effect of umbilical cord milking in term and near term infants: