Primary neonatal resuscitation Order № 312 from 06.08.2007

1. Primary neonatal resuscitation Order № 312 from 06.08.2007 Доц. Багній Н.І. prof. HERYAK S.М.

2. 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.

3. For initial resuscitation of newborns

4. Optional set for resuscitation

5. 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 (notbelow 25 С) andensure 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)

6. 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

7. 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.

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

9. 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.

10. 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 bradypneabreathing <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.

11. 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.

12. Evaluation of mucous membranes and skincolour • 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.

14. 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.

15. 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

16. A – airways • suck briefly, carefully, slowly removing the catheter or rubber pear out; • length of suction should not exceed 5 seconds.

17. 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.).

18. 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.

19. Ensure airway Provide child supine or side position with moderate straighten back head with the caution beneath shoulders

20. 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

21. 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

22. 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).

23. 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

24. 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

25. 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.

26. 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.

27. INTUBATION

28. APPLICATION OF MASKS

29. 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.

30. 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.

31. 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);

32. 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.

33. 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.

35. 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

36. 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.

37. 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).

38. 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.

39. 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.

40. 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

41. Thank you for attention!