Initial Steps

1. Initial Steps

2. Initial Steps • Decide if newborn needs resuscitation • Provide Warmth • Open airway and provide the initial steps of resuscitation • Resuscitate when meconium is present • Provide free-flow oxygen when needed

3. Birth • Term Gestation? • Clear of Meconium? • Breathing or crying? • Good Muscle Tone? • Routine Care • Provide warmth • Clear Airway if needed • Dry • Assess color Yes No 30 seconds • Provide warmth • Position clear airway • (as necessary) • Dry, stimulate, reposition Evaluate Resp, HR and Color Breathing, HR>100, Pink Breathing, HR>100, Cyanotic Pink Observational Care Give Supplementary Oxygen  Endotracheal intubation may be considered at several steps

4. Ask following questions within few seconds of birth • Is the baby born atTerm gestation? • Is the amniotic fluid clear ofMeconium ? • Is the baby breathing orCrying ? • Is theMuscle tone good? Gasping is a significant problem and needs same intervention as apnea

5. What do you do after resuscitation Routine Care • Nearly 90% of newborns need this • Provide warmth by keeping the baby over mothers chest and abdomen • Clear the airway by turning head to one side • Clear airway by wiping the baby’s mouth and nose • Dry • Evaluate color

6. Initial Steps • Provide warmth • Position; clear airway as necessary • Dry, stimulate and reposition

7. What do you do after resuscitation Observational Care • Babies who need initial steps or oxygen supplementation and improve • Need frequent monitoring • Most often cared with the mother

8. What do you do after resuscitation Post Resuscitation Care • Babies who need positive pressure or more extensive resuscitation • Need to be managed in intensive care nursery

9. Provide warmth • Placed under radiant warmer • Leave the baby uncovered under warmer: - to allow full visualization - to permit radiant heat to reach the baby

10. Contd... Premature babies more vulnerable to cold stress • Larger body surface area, thin skin • Less subcutaneous fat, decreased metabolic response • Additional warming techniques: Plastic bags • Monitor for Hyperthermia

11. Initial Steps • Provide warmth • Position; clear airway as necessary • Dry, stimulate and reposition

12. Shoulder Roll Position by slightly extending the neck Sniffing Position

13. Position by slightly extending the neck

15. Clear Airway • Secretions removed from airway with a towel/ bulb syringe/ suction catheter • Copious secretions- turn face to side • Gentle suction- Pressure < 100 mm Hg • Mouth before Nose (M before N) • Stimulation of posterior pharynx causes Vagal stimulation and bradycardia- stop

16. Clear Airway Method depend on: • Presence of meconium • Baby’s level of activity

17. Clear Airway Mouth First and Then Nose

18. Clear Airway Meconium Stained Amniotic Fluid Routine intrapartum suctioning of Mouth and Nose of babies born through MSAF is no longer advisable

19. Meconium present and baby is Vigorous • 12F or 14F suction catheter or bulb syringe for suction of mouth or nose • ET suction not required

20. Vigorous Baby- Definition • Strong respiratory efforts • Good muscle tone • Heart rate > 100 bpm

21. Meconium present and baby is Not Vigorous • Administer free flow oxygen throughout • Clear mouth and posterior pharynx • Insert endotracheal tube into the trachea • Attach the ET tube to suction source • Apply suction as ET is slowly withdrawn for not more than 3 – 5 seconds • Repeat as necessary until no meconium or heart rate indicates further resuscitation

22. Visualizing the glottis and suctioning meconium from the trachea Meconium Present and Baby is Not Vigorous

23. Meconium Aspirator

24. Meconium Aspirator

25. Meconium Aspirator

26. Meconium Aspirator

27. Meconium Aspirator

28. Recommendations • Current guidelines not based on meconium consistency • Techniques such as squeezing the chest, occluding the airway, inserting a finger in the baby’s mouth harmful– not recommended

29. Initial Steps • Provide warmth • Position; clear airway as necessary • Dry, stimulate and reposition

30. Dry, stimulate to breathe and reposition • Use pre-warmed absorbent towels or blankets • Keep head in ‘sniffing’ position to maintain good airway

31. Dry, Stimulate to breathe and Reposition Dry thoroughly Remove we linen Reposition the head

32. Stimulation to Breathe • Suction and drying sufficient stimulation • If inadequate respiration then additional tactile stimulation given briefly by • Slapping or flicking the soles of the feet • Gently rubbing the back, trunk or extremities • Overly vigorous stimulation harmful

33. Acceptable methods of stimulation

34. Hazardous Forms of Stimulation

35. Evaluate: Resp, HR & Color Count the Rate for 6 seconds and multiply by 10 to get the Heart rate

36. Initial Steps • Provide warmth • Position; clear airway as necessary • Dry, stimulate and reposition • Give oxygen, as necessary

37. Free Flow Oxygen If after Initial Steps: • Baby breathing well • Heart Rate > 100 bpm • Central Cyanosis

38. Give Free Flow Oxygen • Flow Rate: 5 Litres / minute • Oxygen tubing • Oxygen mask • Flow-inflating bag and mask • T-piece Resuscitator CAN NOT be given reliably with a mask attached to a Self Inflating Bag

39. Giving Free Flow Oxygen

40. Giving Oxygen • Provide enough oxygen for the baby to become pink • Oxygen given for long periods must be Heated and Humidified • Avoid unheated oxygen at high flow rates (10L/min) to decrease heat loss • Gradually withdraw oxygen when baby pink

41. Giving Oxygen For Term Babies • Use of 100% oxygen is recommended when baby is cyanotic or PPV is required • If oxygen is needed, begin with less than 100% oxygen or RA • However, if no appreciable improvement in 90sec use 100% • Use of variable concentration , guided by pulseoximeter • In situations where oxygen is not available, start PPV with RA.

42. Oxygen For Very Preterm Babies • Use an oxygen blender and pulse oximeter during resuscitation • Begin PPV with oxygen concentration between room air and 100% oxygen • Increase oxygen concentration up or down to achieve saturations between 90 – 95% • If HR does not respond by increasing rapidly to > 100, correct any ventilation problem and use 100% oxygen • If no facility of blender use 100% oxygen

43. Further Evaluation • Respiration • Heart Rate • Count for 6 seconds and multiply by 10 • Feel pulse at base of umbilicus or auscultate • >100 bpm – normal • Color If any of these is abnormal initiate positive pressure ventilation

44. Birth • Term Gestation? • Clear of Meconium? • Breathing or crying? • Good Muscle Tone? • Routine Care • Provide warmth • Clear Airway if needed • Dry • Assess color T Yes A No 30 seconds • Provide warmth • Position clear airway • (as necessary) • Dry, stimulate, reposition Evaluate Resp, HR and Color Breathing, HR>100, Pink Breathing, HR>100, Cyanotic Pink 30 seconds 30 seconds B HR < 100 Apnea Persistent cyanosis Ventilating HR < 60 HR > 60 HR > 100 & Pink C HR < 60 D Observational Care Give Supplementary Oxygen • Provide positive pressure ventilation  Post resuscitation Care • Provide positive pressure ventilation  • Administer Chest Compressions  Endotracheal intubation may be considered at several steps Medications, continue PPV, CC