PRINCIPLES OF NEONATAL RESUSCITATION

INTRODUCTION

The success of the outcome of resuscitation depends greatly on the speed and effectiveness of initiating appropriate management.

Aim

To provide adequate resuscitation to ensure the survival of the neonate and prevention of morbidity.

A Airway

To establish and maintain airway by:

• positioning on .the side or supine.
• gentle suctioning of oropharyrix and nasopharynx.

B Breathing

To establish and maintain respiratory effort for effective pulmonary gas exchange

• spontaneous
• gentle stimulation
• face mask ventilation
• endotracheal tube ventilation

C Circulation

Maintain heart rate and adequate perfusion.

• Check heart rate if less than 80/min and not responding to ventilation, initiate external cardiac massage.

D Drugs

• To reverse the effects of matemal analgesia/anaesthesia.
• To correct acidosis. 
• To correct shock.

E Equipment and Environment

• Maintain temperature
  • Prepare and maintain a warm environment to prevent heat loss following delivery and during resuscitation.
• All resuscitative equipment must be available and ready for use.

F Followup

• Infants with Apgar scores of <3 at 1 minute or <7 at 5 minutes will need to have follow up observation in Special Care Nursery for first 24 hours.
• Parents require explanation and reassurance.

NEONATAL RESUSCITATION PROTOCOL

Checking and Preparation of Equipment

The most essential part of resuscitation is ensuring that all resuscitation equipment is in.good working order and ready for use at any time. Checking is necessary at the beginning of each shift and after use.

Equipment used:

• Radiant warmer
• Suction apparatus
• Air and oxygen supply
• Hand ventilation circuits (Laerdal, anaesthetic bag and mask)
• Intubation equipment
• Resuscitation drugs.

Radiant Warmer

• Check heater light comes on when switched on
• Be able to feel heat output (Servo or Manual control)
• Warmed linen ready to receive baby.

Suction

• With regulator: Check that suction is working and 150mmHG can be reached within 1-2 seconds.
• Via oxygen supply: Feel for adequate suction within 1-2 seconds. Ensure adequate gas supply.
• Make sure that size 8, 10, and 12 suction catheters are available.

Air and Oxygen Supply

Check that cylinder supplies are adequate and flow-meters work correctly.

Laerdal Bag

• Deliver gas at 6 litres/minute.
• Check that all parts are properly connected
• Check that the "duck bill" gapes when bag is compressed
• Make sure that the bag deflates and inflates easily.

lntubation Equipment

• -All laryngoscopes must be brightly lit.
• All parts must be firmly fitted. Spare barrels, blades, bulbs and batteries available.
• Other accessories different sized ETT, introducers, Magill's forceps, lubrication gel, tapes available.

Resuscitation Drugs

• Check all expiry dates and correct strengths on vials or ampoules.
• Know the correct administrative route, dosage and dilution. 

RESUSCITATION PROCEDURE FOLLOWING DELIVERY

Keep warm and dry

• Place baby under radiant warmer or cot with warmed linen.
• Quickly dry with warm wraps and discard wet linen (Evaporation of amniotic fluid is a major cause of heat loss and can be reduced by effective drying of the skin).
• Wrap baby in warm linen.

Suctioning

• Aspirate the oropharynx first, then the nasopharynx. (Nasopharynx suction may trigger a gasp which may lead to aspiration of secretion in the oropharynx)
• Insert catheter to appropriate length (from lips to earlobe)
• Do not take more than 5 seconds (it may cause vagal stimulation leading to bradycardia).
• Use appropriate size suction catheter
• Assess the baby's condition and continue resuscitation as necessary.

Meconlum Aspiration:

• Suction of the oropharynx when the head is delivered, and before the first gasp of breath.
• Thorough suction oforopharynx when the baby is delivered
• If necessary, suction under direct vision may be carried out. The cords are visualised with a laryngoscope and suction is applied. Elective intubation may follow and suction is continued.
• Positive pressure (if required) must not be initiated until the airway is adequately cleared.
• Aspirate stomach following resuscitation.

Administration of Oxygen

N.B. CORRECT VENTILATION TECHNIQUE IS VITALLY IMPORTANT.

• Oxygen therapy is indicated in neonates who are dusky or cyanosed.
• Appropriate size mask.
• It is important to be familiar with the types of resuscitators available: Laerdal,   Anaesthetic bag and mask.

Face Mask Oxygen

• Place mask near to mouth and nose.
• 100% Oxygen and reduce concentration according to response.
• Observe for improvement of colour.
• If there is no improvement, proceed to intubation..

Intubation

Indications

• severe birth asphyxia
• severe aspiration leave in 100% 02 until skilled assessment
• inadequate respiratory effort.

Assess infant's condition after intubation and proceed if indicated.

External Cardiac Massage

This is indicated if the heart rate is <80/minute and decreasing despite suctioning, oxygenation and ventilation.

• Place the pads of 2 fingers on the sternum at the level of the nipple line.
• Depress 1 to 2 cm in a steady action.
• Rate: 120/minute. Assess effectiveness of the massage every 30 seconds.
• Observe for improvement in colour, heart rate and perfusion.

Resuscitation Drugs

Drug tray should contain :

• Neonatal Narcan - opiate antagonist
• Sodium Bicarbonate 8.4% -  correct metabolic acidosis
• Normal Serum Albumin 5% - volume expander
• Adrenalin 1 in 10,000 - cardiac stimulant

Management of the Neonate with the following Apgar Scores at One Minute

APGAR SCORE 10

• Minimal intervention
• Prevent hypothermia dry and wrap up with warm linen.
• Maintain clear airway if necessary, brief suction of oro-pharynx and then nasopharynx.
• Observe for full 5 minutes

APGAR SCORE 4-7

• Prevent hypothermia
• Clear airway as above
• Tactile stimulation may initiate breathing.
• Give face mask oxygen. Hand ventilation by mask may be necessary. Observe for chest movement and spontaneous breathing.
• Neonatal Narcan may be given, if indicated.

APGAR SCORE 0-3

• Prevent hypothermia.
• Clear airway: position infant supine and give brief but thorough suction.
• Immediate hand ventilation by mask.
• If heart rate is less than 80/mia and decreasing, instigate cardiac massage.
• Medical intervention with intubation or resuscitation drugs.

N.B.: If neonate does not breath immediately commence resuscitation stat. Do not wait to assess 1 minute Apgar score.

Adapted from Box Hill Emergency Department Manual
27/9/2000 SLJ